Midterm BP3 Flashcards
Osteoporosis Three types:
Generalized, regional, localized.
Osteoporosis Generalized:
Generalized: Age related, post- menopausal, steroid induced, heparin induced, multiple myeloma, metastasis, hyperparathyroidism, scurvy, osteomalcia, rickets, sickle cell anemia, osteogenesis imperfecta, etc.
Osteoporosis Regional:
Regional:disuse/immobilization,RSD
OP localized:
Localized: infection, inflammatory arthritis, neoplasm
Definition of Osteoporosis
A disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk.
Senile/Post-Menopausal Osteoporosis
GENERAL CONSIDERATIONS=
Increasing age results in generalized osteoporosis of the entire skeleton.
Senile/Post-Menopausal Osteoporosis CLINICAL FEATURES=
• Presentation is typically in the 5th and 6th decades.
• F>M, 4:1.
• Osteoporosis usually only causes pain when
complicated by fracture and deformity, especially in the spine.
• No laboratory findings are useful.
Osteoporotic-related Fractures Stats=
1.3+ million fractures annually
• ~ 500,000 – 750,000 spine
• ~ 250,000 hip
• ~ 240,000 wrist
Up to ___ per cent of elderly people with hip fracture die within 6 months of injury
30%
Senile/Post-Menopausal Osteoporosis
PATHOLOGICAL FEATURES=
- Pathogenesis is unknown.
- Bone quality is normal but deficient in its amount.
- Resorption of cortical and medullary bone results in a thinned cortex and trabecular accentuation.
Senile/Post-Menopausal Osteoporosis
RADIOLOGICAL FEATURES=
• Increased bony radiolucency, cortical thinning, and altered trabecular patterns are the major signs.
Spine changes include accentuated vertical trabeculae “pseudo- hemangiomatous” appearance, “pencil” thin cortices and endplates, and general radiolucency.
Senile/Post-Menopausal Osteoporosis
What dz has Plana -“Pancake” vertebra=
Senile/Post-Menopausal Osteoporosis
-Need to differentiate from serious etiology especially metastatic carcinoma & multiple myeloma.
What dz has Wedged -Trapezoidal shape vertebra=
Senile/Post-Menopausal Osteoporosis
-Also present in traumatic compression fractures of spine.
What dz has BiconcaveEndPlates-“Fish”,”Codfish”, or “Hourglass” vertebra.
Senile/Post-Menopausal Osteoporosis
-May see at multiple contiguous levels.
What dz has Isolated End Plate Infraction
Senile/Post-Menopausal Osteoporosis
- Often only depicted in a single view (oblique).
What dz has Schmorl’s Nodes?
Senile/Post-Menopausal Osteoporosis
-localized intrabody discal herniations.
• Most common in thoracic and upper lumbars.
Pseudohemangiomatous appearance of osteoporosis occurs in advanced cases of _______.
Senile/Post-Menopausal Osteoporosis
Senile/Post-Menopausal Osteoporosis
• PELVIS AND FEMORA=
- Additionally prone to fractures in the pubic rami and femoral neck.
- Principal compressive group of trabeculae in the femur is the last to be obliterated.
Proximal Femora Stress Lines=
#1-PRINCIPAL COMPRESSIVE GROUP #2- PRINCIPAL TENSILE GROUP #3-SECONDARY COMPRESSIVE GROUP #4W - WARD'S TRIANGLE
Senile/Post-Menopausal Osteoporosis most common other associated fractures involve the _____.
distal radius (COLLES’ fracture), humeral neck, and ankle malleoli.
Senile/Post-Menopausal Osteoporosis Insufficiency fractures:
sacrum(H/I/arc), pubis, medial femoral necks, tibia/fibula, calcaneus, metatarsals
Quantify bone mineral and fracture risk assessment with _____.
• DXA (DEXA) (dual energy x-ray absorptiometry)
Dual Energy X-ray Absorptiometry
Advantages=
- Considered gold standard
- Hip/spine/wrist measurements • Low radiation exposure
- Moderate to low cost per test • May perform serial tests
DXA Scan Printout=
- Image of anatomic part being scanned
- Graph that plots bone mineral density for that part against patient’s age
- Numeric data
DXA Numeric data that summarize the findings=
- BMD values for individual regions of interest
- BMD as a % of young-adult population
- BMD as a % of age-matched population
- T-scores and Z-scores (number standard deviations above and below mean)
BMD Categories – WHO Classification
Category Criteria / T-score Normal= > -1 Osteopenia= -1 and -2.5 Osteoporosis= < -2.5 Severe osteoporosis= < -2.5 and fragility fracture
Normal BMD=
BMD or BMC within 1 standard deviation of young adult reference mean (T-score between +1.0 and –1.0)
Low bone mass (osteopenia) BMD=
BMD or BMC more than 1 standard deviation below young adult mean, but less than 2.5 standard deviation (T-score between –1.0 and –2.5)
Osteoporosis BMD=
•BMD or BMC 2.5 standard deviations between the young adult mean (T-score of –2.5 or less)
Severe (established) osteoporosis BMD=
• T-score of 2.5 or less and fragility fracture(s)
Estimation of relative risk of fracture for OP=
• Each standard deviation change in BMD increases fracture risk by approximately a factor of 2
• Relative fracture risk = 2^T-Score (i.e.: T-score= -3.0; 2^3 = 8x more likely to fx vs. young
healthy adult)
• Relative OP fracture risk can also be compared with _____.
age-matched peers (Z-score)
Each standard deviation change in BMD increases fracture risk by approximately a factor of ____.
