Chapter 44 - Metabolic Bone Disease (CHERI Notes) Flashcards
_____ is defined as diminished bone QUANTITY in which the bone is otherwise normal. (p.1067)
OSTEOPOROSIS
_____ term which the bone quantity is normal but the
QUALITY of the bone is abnormal in that it is not
normally mineralized. (p.1067)
OSTEOMALACIA
- results in excess nonmineralized osteoid
It is not possible in most cases to distinguish between
osteoporosis and osteromalacia on plain films; hence
many prefer the term “______” for the plain film finding of diminished mineralization. (p.1067)
OSTEOPENIA
There are myriad causes of osteroporosis; the most common of which is ______ ( the so-called _____). (p._____)
PRIMARY OSTEOPOROSIS
(the so-called SENILE OSTEOPOROSIS or OSTEOPOROSIS
OF AGING)
- This is seen most commonly in post-menopausal women and is a major health concern because of the increase of the vertebal body and hip fractures in this patient population.
______ implies that an underlying disorder; such as thyrotoxicosis or renal disease; has caused the osteoporosis.
(p.1067)
SECONDARY OSTEOPOROSIS
- only about 5% of the cases of osteoporosis are of the secondary type.
- the differential for presumed osteoporosis would have to include the causes of osteomalacia.
The main radiographic finding in osteoporosis is
______ . (p.1067)
THINNING OF THE CORTEX
Although OSTEOPOROSIS; can be seen in any bone;
it is most reliably demonstrated in the ____. (p.1067)
SECOND METACARPAL AT THE MID-DIAPHYSIS
The normal metacarpal cortical thickening should be
approximately ________. (p.1067)
ONE-FOURTH TO ONE-THIRD THE THICKNESS OF THE
METACARPAL
- In OSTEOPOROSIS; this cortical thickness is decreased
- the metacarpal cortex (and all bony cortices; for that matter) decreases in thickness normally with age and is thinner in females than in males of the same age.
TRUE OR FALSE.
Exercise and proper diet seem to help delay the onset
of primary osteoporosis. (p.1067)
TRUE
- calcium additives have not been shown to reverse the
process of primary osteoporosis. - Estrogen clearly plays a role in alleviating postmenopausal
osteoporosis; yet its use in a widespread manner is somewhat
controversial.
A type of osteoporosis that can be seen in a patient
of any age is ______. (p.1067)
DISUSE OSTEROPOROSIS
- it results from immobilization from any cause; most commonly following the treatment of a fracture
- the radiographic appearance of disuse osteoporosis is different from primary osteoporosis is that it occurs somewhat more rapidly and
gives the bone a patchy apperance. - this is from osteoclastic resorption in the cortex causing intracortical holes
- if allowed to continue with disuse; the bone would resemble any bone with marked osteoporosis; that is; severe cortical thinning.
Occasionally; aggressive osteoporosis from disuse can mimic a permeative lesion such as a _____ or ____ because of the
multiple cortical holes that project over the medullary space; thus resembling a MEDULLARY PERMEATIVE PROCESS. (p.1067)
EWING SARCOMA or MULTIPLE MYELOMA
The way to differentiate a true intramedullary permeative process from an intracortical process such as osteoporosis is ____. (p.1067)
TO OBSERVE THE CORTEX AND SEE WHETHER IT IS SOLID OR RIDDLED WITH HOLES
If the cortex is solid; one can assume the ____ PROCESS is emanating from the medullary space. (p.1067)
PERMEATIVE process
If the cortex has multiple holes; assume the permeative pattern is from the _____ process. (p.1069)
CORTICAL process
Two ways a HEMANGIOMA will cause cortical holes. (p.1069)
- from FOCAL HYPEREMIA causing focal osteoporosis
2. by the BLOOD VESSELS themselves tunneling through the cortex.
TRUE OR FALSE?
Radiation can cause cortical holes in bone and mimic a permeative pattern because of the death of cortical osteocytes; which can result in large lacunae in the cortex. (p.1069)
TRUE
- the cortical holes from radiation can be large; in which case they would not be confused with a true permeative process; but they can also be small and resemble an aggressive lesion.
Give 6 differential diagnosIs for permeative bone lesions
usually an aggressive process). (p.1069
- EWING SARCOMA
- INFECTION
- EOSINOPHILIC GRANULOMA in a young person (<30 years of age)
- MULTIPLE MYELOMA
- METASTATIC CARCINOMATOSIS
- PRIMARY LYMPHOMA OF BONE IN AN OLDER PATIENT
Give 3 differential diagnosis for a pseudopermeative pattern (permeative pattern resulting from cortical holes; less sinister).
(p.1069)
- AGGRESSIVE OSTEROPOROSIS
- HEMANGIOMA
- RADIATION CHANGES
___ is the result of too much nonmineralized osteoid. (p.1070)
OSTEOMALACIA
- radiographic findings are almost identical to those of osteroporosis; and for most part; the two disorders are indistinguishable.
