This document discusses osteopenia and its potential underlying causes including osteoporosis, osteomalacia, rickets, hyperparathyroidism, renal osteodystrophy, scurvy, and marrow replacement. It provides definitions, etiologies, and radiographic findings for each condition. Key radiographic signs mentioned include osteopenia, cortical thinning, Looser zones, metaphyseal cupping and fraying, bowing deformities, and subperiosteal resorption. The document aims to help understand these disease processes and their musculoskeletal manifestations on imaging.

1. Musculoskeletal
Osteopenia

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Osteopenia
-Osteopenia is a nonspecific radiographic finding that
indicates increased radiolucency of bone
-Types :
1-Osteoporosis : decreased amount of normal bone
2-Osteomalacia : decreased bone mineralization
3-Rickets
4-Hyperparathyroidism : increased bone resorption
5-Renal Osteodystrophy
6-Scurvy
7-Marrow replacement : bone replaced by tumor , marrow
hyperplasia or metabolic products

7. 1-Osteoporosis :
-Decreased amount of normal bone
-Types :
a) Primary : most common
-Unassociated with an underlying illness
-Type I osteoporosis : postmenopausal
-Type II osteoporosis : senile
-Idiopathic juvenile osteoporosis

9. b) Secondary : less common
1-Endocrine disorders :
-Hypogonadism
-Hyperthyroidism
-Cushing's disease
-Acromegaly
2-Nutritional :
-Malabsorption syndrome
-Alcoholism
-Scurvy

10. 3-Hereditary metabolic or collagen
disorder :
-Osteogenesis imperfecta
-Marfan syndrome
-Ehlers-Danlos syndrome
4-Drugs :
-Heparin
-Exogenous steroids

11. -Radiographic Findings :
*Osteopenia : 30%-50% of bone has to be lost to
be detectable by plain film
*Diminution of cortical thickness
*Decrease in number and thickness of trabeculae
in bone
*Empty box vertebra : apparent increased density
of vertebral endplates due to resorption of
spongy bone
*Vertebral body compression fractures : wedge ,
biconcave codfish bodies , true compression
*Pathologic fractures

12. Osteopenia

13. Severe osteoporosis with multiple vertebral crush fractures

15. Fish vertebra (biconcave end plates involving the superior
and inferior end plate of a vertebral body)

16. 2-Osteomalacia :
a) Definition
b) Etiology
c) Radiographic Features

17. a) Definition :
-Abnormal mineralization of bone is termed osteomalacia in
adults and rickets in children
b) Etiology :
1-Nutritional deficiency of :
-Vitamin D
-Calcium
-Phosphorus
2-Absorption abnormalities :
-GI surgery
-Malabsorption
-Biliary disease

18. 3-Renal :
-Chronic renal failure
-Renal tubular acidosis
-Proximal tubular lesions
-Dialysis induced
4-Abnormal vitamin D metabolism :
-Liver diseases
-Hereditary metabolic disorders
5-Drugs :
-Phenytoin
-Phenobarbital

19. c) Radiographic Features :
-Generalized osteopenia
-Looser zones :
*Also known as cortical infarctions, are wide transverse
lucencies traversing bone usually at right angles to the
involved cortex
*Locations :
1-Pubic rami
2-Medial proximal femur
3-Lateral scapula
4-Posterior proximal ulna
5-Ribs
-Milkman's syndrome : osteomalacia with many Looser's
zones

20. Looser's zones in the inferior femoral neck

22. Looser zones

23. Osteopenic changes involving bony pelvis and proximal femurs ,
multiple pseudofractures / lossers's zones are seen involving
superior and inferior pubic rami bilaterally

24. 3-Rickets :
a) Incidence
b) Etiology
c) Radiographic Features
d) Differential Diagnosis

25. a) Incidence :
-Refers to osteomalacia in the pediatric
population that occurs prior to fusion of the
growth plate

26. b) Etiology :
-Vitamin D deficiency causes failure of mineralization of
bone and cartilage (in adults this is termed
osteomalacia)
-Causes of Vitamin D deficiency include :
1-GI tract :
-Nutritional deficiency (common)
-Absorption abnormalities
2-Skin disease
3-Liver disease
4-Renal :
-Renal tubular acidosis
-Renal failure (loss of calcium)

27. c) Radiographic Features :
1-Growth plate abnormalities (especially
long bones) :
-A widened growth plate is due to rickets
until proved otherwise
-Cupping of metaphysis
-Disorganized (frayed) metaphysis

28. Metaphyseal cupping and fraying in the distal radius and
ulna in rickets

29. Cupping and fraying of the metaphyseal region

30. Severe fraying of the metaphysis

31. Severe metaphyseal changes involving the distal femurs and proximal
tibias and fibulas , note the pronounced demineralization of the
epiphyseal ossification centers

35. Bowing of the femurs , metaphyseal cupping and fraying ,
coarsening of the trabecular pattern , increase in distance between end of
shaft and epiphyseal center, poorly ossified epiphyseal centers

36. 2-Bowing deformities of bones
3-Delayed closing of fontanelles
4-Softening of cranial vault (craniotabes)
5-Rachitic rosary : expansion of the anterior
rib ends at the costochondral junctions

37. Bowing of the legs caused by loading

39. Rachitic rosary

40. Rachitic rosary

41. Rachitic rosary

42. d) Differential Diagnosis :
-Leg bowing in children :
1-Developmental or congenital bowing
2-Blount disease
3-Osteogenesis imperfecta
-Widening of the growth plate :
1-Scurvy
2-Delayed maturation due to illness
-Flaring of the metaphysis :
1-Anaemia
2-Fibrous dysplasia
3-Storage diseases
4-Chronic lead poisoning
5-Bone dysplasia

43. 4-Hyperparathyroidism :
-See endocrine bone diseases

44. 5-Renal Osteodystrophy :
a) Incidence
b) Radiographic Features

45. a) Incidence :
-Refers to musculoskeletal abnormalities
that occur in patients with chronic renal
failure due to concurrent and
superimposed :
1-Osteomalacia (adults)/ rickets (children) :
2-
Secondary hyperparathyroidism (abnormal
calcium and phosphate metabolism)
3-Aluminum intoxication, e.g. if the patient is
on dialysis

46. b) Radiographic Features :
1-Changes of osteomalacia : See osteomalacia
-Osteopenia and cortical thinning
-Looser's zones occur but are uncommon
2-Changes of hyperparathyroidism : See HPT
-Subperiosteal resorption (e.g., SI joint resorption)
-Rugger jersey spine
-Brown tumors
-Osteosclerosis
-Soft tissue calcification
-Chondrocalcinosis

47. 6-Scurvy :
a) Incidence
b) Radiographic Features

48. a) Incidence :
-Rare
-Deficiency of vitamin C (ascorbic acid)
impairs the ability of connective tissue to
produce collagen
-Never occurs before 6 months of age
because maternal stores are transmitted
to fetus

49. b) Radiographic Features :
-Generalized osteopaenia
-cortical thinning, pencil-point cortex
-Periosteal reaction : due to subperiosteal
hemorrhage
-Scorbutic rosary : expansion of the costochondral
junctions, similar to the rachitic rosary
appearance is seen in rickets
-Dense metaphyseal line (Frankel)
-Wimberger's sign : dense epiphyseal rim (ring
epiphysis)
-Corner sign : metaphyseal fractures (Pelkan
spurs)

53. 7-Marrow Replacement :
a) Bone replaced by tumor :
1-Myeloma
2-Leukemia / Lymphoma
3-Metastases (small cell tumors)
4-Myelofibrosis
b) Marrow hyperplasia or metabolic products