Test #4 Flashcards
Normal bone density & structure depends on what?
Normally functioning bone cells in adequate numbers
Normal endocrine balance
Normal nerve & stress timulators
Adequate dietary intake, normal intestinal absorption, & urinary excretion of vit. D, Ca, & P
At what age approx. does bone mass begin to decline?
35 yrs old
What % of bone loss occurs per decade in males? females?
3%; 8%
How can normal progressive bone atrophy be modified?
Anabolic gonadal hormones
Adrenal gluco-corticoids
Diet, exercise, heredity
Most metabolic, endocrine & nutritional disorders are charac. radiographically by what?
Increased bone production (osteosclerosis)
Increased bone resorption (osteopenia)
Inadequate bone mineralization w/ equilibrium in rate of resorption & production
What % of bone loss is required to see loss of density on xray?
30%
How thick should the cortex be compared to the overall diameter of the midpoint of a normal bone?
Cortical thickness should be roughly 1/2 the overall diameter of midpoint of a given bone
What bone is frequently used for the cortical thickness measurement to obtain an index of bone mass?
2nd or 3rd metacarpal
Increased radiolucency of bone or poverty of bone
Osteopenia
What are the M/C causes of osteopenia?
Osteoporosis
Osteomalacia (increase of uncalcified osteoid)
Hyperparathyroidism
Infiltrative diseases
M/C causes of diminished bone density in the vertebrae
Involutional osteoporosis Steroid effect (Cushing's Syndrome) Multiple Myeloma Hyperparathyroidism Leukemia Hemoglobinopathies Osteomalacia
What are the M/C causes of loss of bone density in children?
Leukemia Steroid therapy Cushing's syndrome Osteogenesis imperfecta tarda Idiopathetic juvenile osteopororsis Still's disease Thyrotoxicosis Liver disease Turner's syndrome Paralysis
A skeletal condition in which the quantity of bone is decreased in amount but is normal in composition (quality). Freq. assoc. w/ structural failure
Osteoporosis
What is the M/C encountered metabolic disease of bone?
Osteoporosis
Type of osteoporosis that involves the major portion of the skeleton especially the axial components
Generalized osteoporosis
Type of osteoporosis that is confined to an area or segment of hte body i.e. a limb (Sudecks Atrophy)
Regional osteoporosis
Type of osteoporosis that is a focal loss of bone density involving a small portion of a bone. Examples include tumors & arthritis.
Localized osteoporosis
M/C causes of generalized osteoporosis
Senescent (senile)
Postmenopausal
(AKA Involutional osteoporosis)
Involutional osteoporosis (Senile/postmenopausal) may result from what?
Osteoblastic inactivity & excessive bone resorption
Lack of gonadal hormones necessary for osteoblastic activity
Deficiency of proteins
Inadequate diet & activity
What is the M/C complaint assoc. w/ generalized osteoporosis?
Back pain
What are the most freq. complications which precipitate pain & disability assoc. w/ osteoporosis?
Fxs of the vert. bodies, hips, wrists, ribs, pubic rami, humerus, sacrum
Decrease in height secondary to decrease in vertebral body height producing a kyphosis & spinal rigidity
What are lab features assoc. w/ osteoporosis?
Serum Ca & Alk Phos are normal
Urinary hydroxyproline levels may be elevated
Iatrogenic osteoporosis includes what types?
Heparin-induced osteoporosis
Dilantin-induced osteoporosis
Steroid-induced osteoporosis
What are the radiographic hallmarks of generalized osteoporosis?
Increased radiolucency (osteopenia)
Cortical thinning
Altered trabeculae patterns
What type of hormones are believed to inhibit osteoclastic activity?
Estrogens
What sign is assoc. w/ cortical thinning?
“Pencil thin cortex”
What appearance is assoc. w/ altered trabecular patterns?
pseudohemangiomatous appearance
What major group of trabeculae in the prox. femur is the major weight-bearing group & last to be obliterated in osteoporosis?