Most common cause of OSTEOMALACIA? (p.1070)
RENAL OSTEODYSTROPHY
The only finding pathognomonic for OSTEROMALACIA is a _____. (p.1070)
LOOSER FRACTURE
- a fracture through the large osteoid seams
- extremely uncommon; but tend to occur in the femur; pelvis and scapula.
In children; OSTEOMALACIA is called ____. (p.1070)
RICKETS
- it causes the epiphyses to become flared and irregular and the long bones to undergo bending from the bone softening.
- as in adults; the most common cause is RENAL DISEASE; although other causes such as biliary disease and dietary insufficiencies are occasionally seen.
____ occurs from excess parathyroid hormone.(p.1071)
HYPERPARATHYROIDISM
- Parathyroid hormone causes osteoclastic resorption in bone; which leads to osteoporosis and osteomalacia.
____ is caused by parathyroid adenomas and hyperplasia.
p. 1071
PRIMARY HYPERPARATHYROIDISM
- up to 40% of patients with primary HPT will demonstrate skeletal abnormalities radiographically.
The most common cause of HPT is from ____; which leads to secondary HPT. (p.1071)
RENAL DISEASE
______ is the result of the parathyroids secreting excess PTH in response to the hypocalcemia that occurs. (p.1071)
SECONDARY HYPERPARATHYROIDISM
The radiographic sign that is pathognomonic for HPT is
____. (p.1071)
SUBPERIOSTEAL BONE RESORPTION
- it is most commonly seen on the RADIAL ASPECT OF THE MIDDLE PHALANGES OF THE HAND; but it can be seen in any long bone in the body.
- it is commonly seen on the medial aspect of the proximal tibia; at the sacroiliac joints and in the distal clavicle.
Other radiographic findings of HPT often involves the spine in a manner resembling the stripes on rugby jerseys; hence; the name “______”. (p.1071)
RUGGER JERSEY SPINE
______ are cystic lesions that are often expansile and aggressive in appearance. (p.1071)
BROWN TUMORS
In place of the metabolic bone survey; it is now recommended that ____ be obtained to look for subperiosteal resorption
(in diagnosing HYPERPARATHYROIDISM). (p.1072)
PLAIN FILMS OF THE HANDS
- a radionuclide bone scan can be obtained in selected cases; which will show increased radionuclide uptake by brown tumors and Looser fractures.
- also; investigation of causes of hypercalcemia; which can be caused by metastatic disease or metabolic bone disease; should include a
bone scan.
____ occurs because of a deficiency of the parathyroid glands to secrete normal amounts of PTH. (p.1072)
HYPOPARATHYROIDISM
-the calvarium on occasion will show thickening; and calcification in the basal ganglia of the brain has been described.
_______ is caused by a congenital failure of tissues to respond to PTH. (p.1072)
PSEUDOHYPOPARATHYROIDISM
- parathyroid glands are normal in these cases
- treating these patients with PTH is of no help because the problem lies in the end organs; not the parathyroid glands.
- CHARACTERISTIC APPEARANCE:
obesity; round facies; short stature and brachydactyly. - the tubular hands of the hands and feet are often all short.
In _____; there is no parathyroid abnormality and no end-organ problem; these patients merely resemble patients with pseudohypoparathyroidism. (p. 1072)
PSEUDOPSEUDOHYPOPARATHYROIDISM
MATCHING TYPE:
I. HYPOparathyroidism
II. PSEUDOhypoparathyroidism
III. PSEUDOPSEUDOhypoparathyroidism
A. Parathyroid gland problem
B. End-organ problem
C. Mimicker of pseudohypoparathyroidism morphologically (p.1072)
I. - A.
II. - B.
III. - C.
A secreting adenoma or hyperplasia of the anterior lobe of the pituitary gland will result in accelerated bone growth.
A. If it occurs BEFORE the epiphyses close;
it causes ____.
B. If it occurs AFTER the epiphyses are closed;
the result is ___. (p.1072)
A. GIANTISM
B. ACROMEGALY
Thickening if the heel pad adjacent to the calcaneus has been used as a sign of _____. (p. 1072)
ACROMEGALY
- skull film invariably shows calvarial thickening;enlarged sinuses; and an enlarged sella turcica
- jaw is prognathic
- the terminal tufts of the distal phalanges become hypertrophied and have a so-called SPADE APPEARANCE (an appearance not unlike a spade or shovel)
- the joint spaces are occasionally minimally enlarged because of hypertrophy of the hyaline articular cartilage
- early degenerative joint disease ensues because the cartilage itself is abnormal
A rare manifestation of hyperthyroidism in adults is ______. (p.1073)
- a characteristic appearing periostitis occurs in the metacarpals and phalanges of the hands and feet.
THYROID ACROPACHY
- this occurs only after prior thyroidectomy and the cause is unknown.