2
Z-scores are useful if they show that a patient’s BMD is significantly below an age- matched group; this finding should prompt a more aggressive search for a _____.
secondary cause of osteoporosis.
Laboratory Evaluation is Recommended if Z-score less than ____.
–2.0
Secondary causes of osteoporosis=
- Serum calcium and phosphate (to exclude HPTH);
- Alkalinephosphatase (to exclude liver disease, osteomalacia, Paget’s disease);
- Blood urea nitrogen,creatinine,eletrolytes(to exclude renal disease);
• Thyroid function tests (to exclude
hyperthyroidism);
- Protein electrophoresis (to exclude MM);
- Free testosterone (to exclude male hypogonadism)
Follow-up Scans done at Interval of _____, under most circumstances.
2 years
• Rapid bone turnover (high-dosecorticosteroids)–
6 months interval
REGIONAL OSTEOPOROSIS
REFLEX SYMPATHETIC DYSTROPHY SYNDROME
GENERAL CONSIDERATIONS=
A post-traumatic bone disorder characterized by an acute painful osteoporosis.
REGIONAL OSTEOPOROSIS
REFLEX SYMPATHETIC DYSTROPHY SYNDROME
CLINICAL FEATURES=
- > 50 yrs. of age
- History of recent trauma which may have been trivial.
- Progressive pain, swelling, and atrophy distal to the trauma site.
REGIONAL OSTEOPOROSIS
REFLEX SYMPATHETIC DYSTROPHY SYNDROME
PATHOLOGICAL FEATURES=
Neurovascular imbalance, promoting osseous hyperemia.
REGIONAL OSTEOPOROSIS
REFLEX SYMPATHETIC DYSTROPHY SYNDROME
RADIOLOGICAL FEATURES
- Patchy, mottled osteoporosis.
- Metaphyseal localization.
- Later, more generalized osteoporosis.
- No joint disease.
REGIONAL OSTEOPOROSIS
DISUSE AND IMMOBILIZATION OSTEOPOROSIS=
• Traumatic injuries which are immobilized, motor paralysis, and inflammatory lesions of bones and joints constitute the most common causes of regional osteoporosis.
DISUSE AND IMMOBILIZATION OSTEOPOROSIS Changes appear on x-ray after ___ days, becoming most extreme by _____.
7-10 days, 2-3 months
REGIONAL OSTEOPOROSIS
DISUSE AND IMMOBILIZATION OSTEOPOROSIS
Four radiological patterns of disuse atrophy:
- 1) Uniform: All bones involved exhibit a similar degree of bone loss. This is the most common type.
- 2) Spotty: Localized circular lucencies predominate, especially within the epiphyseal portions of the bones.
- 3) Bands: Linear transverse subchondral or metaphyseal lucent zones.
- 4) Cortical Lamination or Scalloping: Loss of definition in the outer and inner cortical margins may occur.
If function is restored to the involved body part, complete restitution to a normal appearance may be anticipated in what dz?
DISUSE AND IMMOBILIZATION OSTEOPOROSIS
What dz has No associated etiology, and is Sudden and reversible?
REGIONAL OSTEOPOROSIS
TRANSIENT REGIONAL OSTEOPOROSIS
TRANSIENT REGIONAL OSTEOPOROSIS Affects periarticular bones.
Two entities:
1) TRANSIENT OSTEOPOROSIS OF THE HIP
2) REGIONAL MIGRATORY OSTEOPOROSIS
TRANSIENT OSTEOPOROSIS OF THE HIP=
- 20 to 40 yrs.; M>F.
- Associated w/pregnancy in females, left hip exclusively.
- Marked osteoporosis of the femoral head; less severe in femoral neck and acetabulum.
REGIONAL MIGRATORY OSTEOPOROSIS=
- M>F
- Prefers lower extremities (foot, ankle, etc.).
- Localized, regressing, migratory osteoporosis.
LOCALIZED OSTEOPOROSIS=
- Inflammatory Arthritis (i.e. Rheumatoid Arthritis)
- Infection
- Neoplasm
OSTEOMALACIA
GENERAL CONSIDERATIONS=
• A disorder characterized by a lack of osteoid mineralization leading to generalized bone softening.
OSTEOMALACIA CLINICAL FEATURES=
- Muscle weakness, bone pain, and deformities.
- Elevated parathormone, alkaline phosphatase, and urinary hydroxyproline
- Normal to decreased calcium and phosphorous.
OSTEOMALACIA PATHOLOGICAL FEATURES=
- Increased amounts of uncalcified osteoid tissue (“osteoid seams”).