Principle compressive group
This major group of trabeculae is near the lesser trochanter, curves up & lat. towards the greater trochanter & neck
Secondary compressive group
This major group of trabeculae in the prox. femur originates from lat. cortex inf. to greater trochanter, extending in an arc-like fashion medially, terminating at the inf. portion of the femoral head.
Principle tensile group
What is formed by the confluence of the trabeculae groups in the prox. femur?
Ward’s triangle
Where is the M/C place to see fragility fxs assoc. w/ osteoporosis?
the spine
This is characterized by a loss of both ant. & pos. vert. body height. Seen rarely & should suggest a more serious etiology i.e. multiple myeloma, metastatic disease
Vertebral Plana (pancaked or flattened)
M/C presentation of fragility fxs especially in the thoracic region. Can lead to thoracic kyphosis “Dowager’s hump”
Wedged vertebra
This is central depression of the endplates producing an exagerated concavity. Pressure by the nucleus on the weakened bone. IVD space is usually normal in height.
Biconcave vertebra
Localized discal herniations through the endplates. Usually smaller & more irregular margins than those of juvenile onset.
Schmorl’s Nodes (Cartiliaginous nodes)
Schmorl’s nodes are M/C’ly seen in what spinal regions?
Thoracic & upper lumbars
What are the most freq. sites of fx deformity?
Pubic rami
Prox. femur
What sign is assoc. w/ osteoporotic pelvic fxs?
Honda sign
What are features of acute fxs assoc. w/? osteoporosis?
Demonstrate an increase in density beneath the endplate.
May be present up to 8-10 wks post fx
Offset at ant. cortex (abrupt & angular) “Step sign”
May see displaced paraspinal lines secondary to edema
What are features of healed fxs assoc. w/ osteoporosis/
Freq. demonstrate assoc. degenerative changes
No step sign, paraspinal edema or increased density
What are AKAs for regional osteoporosis?
Reflex Sympathetic Dystrophy Syndrome (RSDS) Sudeck's Atrophy Causalgia Posttraumatic osteoporosis Complex regional pain syndrome
Characterized by acute onset of painful regional osteoporosis usually following trivial antecedent trauma
Reflex Sympathetic Dystrophy Syndrome (RSDS)
What age & gender are M/C’ly affected by RSDS?
equal sex distribution after age 50
What are the M/C sites affected by RSDS?
Hands
Shoulders
What are radiographic manifestations of RSDS?
Bone appears mottled secondary to accelerated bone resorption
Periarticular osteoporosis (similar to RA)
Joint spaces maintained
Not bilateral
What are the M/C causes of RSDS?
Immobilization of traumatic injuries
Motor paralysis
Inflammatory lesions
What are radiographic manifestations of RSDS?
Changes begin to appear after 7-10 days of immobilization
Changes are most prominent after 2-3 months
Patterns of bone loss include; uniform, spotty, bands, cortical lamination or scalloping
This describes osteoporosis that occurs suddenly & is reversible, affecting periarticular bones & no known etiology
Transient regional osteoporosis
What are 2 main disorders assoc. w/ transient regional osteoporosis?
Transient osteoporosis of the hip
Regional migratory osteoporosis
Who is affected by transient osteoporosis of the hip?
Males 20-40 & pregnant females (usually the L hip)
What are clinical features of transient osteoporosis of the hip?
Sudden onset of hip pain, antalgia, & limp
Self-limiting, up to 1 year
Marked osteoporosis of the femoral head, less severe in neck & acetabulum
What are features of regional migratory osteoporosis?
Males M/C affected
Usually lower extremity
Localized, regressing, migratory osteoporosis
Condition of the skeleton characterized by the accumulation of increased amounts of uncalcified osteoid
Osteomalacia AKA adult rickets
What are the main factors assoc. w/ osteomalacia?
Calcium, phosphorus, & Vit. D metabolism
What disorders are assoc. w/ osteomalacia?
Deficiencies
Absorption disorders
Gastric bypass
Renal disorders
What are clinical manifestations of osteomalacia?
