Dr.

Donny Susilawardhono SpRad

Bagian Radiologi RSAL Ramelan
 Secara tidak langsung, sebagian masih bisa
memakai plain foto musculoskeletal
 Secara langsung untuk melihat morfologi dari
kelenjar dengan
◦ USG
◦ CT Scan
◦ MRI
◦ Scintigraphy
 Secara langsung, dengan melihat kelenjar
atau struktur anatomis primer tertentu tgt
patofisiologinya,
 Secara tidak langsung dengan melihat efek
yang ditimbulkan
Tulang mengandung :
 Ekstraseluler material :
◦ Matriks organik atau jaringan osteoid (collagen
fibril yang mangandung mucopolysaccharide
ground subastance)
◦ Inorganic crystalline component (hydroxyapatite
atau calcium phosphat)
 Celluler material :
◦ Osteoblast (induced bone formation)
◦ Osteoclast (induced bone resorption)
◦ Osteocyte (inactive cell)
 Increased Radiodensity Increased Radiolucency

Secondary Osteoporosis
hyperparathyroidism

Renal osteodystrophy Osteomalacia

Hyperphosphatasia Rickets

Idiopathic hypercalcemia Scurvy

Paget disease Primary

hyperparathyroidism

Osteopetrosis* Hypophosphatasia

Pycnodysostosis* Hypophosphatemia

Melorheostosis* Acromegaly

Hypothyroidism Gaucher disease

Mastocytosis Homocystinuria

Myelofibrosis Osteogenesis imperfecta*

 Increased Radiodensity Increased Radiolucency

Myelofibrosis Osteogenesis imperfecta*

Gaucher disease Fibrogenesis imperfecta

(reparative stage)

Fluorine poisoning Cushing syndrome

Intoxication with lead, Ochronosis (alkaptonuria)

bismuth, or phosphorus

Osteonecrosis Wilson disease

(hepatolenticular
degeneration)

Hypogonadism
 Osteopenia

Osteoporosis Osteomalacia Hyperparathyroidism

Deficient matrix Normal matrix Normal matrix and

mineralization
Normal Deficient
mineralization mineralization Increased resorption
 Foto polos  Radionuclide and X-Ray
Techniques
 CT Scan ◦ Single Photon
 Scintigraphy Absorptiometry
◦ Dual Photon
 MRI Absorptiometry
 Computed Tomography
Technique
◦ Quantitative Computed
Tomography
 Quantitative Ultrasoud
Techniques

Imaging Techniques for

Kualitatif Measurement Bone Mineral Density
 Radioluscent defect pada cortical bone yang
mencerminkan akumulasi nonmineralized
osteoid tissue
 Characteristic finding dari osteomalacia
 Generalized metabolic bone disease,
characterized by insufficient formation or
increased resorption of bone matrix that
decreased of bone mass
 Osteogenesis imperfecta,  Hyperthyroidism
Gonadal dysgenesis,
Hyperparathyroidism


◦ Turner syndrome (XO),
◦ Klinefelter syndrome (XXY),  Cushing syndrome
 Hypophosphatasia,  Acromegaly
 Homocystinuria,  Estrogen deficiency
Mucopolysaccharidosis
Hypogonadism


 Gaucher disease
 Anemias:  Diabetes mellitus
◦ Sickle-cell syndromes  Pregnancy
◦ Thalassemia
◦ Hemophilia
◦ Christmas disease

Genetic (Congenital) Endocrine

 Scurvy  Myeloma
 Malnutrition  Leukemia
 Anorexia nervosa  Lymphoma
 Protein deficiency  Metastatic
 Alcoholism disease
 Liver disease

Deficiency States Neoplastic

 Heparin-induced  Involutional
 Dilantin-induced (senescent/post
 Steroid-induced menopausal)
 Amyloidosis
 Ochronosis
 Paraplegia
 Weightlessness
 Idiopathic

