Orthopedic Aspects Of Metabolic Bone Disease By Xiu
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Orthopedic Aspects Of Metabolic Bone Disease By Xiu

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Orthopedic Aspects Of Metabolic Bone Disease By Xiu

Orthopedic Aspects Of Metabolic Bone Disease By Xiu

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  • Thank you - a very comprehensive and easy to follow summary on metabolic bone disease. MC David (T&O SpR, UK)
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  • ผู้ป่วย MBD ตอนแรกอาจมา present เพียงเรื่อง LBP ตังนั้นการ diag ให้ได้เร็วๆ เป็นการช่วยผู้ป่วย การ diag เร็วๆ ก็จำเป็นต้องอาศัย clinical, PE, LAB และที่สำคัญ Imaging ซึ่ง Radiologist จะมีส่วนช่วยตรงนี้
  • dual energy X-ray absorptiometry (DXA)
  • dual energy X-ray absorptiometry (DXA) and quantitative CT scan (QCT)
  • Osteopenia= a nonspecific term that describes decreased bone density.
  • Osteopenia= a nonspecific term that describes decreased bone density.
  • Cortex บาง เรียบ แต่ยังเห็นเป็นเส้นที่คมชัด
  • Cortex บาง เรียบ แต่ยังเห็นเป็นเส้นที่คมชัด
  • Osteopenia= a nonspecific term that describes decreased bone density.
  • Osteopenia= a nonspecific term that describes decreased bone density.
  • Osteopenia= a nonspecific term that describes decreased bone density.
  • ให้สังเกตว่า joint space จะปกติ ใช้แยกจากโรคของ arthritis ต่างๆ
  • This patient had a long - standing immobilization due to a fracture of the right humerus . The appearances in the right hand are classical for reflex sympathetic dystrophy, or Sudeck’s atrophy, and include : 1 . Pronounced demineralization of the bones, particularly in the periarticular region . 2 . No joint involvement . ssociated soft tissue atrophy . This condition has been recently renamed the “complex regional pain syndrome” .
  • The most common radiologic sign is generalized osteopenia, a finding shared by many differential diagnoses including multiple myeloma. Looser's zones are linear areas of undermineralized osteoid that occur in a bilateral and symmetric distribution
  • Provisional zone of calcification; the region of the physis adjacent to the metaphysis Occasionally, in patients with rickets caused by chronic renal disease, increased sclerosis due to associated secondary hyperparathyroidism may be seen.
  • Differential diagnosis of rickets includes hypophosphatasia and the Schmid-type of metaphyseal chondrodysplasia .
  • Skeletal deformities depend in part on the age at which the disease develops.
  • In chronic renal failure, secondary hyperparathyroidism often coexists with rickets, osteomalacia, and osteoporosis as part of a spectrum of findings called renal osteodystrophy. triad of renal calculi, diffuse bone pain in combination with characteristic radiologic findings, and dementia resulting from hypercalcemia - elevated serum calcium and alkaline phosphatase, decreased serum phosphate, and elevated urinary calcium and phosphate levels. The diagnosis is confirmed with immunoassay that shows an elevated serum parathyroid hormone level.
  • Brown tumors are composed mostly of osteoclasts and appear as well-defined lytic lesions
  • Primary HPT. Radiograph of the midfemur showing a brown tumor. inferior obturator ramus
  • Certain radiologic findings are more common in patients with secondary hyperparathyroidism than in those with primary hyperparathyroidism
  • vascular calcifications
  • Neuromuscular = hypocalcemia. Premature closure of the physes = short stature
  • diffuse idiopathic skeletal hyperostosis,
  • Obesity, short stature, mental retardation, and brachydactyly. Some patients also have dermatologic, ocular, olfactory, and gustatory abnormalities. As in hypoparathyroidism, hypocalcemia and hyperphosphatemia are often present. Serum parathyroid hormone levels may be normal or elevated.
  • as a result of premature closure of the physes
  • Normocalcemic.
  • Excessive production of thyroid hormone by the thyroid gland results in stimulation of bone formation and bone resorption; however, bone resorption is dominant. Laboratory results show elevated serum levels of calcium, phosphorus, and alkaline phosphatase, and elevated urinary calcium.
  • In addition, patients may develop a myopathy that mimics arthritis.
  • Thyroid acropachy ( 1% of patients ): swelling of the hands and feet with diaphyseal periostitis .
  • Thyroid acropachy ( 1% of patients ): swelling of the hands and feet with diaphyseal periostitis .