Muscular weakness & bone pain Tenderness on palpation Pt may demonstrate a waddling gait Bowing deformities Symptoms related to underlying disease
What are lab manifestations of osteomalacia?
Biochemical studies are not constant
Ca & P levels typically are slightly decreased or normal
Parathormone, alkaline phosphatase & hydroxyproline are often elevated
What are radiographic manifestations of osteomalacia?
Loss of bone density d/t increased amounts of uncalcified osteoid
Coarsened trabeculae pattern
Thinning & lack of cortical definition
What 2 features differentiates osteomalacia from osteoporosis?
Bowing deformities
Pseudofractures
What are types of bowing deformities assoc. w/ osteomalacia?
Inf. displacement of sacrum (Triradiate pelvis)
Med. displacement of acetabulum (protrusio acetabulae)
Bowing of tib/fib
Kyphoscoliosis & increased endplate concavity
Bell-shaped thorax
What are AKAs for pseudofractures?
Increment fxs
Looser’s lines
Milkman syndrome
Umbau zonen
What are features of pseudofractures assoc. w/ osteomalacia?
Linear radiolucenies occurring bilaterally & symmetrically
Seen on concave side of bone (Paget’s is on convex side)
What are the M/C locations to see pseudofractures assoc. w/ osteomalacia?
Axillary margin of scapula Femoral necks & shafts Pubis & ischial rami Ulna Ribs Clavicle
This is a systemic disease of infancy & childhood in which the calcification in growing skeletal elements is deficient
Rickets
What are the 3 main causes of rickets?
Vit. D deficiency rickets Renal osteodystrophy (Renal rickets) Renal Tubular Defect rickets (Fanconi syndrome)
When does Vit D rickets usually develop?
6 months -1 year
What are clinical manifestations of rickets?
Softening of skull bones
Craniotabs may be present
Frontal or parietal bossing may occur
Soft tissue swelling about the growth plates is common
Increased irritability, weakness, delayed development
Delayed closure of fontanels
What is the name of the sign assoc. w/ rickets when ribs show enlargement at the costochondral junction?
Rachitic rosary
What are lab findings assoc. w/ rickets?
Serum alkaline phosphatase is elevated
Serum calcium is normal to slightly decreased
Serum phosphorous is slightly decreased
What radiographic features are unique to rickets vs. osteomalacia?
Widening of the physis
Absence of the zone of provisional calcification
Widened, frayed, & cupped metaphyseal margins (paint-brush metaphysis)
AKA as Barlow’s Disease. Results from chronic deficiency of Vit. C. Found in infants fed on pasteurized or boiled milk formulas which destroys the Vit. C content
Scurvy
What age group is M/C affected by scurvy?
6 month-2 year
What is the clinical hallmark of scurvy?
Tendency towards spontaneous hemorrhage d/t capillary fragility
What are clinical manifestations of scurvy?
Progressive irritability
Legs are tender & edematous (Frog position)
Subcutaneous & mucous membrane hemorrhages occur
Bulging at the costochondral junction
Widening & increased density at the zone of provisional calcification assoc. w/ scurvy is called what?
White line of Frankel
Bony protuberances which occur at the metaphyseal margins & extend at right angles to the shaft assoc. w/ scurvy. D/t ossification at the periosteal attachment
Pelkin spurs
A radiolucent band located beneath the ZOPC. Separation at this point can occur leading to displacement of the epiphysis & plate. Assoc. w/ scurvy.
Trummerfeld zone (AKA Scorbutic zone, Zone of debris)
Irregularity at the metaphyseal margins. Freq. occurs secondary to infractions of the metaphyseal/epiphyseal junction. Assoc. w/ scurvy
Corner sign
The peripheral margins of the epiphysis appears dense while the central portion is more radiolucent. Assoc. w/ scurvy
Wimberger’s sign (Ring epiphysis)
A condition in which overactivity of the parathyroid gland exists w/ a resultant increase in the levels of parathormone (PTH)
Hyperparathyroidism
What are the causes of primary hyperparathyroidism?
