Metabolic Diseases

Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 14 – Metabolic Diseases

Chapter 14
Metabolic Diseases
Thomas H. Berquist
Osteoporosis: Basic Concepts
Suggested Reading
Eastell R. Treatment of postmenopausal osteoporosis. N Engl J Med 1998;338:736–746.
Lanchik L, Sartoris DJ. Current concepts in osteoporosis. AJR Am J Roentgenol 1997;168:905–911.


Osteoporosis: Generalized


FIGURE 14-1 Osteoporosis. (A) Normal right hip with trabecular pattern well demonstrated. (B) Osteoporotic right hip with poorly defined trabeculae (arrows).


FIGURE 14-2 (A) Lateral thoracic spine with osteoporosis and compression fractures. (B) Lateral lumbar space showing endplate compression (fish vertebra) with biconcave appearance.


FIGURE 14-3 Bone mineral density with osteoporosis in a 76-year-old woman with lumbar (A) and hip (B) T scores of -2.9 and -3.1 for the lumbar spine and right hip, respectively.


FIGURE 14-4 DXA study of the spine in a patient with chronic renal failure and renal osteodystrophy. The endplates are dense (arrows) and bone density increased with T-scores of up to 5.8 in L1.
Suggested Reading
Briot K, Roux C. What is the role of DXA, QUS, and bone markers in fracture prediction, treatment allocation, and monitoring? Best Pract Res Clin Rheumatol 2005;19:951–964.
Ralston SH. Bone densitometry and bone biopsy. Best Pract Res Clin Rheumatol 2005;19:487–501.


Osteoporosis: Regional Osteoporosis
FIGURE 14-5 Disuse osteoporosis. Talar neck fracture with screw fixation. Lateral (A) and anteroposterior (AP) (B) radiographs showing osteopenia with sclerosis (arrow) medially caused by avascular necrosis.


FIGURE 14-6 Transient osteoporosis of the hip: (A) AP radiograph of the pelvis showing osteopenia in the left upper femur. Coronal T1-weighted (B) and T2-weighted (C) magnetic resonance images showing abnormal signal intensity in the femoral head and neck with a joint effusion. (D)
Radionuclide bone scan in a different patient during early symptomatic
phase showing increased tracer in the femoral head and neck. (E) Six months later, after symptoms have cleared, the bone scan is normal.


FIGURE 14-7 RSD. (A) Radionuclide bone scan showing increased tracer in the ankle, hind, and midfoot. AP (B) and lateral (C) radiographs showing advanced periarticular osteopenia.


Suggested Reading
Genant HK, Kozir F, Beherman C, et al. The reflex sympathetic dystrophy syndrome. Radiology 1975;117:21–32.
CW, Conway WF, Daniel WW. MR imaging of bone marrow edema pattern:
Transient osteoporosis, transient bone marrow edema, or osteonecrosis. Radiographics 1993;13:1001–1011.
Jones G. Radiographic appearances of disuse osteoporosis. Clin Radiol 1969;20:345–353.


Rickets and Osteomalacia: Basic Concepts
Neonate and Infant Childhood and Adults
  Congenital rubella
  Vitamin D deficiency
  Biliary atresia
  Celiac disease and malabsorption syndromes
  Dietary calcium and phosphate deficiency
  Hypophosphatemic (Vitamin D resistant)
  Pancreatic insufficiency
  Crohn disease
  Small bowel fistulae
  Small bowel and gastric resections
  Obstructive jaundice
  Chronic liver disease
  Anticonvulsive therapy
  Renal tubular disorders
  Axial osteomalacia


FIGURE 14-8 Vitamin D metabolism and diseases leading to rickets and osteomalacia. (From

Berquist TH, ed. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.


Suggested Reading
Rasmussen H, Bordier P, Kurokawa K, et al. Normal control of skeletal and mineral homeostasis. Am J Med 1974;56:751–758.


Rickets and Osteomalacia: Rickets
FIGURE 14-9 “Rachitic rosary.” AP (A) and lateral (B) radiographs of the chest showing prominence of the costochondral junctions (arrows).


FIGURE 14-10 Rickets in a young child with growth plate widening and irregularity in the wrist (A) and knees (B). Note the small epiphyses in the knees.


FIGURE 14-11 Vitamin D-resistant rickets in a 1-year-old child. (A)
AP radiograph of the knees showing irregularity and widening of the
growth plates. The epiphyses are small and irregular as well. (B) Three years after high-dose vitamin D therapy, the knees appear normal. There is residual femoral bowing. (From

Berquist TH, ed. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.


Suggested Reading
Steinbach HL, Noetzli M. Roentgen appearance of the skeleton in osteomalacia and rickets. AJR Am J Roentgenol 1964;91:955–972.


Rickets and Osteomalacia: Osteomalacia
FIGURE 14-12 Osteomalacia. AP radiograph of the pelvis showing osteopenia with bilateral femoral neck pseudofractures (arrows).


FIGURE 14-13 AP radiograph of the tibia showing a midshaft pseudofracture (arrow).
Suggested Reading
Jawarski ZFG. Pathophysiology, diagnosis, and treatment of osteomalacia. Orthop Clin North Am 1972;3:623–652.