  • Onset : after >18 months following surgical / radioactive ablation of thyroid gland for hyperthyroidism (does not occur with antithyroid medication) eu - / hypo - / hyperthyroid state
  • Differentiation from venous stasis, osteomyelitis, leukemia, hypervitaminosis A, and trauma is usually possible on the basis of the characteristic clinical presentation of these disorders. Hypertrophic osteoarthropathy เจ็บ
  • Slipped capital femoral epiphysis is a known complication of hypothyroidism in children.
  • Slipped capital femoral epiphysis is a known complication of hypothyroidism in children.
  • Slipped capital femoral epiphysis is a known complication of hypothyroidism in children.
  • Elevated serum growth hormone stimulates bone formation and causes soft tissue proliferation. In the immature skeleton the same condition is called pituitary gigantism and manifests as delayed skeletal maturation.
  • . Posterior vertebral scalloping has a broad differential, including spinal neoplasms, neurofibromatosis, Marfan syndrome, Ehlers-Danlos syndrome, and achondroplasia. [ 80 ] Degenerative enthesopathy in the peripheral skeleton is also seen in patients with diffuse idiopathic skeletal hyperostosis.
  • Chronic renal failure causes phosphate retention by the kidneys, which results in hypocalcemia and in turn leads to parathyroid hyperplasia and secondary hyperparathyroidism. [ 102 ] [ 118 ] Because normal kidney function is required for vitamin D metabolism, chronic renal failure also results in rickets and osteomalacia. [ 102 ] [ 118 ] On laboratory evaluation, the serum level of calcium may be normal, low, or elevated.
  • Lytic phase of Paget disease of the skull in different patients with osteoporosis circumscripta . (a) Lateral radiograph of a 50-year - old man shows a well - defined area of lysis in the frontal and occipital regions ( arrowheads ). (b) Lateral radiograph of a 60-year - old woman with osteoporosis reveals frontal and occipital areas of osteolysis (*) that are more difficult to detect in this clinical setting .
  • Lytic phase of Paget disease (" blade - of - grass " appearance ) of the appendicular skeleton in different patients . (a) Anteroposterior radiograph of the knee in a 74-year - old man shows a large area of lysis beginning in subchondral bone with a sharp inferior margin ( arrowheads ). (b) Lateral radiograph of the upper tibia in a 41-year - old man shows a lytic lesion in the tibial tubercle, with blade - of - grass appearance superiorly and inferiorly ( arrows ).
  • Mixed phase of Paget disease of the pelvis in different patients . (a) Anteroposterior radiograph of an 81-year - old woman shows extensive involvement by Paget disease with areas of cortical ( iliopectineal and ilioischial lines, arrows ) and trabecular ( arrowheads ) thickening throughout the pelvis and coxa varus deformity in the right hip .

Orthopedic Aspects Of Metabolic Bone Disease By Xiu Orthopedic Aspects Of Metabolic Bone Disease By Xiu Presentation Transcript

  • ORTHOPEDIC ASPECTS OF METABOLIC BONE DISEASE Presented by EKKASIT SRITHAMMASIT, MD. Leon Lenchik , MD et al Department of Radiology, The Bowman Gray School of Medicine, Wake Forest University (LL), Winston-Salem, North Carolina Orthopedic Clinics of North America - Volume 29, Issue 1 (January 1998)
    • Metabolic bone disease (MBD)
    • Encompasses a diverse group of disorders associated with altered calcium and phosphorus homeostasis.
    • To orthopedic surgeons ; MBD is often silent until the patient presents with fracture.
    Introduction
  • Table of content
    • Osteoporosis.
    • Osteomalacia and rickets.
    • Hyperparathyroidism.
    • Hypoparathyroidism.
    • Hyperthyroidism.
    • Hypothyroidism.
    • Renal osteodystrophy.
    • Paget's disease.
  • OSTEOPOROSIS
  • OSTEOPOROSIS
    • Most common metabolic bone disease.
    • One of the most prevalent conditions associated with aging.
  • OSTEOPOROSIS
    • Definition : reduced bone mass of normal composition .
  • OSTEOPOROSIS
    • Clinical definition : requires the presence of a nontraumatic fracture .
    • Histologic definition : requires normally mineralized bone to be present in reduced quantity .
  • OSTEOPOROSIS
  • Diagnosis Osteoporosis
    • Bone densitometry ; gold standard
      • Detection osteoporosis before fractures.
