Deep learning-based automated bone age estimation for Saudi patients on hand radiograph images: a retrospective study.

PURPOSE: In pediatric medicine, precise estimation of bone age is essential for skeletal maturity evaluation, growth disorder diagnosis, and therapeutic intervention planning. Conventional techniques for determining bone age depend on radiologists' subjective judgments, which may lead to non-negligible differences in the estimated bone age. This study proposes a deep learning-based model utilizing a fully connected convolutional neural network(CNN) to predict bone age from left-hand radiographs. METHODS: The data set used in this study, consisting of 473 patients, was retrospectively retrieved from the PACS (Picture Achieving and Communication System) of a single institution. We developed a fully connected CNN consisting of four convolutional blocks, three fully connected layers, and a single neuron as output. The model was trained and validated on 80% of the data using the mean-squared error as a cost function to minimize the difference between the predicted and reference bone age values through the Adam optimization algorithm. Data augmentation was applied to the training and validation sets yielded in doubling the data samples. The performance of the trained model was evaluated on a test data set (20%) using various metrics including, the mean absolute error (MAE), median absolute error (MedAE), root-mean-squared error (RMSE), and mean absolute percentage error (MAPE). The code of the developed model for predicting the bone age in this study is available publicly on GitHub at https://github.com/afiosman/deep-learning-based-bone-age-estimation . RESULTS: Experimental results demonstrate the sound capabilities of our model in predicting the bone age on the left-hand radiographs as in the majority of the cases, the predicted bone ages and reference bone ages are nearly close to each other with a calculated MAE of 2.3 [1.9, 2.7; 0.95 confidence level] years, MedAE of 2.1 years, RMAE of 3.0 [1.5, 4.5; 0.95 confidence level] years, and MAPE of 0.29 (29%) on the test data set. CONCLUSION: These findings highlight the usability of estimating the bone age from left-hand radiographs, helping radiologists to verify their own results considering the margin of error on the model. The performance of our proposed model could be improved with additional refining and validation.

Is hand-wrist radiography still necessary in orthodontic treatment planning?

OBJECTIVES: The aim of our study is to compare the relationship between hand-wrist and cervical vertebra maturation stages with chronological age and to investigate the effect of malocclusion type on the relationship between these methods. MATERIALS AND METHODS: Hand-wrist and cephalometric radiographs of 1000 patients (526 females, 474 males) with a mean age of 13.41 ± 1.83 were analyzed. The methods of Bacetti et al. were used for the cervical vertebra maturation stage, and Björk, Grave and Brown's methods were used for the hand-wrist maturation stage. One-way ANOVA test was applied to compare skeletal classes between them. Tukey post hoc test was used to determine the differences. The relationship between the malocclusion type, cervical vertebra and hand-wrist maturation stages was evaluated with the Spearman correlation test. RESULTS: Spearman's correlation coefficient was 0.831, 0.831 and 0.760 in Class I, II and III females, respectively. In males, it was calculated as 0.844, 0.889 and 0.906, respectively. When sex and malocclusion were not differentiated, the correlation was found to be 0.887. All were statistically significant (P < 0.001). The highest correlation was observed in class III males, while the lowest was found in class III females. CONCLUSION: Cervical vertebrae can be used safely to assess pubertal spurt without hand-wrist radiography. Diagnosing growth and development stages from cephalometric images is important in reducing additional workload and preventing radiation risk.

OSTEOSYNTHESIS OF COMPLEX COMMINUTED HAND BONE FRACTURES BY APPLYING THE LACING METHOD (A CLINICAL CASE STUDY).

Complex comminuted hand injuries are an urgent medical and social problem of national health systems, which is especially sensitive for countries with a low level of socio-economic development. The work aims to substantiate the effectiveness and safety of the shoelace method of hand bone osteosynthesis in complex comminuted fractures (a clinical case study). Clinical case: A 42-year-old female patient was admitted to the clinic with complaints of the presence of a crushed wound on the 2nd finger of the left hand. The shoelace method was applied for hand bone osteosynthesis. The surgical intervention time was 24 minutes, and the time before returning to work or daily activities equaled 7.1 weeks. The time to bone fusion was less than 45 days. The shoelace osteosynthesis method in complex comminuted fractures of the hand bones has prospects for modern clinical practice with the possibility of improving the performance and safety indicators.