Parathyroid adenoma Parathyroid hyperlplasia Parathyroid carcinoma Non-parathyroid tumors which produce a PTH-like substance MENS
Type of hyperparathyroidism that is the response of the gland to chronic hypocalcemia, usually renal glomerular disease by means of a negative feedback
Secondary hyperparathyroidism
Type of hyperparathyroidism that is caused by lack of regulatory efforts of serum calcium following prolonged stimulation as in renal dialysis
Tertiary hyperparathyroidism
In hyperparathyroidism, absorbed bone is replaced by what?
Fibrous tissue (osteitis fibrosa cystica)
In hyperparathyroidism, what is occasionally found in fibrous tissue overgrowth that replaces bone matrix?
Cysts & brown tumors
What is the pathologic hallmark of hyperparathyroidism?
Subperiosteal bone resorption of the outer cortex at the insertion points of ligaments & tendons
What age/gender is M/C’ly affected by hyperparathyroidism?
Females 30-50 yrs of age
What are clinical manifestations of hyperparathyroidism?
Symptoms caused by bone disease, hypercalcemia, & renal disease
75% of pts w/ hyperparathyroidism have what other disease?
Renal disease
What lab values are only increased in primary hyperparathyroidism?
Serum Ca
Urine Ca & P
What are major radiographic features of hyperparathyroidism?
Osteopenia Accentuated trabecular pattern Subperiosteal bone resorption Loss of cortical definition Brown tumors
What is the radiographic hallmark of hyperparathyroidism?
Subperiosteal bone resorption
Where are the earliest changes seen radiographically w/ hyperparathyroidism?
Radial margins of the middle & prox. phalanges of the hand (2nd & 3rd), distal clavicle, & medial aspect of the upper 1/3rd of the tibia. Also inner aspects of the inner femur & humerus
In hyperparathyroidism, subarticular reabsorption causes widening of what joints?
AC joint
Symphysis pubis
SI joint
What radiographic sign is seen in the skull w/ hyperparathyroidism?
Salt & pepper skull
What sign is seen radiographically w/ hyperparathyroidism in the spine?
Rugger-jersey sign (M/C in secondary form)
M/C locations for brown tumors?
Mandible
Pelvis
Ribs
Femors
What is the M/C soft tissue changes in primary hyperparathyroidism?
Chondrocalcinosis
What is the M/C soft tissue changes in secondary parahyperthyroidism?
Periarticular soft tissues may exhibit calcification
Type of calcification that occurs in devitalized tissue?
Dystrophic calcification
Type of calcification that occurs w/ abnormal calcium metabolism?
Metastatic calcification
The result of excess pituitary somatrophic growth hormone from the eosinophilic cells of the ant. pituitary gland.
Acromegaly
What is the difference b/w acromegaly & giantism?
Acromegaly occurs after closure of the epiphyseal plates
Giantism occurs before closure of epiphyseal plates
What is the M/C cause of acromegaly?
Pituitary eosinophilic adenoma
What is the large mandible assoc. w/ acromegaly called?
Lantern jaw
What other conditions are assoc. w/ acromegaly?
Diabetes
Hyperthyroidism
What skin changes are seen w/ acromegaly?
Increase thickness of the soft tissues of the hands & feet
Heel pad measurement >20mm
What are radiographic signs are seen in the skull assoc. w/ acromegaly?
Enlargement of the sella turcica
Enlargement of the paranasal sinuses & mastoids
Thickening of the frontal bone & occiput
Enlarged mandible (lantern jaw)
What are radiographic signs are seen in the hands & feet assoc. w/ acromegaly?
Terminal tufts show a “spade-like” configuration
Shafts of phalanges & metacarpals b/c widened
Generalized increase of joint space d/t cartilage overgrowth
What are the 2 main radiographic signs seen in the spine assoc. w/ acromegaly?
Platyspondylia (increased dimensions of vertebra)
Pos. body scalloping
