The Osler
                                       Institute
                                   Excellence in Continuing Med...
The Osler
                                         Institute
                                     Excellence in Continuing...
Metabolic and
Endocrine Disorders
   Sandor A. Joffe, M.D.
      Attending Radiologist
  Beth Israel Medical Center, NY
Metabolic and Endocrine
Diseases Affecting Bone
   x   Osteoporosis
   x   Vitamin D Disorders
       – Rickets
       – O...
Metabolic and Endocrine
Diseases Affecting Bone
  x   Pituitary Disorders
      –   Acromegaly, gigantism, hypopituitarism...
Terminology
  x   Osteopenia
      – “Poverty of bone”
      – Best radiographic term

  x   Osteoporosis
      – Qualitat...
Osteoporosis
  x Most common metabolic bone
    disease
  x Distribution

      – Generalized
      – Regional
      – Loc...
Age Related Osteoporosis
(senescent or postmenopausal)
  x   Gradual loss of bone mass
      –   Men
           »   Begins...
Differential Diagnosis of
Generalized Osteoporosis
  x   Osteomalacia
      – Rickets   in children with metaphyseal
     ...
Regional Osteoporosis
  x Immobilization or disuse
  x Reflex sympathetic dystrophy

    (RSD)
  x Transient regional oste...
Osteoporosis of Immobilization
and Disuse
 x   Begins 2-3 months after immobilization
 x   Usually subsides within 1-2 yea...
Osteoporosis of Immobilization
and Disuse
  x   X-ray findings (may mimic
      malignancy)
      – Uniform   osteoporosis...
Reflex Sympathetic Dystrophy
  x   Sudeck’s atrophy, shoulder-hand syndrome
  x   Due to a variety of conditions, classica...
Reflex Sympathetic Dystrophy
  x   X-ray findings
      – Softtissue swelling
      – Regional osteoporosis, especially
  ...
Spinal Changes of Osteoporosis
  x Osteopenia (increased radiolucency
    of bone)
  x Thinning or loss of trabeculae

   ...
Spinal Changes of Osteoporosis
  x   Changes in vertebral body shape
      – Cartilaginous   (Schmorl’s) nodes
        » D...
Spinal Changes of Osteoporosis
  x   Changes in vertebral body shape
      – Wedge-shaped
      – Biconcave     (“fish ver...
Osteoporosis in Cortex of
Tubular Bones
  x   Endosteal resorption
      – Scalloped inner margin
      – Cortical thinnin...
Osteoporosis in Spongiosa of
Tubular Bones
  x   Subchondral bone (common in RSD,
      immobilization)
      –   Linear, ...
Other Findings in Osteoporosis
  x   Fractures
      – Vertebral bodies, proximal femur,
       distal radius, proximal hu...
Rickets and Osteomalacia
  x   Rickets
      – Interruptionin development and
       mineralization of growth plate
  x   ...
X-Ray Findings of Rickets
  x   Most prominent in areas of high
      growth
      – Costochondral   junction, distal femu...
X-Ray Findings of Rickets
  x   Widening and cupping of metaphysis
      (disorganized zone of maturation)
  x   Loss of s...
X-Ray Findings of Osteomalacia
  x Osteopenia (loss of trabeculae)
  x Unsharp trabecular margins

