The lecture has been given on Apr. 14th, 2011 by Dr. Salah Mohammad Fatih.

1. Bone & joint diseases Lecture no. 3 Prepared by Dr.Salah Mohammad Fatih MBChB,DMRD,FIBMS(radiology)

2. Rickets & osteomalacia There is poor mineralization of osteoid. If occur before epiphyseal closure, it known as rickets. If occur in adult ,it known as osteomalacia.

3. Radiological finding of rickets The changes are maximal where bone growth is occur, so they best seen in the knees, wrists & ankles Loss of provisional zone of calcification. Indistinct metaphyses& metaphyses become irregular and cupped. Wide growth plate. decreased bone density. Deformities of the bones occur because of bone softening. Greenstick fractures are common

4. This patient shows abnormal bone density, with coarsened abnormal trabeculae in a generalized pattern. Even more prominently, we see widened and irregular metaphyses Rickets

5. The anterior ends of the ribs are quite abnormal in this patient, with splaying at the costochondral junction (rachitic rosary)

6. Radiological findings; Decreased bone density. Looser’s zones; are short lucent band running through the cortex at the Rt angles & may have sclerotic margin, commonest site are scapula, medial aspect of femurs,& pubic rami & ribs Bone deformity due to bone softening e.g. biconcave vertebra bodies osteomalacia

7. This patient has generalized osteopenia. In addition, several of the right lower ribs demonstrate transverse fractures with a wide lucency at the fracture site (arrow). Your diagnosis? Osteomalacia with looser’s zone

8. Hyperparathyroidism Cause mobilization of the calcium from the bone, resulting in a decreased bone density. Hyperparathyroidism could be primary hyperparathyroidism (90 percent due to an adenoma) or secondary hyperparathyroidism due to renal dysfunction.

9. Many patients with primary hyperparathyroidism present with renal stone & minority present with radiologically detected bone changes.

10. Radiological features of hyperparathyroidism Generalized decrease in bone density. The hallmark of hyperparathyroidism is subperiosteal bone Resorption. Soft tissue calcification; vascular & chondrocalcification sometime occur. Brown tumor are occasionally present which are small lytic lesion which could be single or multiple

11. Extensive subperiostealresorption is seen on both the radial and ulnar side of the middle phalanges (white arrows, left hand). brown tumor in the left distal ulna as well as the left trapezoid (black arrows, left hand).a as well as in the right head of the third metacarpal and the base of the proximal phalanx of the fifth digit (black arrows, right hand).

12. Features of both primary & secondary hyperparathyroidism are similar except that brown tumors are much rarer & vascular calcification is commoner in secondary hyperparathyroidism

13. vascular calcification is the predominant finding Hyperparathyroidism from renal osteodystrophy.

14. Generalized increase in bone density

15. Causes; Sclerotic metastases, commonest cause. Osteopetrosis (marble bone disease); congenital, bone sclerotic & brittle leading to multiple fractures. Myelosclerosis;there is replacement of the bone marrow by fibrous tissue & lay down of the bone which is usually appear as patchy areas of sclerosis

16. This child has extremely dense bones throughout the body. There is abnormal modeling at the metaphyses with flaring. Your diagnosis? Osteopetrosis

17. Alteration in trabecular pattern & changes in the shape1-Paget’s disease2-Hemolytic anemia3-Radiation induced bone diseases

18. Usually is the chance finding in elderly. One or more bones may be affected, the usual sites are pelvis, spine , skull & long bones 1-Paget’s disease

20. this patient gives a classic appearance of advanced mixed lytic and sclerotic Paget's disease , bone expansion,loss of corticomedullary differentiation and anterior bowing of the tibia Paget’s disease

21. typical picture-frame appearance of VB due to the enlargement and mixed lytic sclerotic pattern. Paget's dsease

22. There are many types of hemolytic anemia , but radiological changes are seen in main two types; thalassaemia & sickle cell disease. Both causes bone marrow hyperplasia, but sickle cell disease also may show evidence of bone infarction & infection 2-Hemolytic anemia

23. dense striations in a very widened diploic space of the cranium (hair-on-end appearance). Additionally, note that the paranasal sinuses are obliterated Thalassemia

24. The metacarpals and phalanges are squared and show a very thinned endosteal cortex with abnormal density. Resorption of some trabeculae & remaining trabeculae become thick & prominent. Thalassemia

25. Radiological features of marrow hyperplasia Thinning of the cortex & bone expansion. Resorption of some trabeculae & remaining trabeculae become thick & prominent. In the skull; it cause widening of the deploe & perpendicular striation occur which is known as ‘ Hair-on-end’. The ribs may enlarged & phalanges may become rectangular.

26. 3-Radiation induced bone diseases

27. Mixed lytic and sclerotic density is seen involving most of the right upper ribs, the right clavicle, scapula, and proximal humerus. Multiple healed rib fractures are seen in this area. Radiation osteonecrosis

28. Radiotherapy may cause local damage of the bone in the radiation field. Early change may be limited to osteoporosis. In severe case it may cause osteonecrosis; bone thinning & patchy increase in bone density with small lytic areas. Pathological feature may occur Occasionally radiation induce sarcomatous changes , usually osteosarcoma, which occur several years after the radiation therapy.

29. Changes in bone shapes

30. Is congenital disorder. There are multiple bony projections known as osteochondromas or exostoses. They have cartilaginous cup which may contain calcification. When exostoses occur in the long bone , they occur near metaphyses & are directed away form the joint Diaphyseal aclasia (multiple exostoses)

31. Osteochondroma (exostosis)

32. Diaphyseal aclasia (multiple exostoses)

33. Radiological features of joint diseases

35. Rotator cuff tear of the shoulder.

36. Avascular necrosis in the hip joint.

38. Plain film signs indicating presence of arthritis

39. 1-Joint space narrowing; It occur in all forms of joint diseases except avascular necrosis.

40. 2-Soft tissue swelling; Periarticular soft tissue swelling is a feature of inflammatory & infective arthritis. Discrete asymmetrical periarticular soft tissue swelling can be seen in gout due to gouty tophi

41. 3-Osteoporosis; Occur in many type of painful conditions & under use of the bones is an important cause.

42. Diagnosis of arthritis

43. To Dx arthritis, it is important to have the following information; 1-Is more than one joint involved? RA, typically involve several joint while infection & synovial tumors usually involve single joint.

45. Psoriatic arthritis usually affect the DIP.

46. Gout typically involve MTP of the big toe.

47. OA when seen in the hands ,it almost always involves DIP& often affect the CM joint of the thumb & in the large joints, it commonly involve hip& knee, but relatively rare in the ankle , shoulders & elbow joints unless there is some underlying causes.

50. Degenerative arthritis (OA) Is the commonest form of arthritis. Changes occur secondary to wear & tear of the articular cartilage.

52. Radiological features of OA

55. Inflammatory arthritis

57. Rheumatoid Arthritis

58. Radiological features of RA

67. Erosion do no occur.

68. Subchondral sclerosis may be seen.

69. Sclerosis is a prominent feature.

70. No osteoporosis.

72. Erosion is characteristic feature.

73. Subchondral sclerosis is not a feature.

74. Sclerosis not a feature unless there is secondary OA.

75. Osteoporosis often present

77. Ankylosing spondylitis

79. Radiological features

82. Thank you