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Book Reading Fetomaternal

Diagnostic Imaging Obstetric


Woodward: Section 9
Approach to Skeletal Dysplasias
Sarlita Indah Permatasari

Moderator: Dr. Hj. Putri Mirani, SpOG(K)

OBSTETRIC AND GYNAECOLOGY DEPARTEMENT


FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
INTRODUCTION

Several hundreds different types of disorders with significant


skeletal involvement are know, only a fraction of which can be
reliably diagnosed prenatally.

The skeletal dysplasia are a heterogenonous group of relatively


rare conditions involving generalized abnormal bone growth.

Once abnormal development is suspected, this should be followed


by a determination of the severity of the disorder.
Is the condition is lethal or not?
Is pregnancy termination an option for a couple?
What about resuscitative measures at the time of delivery?

However, a multidisciplinary approach to the prenatal diagnosis


of comples fetal abnormalities, including skeletal dysplasias, is
highly recommended.
*
As with imaging of any fetal structures, solid knowlegde of what is
normal variation versus abnormal is critical.
A systematic and thorough evaluation of the fetus following established
guidelines is essential.
When shortened long bones are suspected, all the long bones (bilateral)
should be measured and compared to published standards.

Other skeletal elements that should be measured include the calvarium


(biparietal diameter and circumference), chest, and abdominal
circumference. Measurement of the foot, scapular, and clavicular
lengths is also recommended.
Calculation of various ratios may assist in the diagnosis of a skeletal
dysplasias as well as determination of lethality.
*
Begins with evaluating the long bones.
Sometimes bones that look short are not, and an evaluation may
actually exclude a skeletal dysplasia.
A helpful ratio is the femur : foot length, which is 1:1. a ratio less
than 1:1 is suggestive of skeletal dysplasia.

Long bones that are less than 5th percentile but still within 2-3
standard deviations of the mean have a good likelihood of being
either a normal variation or a nonlethal skeletal dysplasias.
Long bones that are 4+ standard deviations below the mean for
gestation are likely to be associated with skeletal dysplasias.

Severe shorteneing is usually seen in lethal disorders.


*
Proximal shortening (humerus, femur) is rhizomelia whereas
mesomalia is shortening of the middle segment of the limb
(radius/ulna or tibia/fibula)

Acromelia refers to small hands and/or feet


Micromelia refers to all segment being shortened.

Micromelia is more common in the more severe, often lethal,


skleletal dysplasias.
*
The long bones should be evaluated with respect to their shape.

Are they curved or angulated? Crumpled appearing of fractured? Are


the metaphyses broad or irregular? Does the ossification appear
normal?

The finding of underossification with fractures is an important


distinction that may lead to diagnosis, most commonlyl one of
osteogenesis imperfecta.
Defective ossification may also be seen in hypophosphatasia and
achondrogenesis.
*

Severe limb shortening in the first or second trimester is very likely


to be skeletal dysplasias, frequently lethal, whereas third trimester
mold long bone shortening mat be either familial, a normal
variation, or associated with growth restriction of the fetus.

In addition, nonlethal skeletal dysplasias such as achondrophasia


may be suspected when mild long bone shortening is found on
ultrasound in the latter part of pregnancy.
*
Platyspondyly (flattening of the vertebral bodies with increased
space between the vertebrae) is best observed on sagittal view of
the spine, may be difficult to asses by ultrasound early in gestation.

Abnormal curvaturevof the spine, such as lumbar kyphosis or


scoliosis, may also be seen in many skeletal dysplasias.

What about the distal spine? If missing or hypoplastic, caudal


dysplasias may be present, with diabetic embryopathy included in
the differential diagnosis.

Is the spine normally ossified? Achondrogenesis is commonly


associated (often severe) underossification of the spine.
*
Abnormalities of the skull are very common in the skeletal
dysplasias.

Craniosynostosis of varied sutures may be found in many skeletal


dysplasias and often explains the abnormal skull shapes.

Complex craniosynotosis may result in kleeblattschadel (cloverleaf


skull) which is common in type II thanatophoric dysplasia as weel as
some other nonskleletal syndromes, such as Pfeiffer syndrome.
*
There may be the appearance of a shelf where the smaller chest
connects to the larger, protuberant appearing abdomen.
This difference may be striking, especially in the more lethal
conditions, and it predicts a high risk of pulmonary hypoplasias.

The ribs are also evaluated when looking at the chest. If very short,
the chest will be small; this is more commonly seen in lethal skeletal
dysplasias.

Fractures of the ribs may appear as displaced bone or as beading


due to callus formation.
*
Short digits or brachydactyly are very common in skeletal
dysplasias.
The great toe or thumbs may be broad or deviated.
Polydactyly (extra digits) and syndactyly (fused digits) are less
common, but will provide clues regarding possible diagnoses.
*
Surfaces rendering by 3D ultrasound may help delineate phenotypic
features useful in identification of specific syndromes; It may also
help counseling families.