Iatrogenic Miscellaneous
 Immobilization (cast)
 Disuse
 Pain
 Infection
 Reflex sympathetic dystrophy syndrome (Sudeck
atrophy)
 Transient regional osteoporosis:
◦ Transient osteoporosis of the hip
◦ Regional migratory osteoporosis
◦ Idiopathic juvenile osteoporosis
 Paget disease (hot phase)
Target sites
of
Osteoporosis
Periarthricular Porosis
Osteoporosis
with
fracture
 Principal Compressive Group
◦ Extend from medial cortex of femoral neck to superior part of femoral head
◦ Major weight-bearing trabeculae
◦ In normal femur are the thickest and most densely packed
◦ Appear accentuated in osteoporosis
◦ Last to be obliterated
 Secondary Compressive Group
◦ Originate at the cortex, near the lesser trochanter
◦ Curve upward and laterally toward the greater trochanter and upper femoral
neck
◦ Characteristically thin and widely separated
 Principal Tensile Group
◦ Originate from the lateral cortex, inferior to the greater trochanter
◦ Extend in an arch-like configuration medially, terminating in the inferior
portion of the femoral head
 Secondary Tensile Group
◦ Arise from the lateral cortex below the principal tensile group
◦ Extend superiorly and medially to terminate after crossing the middle of the
femoral neck
 Greater Trochanter Group
◦ Composed of slender and poorly defined tensile trabeculae
◦ Arise laterally below the greater trochanter
◦ Extend upward to terminate near the greater trochanter's superior surface
 Ricket (anak-anak) dan osteomalacia
(dewasa)
 Faulty mineralization (calcification) of bone
matrix
 Nutritional Deficiency
◦ Vitamin D Dietary
◦ Insufficient sunlight
◦ Impaired synthesis
◦ Calcium
◦ Phosphorus

 Absorption Abnormalities
◦ Gastric surgery
◦ Intestinal surgery (bypass)
◦ Gastric disorders (obstruction)
◦ Intestinal disorders (sprue)
 Renal Disorders
◦ Renal tubular disorders
 Proximal tubular lesions (failure of absorption of inorganic phosphate,
glucose, amino acids)
 Distal tubular lesions (renal tubular acidosis)
 Combined proximal and distal tubular lesions
◦ Renal osteodystrophy

 Miscellaneous
◦ Associated with
 Wilson disease
 Fibrogenesis imperfecta
 Fibrous dysplasia
 Neurofibromatosis
 Hypophosphatasia
 Neoplasm
Target site
Of
Rickets
 Infantile
Rickets
 Vitamin D – resistant Rickets
 6 -18 months
 Generalized demineralisation of skeleton
 Tend to bowing deformities (in weight bearing
bones, when begin to stand and walk)
 Restless & sleep poorly
 Closing of fontanella is delayed
 Softening of cranial vault (craniotabes)
 Enlargement of cartilage at costochondral
junction (rachitic rosary)
 Serum calcium dan phosphorous low
 ALP increased
 Radiologic landmark :
◦ Observed in metaphyse and epiphyse
 Widening of the growth plate
 Cupping and flaring metaphysis, which appear
disorganized and frayed
◦ Similar changes seen in secondary ossification
centers of ephypise
 Bones become radiolucent
 Loss of sharpness at the periphery
 Bowing deformities
8-year-old boy with untreated dietary rickets shows osteopenia of the
bones, widening of the growth plates of the distal radius and ulna, and
flaring of the metaphyses, all typical features of this condition
•4-year-old boy shows widening
of the growth plates of the
distal femur and proximal tibia
secondary to lack of
mineralization in the provisional
zone of calcification.

•Note also cupping and flaring

of the metaphyses.
3-year-old girl with vitamin D-
deficiency rickets shows
increased bone radiolucency,
widening of the growth plates,
cupping and flaring of the
metaphyses, and blurring of the
outline of the secondary
ossification centers, all
radiographic hallmarks of this
condition.

Note also bowing of the tibia and

fibula, a frequent feature of
rickets
 Pathofisiologi sama dgn Ricket
 Proses terjadi setelah pertumbuhan tulang
terjadi
 Seringkali terjadi ok “faulty absorption” ari
vitamin D larut lemak di GIT yang sekunder
ok malabsorption syndrome
 Histologically, osteomalacia is characterized by excessive quantities of
inadequately mineralized bone matrix (osteoid) coating the surfaces of
trabeculae in spongy bone and lining the haversian canals in the cortex.

