DI 2 Final (Nutritional, Metabolic, Endocrine & Hematologic)

Question 1

List the three presentations/types of osteoporosis.

Answer 1

Generalized
Risks:
Age related
Post menopausal
Steroid and heparin induced
Multiple myeloma
Metastasis
Hyperparathyroidism
Scurvy 
Osteomalacia
Rickets
Sickle cell anemia
Osteogenesis imperfect

Regional – dt disuse, immobilization, RSD (reflex sympathetic dystrophy)

Localized – dt infx, inflammatory arthritis, neoplasm

Question 2

What is the most common cause of generalized osteoporosis?

Answer 2

Increasing age

Question 3

What is the standard imaging modality to quantify bone mineral density?

Answer 3

DEXA

Question 4

What causes rickets and osteomalacia?

Answer 4

Osteomalacia – lack of osteoid mineralization leading to generalized bone softening, bones lack a proper amount of calcium

Rickets (Osteomalacia in kids) – systemic skeletal disorder dt
deficiency primarily of vit D

Question 5

What are the classic radiographic features of rickets?

Answer 5

Osteopenia (Generalized)
Rachitic rosary (costal) 
Frayed “paintbrush” and cupped metaphyses
Coarse trabecular changes
Widened growth plates
Absent zone of provisional calcification

Question 6

What causes scurvy and what are the classic radiographic features?

Answer 6

Scurvy: Caused by Vit C deficiency
(depressed intercellular substance formation, especially in connective tissue, cartilage and bone)

1. Abnormalities occurring at the growing ends of long bones
2. Osteoporosis
3. Dense zone of provisional calcification (White Line of Frankel)
4. Ring Epiphysis (Limburger’s sign)
5. Pelken’s spurs
6. Scorbutic zone (Trummerfeld zone)
7. Subperiosteal hemorrhages

Question 7

What are the classic radiographic features of hyperparathyroidism in the spine, skull, and hand?

Answer 7

Hand:
1. Radial margins of the proximal and middle phalanges of the 2nd and 3rd digits with ACROOSTEOLYSIS

2. Subperiosteal resorption (hallmark feature) (below)
   White line of FRANKEL and LIMBURGER’S SIGN & TRUMMERFELD ZONE

Skull:
“salt and pepper”
resorption of lamina dura

Spine:
“Rugby jersey” spine
Osteopenia
Trabecular accentuation
End plate concavities
widened SI joints

Question 8

What are the face, skull, and foot changes seen with acromegaly?

Answer 8

ACROMEGALY is due to pituitary eosinophilic adenoma secreting growth hormone after the growth plates have fused-> excessive production of growth hormone prior to the closure of the long bone growth centers will manifest as gigantism

Face
Prominent forehead
Thickened tongue

Skull
Sella turcica enlargement (dt pituitary neoplasm)
Sinus overgrowth
Malocclusion
Widened mandibular angle (prognathism)

Foot
Heel pad greater than 20 mm (approx. 1 inch)

Question 9

What osseous changes might long term corticosteroids cause?

Answer 9

Cushing’s dz and Steroid-Induced Osteonecrosis are both caused by the presence of excessive quantities of glucocorticoid steroids released by the adrenal cortex

A. Osteoporosis of Cushing’s Disease:

1. Cortices are thinned, density diminished and deformities evident
2. Biconcave end plate configurations (this differentiates from old age osteoporosis)

B. Osteonecrosis/Avascular Necrosis
1. Seen in femoral and humeral heads, distal femora (knee) and talus
2. Ischemic Necrosis- “Intravertebral vacuum cleft sign” – D/T collapse of a vertebral body following steroid medication from ischemic necrosis
(looks like a compression fx with wedging anteriorly and vacuum of air inside vertebral body)

Question 10

The “H”-shaped vertebra is classically seen in what condition?

Answer 10

Sickle Cell Anemia
(caused by osteoporosis of vertebral bodies – deformed at end plates with central depression due to hypoplasia of central portion of vertebrae)

Question 11

What are some complications to the skeleton secondary to sickle cell anemia?

Answer 11

1. Osteomyelitis and AVN: Staph aureus and salmonella
2. Vertebral body collapse
3. (PMEH) Posterior Mediastinal ExtraMedullary Hematopoiesis

Question 12

Which anemia tends to result in “honeycomb” trabecular patterns?

Answer 12

Thalassemia

Question 13

Hemophilic arthropathy typically occurs in which joints?

Answer 13

Knee, ankle, elbow (bilateral and symmetrical) – all weight bearing joints

Knee will show enlarged epiphyses, widened intercondylar notch, squared inferior patella

Ankle may show tibiotalar slant deformity

Pseudotumors – destructive intraosseous hemorrhages – most commonly occur in femur and pelvis

Question 14

What is a common differential diagnosis when encountering hemophilic arthropathy of the knee (hint: think childhood arthritis)?

Answer 14

Juvenile Rheumatoid Arthritis

Question 15

List some common sites for avascular necrosis/osteonecrosis.

Answer 15

Femoral head, epiphyses, humoral head, knees, neck of the talus, waist of scaphoid

Question 16

List 5 typical causes of avascular necrosis/osteonecrosis.

Answer 16

post traumatic, corticosteroid use, caison’s disease, pancreatitis, post-surgical, collagen disease, radiation, alcoholism, gout