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Metabolic Bone Diseases - NEET PG Radiology

Apr 10, 2023

Metabolic bone diseases - NEET PG Radiology

Metabolic bone diseases are a group of disorders that affect the skeletal system and result in changes to bone structure and function. These diseases can be challenging to diagnose and manage, making them a crucial topic in radiology.

In the case of metabolic bone diseases, radiology plays a critical role in diagnosing and monitoring these diseases.

Let’s learn more about metabolic bone diseases and how radiology allows doctors  to diagnose and manage these conditions effectively.

  • Hyperparathyroidism (Primary)
Hyperparathyroidism (Primary)
Hyperparathyroidism (Primary)
  • Pathognomonic Features
    • At 2nd& 3rd proximal / mid phalanges on Radial aspect: Subperiosteal resorption
  • In skull :Salt & pepper skull appearance

       Loss of lamina dura Normal lamina dura

  • Multifocal irregular lytic lesions scattered throughout body in metaphysis k/a “Brown tumors/Osteitis cystica fibrosa”

Important Information

  • Brown tumors : Bleeding occurs within them resulting in hemosiderin deposition 

ENT Residency

Secondary hyperparathyroidism

Secondary hyperparathyroidism
  • Chronic kidney disease →↓Ca2+, ↑PO3 → HPT (2°)
  • Hallmark finding : Sclerosis
  • Alternative bands of sclerosis & osteopenia: Rugger jersey spine
  • Knee & wrist : Calcification of meniscus k/a chondrocalcinosis

Important Information

  • Chondrocalcinosis
    • 2°HPT
    • Pseudo gout (due to calcium pyrophosphate deposition)
      • Wrist : Triangular fibrocartilage calcification 
      • Knee: Meniscus calcification 

Paget’s Disease

Paget’s Disease
  • May have visual loss, hearing loss (because cranial nerves getting compressed)
  • Sclerotic phase
    • Skull markedly enlarged with multiple sclerotic spots :Cotton wool skull
    • ↑Hat size: Tam O’ Shanter sign
  • Lytic phase
Lytic phase
  • Osteoporosis circumscripta [large area of decreased bone density]
  • In long bones 
Osteoporosis circumscripta
  • Lysis with advancing edge :Blade of grass / candle flame sign
  • Spinal manifestation
Spinal manifestation
  • Peripheral sclerosis, central osteopenia: Picture frame vertebra
  • Ivory vertebra

Important Information

  • Ivory vertebra
    • Lymphoma 
      • Hodgkin 
    • Sclerotic metastasis
      • Prostate : male
      • Breast : female
    • Paget’s disease
    • In case of treated TB
  • In bone scan
In bone scan
  • Tc99m with MDP (Methyl Diphosphonate) [Picks up new bone formation area]
  • “Mickey Mouse sign” in vertebra
  • “Lincoln sign” in mandible

Mickey Mouse Sign

  • USG LL → Sapheno femoral junction [GSV, SFV, SFA]
  • USG Antenatal→ Anencephaly 
  • Bone scan → Paget’s disease
  • Brain MRI → Midbrain atrophy in case of PSNP


  • Due to increased growth hormone (after growth plate fusion)
  • Over growth in distal phalanges : “Spade phalanx
  • Gross increase in heel pad thickness
    • > 23 mm in female
    • > 25 mm in male
  • In skull
    • Widened sella
    • Prognathism
    • Enlarged sinuses
    • Thick bones, PNS

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis
  • Multisystemic disorder 
  • Child  with multiple bone swelling, multiple lymph nodes, multiple skin lesions
  • In skull
    • Lytic lesion: Geographical with beveled margin (differential destruction of outer & inner table)
  • Spine
    • One of the Vertebra completely destroyed :“Vertebra plana”

Important Information

  • LCH : MC cause of vertebra plana in children
  • Ewing sarcoma, lymphoma, leukemia can also cause vertebra plana
  • Mandible
    • “Floating teeth sign” (due to multiple erosion in mandible)

Radiology Related Articles:

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Multiple Myeloma

Multiple Myeloma
  • Multiple punched out lesion Aka Raindrop appearance [Also seen in lytic metastasis]

Sturge – Weber syndrome 

Sturge – Weber syndrome 
  • Complete cerebral atrophy with tram track calcification which leads to refractory seizure 
  • Port wine stain
  • MC affected: Ophthalmic branch of Trigeminal nerve
  • Congenital glaucoma (+)

Hemolytic Anemia

Hemolytic Anemia
  • Sickle cell anemia, Thalassemia
  • Hair on end / Crew cut appearance 

Raised ICP

Raised ICP
  • Copper beaten sign
  • Earliest sign on X-ray
    • Children: Sutural diastasis (Sutural widening )
    • Adults : Dorsum sella erosion


  • Congenital dysplasia
  • Child with hepatosplenomegaly having pancytopenia
  • Diffuse ↑ density
  • Bone within Bone appearance / Sandwich sign 


  • Diffuse ↓ density
  • End plates compressed :“Codfish appearance ” [due to weak bone & weight of the body]
  • Important Information
  • Codfish appearance also seen in Osteomalacia (Vit D def. in adults)
  • IOC: Dexa Scan (Dual energy X-ray absorptiometry)
    • If we compare the bone mineral density of the patient with young adult : T score
    • If we compare the bone mineral density of the patient with the same aged person : Z-score
    • WHO scoring used T-score
      • +2 to -1 : Normal 
      • -1 to -2.5 : Osteopenia
      • < -2.5 SD : Osteoporosis


  • Child with widening of joints predominantly wrist, ankle 
  • Vit D deficiency
  • Earliest finding: Increased growth plate / Zone of provisional calcification 
    • Due to decreased vitamin D →↓Ca2+ 
    • Unmineralized osteoid accumulates near growth plate
  • Seen in Metaphysis: Cupping, Splaying, Fraying (irregularities)
  • Sign of healing rickets
  • White metaphyseal line

Important Information

  • White metaphyseal line
    • Healing rickets
    • Lead poisoning 
    • Treated Leukemia
    • Scurvy


  • Vitamin C deficiency
  • Bone density decreased
  • Frenkel’s white line
  • Wimberger sign [Epiphyseal sharp margin]
  • Pelkan spur (metaphyseal projection)
  • Trummerfeld zone (Translucent zone above white line)
  • Subperiosteal hemorrhage
    • Very painful [Scurvy is known as Pseudo paralysis state]

Chronic Osteomyelitis

Chronic Osteomyelitis
  • Central white dead bone (no demineralization) → Sclerotic k/a Sequestrum
  • Surrounding translucent granulation → Involucrum
  • Defect through which the pus comes out → Cloaca (then will have draining sinus)

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