Musculoskeletal

Osteopenia

Mohamed Zaitoun

Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals

EgyptFINR (Fellowship of Interventional

Neuroradiology)-Switzerlandzaitoun82@gmail.com

Knowing as much as possible about your enemy precedes successful battle

and learning about the disease process precedes successful management

Osteopenia-Osteopenia is a nonspecific radiographic finding that

indicates increased radiolucency of bone-Types :1-Osteoporosis : decreased amount of normal bone2-Osteomalacia : decreased bone mineralization3-Rickets4-Hyperparathyroidism : increased bone resorption5-Renal Osteodystrophy6-Scurvy7-Marrow replacement : bone replaced by tumor , marrow

hyperplasia or metabolic products

1-Osteoporosis :-Decreased amount of normal bone-Types :a) Primary : most common-Unassociated with an underlying illness-Type I osteoporosis : postmenopausal-Type II osteoporosis : senile-Idiopathic juvenile osteoporosis

b) Secondary : less common1-Endocrine disorders :-Hypogonadism-Hyperthyroidism-Cushing's disease-Acromegaly2-Nutritional :-Malabsorption syndrome-Alcoholism-Scurvy

3-Hereditary metabolic or collagen disorder :

-Osteogenesis imperfecta-Marfan syndrome-Ehlers-Danlos syndrome4-Drugs :-Heparin-Exogenous steroids

-Radiographic Findings :*Osteopenia : 30%-50% of bone has to be lost to be

detectable by plain film*Diminution of cortical thickness*Decrease in number and thickness of trabeculae in

bone*Empty box vertebra : apparent increased density of

vertebral endplates due to resorption of spongy bone

*Vertebral body compression fractures : wedge , biconcave codfish bodies , true compression

*Pathologic fractures

Osteopenia

Severe osteoporosis with multiple vertebral crush fractures

Fish vertebra (biconcave end plates involving the superior and inferior end plate of a vertebral body)

2-Osteomalacia :a) Definitionb) Etiologyc) Radiographic Features

a) Definition :-Abnormal mineralization of bone is termed osteomalacia in

adults and rickets in children

b) Etiology :1-Nutritional deficiency of :-Vitamin D-Calcium-Phosphorus2-Absorption abnormalities :-GI surgery-Malabsorption-Biliary disease

3-Renal :-Chronic renal failure-Renal tubular acidosis-Proximal tubular lesions-Dialysis induced4-Abnormal vitamin D metabolism :-Liver diseases-Hereditary metabolic disorders5-Drugs :-Phenytoin-Phenobarbital

c) Radiographic Features :-Generalized osteopenia-Looser zones :*Also known as cortical infarctions, are wide transverse lucencies

traversing bone usually at right angles to the involved cortex*Locations : 1-Pubic rami2-Medial proximal femur3-Lateral scapula4-Posterior proximal ulna5-Ribs-Milkman's syndrome : osteomalacia with many Looser's zones

Looser's zones in the inferior femoral neck

Looser zones

Osteopenic changes involving bony pelvis and proximal femurs , multiple pseudofractures / lossers's zones are seen involving superior and inferior pubic rami bilaterally

3-Rickets :a) Incidenceb) Etiologyc) Radiographic Featuresd) Differential Diagnosis

a) Incidence :-Refers to osteomalacia in the pediatric

population that occurs prior to fusion of the growth plate

b) Etiology :-Vitamin D deficiency causes failure of mineralization of

bone and cartilage (in adults this is termed osteomalacia)-Causes of Vitamin D deficiency include :1-GI tract :-Nutritional deficiency (common)-Absorption abnormalities2-Skin disease3-Liver disease4-Renal :-Renal tubular acidosis-Renal failure (loss of calcium)

c) Radiographic Features :1-Growth plate abnormalities (especially

long bones) :-A widened growth plate is due to rickets

until proved otherwise-Cupping of metaphysis-Disorganized (frayed) metaphysis

Metaphyseal cupping and fraying in the distal radius and ulna in rickets

Cupping and fraying of the metaphyseal region

Severe fraying of the metaphysis

Severe metaphyseal changes involving the distal femurs and proximal tibias and fibulas , note the pronounced demineralization of the epiphyseal ossification centers

Bowing of the femurs , metaphyseal cupping and fraying ,coarsening of the trabecular pattern , increase in distance between end of shaft and epiphyseal center, poorly ossified epiphyseal centers

2-Bowing deformities of bones3-Delayed closing of fontanelles4-Softening of cranial vault (craniotabes)5-Rachitic rosary : expansion of the anterior

rib ends at the costochondral junctions

Bowing of the legs caused by loading

Rachitic rosary

Rachitic rosary

Rachitic rosary

d) Differential Diagnosis :-Leg bowing in children :1-Developmental or congenital bowing2-Blount disease3-Osteogenesis imperfecta-Widening of the growth plate :1-Scurvy2-Delayed maturation due to illness-Flaring of the metaphysis :1-Anaemia2-Fibrous dysplasia3-Storage diseases4-Chronic lead poisoning5-Bone dysplasia

4-Hyperparathyroidism :-See endocrine bone diseases

5-Renal Osteodystrophy :a) Incidenceb) Radiographic Features

a) Incidence :-Refers to musculoskeletal abnormalities that

occur in patients with chronic renal failure due to concurrent and superimposed :

1-Osteomalacia (adults)/ rickets (children) :2-Secondary hyperparathyroidism (abnormal

calcium and phosphate metabolism)3-Aluminum intoxication, e.g. if the patient is

on dialysis

b) Radiographic Features :1-Changes of osteomalacia : See osteomalacia-Osteopenia and cortical thinning-Looser's zones occur but are uncommon2-Changes of hyperparathyroidism : See HPT-Subperiosteal resorption (e.g., SI joint resorption)-Rugger jersey spine-Brown tumors-Osteosclerosis-Soft tissue calcification-Chondrocalcinosis

6-Scurvy :a) Incidenceb) Radiographic Features

a) Incidence :-Rare-Deficiency of vitamin C (ascorbic acid)

impairs the ability of connective tissue to produce collagen

-Never occurs before 6 months of age because maternal stores are transmitted to fetus

b) Radiographic Features :-Generalized osteopaenia-cortical thinning, pencil-point cortex-Periosteal reaction : due to subperiosteal hemorrhage-Scorbutic rosary : expansion of the costochondral

junctions, similar to the rachitic rosary appearance is seen in rickets

-Dense metaphyseal line (Frankel)-Wimberger's sign : dense epiphyseal rim (ring

epiphysis)-Corner sign : metaphyseal fractures (Pelkan spurs)

7-Marrow Replacement : a) Bone replaced by tumor :1-Myeloma2-Leukemia / Lymphoma3-Metastases (small cell tumors)4-Myelofibrosisb) Marrow hyperplasia or metabolic products