 Radiographically, osteomalacia presents with generalized osteopenia,

and multiple, bilateral, and often symmetric radiolucent lines are seen in
the cortex perpendicular to the long axis of the bone; they are referred
to as “pseudofractures” or Looser zones.

 These defects, which represent cortical stress fractures filled with poorly
mineralized callus, osteoid, and fibrous tissue, are common along the
axillary margins of the scapulae, the inner margin of the femoral neck,
the proximal dorsal aspect of the ulnae, the ribs, and the pubic and
ischial rami

 The condition, described by Milkman and known as “Milkman

syndrome,” is a mild form of osteomalacia in which the pseudofractures
are particularly numerous.
 Generalized osteitis fibrosa cystica or Recklinghausen
disease of bone
 Overactivity of the parathormone-producing parathyroid
glands.
 Increased production of this hormone is secondary to
either gland hyperplasia (9% of cases) or adenoma (90%);
only in very rare instances (1%) does hyperparathyroidism
occur secondary to parathyroid carcinoma.
 Excessive secretion of parathormone, which acts on the
kidneys and on bone, leads to disturbances in calcium and
phosphorus metabolism, resulting in hypercalcemia,
hyperphosphaturia, and hypophosphatemia.
 Renal excretion of calcium and phosphate is increased,
and serum levels of calcium are elevated, while those of
phosphorus are reduced. Serum levels of alkaline
phosphatase are also elevated.
 Hyperparathyroidism can be divided into primary,
secondary, and tertiary forms. The classic form of
the disorder,
 Primary hyperparathyroidism, is marked by
increased secretion of parathormone resulting
from hyperplasia, adenoma, or carcinoma of the
parathyroid glands. S
 Secondary hyperparathyroidism is caused by
increased secretion of parathyroid hormone in
response to a sustained hypocalcemic state.
 Tertiary hyperparathyroidism represents a
transformation from a hypocalcemic to a
hypercalcemic state.
 Primary hyperparathyroidism is usually
associated with hypercalcemia.
 Women are affected about three times as
often as men, and the condition is most often
seen in the patient's third to fifth decade
 Usually the fundamental cause of parathyroid
gland hyperfunction is impaired renal
function.
 Hyperphosphatemia due to renal failure
results in chronic hypocalcemia, which in turn
promotes increased parathyroid secretion.
 Although secondary hyperparathyroidism is
usually hypocalcemic, it may be
normocalcemic as an adaptive response to
the hypocalcemic state.
 The parathyroid glands “escape” from the
regulatory effect of serum calcium levels.
 Patients in whom this escape occurs are
usually receiving kidney hemodialysis; they
are considered to have autonomous
hyperparathyroidism
Target Site
Of
Hyperparathyroidism
 Generalized osteopenia; subperiosteal,
subchondral, and cortical bone resorption;
brown tumors; and soft-tissue and cartilage
calcifications.
 Intracortical resorption is manifested by
longitudinal striations, a finding known as
“tunneling,” which can be most clearly
appreciated on magnification studies
 In the skull, there is a characteristic mottling
of the vault, which yields a “salt-and-pepper”
appearance
 loss of the lamina dura around the tooth
socket, which normally is seen as a thin sharp
white line surrounding the peridental
membrane that attaches the tooth to bone
 Generalized increase in bone density occurs,
particularly in younger patients.
 In the spine, this change is reflected in dense
sclerotic bands seen adjacent to the vertebral end
plates, giving the vertebrae a sandwich-like
appearance (“rugger-jersey” spine)
 However, it must be kept in mind in the evaluation of
hyperparathyroidism that osteosclerotic changes may
also occur as a manifestation of healing, either
spontaneously or as a result of treatment.
 Deposition of calcium in fibrocartilage, articular
cartilage, and soft tissue is common, and vascular
calcifications are much more frequent in patients with
secondary hyperparathyroidism
Primary
hyperparathyroidism
Primary
Hyperparathyroidism

Subchondral bone resorption is

present at the head of the second
metacarpal (arrow).