      • Determination disease severity.
      • Estimation risk of fracture.
      • Serial BMD measurements enable determination of rate of bone loss or gain and thereby help in monitoring therapy.
    • Plain film ; loss of 30% to 50% of bone is required before it is detected on conventional radiographs.
  •  
  • Ostoporosis Classification
    • Primary osteoporosis . (idiopathic) : more common
      • Type 1 (postmenopausal)
      • Type 2 (age-related or senile)
    • Secondary osteoporosis .
      • Metabolic (acromegaly, hypercorticism, hyperthyroidism, hyperparathyroidism, hypogonadism, pregnancy, diabetes mellitus)
      • Congenital (osteogenesis imperfecta, Ehlers-Danlos syndrome, homocystinuria, mastocytosis, ochronosis, Gaucher's disease)
      • Nutritional (alcoholism, malnutrition, calcium deficiency, scurvy)
      • Drug-related (steroids, heparin).
  • Radiological finding (1)
    • The m/c radiologic finding is generalized osteopenia .
      • Cortical thinning and accentuation of weightbearing trabeculae.
      • The bone surfaces are well defined , with sharp margins.
  • Radiological finding (2)
    • Fractures - vertebral deformities, which are also common, include biconcave end plates ( fish vertebrae ) and anterior wedging.
    • Lateral radiograph of the lumbar spine in a 55-year-old woman with postmenopausal osteoporosis shows generalized osteopenia, compression fractures, and biconcave vertebral endplates ("fish vertebra"). Notice thin, well-defined vertebral cortices ( arrows ).
  •  
  • Radiological finding (3)
    • Patients with osteoporosis secondary to excess steroids.
      • Generalized osteopenia.
      • Fractures with exuberant callus
      • Steroid-related complications;
        • Intravertebral vacuum (nitrogen gas);
        • Avascular necrosis.
        • Osteomyelitis.
  • Differential considerations for diffuse osteopenia
    • Osteomalacia.
      • indistinct trabeculae and poorly defined interfaces between cortical and trabecular bone.
      • Presence of Looser's zones.
    • Hyperparathyroidism.
      • bone resorption at characteristic sites.
    • Multiple myeloma.
      • MR imaging may show areas of marrow replacement.
  • Regional or localized osteoporosis
    • Immobilization and disuse
    • Reflex sympathetic dystrophy syndrome (RSDS)
    • Transient regional osteoporosis
      • Transient osteoporosis of the hip.
      • Regional migratory osteoporosis.
    • Inflammatory arthritis.
    • Tumors
    • Infection.
  • Radiologic findings in regional osteoporosis (1)
    • RSDS : mediated by the sympathetic nervous system and is characterized by
      • aggressive osteoporosis,
      • soft tissue swelling.
      • The cause is usually traumatic, but the disease may also be idiopathic.
    • AP radiograph of the hand in a patient with reflex sympathetic dystrophy syndrome shows soft-tissue swelling and periarticular osteopenia.
  •  
  • RICKETS AND OSTEOMALACIA
  • Rickets and osteomalacia
    • Rickets and osteomalacia are similar histologically.
    • Abnormality in vitamin D metabolism.
    • Incomplete mineralization of normal osteoid tissue.
    Rickets Occurs in children A ffects immature bone Osteomalacia Occurs in adult Affects mature bone
  • Rickets and osteomalacia Maintain calcium and phosphate homeostasis.
  • Clinical findings of Rickets and Osteomalacia
    • Rickets: stunted skeletal growth.
    • Apathetic, Irritable, Hypokinetic.
    • Frontal bossing, softening of the skull, dental caries, rachitic rosary, kyphosis, joint enlargement, or bowing of long bones.
    • Fractures and slipped capital femoral epiphyses.
    Depend in part on the etiology and severity of the disorder, as well as the age of the patient at presentation
  •  
  • Clinical findings of Rickets and Osteomalacia
    • Osteomalacia: more subtle.
    • Fatigue, malaise, or bone pain.
    • Proximal muscle weakness and abnormal gait may be present.
    Depend in part on the etiology and severity of the disorder, as well as the age of the patient at presentation
  • Radiologic findings of Osteomalacia
    • The M/C radiologic sign is generalized osteopenia .
    • Coarsened and indistinct bony trabeculae .
    • Poorly defined interfaces between cortical and trabecular bone.