Renal Osteodystrophy



FIGURE 14-14 Renal osteodystrophy in an adult. (A)
Radiograph of the hand showing chondrocalcinosis (1), subperiosteal
resorption of the radial aspect of the middle phalanges (2), and
subtendinous resorption (3). (B) Lateral radiograph of the lumbar spine showing endplate sclerosis (“rugger jersey spine”). (C) AP view of the femur showing bowing with a proximal pseudofracture (arrow).


FIGURE 14-15 Renal osteodystrophy in the immature skeleton. (A)
AP radiograph of the hand and wrist showing physeal irregularity in the
distal radius and ulna. There is subtle subperiosteal resorption in the
radial aspect of the middle phalanges (arrows). (B)
AP radiograph of the pelvis showing widening and irregularity of the
sacroiliac joints caused by subchondral bone resorption. The femoral
physis also is slightly irregular.


Suggested Reading
Mankin HJ. Rickets, osteomalacia, and renal osteodystrophy. Part II. J Bone Joint Surg 1974;56A:352–386.


Parathyroid Disorders: Hyperparathyroidism


FIGURE 14-16
Primary HPT. Posteroanterior radiograph of the fingers showing early
subperiosteal resorption in the characteristic radial side of the
middle phalanges (arrows). Cortical bone thickness also is reduced.


FIGURE 14-17
Secondary HPT. Radiograph of the hand showing resorption of the first
to third tufts with soft tissue calcification (1). There is articular
calcification (2), and subperiosteal and subligamentous resorption (3).


FIGURE 14-18 Primary HPT. Radiograph of the midfemur showing a brown tumor.


FIGURE 14-19 Secondary HPT. Radiograph of the pelvis and hips showing diffuse osteosclerosis.
Suggested Reading
Resnick D, Kransdorf MJ. Parathyroid disorders and renal osteodystrophy. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier- Saunders; 2005:603–622.


Parathyroid Disorders: Hypoparathyroidism, Pseudohypoparathyroidism, and Pseudo-pseudohypoparathyroidism


FIGURE 14-20 Pseudohypoparathyroidism. (A,B) AP radiographs of the hands showing shortening of the fourth and fifth metacarpals.
Suggested Reading
Burnstein MI, Kottainaser SR, Pettifar JM, et al. Metabolic bone disease in pseudohypoparathyroidism. Radiology 1985;155:351–356.


Thyroid Disorders


FIGURE 14-21 Thyroid acropachy. (A,B) Radiographs of the hands showing diaphyseal periostitis (arrows) and generalized swelling. (C) Radiograph in a different patient showing marked soft tissue prominence.


Suggested Reading
Meurier RJ, Bianchi GG, Edouad CM, et al. Bony manifestations of thyrotoxicosis. Orthop Clin North Am 1972;3:745–775.


Pituitary Disorders


FIGURE 14-22 Acromegaly. (A,B) Radiographs of the hands showing spadelike tufts and metacarpophalangeal joint space widening.
Suggested Reading
Lang EK, Bessler WT. The roentgen features of acromegaly. AJR Am J Roentgenol 1961;86:321–328.


Paget Disease



FIGURE 14-23 Calvarial features. (A) Lateral view of the skull showing a large geographic lytic area (arrows) (osteoporosis circumscripta). (B) Radionuclide scan showing dramatically increased tracer in this region. AP (C) and lateral (D) radiographs of the tibia show lytic Paget’s disease with sharp margination (“blade-of-grass”).


FIGURE 14-24 Sclerotic phase. (A) Lateral radiograph of the skull showing thickening and sclerosis with basilar invagination. (B,C) Computed tomography images showing sclerotic areas in the markedly thickened calvarium.


FIGURE 14-25 Paget disease in the tibia and talus. (A) Radionuclide bone scan showing intense increased uptake in the distal tibia and talus on the left. AP (B) and lateral (C) radiographs showing lytic changes proximally with sharp demarcation (arrow) (“blade of grass”) at the upper margin. There is trabecular thickening distally and a stress fracture in the fibular (open arrow). (D)
Fat-suppressed T2-weighted magnetic resonance image showing variable
signal intensity changes in the involved tibia. This image would be
confusing to interpret without the radiograph for comparison.


FIGURE 14-26 Paget disease in the spine. AP (A) and lateral (B)
radiographs showing involvement of T12, L2, and L5, with sclerosis,
increased size (L2), and cortical and trabecular thickening.


FIGURE 14-27
Paget disease in the pelvis. AP radiograph showing mixed lytic and
sclerotic changes, with cortical thickening and protrusio acetabuli in
the left hip.
Suggested Reading
Roberts MC, Kressel HY, Fallon MD, et al. Paget disease. MR image findings. Radiology 1989;177:341–345.
M, Khanna G, El-Khoury GY. T1-weighted MR imaging for distinguishing
large osteolysis of Paget disease from sarcomatous degeneration. Skel Radiol 2001;30:378–383.

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