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Sir William Osler (1849-1919)
The Osler Institute
Excellence in Continuing Medical Education
Radiology Review Course Notes
Disc 1
Disc 2
Disc 3
Disc 4
Disc 5
Copyright 2008, The Osler Institute. All Rights Reserved.
Sir William Osler (1849-1919)
The Osler Institute
Excellence in Continuing Medical Education
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.
Metabolic and Endocrine Disorders
Sandor A. Joffe, M.D.Attending Radiologist
Beth Israel Medical Center, NY
Metabolic and EndocrineDiseases Affecting Bone
◆ Osteoporosis◆ Vitamin D Disorders
– Rickets– Osteomalacia
◆ Parathyroid Disorders– Hyperparathyroidism– Renal Osteodystrophy– Hypoparathyroidism– Pseudohypoparathyroidism– Pseudopseudohypoparathyroidism
Metabolic and EndocrineDiseases Affecting Bone
◆ Pituitary Disorders– Acromegaly, gigantism, hypopituitarism
◆ Thyroid Disorders– Hyperthryoidism, thyroid acropachy,
hypothyroidism◆ Other Disorders
– Cushing syndrome, diabetes mellitus, complications of pregnancy, Paget disease
Terminology◆ Osteopenia
– “Poverty of bone”– Best radiographic term
◆ Osteoporosis– Qualitatively normal bone– Quantitatively deficient bone
◆ Osteomalacia– Inadequately mineralized bone matrix (osteoid)
Osteoporosis◆ Most common metabolic bone
disease◆ Distribution–Generalized–Regional–Localized
Age Related Osteoporosis(senescent or postmenopausal)
◆ 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
Differential Diagnosis ofGeneralized Osteoporosis
◆ Osteomalacia–Rickets in children with metaphyseal
changes– In adults, indistinct trabeculae and
looser zones◆ Hyperparathyroidism–Subperiosteal resorption
Regional Osteoporosis◆ Immobilization or disuse◆ Reflex sympathetic dystrophy
(RSD)◆ Transient regional osteoporosis–Transient osteoporosis of the hip–Regional migratory osteoporosis
Osteoporosis of Immobilizationand Disuse
◆ Begins 2-3 months after immobilization◆ Usually subsides within 1-2 years
(sooner with mobilization)◆ High bone turnover
– ↑↑ resorption– ↑ or ↓ formation
◆ Loss of calcium◆ Mainly in appendicular skeleton
Osteoporosis of Immobilizationand Disuse
◆ 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
Reflex Sympathetic Dystrophy◆ Sudeck’s atrophy, shoulder-hand syndrome◆ Due to a variety of conditions, classically minor
trauma◆ Pathogenesis is unknown but may be related to
spinal reflexes◆ Most common in shoulder and hand◆ Stiffness, pain, tenderness, weakness, swelling◆ Variable duration, may be irreversible
Reflex Sympathetic Dystrophy◆ X-ray findings–Soft tissue swelling–Regional osteoporosis, especially
periarticular–No erosions or joint space narrowing
◆ Bone scan– Increased periarticular activity
Spinal Changes of Osteoporosis◆ Osteopenia (increased radiolucency
of bone)◆ Thinning or loss of trabeculae–Particularly horizontal trabeculae–Relative prominence of vertical
trabeculae may mimic hemangioma
Spinal Changes of Osteoporosis◆ 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
Spinal Changes of Osteoporosis◆ Changes in vertebral body shape–Wedge-shaped–Biconcave (“fish vertebrae”)» Seen in other metabolic disorders
(osteomalacia, HPT)–Compression
Osteoporosis in Cortex ofTubular Bones
◆ Endosteal resorption– Scalloped inner margin– Cortical thinning
◆ Intracortical resorption (seen with moderate to rapid bone turnover)– Longitudinal linear radiolucent striations
◆ Subperiosteal resorption (seen with rapid bone turnover)– Irregularity of outer margin
Osteoporosis in Spongiosa ofTubular Bones
◆ Subchondral bone (common in RSD, immobilization)– Linear, band-like, or spotty radiolucencies
◆ Metaphysis– Band-like radiolucencies
◆ Diffuse (common in senile osteoporosis)– Homogeneous or spotty radiolucencies
Other Findings in Osteoporosis◆ Fractures–Vertebral bodies, proximal femur,
distal radius, proximal humerus◆ Insufficiency fractures–Pelvis, sacrum, femoral neck, tibia,
sternum
Rickets and Osteomalacia◆ Rickets– Interruption in development and
mineralization of growth plate◆ Osteomalacia– Inadequate or delayed mineralization
of osteoid in mature cortical bone
X-Ray Findings of Rickets◆ Most prominent in areas of high
growth–Costochondral junction, distal femur,
proximal humerus, proximal and distal tibia, and distal ulna and radius
◆ Widening of growth plate (deficient mineralization)
X-Ray Findings of Rickets◆ Widening and cupping of metaphysis
(disorganized zone of maturation)◆ Loss of sharp epiphyseal margin◆ Periarticular swelling◆ Rachitic rosary◆ Bowing of long bones (displacement of
epiphyses due to weak growth plate)
X-Ray Findings of Osteomalacia◆ Osteopenia (loss of trabeculae)◆ Unsharp trabecular margins
(inadequately mineralized osteoid)◆ Cortical lucencies
X-Ray Findings of Osteomalacia◆ 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