    • Looser's zone , or pseudofracture. (more specific but less common)
    • End plate deformities and fractures of vertebral bodies, bowing and fractures of long bones, and basilar invagination of skull.
    The radiologic findings of osteomalacia are often nonspecific, difficult to confirm the diagnosis with imaging studies
  • Radiologic findings of Osteomalacia
    • Looser's zone.
    • Linear areas of undermineralized osteoid that occur in a bilateral and symmetric distribution .
    • Characteristic sites; inner margins of femoral neck, proximal ulna, axillary margin of the scapula, pubic rami, and ribs.
    • DDx; Paget's disease or fibrous dysplasia.
    • AP radiograph of the hip in a 50-year-old man with osteomalacia shows coarsened trabecular pattern with indistinct trabeculae.
    • AP radiograph of the hip in a patient with osteomalacia shows multiple Looser zones ( arrows) in the superior pubic ramus.
  •  
    • Osteomalacia. AP radiograph of the pelvis showing osteopenia with bilateral femoral neck pseudofractures (arrows).
  • Radiologic findings of Rickets
    • The M/C radiologic sign is generalized osteopenia .
    • Increased lucency , widening , elongation , irregularity , and cupping of the metaphyses.
      • Earliest; Slight axial widening of the physis
      • Next; Increased lucency of the zone of provisional calcification.
      • More advance; The physis widens and its contour becomes irregular.
    • Occasionally, in patients with rickets caused by chronic renal disease, increased sclerosis may be seen.
  • Radiologic findings of Rickets
    • The regions of highest yield on radiologic evaluation of rickets are those that are undergoing rapid growth .
      • Costochondral junctions of middle ribs (rachitic rosary)
      • Distal femur
      • Both ends of the tibia
      • Distal radius and ulna
      • Proximal humerus.
  • Radiologic findings of Rickets
    • The complication of rickets.
      • Skeletal deformities.
      • In neonates; posterior flattening and squaring of the skull, or craniotabes, may be seen.
      • In early childhood; bowing deformities of arms and legs are common.
      • Older children: scoliosis, vertebral end plate deformities, basilar invagination of the skull may be seen.
      • Advance disease: Slipped capital femoral epiphysis.
    • A, AP radiograph of the knee in a 2-year-old girl with rickets shows generalized osteopenia and widening of the metaphyses of the proximal tibia and fibula. B, AP radiograph of the wrist in another child with rickets shows generalized osteopenia, as well as widening and irregularity of the metaphyses of the distal radius and ulna.
    • Rickets in a young child with growth plate widening and irregularity in the wrist ( A ) and knees ( B ). Note the small epiphyses in the knees.
    • Rachitic rosary . (A) and lateral (B) radiographs of the chest showing prominence of the costochondral junctions (arrows).
    • Vitamin D-resistant rickets in a 1-year-old child. ( A ) AP radiograph of the knees showing irregularity and widening of the growth plates. The epiphyses are small and irregular as well. ( B ) Three years after high-dose vitamin D therapy, the knees appear normal. There is residual femoral bowing.
  • HYPERPARATHYROIDISM
  • HYPERPARATHYROIDISM
    • Primary
      • Parathyroid adenoma
    • Secondary
      • chronic renal insufficiency.
    Hyperparathyroidism may result in either bone resorption or bone formation, bone resorption usually dominates .
  •  
  • Radiologic findings of HYPERPARATHYROIDISM
    • The M/C radiologic abnormality is generalized osteopenia .
    • Bone resorption , bone sclerosis, brown tumors , chondrocalcinosis, soft tissue calcification, and vascular calcification.
    • Brown tumors appear as well-defined lytic lesions.
      • After resection of parathyroid adenomas, the lesions may become sclerotic and may mimic blastic metastasis.
    • Bone resorption , the most characteristic finding , is usually classified as
      • subchondral, trabecular, endosteal, intracortical, subperiosteal, subligamentous, and subtendinous.
  •  
  • Radiologic findings of HYPERPARATHYROIDISM
    • Subperiosteal resorption - M/C
      • Usually occurs in the hands and feet .
      • M/C affected site: radial aspects of the middle phalanges.
      • Acro-osteolysis or phalangeal tufts resoption may also be present.
    • Trabecular resorption
      • Often seen in the diploic space of the skull, where it has a characteristic salt and pepper appearance .
    • Subchondral resorption
      • May be seen in the sacroiliac joints, sternoclavicular joints, acromioclavicular joints, symphysis pubis, and discovertebral junction .