- Pseudofractures–probably insufficiency fractures healing with uncalcified osteoid.
Alternate Terms for Pseudofractures:
Increment fractures, Milkman’s syndrome, Loosers lines, Umbau zonen
OSTEOMALACIA RADIOLOGICAL FEATURES=
- Decreased bone density (all bones)
- Coarse trabecular pattern (decrease in overall bony trabeculae enhances the contrast of those remaining causing texture to appear coarse and mottled)
- Loss of cortical definition (is thinner and mottled)
OSTEOMALACIA
RADIOLOGICAL FEATURES continued=
- Pseudofractures (see in Paget’s disease, fibrous dysplasia, rickets) are recognized by their bilateral symmetry and perpendicular orientation to the cortex.
- Deformities (majority in weight bearing bones)
• Systemic skeletal disorder due to a deficiency primarily of vitamin D=
Rickets
• Three forms of rickets:
- 1) Vitamin D Deficiency. A lack of dietary vit. D or natural light exposure
- 2) Renal Osteodystrophy. (Renal Rickets) Chronic renal disease
- 3) Renal Tubular Defect. A failure to resorb phosphate in the urine interferes w/osseous mineralization due to the lack of phosphate
RICKETS
CLINICAL FEATURES=
- Ages 6 months to 1 year
- Growth plate swellings
- Irritability
- Deformities
- Tetany
- Delayed maturity
- Weakness
- Elevated alkaline phosphatase levels
RICKETS
PATHOLOGICAL FEATURES=
• Growth plate cartilage hypertrophies; fails to mineralize or degenerate.
RICKETS
RADIOLOGICAL FEATURES=
• Generalized osteopenia • Coarse trabecular changes • Widened growth plates • Rachitic (costal) Rosary • Absent zone of provisional calcification • Frayed "paintbrush" and cupped metaphyses
SCURVY (Barlows Disease)=
- Vitamin C (ascorbic acid) deficiency.
- Capillary fragility.
- 4-10 months to develop.
- Few radiographic signs in adults, osteopenia.
SCURVY
CLINICAL FEATURES=
- Latent period of months
- Usually aged 4-14 months
- Spontaneous hemorrhages
- Swelling
- Irritability
- Pain
- Lyingmotionless (“frog-legged”)
- Costal Rosary (Scorbutic Rosary)
- Serumascorbicacid,0.6mg/100ml
SCURVY PATHOLOGICAL FEATURES=
• Depresses intercellular substance formation, especially in connective tissue, cartilage, and bone
SCURVY RADIOLOGICAL FEATURES=
- A combination of abnormalities occurring at the growing ends of long bones represent the most characteristic findings
- Osteoporosis
- Dense zone of provisional calcification (White Line of Frankel)
SCURVY
RADIOLOGICAL FEATURES=
- Ring epiphysis (Wimberger’s sign)
- Pelken’s spurs
- Scorbutic zone (Trummerfeld zone)
- Subperiosteal hemorrhages (due to the deficiency of intercellular cement which in turn promotes vascular fragility)
HYPERPARATHYROIDISM
GENERAL CONSIDERATIONS=
• Increased parathyroid activity liberates parathormone, which exerts a strong osteoclastic effect on the skeleton.
HYPERPARATHYROIDISM CLINICAL FEATURES=
- Three forms—primary (Parathyroid tumor), secondary (renal disease), and tertiary (renal dialysis)
- F>M, 3:1
- 30-50 years of age
HYPERPARATHYROIDISM
CLINICAL FEATURES=
- Weakness
- Lethargy
- Polydipsia
- Polyuria
- Elevated alkaline phosphatase and parathormone levels
HYPERPARATHYROIDISM PATHOLOGICAL FEATURES=
- Osteoclastic and osteolytic resorption with fibrous tissue replacement (osteitis fibrosa cystica)
- Brown tumors due to hemorrhagic giant cell proliferations
- Hallmark is subperiosteal bone resorption
HYPERPARATHYROIDISM
RADIOLOGICAL FEATURES=
- Bone changes consist of:
- Osteopenia
- Accentuated trabecular patterns
- Subperiosteal resorption
- Loss of cortical definition
- Brown Tumors
HYPERPARATHYROIDISM
TARGET SITES: Hand=
• Hand: Subperiosteal resorption, radial margins of the proximal and middle phalanges of the 2nd and 3rd digits, w/acroosteolysis.
HYPERPARATHYROIDISM
TARGET SITES: Skull=
• Skull: “Salt and pepper”, resorption of lamina dura.
HYPERPARATHYROIDISM
TARGET SITES: Spine=
• Spine: Osteopenia, trabecula accentuation, end plate concavities, “rugger jersey” spine, widened sacroiliac joints.
3 HYPERPARATHYROIDISM
TARGET SITES:
Spine, Skull, Hand
HYPERPARATHYROIDISM
RADIOLOGICAL FEATURES=
- Soft tissue changes include:
- Nephrocalcinosis • Renal calculi • Chondrocalcinosis
- Calcification in various periarticular tissues and visceral organs
ACROMEGALY
GENERAL CONSIDERATIONS=
- 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.