Adaptive Multi-Dimensional Weighted Network With Category-Aware Contrastive Learning for Fine-Grained Hand Bone Segmentation.

Accurately delineating and categorizing individual hand bones in 3D ultrasound (US) is a promising technology for precise digital diagnostic analysis. However, this is a challenging task due to the inherent imaging limitations of the US and the insignificant feature differences among numerous bones. In this study, we have proposed a novel deep learning-based solution for pediatric hand bone segmentation in the US. Our method is unique in that it allows for effective detailed feature mining through an adaptive multi-dimensional weighting attention mechanism. It innovatively implements a category-aware contrastive learning method to highlight inter-class semantic feature differences, thereby enhancing the category discrimination performance of the model. Extensive experiments on the challenging pediatric clinical hand 3D US datasets show the outstanding performance of the proposed method in segmenting thirty-eight bone structures, with the average Dice coefficient of 90.0%. The results outperform other state-of-the-art methods, demonstrating its effectiveness in fine-grained hand bone segmentation. Our method will be globally released as a plugin in the 3D Slicer, providing an innovative and reliable tool for relevant clinical applications.

Development of a simplified new method of bone age estimation using three bones of the hand and wrist.

Though the Greulich and Pyle (GP) method is easy, inter-observer variability, differential maturation of hand bones influences ratings. The Tanner-Whitehouse (TW) method is more accurate, but cumbersome. A simpler method combining the above, such that it utilizes fewer bones without affecting accuracy, would be widely used and more applicable in clinical practice. OBJECTIVES: 1. Devising a simplified method utilizing three bones of the hand and wrist for bone age (BA) assessment. 2. Testing whether the 3 bone method gives comparable results to standard methods (GP,TW2,TW3) in Indian children. METHODS: Developmental stages and corresponding BA for radius, hamate, terminal phalanx (left middle finger) epiphyses combining stages from GP,TW3 atlases were described; BA were rated by two blinded observers. 3 bone method ratings were compared with the same dataset analyzed earlier using GP,TW2,TW3 (4 raters). RESULTS: Radiographs analysed:493 (Girls=226). Mean chronological age:9.4 ± 4.6 yrs, mean BA 3 bone:9.8 ± 4.8 yrs, GP:9.6 ± 4.8 yrs, TW3:9.3 ± 4.5 yrs, TW2:9.9 ± 5.0 yrs. The 3 bone method demonstrated no significant inter-observer variability (p = 0.3, mean difference = 0.02 ± 0.6 yrs); a strong positive correlation (p < 0.0001) with GP (r = 0.985), TW3 (r = 0.983) and TW2 (r = 0.982) was noted. Bland-Altman plots demonstrated good agreement; the root mean square errors between 3 bone and GP,TW3,TW2 ratings were 0.6,0.7,0.6 years; mean differences were 0.19,0.49,-0.14 years respectively. Greatest proportion of outliers (beyond ±1.96 SD of mean difference) was between 6 and 8 years age for difference in 3 bone and GP, and between 4-6 years for difference in 3 bone and TW3,TW2. CONCLUSION: The 3 bone method has multiple advantages; it is easier, tackles differential maturation of wrist and hand bones, has good reproducibility, without compromising on accuracy rendering it suitable for office practice.

Should we consider the sex when estimating bone age from hand bone biometrics?

BACKGROUND: Recently, it was proposed to estimate age from the biometric information of hand bones. We observed that these estimations became less precise as children get older, especially from the age of 13-15 years. OBJECTIVE: This study aimed to evaluate the influence of considering sex for age estimation based on hand bones biometrics. MATERIALS AND METHODS: The study sample consisted of metacarpals and proximal phalanges measurements collected on 1003 medical images performed at Nancy and Marseille Hospitals of individuals aged under 21 years. This sample was divided into two subgroups delineated by the age of 13, as it is a relevant legal threshold for most European countries. First, the influence of sex on the hand bones biometrics and on the estimated age was evaluated. Then, based on these results, new sex-specific age estimation formulas were constructed from linear models and their precision was assessed using residual analysis, in comparison with previous global formulas. RESULTS: An influence of sex was only highlighted from the age of 13 and for the total study sample. Thus, new sex-specific age estimation formulas were built for the [1-21] global sample and the [13-21] subsample. Even though the differences with the previous formulas were minor, age was more accurately estimated when sex was considered. CONCLUSION: Considering sex in age estimation is relevant when relying on hand bone biometrics. A new tool was proposed to select the most appropriate age estimation formula, based on the discriminant analysis result and the a priori knowledge of the sex.