    • AP radiograph of the hand in a 66-year-old woman with primary hyperparathyroidism owing to parathyroid adenoma shows subperiosteal bone resorption ( arrows) along the radial aspect of 2nd, 3rd, and 4th middle phalanges.
  •  
    • AP radiograph of the knee in a child with hyperparathyroidism shows subperiosteal bone resorption ( arrow ) along the proximal medial tibia.
    • Lateral radiograph of the skull in a 23-year-old man with secondary hyperparathyroidism shows trabecular resorption of the diploic space ("salt and pepper" appearance).
  •  
    • Dental radiograph in another child with hyperparathyroidism shows resorption ( arrow ) of the lamina dura of the mandible.
  • Radiologic findings of HYPERPARATHYROIDISM
    • Secondary
    • Bony sclerosis; focal or generalized.
    • Rugger-jersey appearance of spine.
    • Soft tissue and vascular calcification.
    • Primary
    • Chondrocalcinosis
    • usually seen in the menisci of the knee, the triangular fibrocartilage of the wrist, and the pubic symphysis
    • AP radiograph of the wrist in an 83-year-old woman with primary hyperparathyroidism shows chondrocalcinosis ( arrow) of the triangular fibrocartilage.
  •  
    • Secondary HPT . Radiograph of the pelvis and hips showing diffuse osteosclerosis .
    • A, AP radiograph of the spine in a patient with secondary hyperparathyroidism shows generalized bone sclerosis, small kidneys, and left renal calculi. B, Lateral radiograph of the lumbar spine in another patient with secondary hyperparathyroidism shows horizontal, bandlike ("rugger jersey") sclerosis of the vertebral bodies ( arrows ).
  •  
    • AP radiograph of the hand in a 50-year-old man with renal osteodystrophy shows acro-osteolysis ( short arrows ), subperiosteal bone resorption ( long arrows ), and vascular calcifications.
    • Secondary HPT . Radiograph of the hand showing resorption of the first to third tufts with soft tissue calcification ( 1 ). There is articular calcification ( 2 ) , and subperiosteal and subligamentous resorption ( 3 ).
  • The differential diagnosis of HYPERPARATHYROIDISM
    • Focal subperiosteal resorption involving a single bone
      • Neoplasms or osteomyelitis.
    • Bone sclerosis in patients with secondary hyperparathyroidism.
      • Metastatic disease, radiation-induced bone disease, hypoparathyroidism, myelofibrosis, mastocytosis, sickle-cell disease, and Paget's disease.
    • Chondrocalcinosis
      • Pyrophosphate arthropathy (CPPD) or hemochromatosis.
    • Brown tumors
      • includes other focal lytic lesions, such as giant cell tumor and fibrous dysplasia.
  • HYPOPARATHYROIDISM
    • The M/C cause is excision of or trauma to the parathyroid glands .
      • may not be recognized for years after surgery.
    HYPOPARATHYROIDISM
    • Clinical presentation:
    • Neuromuscular dysfunction.
    • Short stature.
    • Delay or failure of tooth eruption.
    • Gastrointestinal complaints.
    HYPOPARATHYROIDISM
    • Radiologic findings are varied.
    • Bony sclerosis. = M/C finding
      • Focal or generalized
    • Subcutaneous calcification.
    • Calvarial thickening
    • Basal ganglia calcification
    • Hypoplastic dentition
    • Premature physeal fusion
    • Spinal ossification.
    • Occasionally : Osteoporosis, Enthesopathy, Dense metaphyseal bands.
    Radiologic findings of HYPOPARATHYROIDISM
    • Lateral radiograph of the skull in a 5-year-old girl with pseudohypoparathyroidism shows thickening ( arrows) of the calvarium.
    • Widespread bony sclerosis.
      • Blastic metastasis, myelofibrosis, renal osteodystrophy, sickle-cell disease, and fluorosis.
    • Dense metaphyseal.
      • Leukemia therapy, heavy-metal poisoning, or hypothyroidism.
    • Calcifications of the basal ganglia
      • Toxoplasmosis or cytomegalovirus infections, after radiation therapy, and after carbon monoxide exposure.
    • Subcutaneous calcifications.
      • Collagen-vascular diseases, hypervitaminosis D, and renal osteodystrophy.
    differential diagnosis of HYPOPARATHYROIDISM
    • Inherited disorder
    • End-organ resistance to parathyroid hormone.
    • X-linked dominant trait
    • More common in women.
    • Shares many features with hypoparathyroidism.
