Di Imaging 1 FINAL

What is transient osteoporosis of the hip?

NEED MRI TO MAKE DIAGNOSIS

young to middle aged adults

onset of sudden pain, antalgia and limp

usually bilateral in men and left hip in women

What are the radiographic findings of transient osteoporosis of the hip?

periarticular osteoporosis

joint space normal

fracture may occur

“HOT ON BONE SCAN”

decreased T1 and increased T2 marrow edema

What is osteomalacia?

altered bone quality

lack of calcium salts deposited

What are the two main causes of osteomalacia?

Vitamin D metabolism

Kidney disease

Rickets is childhood _

osteomalacia

How is vitamin D metabolized?

vitamin D hydroxylated by kidney as needed to form the active form 1,25 D

malnutrition, malabsorption, renal disease can all lead to osteomalacia or rickets

What is rickets?

osteopenia

coarsened trabeculation

LOOSER ZONES→ pseudofractures, horizontal osteoid seams (MILKMAN SYNDROME)

DEFORMITIES→ extremities

bone biopsy is the best diagnostic procedure

What is seen with osteomalacia?

osteopenia

coarsened trabeculation

looser’s zones→ linear regions of unmineralized osteoid

bone softening deformities

basilar invagination

acetabular protrusion

What are some features of rickets?

systemic disease of infant and young children

childhood osteomalacia

deficiencies of vitamin D, calcium, or phosphate

decreased quantity of normal calcified osteoid

What is some clinical presentations of rickets?

muscle tetany

soft tissue swelling around growth plates due to hypertrophied cartilage

calcium and phosphorus levels normal to low

elevated alkaline phosphatase

What are some causes of rickets?

1. Inadequate intake of vitamin D

2. inadequate UV exposure

3. malabsorption

4. kidney disease

5. anticonvulsants

What is seen radiographically with Rickets?

1. WIDENED, BULKY PHYSEAL PLATES AND IRREGULARITY (FRAYING)

2. SPLAYING (CUPPING) OF THE WEAKENED BONE at junction of metaphysis and epiphysis

3. RACHITIC ROSARY of chest due to cartilage overgrowth and metaphyseal splaying

4. PAINTBRUSH METAPHYSIS

What is scruvy?

barlow’s disease

long term deficiency of vitamin C

primarily involves infants

manifested by spontaneous hemorrhage due to capillary fragility

cutaneous petechiae, bleeding gums, hematuria

OFTEN MISTAKEN FOR CHILD ABUSE

low serum ascorbic acid levels

Vitamin C is essential for _

formation of intercellular substances such as collagen

What are radiological features of scurvy?

1. Dense zone of provisional calcification (WHITE LINE OF FRANKEL) due to delayed conversion to bone

2. Beak like metaphyseal outgrowths (PELKEN’S SPURS) extend at right angles to the shaft

3. radiodense sclerosis around epiphysis, radiolucent centrally (WIMBERGER’S RING SIGN)

4. SUBPERIOSTEAL HEMORRHAGE

What is hyperparathyroidism?

overactivity of the parathyroid gland causing overexpression of PTH

PTH is strong osteoclastic hormone→ breakdown of matrix

What are the types of hyperparathyroidism?

Primary→ parathyroid gland adenoma

Secondary→ RENAL OSTEODYSTROPHY→ chronic renal disease and hemodialysis

Tertiary→ patients who are secondary and on dialysis can develop pituitary hyperplasia that causes overexpression

Hyperparathyroid findings and chronic renal disease would result in what type of hyperparathyroidism?

secondary hyperparathyroidism

What is the MC type of hyperparathyroidism?

Primary HPT

What is primary HPT?

MC type

MC cause of hypercalcemia

parathyroid adenoma 90% of time

What is secondary HPT?

complication of chronic renal disease

persist loss of calcium and resorption of phosphorus

What are the clinical features of HPT?

30-50 year old women

bone pain, fractures, weakness, lethargy, polydispia, polyuria

Hypercalcemia leads to muscle weakness, renal stones, pancreatitis

Hypercalcemia in PRIMARY

What is the phrase to remember the clinical features of HPT?

stones, bones, abdominal groans and psychiatric moans

1. renal stones

2. hypercalcemia and bone lesions

3. peptic ulcers and pancreatitis

4. confusion, lethargy, weakness

What are the radiographic features of HPT?

osteopenia

SUBPERIOSTEAL RESORPTION

RADIAL ASPECT OF THE MIDDLE AND PROXIMAL PHALANGES OF THE 2ND AND 3RD FINGER

distal tuft resorption

brown tumors

osteitis fibrosa cystica→ loves proximal humerus

What is the most definitive radiographic sign of HPT?

subperiosteal resorption MC at the radial margins middle and proximal phalanges of the 2nd and 3rd digits

What MC to cause resorption of distal clavicle?

hyperparathyroidism

What are signs of HPT in axial skeleton?