Bone-specific median age of hand-wrist maturation from Sudan.

BACKGROUND: Maturation of bones in the hand-wrist region varies among individuals of the same age and among world groups. Although some studies from Africa report differences to other ethnic groups, the lack of detailed bone-specific maturity data prevents meaningful comparisons. AIM: The aim of this study was to describe bone-specific maturity for developing hand-wrist bones in individuals in Khartoum, Sudan. SUBJECTS AND METHODS: The sample was selected from healthy patients attending a dental hospital in Khartoum with known age and ancestry (males = 280, females = 330; aged between 3 and 25 years). Bones were assessed from radiographs of the left hand and wrist after the Greulich and Pyle Atlas (1959). Median ages of attainment for bone stages were calculated using probit analysis for each stage in males and females separately. RESULTS: Maturity data for stages of the phalanges, metacarpals, carpals and radius and ulna in males and females are presented. Median ages in females were earlier compared to males for all stages. These results are largely earlier than previously published findings or where these could be calculated. CONCLUSION: These results of individual maturity stages of phalanges, metacarpals, carpals and the distal epiphyses of the radius and ulna are useful to assess maturity in growing individuals from Sudan.

[Radiological methods for age diagnostics : Clinical and forensic aspects]. / Radiologische Methoden zur Altersdiagnostik : Klinische und forensische Aspekte.

Age diagnostics play an increasing role in radiology. Medical and forensic questions are indications for the application of age diagnostics. In addition to X­rays of the hand in childhood, panoramic tomography and computed tomography are currently the standard procedures. Alternative modalities without ionizing radiation (sonography, magnetic resonance imaging) have not (yet) been established. The purpose of this article is to present the indications and methods of age diagnostics in the clinical and forensic contexts and to familiarize you with their advantages and disadvantages as well as the possibility of determining the final length.

External validation of deep learning-based bone-age software: a preliminary study with real world data.

Artificial intelligence (AI) is increasingly being used in bone-age (BA) assessment due to its complicated and lengthy nature. We aimed to evaluate the clinical performance of a commercially available deep learning (DL)-based software for BA assessment using a real-world data. From Nov. 2018 to Feb. 2019, 474 children (35 boys, 439 girls, age 4-17 years) were enrolled. We compared the BA estimated by DL software (DL-BA) with that independently estimated by 3 reviewers (R1: Musculoskeletal radiologist, R2: Radiology resident, R3: Pediatric endocrinologist) using the traditional Greulich-Pyle atlas, then to his/her chronological age (CA). A paired t-test, Pearson's correlation coefficient, Bland-Altman plot, mean absolute error (MAE) and root mean square error (RMSE) were used for the statistical analysis. The intraclass correlation coefficient (ICC) was used for inter-rater variation. There were significant differences between DL-BA and each reviewer's BA (P < 0.025), but the correlation was good with one another (r = 0.983, P < 0.025). RMSE (MAE) values were 10.09 (7.21), 10.76 (7.88) and 13.06 (10.06) months between DL-BA and R1, R2, R3 BA. Compared with the CA, RMSE (MAE) values were 13.54 (11.06), 15.18 (12.11), 16.19 (12.78) and 19.53 (17.71) months for DL-BA, R1, R2, R3 BA, respectively. Bland-Altman plots revealed the software and reviewers' tendency to overestimate the BA in general. ICC values between 3 reviewers were 0.97, 0.85 and 0.86, and the overall ICC value was 0.93. The BA estimated by DL-based software showed statistically similar, or even better performance than that of reviewers' compared to the chronological age in the real world clinic.

Giant cell tumour of hand bones: outcomes of treatment.

The purpose of this study was to report the incidence of giant cell tumour of the hand bones in an Asian population, document treatment options and report outcomes of treatment. Of 698 giant cell tumours of bone that underwent surgery between January 2011 and December 2020 at our institute, only 22 (3%) were in the hand. Fourteen occurred in the metacarpals, eight in the phalanges. Fifteen were primary tumours and seven had recurrent disease. Twenty lesions had an associated soft tissue component. Two patients treated for primary disease and one who had been treated for recurrence had local recurrence. Recurrence occurred in two of nine patients treated with curettage, one of three with resection and none of five with ray or digit amputation. Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control.Level of evidence: IV.

