Wrist Swelling in a Neonate
Radiology Cases in Pediatric Emergency Medicine
Volume 6, Case 4
Jennifer M. Ragsdale, MD
Shawn N. Gentry, MD
Martin I. Herman, MD
LeBonheur Children's Medical Center
University of Tennessee School of Medicine
This is a 2-1/2 month old female whose mother
brought her to the ED with a chief complaint of refusing
to use her right arm since she had awoken that
morning. Also, the child had been noted to be warm to
touch for one day, but her temperature was not
checked. Mother had also observed that the child's
right wrist appeared slightly swollen and red for one
day. The patient had spent the previous day in the care
of her aunt. No history of trauma was given. Four days
prior, she had a one day episode of fever occurring
approximately 24 hours after receiving her first set of
immunizations. Her oral intake was good. Urinary
output was normal. No vomiting or diarrhea. She had
a 2-3 day history of clear nasal drainage.
PMH - She was a full term vaginal delivery without
complications. Birth weight 3.5 kg. Prenatal history
was significant for maternal syphilis for which she was
Exam showed a healthy appearing female infant.
The exam was normal except for a seemingly tender
right wrist (cries with palpitation). No deformity was
noted. No tenderness in right upper arm. No skin
abnormalities. Radiographs of the wrist were obtained.
View wrist radiographs.
Question: This radiograph shows? (1) lytic lesions,
(2) artifacts, (3) surgically induced lesions from internal
fixation devices, (4) pathologic fracture, (5) normal bone
Question: What do you think is the cause of these
findings? (1) fibrous dysplasia, (2) enchondroma, (3)
giant cell tumor, (4) lymphoma, (5) congenital syphilis,
A skeletal survey is obtained.
View shoulder radiographs.
View elbow radiographs
View lower extremity radiographs
There is soft tissue swelling of the right wrist with
destructive lytic changes of the metaphyses of the right
radius and ulna. There is periosteal reaction of the
distal ulna and possibly the distal radius.
The shoulder radiographs are probably normal.
The elbow radiographs show some mild periosteal
reaction of the humerus which is difficult to appreciate.
The lower extremities show periosteal reaction of the
femurs and tibiae. There are destructive metaphyseal
abnormalities of the medial aspects of the tibiae. These
findings are compatible with the Wimberger sign of
congenital syphilis. There is scalloping and destruction
of the upper medial tibial metaphyses bilaterally with
diaphyseal periosteal new bone deposition. There is
also some destruction of the left fibula proximally with
Radiographs of the skull (not shown here) showed
no intracranial calcifications. The sella turcica was
normal. Radiographs of the spine, ribs, chest and
abdomen were normal.
Discussion: One must consider several etiologies of
cystic/lytic lesions on pediatric radiographs; several
which predispose to pathologic fractures. The
differential diagnosis includes: simple bone cyst (lucent
lesion, sharply demarcated, presents as pathologic
fracture), fibrous dysplasia (radiolucent area
in long bones, beginning in early childhood), giant cell
tumor (eccentric lucent lesion in metaphysis of long
bones, not involving the joint, 20% malignant),
enchondroma (benign, lucent, well-demarcated near
epiphysis in children and adults), chondroblastoma
(rare, benign eccentric oval lucency in epiphysis),
lymphoma, infection (fungal infection, cystic
osteomyelitis), angiomatous lesion (lucent metaphyseal
lesion, rare congenital malformation) and syphilis of the
Syphilis of the bone is rare. There are two forms.
The infantile form involves the metaphyseal regions of
multiple bones. The juvenile form is diffuse or localized
with subperiosteal thickening. This case most likely
represents a syphilitic lesion because of the location of
the lucent area and the mother's history of syphilis
The etiology of syphilis is the spirochete Treponema
pallidum. Syphilis is described in three stages. Stage
one is the manifestation of the painless chancre usually
found on the genitalia. If untreated, within a few
months, syphilis develops into stage two in which the
patient develops a maculopapular rash which is
generalized and often involving the palms and soles.
During stage two the patient often has flu-like
symptoms including malaise, headache,
lymphadenopathy, fever, and arthralgias. These
symptoms of stage two may wax and wane over a
period of many years. The tertiary stage manifests
years later as neurosyphilis, aortitis, and gummatous
changes of the skin, bone, and viscera. Transmission
of the spirochete is via sexual contact or
transplacentally. The risk of transplacental
transmission is nearly 100% during the second stage of
syphilis and slowly decreases thereafter. Fetuses
infected with syphilis may develop hydrops fetalis and
may be premature or stillborn. Congenital syphilis may
present in a variety of ways. Common features include
rhinitis, the saddle bridge nose, and Hutchison teeth.
Other clinical findings include hepatosplenomegaly,
lymphadenopathy, neurocutaneous lesions,
osteochondritis, hemolytic anemia, and
thrombocytopenia. Treatment for congenital syphilis is
10-14 days of IV penicillin G. If more than one day of
therapy is missed the entire course must be restarted.
1. Syphilis, Section 3. In: Peter G, Hall CB, Halsey
NA, et al (eds). 1997 Red Book: Report of the
Committee on Infectious Diseases, 24th edition.
American Academy of Pediatrics, Elk Grove Village, IL,
2. Bubbly Lesions of Bone. In: Eisenberg RL.
Clinical Imaging: An Atlas of Differential Diagnosis.
Aspen Publishers, Aspen, CO, 1998, pp508-609.
3. Azimi P. Sprichetal Infections, Chapter 201. In:
Nelson WE, Behrman R, Kliegman R, et al (eds).
Textbook of Pediatrics, 15th edition. WB Saunders Co,
Philadelphia, PA, 1996, pp853-856.
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