Echocardiography in cases with suspected cardiac defects is also


indicated.
Evaluation of skeletal dysplasia generally begins with long bones.
It is important to know the normal appearance at various gestational ages.

A normal 20-week fetus shows


This 14 wks fetus has a normal appropriate placement of calipers at
appearing, straight femur the ends of the diaphysis for
measurement.

There is no evidence of
metaphyseal flaring or
irregularity

A calcified distal femoral


epiphysis (absent here) would be
evident by about 32 wks.
Extremities
edema Severe micromelia

Abnormal foot
posture

3D ultrasound of the lower extremities Ultrasound of the lower extremities of


of a fetus with campomelic dysplasia a fetus with achondrogenesis
shows the typical anterior tibial bowing. illustrates several fetures of a lethal
skeletal dysplasia
a shortened distal
A very short, curved extremity and
(telephone receiver) irregular, poorly
femur ossified long
bones.

Ultrasound of a mid-
Ultrasound of a 3rd trimester fetus
trimester fetus
with type I thanatophoric dysplasia

Typical findings seen in lethal osteogenesis imperfecta


Gentle curved and
tapered appearance
The sacral Normal ossification
spine is
underossified

At 20 weeks sacral
Normal developmental ossification is well seen
finding in early gestation

Spinal alignment and ossification often gives


important clues to a dysplasia.
Sagital ultrasound of a 14-week fetus shows the
normal appearance of the early spine.
Compared with
Lumbar kyphosis the abdomen

Very small
chest

Platyspondyly,
With flat vertebral Which appears protuberant in this
bodies and increased fetus with thanatophoric dysplasiia.
space between the
vertebrae
Common finding in lethal skeletela
dysplasia

Sagittal ultrasound of a fetus with In addition to evaluating the spine, the


thanatophoric dysplasia sagittal plane is also used to evaluate the
chest/abdomen contour.
Compared
with the Abnormally Quite
abdomen small chest small
chest

Absent spine
ossification
Very short and
crumpled ribs

Sagittal ultrasound of a fetus


with type IA achondrogenesis Sagittal ultrasound of a 3rd trimester
fetus with achondrogenesis
4 fingers, each with 3
distinct phalanges 5 toes

thumb

This view of a fully open hand is often more


easily seen earlier in gestation. The hand at
rest is often partially closed later in
gestation.

The hands and feet may also be affected in a skleletal dysplasia.

The 14-week fetus shows normal appearance of a fetal hand and foot
Severe brachydactyly
Brachydactyly,
fingers frequently remain separated

Trident hand

Ultrasound shows abnormal hand


with short fingers all of the same Ultrasound of the hand of a fetus with
length. achondroplasia. Very similar to that
seen in lethal thanatophoric dysplasia
Typically seen in fetuses with
thanatophoric dysplasia, a lethal
skeletal dysplasia.

It is also seen in achondroplasia


Severe brachydactyly As long than the
entire leg

The foot is also short and broad 1:1

Severe micromelia
with a foot length

Ultrasound of the foot of 3rd A normal femur : foot length ratio is


trimester fetus with Kniest 1:1; a ratio less than this suggests a
sydrome skeletal dysplasia
A cystic hygroma
A normal shape with 2 of
the normal unfused
cranial sutures shown

The calvarium should be evaluated for both shape


This is common in some
and ossification.
severe skeletal dysplasias
Contour abnormalities are very common in skeletal
dysplasias as well as other disorders.

Craniosynostosis may also present with anusual


shape
Low set ear Severe
proptosis

Abnormally round
calvarial shape

Cloverleaf
skull

Coronal ultrasound illustrates Both of these features suggest


typical features seen in a craniosynostosis associated with
number of craniosynostosis shallow orbits.
syndromes as well as in type II
thanatophoric dysplasia
Depression
of the skull

Profoundly
underossifie
d calvarium
Very short
humerus

Thin ribs & beaded

Axial ultrasound of 3rd trimester fetus Sagittal radiograph of a stillborn 3rd


trimester fetus with type II perinatal
lethal osteogenesis imperfecta.
Normal maxilla,
mandible, and nasal Mild frontal
bone bossing
Short nose

micrognathia

In addition to the general skull


shape, the facial profile may Sagittal ultrasound of a 3rd trimester
give added information. 20 fetus with Kniest dysplasia shows a
weeks fetus. very abnormal profile.
mid-face
Prominent hypoplasia
soft tissue mid-face
of the lips hypoplasia

micrognathia

Sagittal ultrasound of another 3rd Sagittal ultrasound of another fetus


trimester fetus. with a lethal skeletal dysplasia
The calvarium is small and round illustrates what us a common theme
when evalutaing the abnormal facial
profile in this class of disorders.
Frontal bossing Frontal bossing
Depressed
nasal brigde Depressed
nasal brigde

micrognathia

Short nose,
micrognathia,
very short neck

Sagittal ultrasound of a fetus


Sagittal ultrasound of a fetus with
with thanatophoric dysplasia
achondroplasiashows a very similar
(TD), the nost prenatally
profile to TD.
diagnosed skleletal dysplasia.