Traditional and New Methods of Bone Age Assessment-An Overview

Bone age is one of biological indicators of maturity used in clinical practice and it is a very important parameter of a child's assessment, especially in paediatric endocrinology. The most widely used method of bone age assessment is by performing a hand and wrist radiograph and its analysis with Greulich-Pyle or Tanner-Whitehouse atlases, although it has been about 60 years since they were published. Due to the progress in the area of Computer-Aided Diagnosis and application of artificial intelligence in medicine, lately, numerous programs for automatic bone age assessment have been created. Most of them have been verified in clinical studies in comparison to traditional methods, showing good precision while eliminating inter- and intra-rater variability and significantly reducing the time of assessment. Additionally, there are available methods for assessment of bone age which avoid X-ray exposure, using modalities such as ultrasound or magnetic resonance imaging.

Bone age estimation with the Greulich-Pyle atlas using 3T MR images of hand and wrist.

The age estimation of the hand bones by means of X-ray examination is a pillar of the forensic age estimation. Since the associated radiation exposure is controversial, the search for ionizing radiation-free alternatives such as MRI is part of forensic research. The aim of the current study was to use the Greulich-Pyle (GP) atlas on MR images of the hand and wrist to provide reference values for assessing the age of the hand bones. 3T hand MR images of 238 male participants between the ages of 13 and 21 were acquired using 3D gradient echo sequences (VIBE, DESS). Two readers rated the images using the X-ray-based GP atlas method. A descriptive analysis and a transitional analysis were used for the statistical processing of the data. The agreement between and within the raters was assessed. In addition, a comparison was made with the chronological age and with X-ray studies. The descriptive analysis and the transition analysis showed similar results. Both evaluations showed good agreement with X-ray studies. The comparison with the chronological age showed a difference of 0.37 and 0.54 years for the two readers. The age estimate based on the cross-validated transition analysis showed a mean error of -0.28 years. Inter- and intra-rater agreement were good. In summary, it can be concluded that age estimation of hand bones with MR images is routinely applicable with the GP atlas as an alternative without ionizing radiation. However, in order to reduce the estimation error, a multi-factorial assessment based on examinations of several body regions is still recommended.

Hand Bone Age Radiography: Comparison Between Slot-scanning and Conventional Techniques.

BACKGROUND: Determination and longitudinal monitoring of progressive skeletal maturity are essential in the management of children with scoliosis. Although different methods for determining skeletal maturity exists, the most widely practiced method relies on the ossification pattern of the bones of the hand and wrist, which is traditionally acquired using conventional techniques and after the acquisition of the spine using the low-dose slot-scanning technique. Whereas the existing published literature has published promising results on the use of the slot-scanning technique to acquire these hand and wrist radiographs, image quality and radiation dose have not been systematically compared between these techniques. Thus, the objective of our study is to compare image quality, interpretation reliability, and radiation dose of hand bone age radiographs between slot-scanning and conventional techniques using age- and sex-matched children. METHODS: This retrospective study included children who underwent hand radiographs using slot-scanning between October 1, 2019 and December 31, 2019; and matched children who underwent conventional radiography. Blinded to technique, 5 readers reviewed all radiographs after randomization to rate image quality and to determine bone age using the Greulich and Pyle classification. Dose area product was recorded. Mann-Whitney and t tests were used to compare variables between techniques and intraclass correlation (ICC) to determine observer agreement. RESULTS: Our study cohort of 194 children (128 girls, 66 boys; mean age: 13.7±2.3 y) included 97 slot-scanning and 97 conventional radiographs. One (1%) slot-scanning and no conventional radiograph was rated poor in image quality. There was almost perfect interpretation reliability with slot-scanning with high interobserver (ICC=0.948) and intraobserver (ICC=0.996) agreements, comparable with conventional radiographs (ICCs=0.919 and 0.996, respectively). Dose area product (n=158) was lower (P<0.002) with slot-scanning than with conventional techniques. CONCLUSION: Almost perfect interobserver reliability and intraobserver reproducibility with slot-scanning radiographs (performed using significantly lower radiation doses) suggest that this technique for hand bone age determination can be a reliable adjunct to scoliosis monitoring. LEVEL OF EVIDENCE: Level III.

Relationship between calcifications and structural lesions on hand radiography and axial calcifications on CT-scan: A retrospective study in systemic sclerosis.