    Pseudohypoparathyroidism
    • Similar to those of hypoparathyroidism
    • Bony sclerosis, Soft tissue calcification, Dense metaphyseal bands, Calvarial thickening and Basal ganglia calcification.
    • In addition
    • Short metacarpals, metatarsals, and phalanges; diaphyseal exostoses; and cone-shaped epiphyses.
    • Typically, the first, fourth, and fifth rays are shortened.
    • Growth deformities
      • Bowing of long bones.
    Radiologic findings of Pseudohypoparathyroidism
    • Pseudohypoparathyroidism. ( A,B ) AP radiographs of the hands showing shortening of the fourth and fifth metacarpals.
    • AP radiograph of the hand in another child with pseudohypoparathyroidism shows short 3rd, 4th, and 5th metacarpals.
    • Incomplete genetic manifestation of PHP.
    • End-organ resistance to parathyroid hormone.
    • Share most of their clinical and radiologic features of pseudohypoparathyroidism.
    Pseudopseudohypoparathyroidism
  • HYPERTHYROIDISM
  • HYPERTHYROIDISM
    • Children; causes accelerated skeletal maturation and advanced bone age.
    • Adults; causes generalized osteoporosis leading to vertebral fractures and kyphosis.
  • HYPERTHYROIDISM
    • The M/C causes of hyperthyroidism in adults are toxic diffuse goiter and toxic nodular goiter .
    • Excessive production of thyroid hormone by the thyroid gland results in bone resorption is dominant.
  • HYPERTHYROIDISM
    • Patients may experience
      • Weakness.
      • Fatigue
      • Nervousness
      • Weight loss
      • Palpitations
      • Diarrhea
      • Hypersensitivity to heat.
  • Radiologic findings in HYPERTHYROIDISM
    • Pt with radiologic abnormalities typically have had the disease for at least 5 years, more common in men
  • Radiologic findings in HYPERTHYROIDISM
    • Skeletal findings
    • Generalized osteopenia: M/C Finding
    • Thyroid acropachy (0.5% to 1%) .
    • Kyphosis and insufficiency fractures are occasionally seen.
  • Radiologic findings in HYPERTHYROIDISM
    • Thyroid acropachy
    • A dense, solid periosteal reaction with a feathery contour
      • Asymmetric distribution
      • Radial margin of metacarpals and phalanges.
      • Occasionally, long bones are also involved.
    • Soft tissue swelling
      • Hands, feet, and pretibial region of the leg.
    • AP radiographs of the hand in a 46-year-old man with thyroid acropachy who presented with hand swelling and hypothyroidism 2 years after a thyroidectomy. Note the dense, solid periosteal reaction with feathery contour ( arrows) along the shafts of 2nd, 3rd, and 4th proximal and middle phalanges.
    • Thyroid acropachy. ( A,B ) Radiographs of the hands showing diaphyseal periostitis ( arrows ) and generalized swelling. ( C ) Radiograph in a different patient showing marked soft tissue prominence.
  • Differential for HYPERTHYROIDISM
    • Thyroid acropachy
      • Periosteal reaction involving multiple bones
      • Hypertrophic osteoarthropathy:
        • long bones.
        • Feathery contour is absent.
      • Pachydermoperiostosis:
        • Long bones.
        • Periosteal reaction extends to the metaphyses and epiphysis.
    • A, AP radiograph of the leg in a child with hypertrophic osteoarthropathy shows thin periosteal reaction ( arrowheads ) along the diaphyses of the tibia and fibula. The hands were not involved. B, Frontal radiograph of both forearms in a patient with pachydermoperiostosis shows dense periosteal reaction involving the diaphyses and metaphyses of both radii and ulnae.
  • HYPOTHYROIDISM
  • HYPOTHYROIDISM
    • Manifests
    • Delayed physeal closure and bone age.
    • In infants: cretinism
    • In children: mental retardation, obesity, developmental delay, growth retardation, lethargy, and constipation.
    • In adults: dry coarse skin and hair, fatigue, lethargy, paresthesias, constipation, and bradycardia.
    • Causes of hypothyroidism
    • Surgery, tumors, iodine deficiency, medications, and pituitary disorders.
  • The radiologic findings in HYPOTHYROIDISM
    • Depend on the patient's age at presentation.
    • In infants:
      • Absence epiphysis : distal femoral and proximal tibial.
      • In the skull, wormian bones and prolonged separation of sutures.
