Metaphyseal Cupping

Metaphyseal cupping refers to the inward bulging of the metaphysis. Focal metaphyseal cupping can occur in response to injury to the central portion of the physis (e.g., from trauma, iatrogenic or otherwise; infection; radiation; etc.).

More generalized metaphyseal cupping can occur in:

• Rickets: Widened and frayed metaphyses. Look for widening of the physes.
  • Nutritional: 3-6 months of age. May be seen with exclusively breast-fed babies who don't get vitamin D supplements.
  • Vitamin D malabsorption: Liver disease, biliary obstruction, inflammatory bowel disease, celiac disease, etc.
  • Renal:
  • Hereditary: Vitamin-D dependent types (vitamin D dependent rickets types I and II) and Vitamin-D resistant types (familial hypophosphatemic rickets and hereditary hypophosphatemic rickets with hypercalciuria).
  • Medications: Antacids, anticonvulsants, steroids, loop diuretics.
• Sickle Cell Anemia:
• Achondroplasia: Associated with flaring and medial slanting of the femoral metaphyses early on with progression to an inverted V configuration later.
• Hypervitaminosis A: Distal femur typically involved. Hyperostosis can also be seen (more pronounced in ulna and metatarsals). Increased intracranial pressure and subsequent widening of the sutures.
• Metaphyseal dysplasias: For example, Schmid type (milder, autosomal dominant), Jansen type (more severe).

Scurvy is included in some differentials; however, cupped metaphyses are rare in this disorder.

References

• Caffey J. Traumatic cupping of the metaphyses of growing bones. Am J Roentgenol Radium Ther Nucl Med. 1970 Mar;108(3):451-60.
• Nield LS, Mahajan P, Joshi A, Kamat D. Rickets: not a disease of the past. Am Fam Physician. 2006 Aug 15;74(4):619-26.
• Sprogue PL. Epiphyseo-metaphyseal cupping following infantile scurvy. Pediatr Radiol. 1976 Feb 13;4(2):122-3.