A 15-year-old girl presented with lower limb deformity and abnormal gait for 5 years. Laboratory tests found elevated calcium and PTH levels, indicating primary hyperparathyroidism. Primary hyperparathyroidism causes oversecretion of PTH by the parathyroid glands, leading to increased bone resorption and osteopenia on radiographs. Characteristic findings include subperiosteal bone resorption, especially of the fingers, though findings are nonspecific. While imaging has limited diagnostic value, subperiosteal resorption suggests primary hyperparathyroidism.

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