  • The radiologic findings in HYPOTHYROIDISM
    • Depend on the patient's age at presentation.
    • In children:
      • Fragmented, irregular epiphysis. Referred to as epiphyseal dysgenesis, the appearance may simulate that of Legg-Calve-Perthes disease.
      • Slipped capital femoral epiphysis.
      • In the spine, anteriorly wedged bullet vertebrae.
      • Dentition and pneumatization of the sinuses may be delayed.
      • Occasionally, dense metaphyseal bands are seen.
    • A, Radiograph of the knee in a 2-year-old boy with delayed bone maturity owing to hypothyroidism shows nonossification of the epiphysis of the distal femur and proximal tibia. Both epiphyses should be ossified by 1 month of age. B, AP radiograph of the left hip in another child with hypothyroidism shows a fragmented, irregular ( arrow) proximal femoral epiphysis. This appearance may mimic Legg-Calve-Perthes disease.
  • The radiologic findings in HYPOTHYROIDISM
    • Depend on the patient's age at presentation.
    • In adults :
      • Usually mild.
      • Generalized osteoporosis is M/C.
      • Occasionally, soft tissue edema, dystrophic calcification, ligamentous laxity, and carpal tunnel syndrome are present.
      • Coxa vara may develop .
  • ACROMEGALY
  • ACROMEGALY
    • Results from excessive growth hormone after physeal closure .
    • Third or fourth decade of life.
    • Usually caused by a pituitary adenoma .
  • ACROMEGALY
    • Clinical findings;
    • Coarse facial features
    • Thick skin
    • Poor dental occlusion
    • Thick calvarium
    • Deepening of voice
    • Lantern jaw
    • Prominent tongue
    • Broad hands
    • Organomegaly (kidneys, liver, pancreas, spleen thyroid, heart).
    • Arthropathy mostly involves large joints.
    • Compressive neuropathy, such as carpal tunnel syndrome or spinal cord compression, may result from soft tissue and bony hypertrophy.
    • Fatigue and lethargy are also quite common.
  • Radiographic findings of ACROMEGALY
    • Bony and soft tissue overgrowth
    • Soft tissue thickening is classically seen in the heel pads and digits .
    • Bony enlargement is most notable in the skull, vertebra, phalnageal tufts.
    • Calvarial thickening, prominent supraorbital ridges.
    • Joint
    • In the early stages of the disease, joint-space widening is seen.
    • In later stages, as the thickened cartilage, and radiologic signs of joint-space narrowing , subchondral sclerosis, subchondral cysts, and osteophytes become apparent.
  • Radiographic findings of ACROMEGALY
    • Additional radiologic findings
      • enlargement of costochondral junctions
      • enlargement of the sella turcica and paranasal sinuses
      • intervertebral disk widening
      • posterior vertebral scalloping
      • Spade like phalangeal tufts.
      • degenerative enthesopathy
      • periarticular calcification
      • osteoporosis.
    • The most common musculoskeletal complications of acromegaly are premature osteoarthritis and degenerative disk disease .
    • A, Lateral radiograph of the foot in a patient with acromegaly shows soft-tissue thickening of the heel pad. B, Lateral radiograph of the skull in another patient with acromegaly shows enlarged prognathic mandible and enlarged sella turcica ( arrow).
    • AP radiograph of the hand in a patient with arthropathy of acromegaly shows joint-space narrowing and osteophytes involving the 3rd and 4th interphalangeal joints.
    • AP radiograph of the distal phalanx in a 36-year-old man with acromegaly shows spade-like phalangeal tuft with soft-tissue overgrowth.
  • The radiologic differential diagnosis in ACROMEGALY
    • In advanced disease, the combination of soft tissue and bony findings allows accurate diagnosis.
    • Earlier in the disease course, isolated radiologic findings allow some differential considerations.
  • The radiologic differential diagnosis in ACROMEGALY
    • Pachydermoperiostosis
      • Enlarged sinuses, prominent supraorbital ridges, and thickened phalanges.
      • Sella turcica is normal, no joint-space widening. does not occur.
    • Long-term phenytoin therapy- Heel pad thickening
  • RENAL OSTEODYSTROPHY
  • RENAL OSTEODYSTROPHY
    • Bone disease in patients with chronic renal insufficiency.
    • It combines features of rickets, osteomalacia, secondary hyperparathyroidism, and osteoporosis.
    • Aluminum toxicity is an additional component that may be seen in patients undergoing dialysis.