The objectives of this study were to describe the prevalence and characteristics of radiographic lesions of the hands, and calcifications of the spine on computer tomography scans (CT-scans), and to investigate the relationships between radiographic and CT-scan abnormalities and clinical features in a population of patients with systemic sclerosis (SSc).Subjects underwent X-ray examination of the hands, and thoracic or thoraco-abdominal and pelvic CT scan or lumbar CT scan in the year. Structural lesions on hand X ray was scored and spinal calcifications were evaluated in the anterior, intracanal and posterior segments. Intra and inter-reliability was tested for radiography and CT- scan. Prognostic factors considered were interstitial pulmonary lesions on the CT scan, pulmonary arterial hypertension (PAH) and death.This study involved 77 SSc patients, 58 (75%) with limited cutaneous SSc (lcSSc) and 19 (25%) with diffuse SSc (dSSc). The prevalences of radiographic lesions of the hand were 28.6% for periarticular calcifications and 26% for calcinosis. On CT scan, 64 (83%) patients exhibited at least 1 calcification. Spine calcifications were depicted in 80.5%, 27.3%, and 35.1% at the anterior, intracanal and posterior segments respectively. Calcifications were mainly localized on thoracic spine. Inter reader reliabilities were good for hands and moderate for spine respectively. Spine calcifications and periarticular calcifications in the hands were associated (P = .012). Calcinosis in the hands was related to PAH (P = .02). Posterior calcification segment and foraminal calcifications were associated with interstitial lung disease (ILD) (P = .029) and death (P = .001).More than 80% of systemic sclerosis patients presented spine calcifications. A significant association between hands and spinal calcifications were confirmed and some localization in the posterior segment considered as a bad prognostic factor.

Relationship between hand and wrist bone age assessment methods.

Assessment of skeletal maturity is crucial for managing growth related problems. Tanner and Whitehouse (TW) hand and wrist bone age assessment is an accurate method; however, it is complex and labor-intensive. Several simplified methods derived from the TW method were proposed, and each had its own character. The purpose of this study is to explore the relationship between these methods for accurate usage.Between 2018 and 2019, a cross-sectional study was performed with consecutive left hand and wrist x-rays obtained from a pediatric orthopedic clinic. Bone age assessments included the distal radius and ulna (DRU) classification, Sanders staging (S), thumb ossification composite index (T), and TW method. Somers delta correlation was conducted to determine the interchangeability of these stages. The mean bone age and standard deviation (SD) of each subgrade were compared and analyzed.Totally 103 films (92 girls) were analyzed with mean age of 12.1 years (range: 8.0-17.9 years). The radius (R) stages had good correlation with S, T, and U stages with a very high Somers delta correlation (P < .05). R5 had relatively large SD (1.5) and referred to T2 and T3; R6 and R7 had the smallest SD (0.3) with reference to T4 or S2; R8 referred to T5 or S3, S4, S5; R9 referred to S6 and S7.The internal relationship between the DRU and digital stages system was well proven. We also provided a simple and accurate way to assess the bone age by combination of some subgrades with smaller SD: 10y-proximal thumb covered without sesamoid (T2); 10.5y-sesamoid just appearing (T3); 11y-distal radial physis just covered (medial double joint line, R6); 11.5y-medial capping of distal radial physis (R7); 12y-bilateral capping of distal radial physis (R8) / phalangeal capping without fusion (S3); 12.5y-distal phalangeal physes start to fuse (S4); 13y-distal phalangeal physes fused (S5); 13.5y-proximal phalangeal physes start to fuse (S6); 14.5y-proximal phalangeal physes fused (S7); 15y-distal radial physis almost fused (R10).Level of Evidence: Diagnostic study, level III.

Actinomycotic Osteomyelitis of the Hand and Wrist Treated with Pharmacotherapy Alone: A Case Report.

CASE: Primary infection by Actinomyces is uncommon because susceptibility to infection requires breakdown of the normal protective mucosal barrier. Furthermore, involvement of the upper extremity is rare. This case report presents clinical, radiological, and pathological findings in a 26-year-old patient with actinomycosis of the hand that was treated successfully by pharmacotherapy alone without any surgical debridement. CONCLUSION: Primary actinomycoses of the hand and upper extremity present as a challenging condition. It requires a high index of clinical suspicion and histopathologic diagnosis to guide treatment, typically involving antimicrobial therapy. This case highlights the usefulness of conservative treatment with antimicrobial therapy without surgical debridement.

