Musculoskeletal

Endocrine Bone Disease

Mohamed Zaitoun

Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals

EgyptFINR (Fellowship of Interventional

Neuroradiology)-Switzerlandzaitoun82@gmail.com

Knowing as much as possible about your enemy precedes successful battle

and learning about the disease process precedes successful management

Endocrine Bone Diseasea) Hyperparathyroidismb) Thyroid Acropachyc) Acromegaly

a) Hyperparathyroidism :1-Incidence2-Types3-Radiographic Features

1-Incidence :-Increased levels of parathyroid hormone

(PTH) lead to increased osteoclastic activity

-The resultant bone resorption produces :a) Cortical thinning (subperiosteal

resorption)b) Osteopaenia

2-Types :a) Primary HPT :-Adenoma , 85% (single, 90 %)-Hyperplasia , 12%-Parathyroid carcinoma , 1%-3%b) Secondary HPT :-Most often secondary to renal failurec) Tertiary HPT :-Results from autonomous glandular function after

long-standing renal failure

3-Radiographic Features :1-General osteopenia2-Bone resorption 3-Rogger Jersey Spine4-Brown Tumors5-Salt & Pepper Sign in Skull6-Superior & Inferior Rib Notching7-Findings in secondary (and tertiary)

hyperparathyroidism

1-General osteopenia2-Bone resorption is virtually

pathognomonic: a) Subperiosteal bone resorption :

classically affects the radial aspects of the proximal and middle phalanges of the 2nd and 3rd fingers

b) Phalangeal tufts (Acro-osteolysis)

-N.B. :*Differential Diagnosis of Acro-osteolysis : PINCH FO1-Psoriasis2-Injury (thermal /frostbite)3-Neuropathy (congenital insensitivity to pain, diabetes,

leprosy & myelomeningocele)4-Collagen vascular disease (Scleroderma, Raynaud's)5-Hyperparathyroidism6-Familial 7-Other (Polyvinyl chloride exposure , snake/scorpion

venom)

Subperiosteal resorption

Subperiosteal resorption

Subperiosteal resorption that has resulted in severe tuftal resorption (white arrows) , also note the subperiosteal and intracortical resorption of the middle phalanges (black arrows)

Subperiosteal resorption that has resulted in severe tuftal resorption (arrows)

Acroosteolysis (also subperiosteal resorption)

3-Rugger Jersey Spine :-Sclerotic bands along the superior and

inferior endplates give a striped appearance to the vertebral bodies with a relative band of lucency at the center of each vertebral body

Rugger Jersey Sign

Rugger Jersey Spine

4-Brown Tumors :-Also known as osteitis fibrosa cystica-Can be found anywhere in the skeleton but

especially in the pelvis, jaw and femur-Well-defined purely lytic lesions  

Brown tumor

Brown tumor

Brown tumor

Brown tumors

5-Salt & Pepper Sign in Skull :-Multiple tiny hyperlucent areas in the skull

vault caused by resorption of trabecular bone

Salt & Pepper skull

6-Superior & Inferior Rib Notching :-Rib notching refers to deformation of the

superior or inferior surface of the rib-It can affect single rib (from trauma or

solitary masses e.g. schwannoma) or can affect multiple ribs

a) Superior Rib Notching :1-Abnormal osteoblastic activity :-Osteogenesis imperfecta2-Connective tissue diseases :-Rheumatoid arthritis-Systemic lupus erythematosus (SLE)-Marfan syndrome-Sjogren's syndrome3-Abnormal osteoclastic activity :-Hyperparathyroidism4-Miscellaneous :-Neurofibromatosis type 1-Restrictive lung disease-Poliomyelitis

b) Inferior Rib Notching : (Roesler sign)1-Enlarged collateral vessels :-Coarctation of the aorta-Interrupted aortic arch-Subclavian artery obstruction : Takayasu disease-AVM of the chest wall -SVC obstruction with enlarged venous collaterals-pulmonary AVM2-Neurogenic Tumors :-Schwannoma (usually single)c) Superior & Inferior Rib Notching :-Hyperparathyroidism

Rib Notching in coaractaion of aorta

7-Findings in secondary (and tertiary) hyperparathyroidism :

-Are often associated with the osteosclerosis of renal osteodystrophy, soft tissue calcifications and the osteomalacia of vitamin D deficiency

b) Thyroid Acropachy :1-Incidence2-Radiographic Features

1-Incidence :-One of the extra-thyroidal manifestations of

autoimmune thyroid disease-Occurs in about 1% of patients with Grave’s

Disease-Almost always associated with ophthalmopathy

and  thyroid dermopathy (pretibial myxedema) -May occur after radioactive treatment for

hyperthyroidism

2-Radiographic Features :-Thick periosteal reaction of phalanges and

metacarpals-Soft tissue swelling

Thick wavy periosteal reaction is seen along the shafts of the 1st through 4th metatarsals bilaterally (white circles)

c) Acromegaly :1-Incidence2-Radiographic Features

1-Incidence :-Elevated growth hormone (adenoma,

hyperplasia) results in :*Children (open growth plates) : gigantism*Adults (closed growth plates) : acromegaly

= gradual enlargement of hands and feet and exaggeration of facial features

-It most commonly affects adults in middle age

2-Radiographic Features :a) Skull :-Calvarial thickening, enlarged sinuses and

an enlarged sella turcica-Prognathic jaw

Thickened calvarium with pituitary enlargement

Enlarged sella with double flooring , thickened skull vault , pneumosinus dilatans and prognathism

b) Hands :-Terminal phalangeal tufts become

hypertrophied and have a spade appearance which is called spade phalanx sign

-Joint spaces may be minimally enlarged-Premature osteoarthritis can set in the

advanced stages of acromegaly

Widening of the terminal tufts (between long arrows) , bases of the distal phalanges , thickening of the digit soft tissues (between arrowheads) and widening of the metacarpophalangeal joints (between short arrows)

c) Feet :-Heel pad thickness may be increased

(more than 25 mm)

d) Enlarged pituitary with uptake of gadolinium :

-The MR diagnosis of a pituitary macroadenoma is relatively straightforward

-Dynamic contrast enhanced MR increases the sensitivity to detect microadenomas , which are hypoenhancing as compared to the normal pituitary gland

Pituitary macroadenoma

Pituitary microadenoma