    • In children with chronic renal failure, the findings of rickets dominate , whereas in adults the findings of secondary hyperparathyroidism are more prominent.
  • Radiologic findings in RENAL OSTEODYSTROPHY
    • Combination of the findings of rickets, osteomalacia, secondary hyperparathyroidism, and osteoporosis
    • Periosteal neostosis (lucency between the periosteum and subjacent bone) may be present.
      • It is usually seen in asymmetric distribution in the metatarsals, femur, and pubic rami .
  • The differential diagnosis of RENAL OSTEODYSTROPHY
    • Periosteal neostosis
      • hypertrophic osteoarthropathy, osteomyelitis, or neoplasm.
    • Soft tissue calcification
      • Collagen-vascular diseases, idiopathic tumoral calcinosis, hydroxyapatite crystal deposition disease, and hypervitaminosis D.
  • RENAL OSTEODYSTROPHY
    • The most common complications in patients with renal osteodystrophy are insufficiency fractures .
    • In patients who have had renal transplantation, osteonecrosis, insufficiency fractures, tendinitis, and tendon ruptures are common.
    • Frog-lateral radiograph of the hip in a patient with osteonecrosis of the femoral head shows a characteristic subchondral lucency ( arrow) and collapse of the femoral head.
  • PAGET'S DISEASE
  • PAGET'S DISEASE
    • A common disorder of unknown etiology that is characterized by excessive and abnormal remodeling of bone.
    • Men > women
    • Age > 40 years.
    • Polyostotic > monostotic.
  • PAGET'S DISEASE
    • Asymptomatic.
    • Bone pain, progressive bony enlargement, bowing of long bones, or fractures at presentation.
    • Deafness
      • from cranial-nerve compression at the skull base or from middle-ear ossicle involvement.
    • The spinal cord compressed
      • basilar invagination of the skull or enlargement of the vertebrae.
  • Radiologic findings of PAGET'S DISEASE
    • Epiphyseal involvement with sharply demarcated lysis that advances down the diaphyses is quite specific.
    • Three sequential stages may be seen:
      • Lytic; most common in skull and long bones.
      • Mixed
      • Sclerotic; typically involves the axial skeleton.
    • The hallmarks of advanced Paget's disease are bone enlargement and increased bone sclerosis .
    • Cortical and trabecular thickening and distortion are also frequently present.
  • Radiologic findings of PAGET'S DISEASE
    • Spine
      • M/C in lumbar region: picture-frame vertebra, ivory vertebra, or compression fractures.
    • Skull
      • Lytic phase, or osteoporosis circumscripta , usually begins in the frontal or occipital bones.
      • More advanced disease in the skull manifests a cotton wool appearance of mixed sclerosis and lysis.
    • Pelvis
      • The earliest finding = thickening of the iliopectineal line.
      • Occasionally, patchy areas of lucency and sclerosis.
      • Protrusion deformity of the acetabula is a well-recognized complication of advanced disease of the pelvis.
  • Radiologic findings of PAGET'S DISEASE
    • Long bones
      • Lysis of subarticular bone is seen initially.
      • A wedge of lucency down the diaphyses: flame-shaped or blade-of-grass.
      • In the tibia, the lytic phase occasionally begins in the diaphysis.
      • Advanced disease of the long bones is characterized by coarsened trabecula, bony sclerosis, bony enlargement, and deformity.
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    • A, Frontal radiograph of the pelvis in a patient with advanced Paget's disease shows bony enlargement, bone sclerosis, and trabecular disorganization involving the right femur, right hemipelvis, and sacrum. B, Frontal radiograph of humerus in another patient with advanced Paget's disease shows bony enlargement, cortical and trabecular thickening, and trabecular disorganization.
    • Frontal radiograph of the femur in a patient with advanced Paget's disease shows bowing deformity of the femur along with bony enlargement, bone sclerosis, cortical thickening, and trabecular disorganization.
  • Complications of PAGET'S DISEASE
    • Basilar invagination
    • Spinal stenosis
    • Premature osteoarthritis
    • Insufficiency fractures
    • Osteomyelitis
    • Neoplasms: osteosarcomas.
    • Sarcomatous degeneration: common in patients with widespread disease
    • Frontal radiograph of the pelvis in a patient with widespread Paget's disease shows enlargement and cortical thickening of the pelvis. Additionally, there is an expansile lytic lesion ( arrows) in the ischium, representing malignant degeneration of Paget's disease into fibrosarcoma.
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