Osteosclerosis→ Rugger jersey spine

subperiosteal resorption at SI joints

(SALT AND PEPPER SKULL)

Rugger jersey spine is where?

sub endplates (sclerosis)

What is the worm like appearance on the sacrum? BONUS QUESTION

LIPPES LOOP

What is a brown tumor?

feature of HPT

geographic lytic lesion containing osteoclasts and mononuclear cells

hemosiderin from hemorrhage produces the grossly brown color

soft tissue calcifications with HPT indicate _

secondary over primary

Anterior pituitary produces what?

1. GH

2. ACTH

3. TSH

4. FSH/LH

5. Prolactin

Posterior pituitary has what hormones?

1. ADH

2. Oxytocin

25% of the US population have _

small pituitary adenomas

What are the two types of adenomas?

1. Macroadenoma→ increased sella turcica size

2. Microadenoma

Pituitary tumors cause what symptoms?

1. Headaches

2. Visual disturbances as the tumor compresses optic chiasm

What is the normal size of sell turcica?

16×12mm

What can be the causes of enlarged sella turcica?

1. Empty sella

2. tumor

3. normal variant

4. aneurysm

What is the primary way to diagnose a pituitary tumor?

MRI

What is acromegaly and gigantism?

pituitary adenoma secreting Growth hormone

PROMINENT IN THE HANDS AND FEET

What is acromegaly?

large extremities

oversecretion of GH from pituitary adenoma occurring after the closure of open growth centers

What are the skull radiographic findings of acromegaly?

1. soft tissue thickening

2. coarse facial features

3. malocclusion

4. protruding jaw with malocclusion

5. prominent forehead→ FRONTAL BOSSING

6. enlarged sella turcica

What are extremity radiographic features of acromegaly?

“spade-like” distal tufts

hooking osteophytes

widened shaft

Positive ulnar deviation can cause _

TFCC degeneration

ulnar abutment impaction of lunate

Negative ulnar variance can cause _

lunate avascular necrosis

Heel pad thickness that is greater than 23mm can indicate _

acromegaly

What is gigantism?

onset of GH over secretion occurs prior to skeletal maturation

What is hypercortisolism?

disease caused by increased production of cortisol or by excessive use of cortisol or other steroid hormones

What are causes of cushings?

MC exogenous corticosteroid administration

increased in patients requiring immunosuppression

What is cushings?

endogenous over secretion by pituitary adrenocorticotropic hormone ACTH

adrenal cortex adenoma

ectopic ACTH secreting tumor

What are some symptoms of cushing’s syndrome?

patient is obese

accelerated hair growth

BUFFALO HUMP

PURPLE STRIAE ON ABDOMEN

VERTEBRA AND RIB FRACTURE→ cortisol causes more osteoclastic activity

What are some clinical features of cushing’s syndrome?

MOON FACIES

BUFFALO HUMP TORSO

ABDOMINAL STRIAE

back pain secondary to compression fracture

easy bleeding

What are radiographic features of cushings?

1. osteopenia

2. compression fractures

3. avascular necrosis

4. atherosclerotic plaquing

History of type 2 diabetes and a buffalo hump can indicate _

cushing’s syndrome

What is skeletal dysplasia?

faulty develeopment

genetic mutations, inherited and congenital

What is achondroplasia?

MC congenital dwarfing

marked by hypochondroplasia→ lack of cartilage development

normal life expectance and mental status

marked rhizomelic micromelia→ short hip and shoulders

Achondroplasia can have an early death due to _

1. sleep apnea

2. foramen magnum stenosis

What are the clinical things seen with achondroplasia?

1. long bones are shortened

2. protuberant abdomen

3. characteristic “trident hands”

4. narrowing of spinal canal, small foramen magnum

What are radiographic findings with achondroplasia?

1. narrow broad pelvic inlet→ CHAMPAGNE GLASS

2. broad ilia, ribs, and sternum

3. metaphyseal cupping (splayed appearance)

4. TOMBSTONE PELVIS due to squaring of the iliac wings

What are imaging findings in spine for achondroplasia?

