Wimberger ring sign | Radiology Signs

Answer:

The Wimberger ring sign is a thin, dense sclerotic rim encircling a markedly lucent, osteopenic epiphyseal ossification centre, so the epiphysis appears as a bright ring around an empty centre. It is a feature of scurvy, that is vitamin C deficiency, in infants and young children. It should be read together with the rest of the scorbutic skeletal survey: the dense white line of Frankel at the zone of provisional calcification, the lucent Trümmerfeld (scurvy) zone immediately beneath it, Pelkan spurs at the metaphyseal corners, generalised osteopenia with a ground-glass texture, and subperiosteal haemorrhage that calcifies dramatically on treatment. It must be kept entirely separate from the similarly named Wimberger sign of congenital syphilis, which is a destructive erosion of the medial proximal tibial metaphyses and is a different finding in a different disease. The distinction is one of the more common examination traps and the two are best learned as a pair.

Why is it called so?

It is named for Hans Wimberger; the appearance is a sharply defined ring of density around a lucent epiphysis.

Pathophysiology

Vitamin C is required as a cofactor for prolyl and lysyl hydroxylase in collagen synthesis. Without it, osteoblasts cannot lay down normal collagenous osteoid, so new bone formation nearly ceases while resorption continues, producing profound osteopenia of the epiphyseal ossification centre. The peripheral rim of the ossification centre, however, consists of bone laid down earlier and continues to receive the calcium of the provisional zone of calcification, which does not depend on collagen synthesis; it therefore stands out as a relatively dense shell around the demineralised interior. The same dissociation between preserved provisional calcification and failed osteoid formation explains the Frankel line and the Trümmerfeld zone.

Alternative names: Wimberger sign of scurvy, ringed epiphysis

Other associated named signs: Frankel line, Trümmerfeld zone, Pelkan spur, scorbutic rosary, and the distinct Wimberger sign of congenital syphilis

References

1. Susilo F, Clarissa S, Handoyono QF, Simargi Y, Ronny, Nurprasetyo. A case report of a childhood scurvy musculoskeletal manifestation: Radiologic findings and diagnostic implications. Radiol Case Rep. 2024;19(8):3235-3239. PMID: 38800077.