orthopaedics

2. Case
 15 yr old, girl.
 Referred to Dr. Wade for LL deformity &
abnormal gait for the last 5 yrs
 Increasing with time, associated with generalized
bone pain.
 V/S stable … Afebrile.
 CBC: N RP: N Ca: 3,39
 Al. Ph.: 300 PTH: 1092

6. Overview
 Parathyroid glands function
 Maintain serum calcium concentrations
 Regulate bone metabolism.
 PTH secretion stimulated by a fall in the
extracellular calcium concentration
 Hydroxylation of 25-hydroxy-vitamin D at the
proximal convoluted tubule in the kidney
 Increases renal & GI calcium reabsorption.
 Increases bone resorption through stimulation of
osteoclast-activating factors from osteoblasts.

7. Overview
 Calcium
 At parathyroid gland, Binds to the calcium receptor
 PTH secretion and parathyroid cell growth are
inhibited.
 At the kidney, inhibits the 1-hydroxylation of 25-
hydroxy-vitamin D.
 At thyroid C cells, stimulating calcitonin release 
regulate bone resorption.

9. Classification
 Primary hyperparathyroidism
 Oversecretion of PTH due to gland pathology.
 Secondary hyperparathyroidism
 Reaction of the parathyroid glands to a hypocalcaemia
caused by something other than a parathyroid
pathology, e.g. chronic renal failure.
 Tertiary hyperparathyroidism
 Hyperplasia of the parathyroid glands and a loss of
response to serum calcium levels.
 Seen in patients with chronic renal failure and is an
autonomous activity.

10. PTH
Serum Ca
Type
H
H
Primary
H
L / N
Secondary
H/O chronic kidney
failure & 2ry
H
H
Tertiary

11. Radiological Findings
 Plain-film radiography has limited diagnostic
value, especially in the early stages of the disease.
 Normal findings do not rule out
hyperparathyroidism.
 Most of findings on radiographs are not specific.

12. Radiological Findings (1)
 Osteopenia is one of the most common findings
 Fine trabeculations are initially lost, ended with
ground appearance in the trabeculae.

13. Radiological Findings (2)
 Bone resorption:
 Subperiosteal
 Intracortical
 Trabecular
 Endosteal
 Subchondral
 Subligmentous
 Subtendouns

14. Subperiosteal Bone Resorption
 An early and pathognomonic sign.
 Can affect many sites, the most common site is
the middle phalanges of the index and middle
fingers, on the radial aspect.

19. Intracortical Bone Resorption
 Indicator of rapid bone turn over.

20. Trabecular Bone Resorption
 Usually seen in advanced disease.

21. Endosteal Bone Resorption
 Medullary cavity widens with thinning of the
inner cortex.

22. Subchondral Bone Resorption
 Most common in the joints of the axial skeleton.

23. Subligamentous & Subtendinous
Bone Resorption
 At insertion sites on bones.

24. Radiological Findings (3)
 Rugger-jersey spine.
 Ill-defined bands of increased bone density
adjacent to the vertebral endplates
 More common in secondary disease

25. Radiological Findings (4)
 Brown tumors
 Well-circumscribed lytic lesions of bone that
represent the osteoclastic resorption of an area of
bone with fibrous replacement.
 Consist of fibrous tissue, woven bone and supporting
vasculature, but no matrix.
 Single or multiple, present in any site, usually
occur in cortical bone.
 Become sclerotic on radiographs.

31. Radiological Findings (5)
 Abnormal calcification
 Chondrocalcinosis
 Vascular calcification
 Calcified pulmonary nodules
 Cerebral subcortical calcification
 Calcification within the eyes
 Layering of soft-tissue calcification
 Cardiac calcifications
 Breast calcifications
 Renal calcification
 Hepatic calcification

33. Take Home Massage
 Elevated serum Ca levels & PTH levels, diagnosis
of primary hyperparathyroidism is certain.
 Radiologic features of primary
hyperparathyroidism are similar to secondary
form of the disease.
 The most common radiologic finding in primary
hyperparathyroidism is osteopenia
 Radiographic findings of subperiosteal resorption
should prompt consideration of the primary
hyperparathyroidism