Dural ectasia (MRI)

posterior scalloping

short pedicles

rounded “bullet” vertebrae

horizontal sacrum

If fibular is taller than tibia then you may suspect _

achondroplasia

What is imaging findings in skull for achondroplasia?

macrocephaly (large skull)

frontal bossing

foramen magnum stenosis

Achondroplasia is associated with _

Arnold-chiari malformation

What is trident hand?

short metatarsals

What is cleidocranial dysplasia?

defect of intramembranous bone growth

skull, clavicle and midline defects

widened/underdeveloped pubic symphysis

What are imaging findings of cleidocranial dysplasia?

skull→ inverted “pear” shape and wormian bone

clavicles→ hypoplasia

drooping shoulders

What is marfan’s syndrome?

collagen disorder fails to produce normal collagen connective tissue disorder

tall stature, arachnodactlyly, heart valve defects, aortic aneurysm

spontaneous lung collapse

What is arachnodactyly?

abnormally long fingers and toes

positive thumb sign→ entire thumbnail protrudes beyond ulnar border of hand

positive wrist sign→ thumb and 5th finger overlap when encircling the wrist

Majority of adults with marfan’s syndrome have _

aortic dilation and if untreated can lead to aortic dissection (pectus excavatum)

What is osteogenesis imperfecta?

“brittle bone disease”

inherited disorder marked by abnormal Type 1 collagen formation

What are the four major clinical criteria for osteogenesis imperfecta?

1. Skeletal fragility

2. Blue sclera

3. Abnormal dentition

4. premature ostosclerosis→ deafness

What is found on imaging with osteogenesis imperfecta?

osteopenia

bowed long bones

thin cortices

multiple fractures

often confused with child abuse

zebra stripes are associated with _

osteogenesis imperfecta→ bisphosphonate therapy

What is osteopetrosis?

group of entities, representing a type of sclerosing bone disease

decreased osteoclastic activity

What are imaging findings for osteopetrosis?

loss of medullary space

hypoplasia of frontal sinuses

BONE WITHIN A BONE OR ENDOBONE

SANDWICH VERTEBRAE

ERLENMEYER FLASK DEFORMITY

“Marble bone” refers to _

osteopetrosis→ super bright with dark center of vertebrae

What are the seropositive arthritis?

1. RA

2. JCA

3. SLE

4. Scleroderma

5. Jaccouds

What are the seronegative arthritisis?

1. AS

2. Enteropathic

3. Psoriatic

4. Reactive

What are the key features of RA?

Marginal erosions→ erosion of ulnar styloid

soft tissue swelling symmetrical joint space loss

“Rat bite” erosions

MC at MCP and PIP and ulnar styloid

boutinnere deformity→ flex PIP

swan neck deformity→ extend PIP

Baker cyst in the knee

odontoid erosions→ evaluate ADI

What is key things for JCA?

under 16 years old

polyarticular MC

females

bone shortening

periostitis

growth plates

ballooning of epiphysis

hemophilia→ male

fusion of carpals

tower vertebrae

What are key points with SLE?

malar rash

non erosive changes

+ANA

females

kidney involvement

ulnar deviation at fingers (MCP)

hand MC location

AVN bilaterallly

What are key points of scleroderma?

esophagus problems

systemic sclerosis

males 30-50 years old

raynauds

tight skin and pursed lips and flex fingers at PIP

acrolysis and calcium deposits

CREST

+ANA

DIP joints gone

What are key things with Jaccouds?

SLE with history of rheumatoid fever or strep→ MITRAL VALVE DISEASE

What are key points about ankylosing spondylitis?

HLA-B27+

begins in thoracics and lumbars

males

synovial inflammation and pannus

SI AND SPINE

SACROILITIS→ bilateral and symmetrical

MARGINAL SYNDESMOPHYTES

pain worse in AM and not better in 30 minutes

DAGGER SIGN

BAMBOO SPINE

RAILROAD TRACK

SHINY CORNER

ROMANUS LESION

WHISKERING

What are key points of enteropathic arthritis?

marginal syndesmophytes

sacroiliitis→ bilateral and symmetrical

AS WTIH BOWEL ISSUES

What are key points of psoriatic arthritis?

DIP joints

hand

sacroilitis→ asymmetrical

nonmarginal syndesmophytes

psoriasis→ scaly rash

MOUSE EARS

ACRO-OSTEOLYSIS

SAUSAGE DIGITS

NAIL BED PROBLEMS

What are key points of reactive arthritis?

Reiter’s arthritis

foot

sacroiliitis→ asymmetrical

cant see, pee, dance with me

males

chlamydia

lover’s heel

swollen achillis

keratoderma

What is osteitis condensans Ilii?

MIMICS AS

sclerosis in SI joints

seen in postpartum females

stress reaction

What are key points of multiple myeloma?

rain drop skull

primary malignancy of bone

over 40 years old

What are the types of spondylolisthesis?

Type 1→ congenital→ SBO at L5/C1

Type 2→ isthmic

Type 2a→ Pars defect at L5 Mc in kid athletes

Type 3→ degenerative at L4

Type 4→ post traumatic→ hangmans fracture at C2

Type 5→ patholigcal

Type 6→ iatrogenic