A Prospective Study Comparing Adolescent and Post-Adolescent Periods Regarding Effects of Activator Appliance in Patients with Class II Mandibular Retrognathia by Using 3dMDface Analysis and Cephalometry.

BACKGROUND The purpose of this prospective study was to compare adolescent and post-adolescent growth periods regarding the effectiveness of conventional activator appliance in patients with Class II mandibular retrognathia by using lateral cephalometric radiographs and three-dimensional photogrammetry (3dMDface). MATERIAL AND METHODS We enrolled 2 groups: 15 patients in the adolescent growth period and 17 patients in the post-adolescent growth period. All patients had Class II anomaly with mandibular retrognathia and were treated with conventional activator appliances. Lateral cephalometric radiographs and three-dimensional photogrammetric views were obtained at the beginning and end of the activator treatment of Class II patients. Maxillomandibular discrepancy, mandibular protrusion and lengths, convexity angles, facial heights, and dental measurements were evaluated cephalometrically. Projections of the lips and the chin and volumetric measurements of the lip and the mandibular area were assessed using three-dimensional photogrammetry. RESULTS Conventional activator therapy resulted in similar effects in both growth periods regarding improvements in the mandibular sagittal growth and maxillomandibular relationship (ANB° and the SNB° angles). Mandibular effective length was increased (Co-Gn length) and the maxillary horizontal growth was restricted (decreased SNA° angle) in both groups following the treatment. Treatment duration was significantly longer in the post-adolescent group. Increases in the projections of menton, pogonion, and sublabial points were observed in the three-dimensional photogrammetric views. Total lip volume was reduced while the mandibular volume was significantly increased in both groups. Lower gonial angle showed a greater increase in the post-adolescent group. CONCLUSIONS Correction of Class II anomaly with mandibular retrognathia was achieved with a combination of dental and skeletal changes in both growth periods. Conventional activator therapy may be an alternative treatment approach in the late growth period as it led to significant skeletal and dental changes.

Statistical shape analysis of hand and wrist in paediatric population on radiographs

Background/aim: The goal of this study was to compare differences in hand and wrist shapes and to evaluate these according to growth and allometry in children on radiographs related to bone age. Materials and methods: The study included 263 males and 189 females. A total of 452 left hand and wrist radiographs were retrospectively collected. Standard anatomical landmarks marked on radiographs. Results: There were seen to be significant differences in comparisons of hand and wrist shapes according to sex (P = 0.009). The most suitable model in the growth models was seen as the Gompertz growth model for both females and males (model P < 0.001). For the relationship between shape and size to evaluate allometry, significant models were obtained in females (model P = 0.017, MSE = 0.0002) and in males (model P < 0.001, MSE = 0.0002). In our study, the difference between the sexes was found mostly in the radiocarpal region. It was observed that the deformation of the carpal bones started in the distal row carpal bones. Conclusion: Significant differences were found in hand and wrist shapes according to sex. Models for growth and allometry of hand and wrist shapes were found to be significant in children.

Vitamin C deficiency mimicking inflammatory bone disease of the hand.

BACKGROUND: Severe vitamin C deficiency, or scurvy, encompasses a syndrome of multisystem abnormalities due to defective collagen synthesis and antioxidative functions. Among the more common presentations is a combination of oral or subcutaneous hemorrhage with lower extremity pain, the latter often exhibiting inflammatory bone changes on magnetic resonance imaging (MRI). CASE PRESENTATION: A 12-year-old male with anorexia nervosa presented with asymmetric painful swelling of multiple fingers of both hands. Imaging demonstrated soft tissue and bone marrow edema of several phalanges, without arthritis, concerning for an inflammatory process. Extensive imaging and laboratory evaluations were largely unrevealing, with the exception of a severely low vitamin C level and a moderately low vitamin D level. A diagnosis of scurvy was made and supplementation was initiated. Within 3 weeks of treatment, serum levels of both vitamins normalized and the digital abnormalities resolved on physical exam. CONCLUSIONS: This represents the first description of scurvy manifesting with bone and soft tissue changes limited to the hands. There must be a high index of suspicion for scurvy in children with restricted dietary intake or malabsorption who have bone pain, irrespective of location of the lesions.