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