    (inadequately miner...
X-Ray Findings of Osteomalacia
  x   Pseudofractures (Looser zones)
      – Lucencies with sclerotic margins perpendicular...
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  1. 1. The Osler Institute Excellence in Continuing Medical Education Sir William Osler (1849-1919) Radiology Review Course Notes Disc 1 Disc 2 Disc 3 Disc 4 Disc 5 Copyright 2008, The Osler Institute. All Rights Reserved.
  2. 2. The Osler Institute Excellence in Continuing Medical Education Sir William Osler (1849-1919) Radiology Disc 1 Notes Metabolic and Endocrine Disease Articular Disorders Bone Trauma Bone and Soft Tissue Tumors Questions and Answers Overview of Cardiac Cardiac Applications Interventional Radiology Copyright 2008, The Osler Institute. All Rights Reserved.
  3. 3. Metabolic and Endocrine Disorders Sandor A. Joffe, M.D. Attending Radiologist Beth Israel Medical Center, NY
  4. 4. Metabolic and Endocrine Diseases Affecting Bone x Osteoporosis x Vitamin D Disorders – Rickets – Osteomalacia x Parathyroid Disorders – Hyperparathyroidism – Renal Osteodystrophy – Hypoparathyroidism – Pseudohypoparathyroidism – Pseudopseudohypoparathyroidism
  5. 5. Metabolic and Endocrine Diseases Affecting Bone x Pituitary Disorders – Acromegaly, gigantism, hypopituitarism x Thyroid Disorders – Hyperthryoidism, thyroid acropachy, hypothyroidism x Other Disorders – Cushing syndrome, diabetes mellitus, complications of pregnancy, Paget disease
  6. 6. Terminology x Osteopenia – “Poverty of bone” – Best radiographic term x Osteoporosis – Qualitatively normal bone – Quantitatively deficient bone x Osteomalacia – Inadequately mineralized bone matrix (osteoid)
  7. 7. Osteoporosis x Most common metabolic bone disease x Distribution – Generalized – Regional – Localized
  8. 8. Age Related Osteoporosis (senescent or postmenopausal) x Gradual loss of bone mass – Men » Begins in 5th-6th decade » 0.4%/year – Women » Begins in 4th decade » 0.75-1.0%/year » 2-3%/year after menopause – Related to estrogen deficiency
  9. 9. Differential Diagnosis of Generalized Osteoporosis x Osteomalacia – Rickets in children with metaphyseal changes – In adults, indistinct trabeculae and looser zones x Hyperparathyroidism – Subperiosteal resorption
  10. 10. Regional Osteoporosis x Immobilization or disuse x Reflex sympathetic dystrophy (RSD) x Transient regional osteoporosis – Transientosteoporosis of the hip – Regional migratory osteoporosis
  11. 11. Osteoporosis of Immobilization and Disuse x Begins 2-3 months after immobilization x Usually subsides within 1-2 years (sooner with mobilization) x High bone turnover – ↑↑ resorption – ↑ or ↓ formation x Loss of calcium x Mainly in appendicular skeleton
  12. 12. Osteoporosis of Immobilization and Disuse x X-ray findings (may mimic malignancy) – Uniform osteoporosis (most common) – Speckled or spotty osteoporosis (especially periarticular) – Band-like osteoporosis (subchondral, metaphyseal) – Cortical lamellation or scalloping
  13. 13. Reflex Sympathetic Dystrophy x Sudeck’s atrophy, shoulder-hand syndrome x Due to a variety of conditions, classically minor trauma x Pathogenesis is unknown but may be related to spinal reflexes x Most common in shoulder and hand x Stiffness, pain, tenderness, weakness, swelling x Variable duration, may be irreversible
  14. 14. Reflex Sympathetic Dystrophy x X-ray findings – Softtissue swelling – Regional osteoporosis, especially periarticular – No erosions or joint space narrowing x Bone scan – Increased periarticular activity
  15. 15. Spinal Changes of Osteoporosis x Osteopenia (increased radiolucency of bone) x Thinning or loss of trabeculae – Particularlyhorizontal trabeculae – Relative prominence of vertical trabeculae may mimic hemangioma
  16. 16. Spinal Changes of Osteoporosis x Changes in vertebral body shape – Cartilaginous (Schmorl’s) nodes » Disc herniation into the vertebral body » Due to weakness of cartilaginous endplate or subchondral bone » Surrounding sclerosis
  17. 17. Spinal Changes of Osteoporosis x Changes in vertebral body shape – Wedge-shaped – Biconcave (“fish vertebrae”) » Seen in other metabolic disorders (osteomalacia, HPT) – Compression
  18. 18. Osteoporosis in Cortex of Tubular Bones x Endosteal resorption – Scalloped inner margin – Cortical thinning x Intracortical resorption (seen with moderate to rapid bone turnover) – Longitudinal linear radiolucent striations x Subperiosteal resorption (seen with rapid bone turnover) – Irregularity of outer margin
  19. 19. Osteoporosis in Spongiosa of Tubular Bones x Subchondral bone (common in RSD, immobilization) – Linear, band-like, or spotty radiolucencies x Metaphysis – Band-like radiolucencies x Diffuse (common in senile osteoporosis) – Homogeneous or spotty radiolucencies
  20. 20. Other Findings in Osteoporosis x Fractures – Vertebral bodies, proximal femur, distal radius, proximal humerus x Insufficiency fractures – Pelvis, sacrum, femoral neck, tibia, sternum
  21. 21. Rickets and Osteomalacia x Rickets – Interruptionin development and mineralization of growth plate x Osteomalacia – Inadequate or delayed mineralization of osteoid in mature cortical bone
  22. 22. X-Ray Findings of Rickets x Most prominent in areas of high growth – Costochondral junction, distal femur, proximal humerus, proximal and distal tibia, and distal ulna and radius x Widening of growth plate (deficient mineralization)
  23. 23. X-Ray Findings of Rickets x Widening and cupping of metaphysis (disorganized zone of maturation) x Loss of sharp epiphyseal margin x Periarticular swelling x Rachitic rosary x Bowing of long bones (displacement of epiphyses due to weak growth plate)
  24. 24. X-Ray Findings of Osteomalacia x Osteopenia (loss of trabeculae) x Unsharp trabecular margins (inadequately mineralized osteoid) x Cortical lucencies
  25. 25. X-Ray Findings of Osteomalacia x Pseudofractures (Looser zones) – Lucencies with sclerotic margins perpendicular to cortex (inadequately mineralized osteoid) – Do not extend across entire bone – Scapula, ribs, pubic rami, medial proximal femora, posterior proximal ulnae – Bilaterally symmetric – May fracture

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