- In children; hyperthyroidism can result in increased skeletal maturation; however this is seldom marked.
A useful differential point that can be used to tell thyroid acropachy from other causes of diffuse periostitis. (p.1073)
INVOLVEMENT OF THE ULNAR ASPECT OF THE 5TH METACARPAL
Decreased thyroid secretion or ____; results in delayed skeletal maturation in children. (p. 1073)
CRETINISM
- delay in ossification of epiphyseal centers with occasional appearance of “stippled” epiphyses is seen
- a delay in epiphyseal closure also occurs; in some instances with failure of epiphyseal closure noted in the third and fourth decade.
The radiographic finding of DIFFUSE INCREASED BONE DENSITY; _____ is somewhat uncommon.(p.1073)
OSTEOSCLEROSIS
Mnemonic AID for DIFFUSE OSTEOSCLEROSIS
differentials: (p.1073)
“Regular Sex Makes Occasional Perversions Much
More Pleasurable And Fantastic”
Identify them. (10)
- Renal osteodystrophy
- Sickle cell disease
- Myelofibrosis
- Osteopetrosis
- Pyknodysostosis
- Metastatic carcinoma
- Mastocytosis
- Paget disease
- Athletes
- Fluorosis
____ is by far the most common disease in which osteosclerosis is seen. (p. 1073-1074)
RENAL DISEASE
Most common presentation of RENAL OSTEODYSTROPHY is ___. (p.1074)
OSTEOPENIA
- about 10% to 20% of the patients with renal osteodystrophy will exhibit osteosclerosis
the sine quanon of renal osteodystrophy is ______.; seen earliest and most reliably at the radial aspect of the middle phalanges of the hands. (p. 1074)
SUBPERIOSTEAL BONE RESORPTION
Aside from dense bones; what other two additional signs are due to SICKLE CELL DISEASE in the bone? (p.1074)
- Bone infarcts
- Step-off deformities of the vertebral body endplates
- these are also called “FISH” vertebrae after their appearance like the vertebrae found in fish.
- avascular necrosis of the hip is frequently an accompanying finding.
Also called AGNOGENIC MYELOID METAPLASIA; ____ is a disease caused by progressive fibrosis of the marrow in patients older than 50 years of age. (p. 1074)
MYELOFIBROSIS
- leads to anemia with marked splenomegaly and extramedullary hematopoiesis
Whenever osteosclerosis is seen in the a patient older thatn 50 years of age; a search should be made for a ____ and ____. (p. 1074)
LARGE SPLEEN and EXTRAMEDULLARY HEMATOPOIESIS
A hereditary abnormality that results in extremely dense bones throughout the skeleton. (p. 1074)
OSTEOPETROSIS
- CONGENITA FORM
- occurs at birth and can be lethal
- TARDA FORM
- is seen in older children and adults has milder clinical problems.
A characteristic finding in OSTEOPETROSIS often seen in the vertebral bodies in which the vertebae have a small replica of the vertebral body inside the normal one. (p. 1075)
BONE-IN-BONE APPEARANCE
Also a characteristic finding in OSTEOPETROSIS in which the endplates are densely sclerotic; giving the appearance of a sandwich. (p.1075)
SANDWICH VERTEBRAE
- resembles a rugger jersey spine but can be differentiated by being much denser and more sharply defined
The distinguishing radiographic finding that is essentially pathognomonic for PYKNODYSOSTOSIS is ______. (p.1075)
ACROOSTEOLYSIS WITH SCLEROSIS
*** The distal phalanges often have the appearance of chalk that has been put into a pencil sharpener: they are pointed and dense.
Another name for PYKNODYSOSTOSIS? (p.1075)
TOULOUSE-LAUTREC SYNDROME
- named from the famous artist who was afflicted with pyknodysostosis
_____ is a characteristis skin lesion found in patients with mastocytosis. (p. 1076)
URTICARIA PIGMENTOSA
Paget disease classically causes bony enlargement; which most commonly occurs in the ___. (p.1077)
PELVIS
- the iliopectineal line on the pelvic brim must be thickened if Paget disease is present.
- it can occur in any bone in the body; including the smaller bones of the hands and feet.
Enumerate the 3 distinct phases of Paget Disease (p.1077)
- Lytic phase
- Sclerotic phase
- Mixed lytic-sclerotic phase
Phase of Paget disease which often has a sharp leading edge called a flame-shaped or blade-of-grass leading edge. (p.1077)
LYTIC PHASE
In a long bone; with the sole exception being the tibia; Paget Disease always starts at the ____. (p.1077)
END OF THE BONE
- therefore if a lesion is present in the middle of a long bone and does not extend to either end; one can safely exclude Paget Disease
TRUE OR FALSE?
Plain film radiographs of professional athletes quite often demonstrate increased cortical thickness and apparent diffuse osteosclerosis to the point of appearing pathologic. (p.1077)
TRUE
- increased stress causes hypertrophy of bone as well as muscle.