Note also subperiosteal resorption

at the proximal and distal phalanges
(open arrows).
Primary
Hyperparathyroidism

resorption of the
acromial end of the right
clavicle
 Primary Hyperparathyroidism
decrease in the overall density of the bone and a granular appearance of
the vault—the so-called salt-and-pepper skull
Primary
Hyperparathyroidism
Brown tumor
Secondary
Hyperparathyroidism
17-year-old boy with chronic
renal failure developed
secondary
hyperparathyroidism

Rugger-Jersey spine
 Secondary Hyperparathyroidism
48-year-old woman shows evidence of soft-tissue and vascular
calcifications, characteristic findings in secondary hyperparathyroidism.
Note also diffuse osteopenia.
 Evaluasi terbaik dengan modalitas MRI
 Kedua dengan CT Scan
 Foto polos :
◦ Ballooning sella
◦ Double floor
Sella Measurement
Children
Sella Measurement - Adult
Double floor Baloning sella tursica
Sisi kiri Sella Sisi kanan Sella
MRI MRI
CT Scan CT Scan
 Tidak tampak jelas pada foto polos biasa
 Dengan foto polos, tampak sebagai soft
tissue area, lihat airway
 USG Grayscale dan Powerdoppler - sensitif
 MRI – Sensitif
 CT Scan – spesifik
 Scintigraphy
 USG dengan doppler
◦ Mudah, murah, praktis
◦ Mengevaluasi kista dan nodule dengan baik
 CT Scan
◦ Evaluasi morfologis dengan baik
 MRI
◦ Evaluasi morfologis terbaik
 Scintigraphy
Thoracic
Goiter
 Sulit ditemukan
 Modalitas yang paling sensitif adalah MRI
 Tampak jelas bila membesar
 Modalitas yang dapat dipakai adalah USG, CT
Scan, MRI
 Perlu diperhatikan ukuran, homogenitas
parenchyme dan ductus pancreaticus
 Diterbitkan sebagai buku yang bernama : A
Radiographic Standard of Reference for the
Growing Hand and Wrist
 Disiapkan untuk : The United States National,
Health Examination Survey
 Diterbitkan oleh : The Press of Case Western
Reseve University, Chicagi, 1950
 Dibuat oleh :
◦ S.Idle Pyle PhD
◦ Alice M. Waterhouse MD
◦ William Walter Greulich PhD
 Vicente Gilsanz, M.D., Ph.D. Department of
Radiology, Childrens Hospital Los Angeles,, 4650
Sunset Blvd., MS#81, Los Angeles, CA 90027
 Osman Ratib, M.D., Ph.D., Department of
Radiology, David Geffen School of Medicine at
UCLA, 100 Medical Plaza, Los Angeles, CA 90095
 ISBN 3-540-20951-4 Springer-Verlag Berlin
Heidelberg New York, Library of Congress
Control Number: 2004114078
 Springer-Verlag Berlin Heidelberg New York
 Terbaru th 2005
 Bone age assessment is frequently performed
in pediatric patients to evaluate growth and
to diagnose and manage amultitude of
endocrine disorders and pediatric syndromes
 Bones in the hand and wrist are the most
suitable indicators of skeletal maturity during
the different phases of postnatal
development.

Vicente Gilsanz · Osman Ratib

Hand Bone Age
 Six major categories and highlighted in
parentheses the specific ossification centers that
are the best predictors of skeletal maturity for
each group:
◦ 1) Infancy (the carpal bones and radial epiphyses);
◦ 2) Toddlers (the number of epiphyses visible in the long
bones of the hand);
◦ 3) Pre-puberty (the size of the phalangeal epiphyses);
◦ 4) Early and Mid-puberty (the size of the phalangeal
epiphyses);
◦ 5) Late Puberty (the degree of epiphyseal fusion); and,
◦ 6) Post-puberty (the degree of epiphyseal fusion of the
radius and ulna).
Vicente Gilsanz · Osman Ratib
Hand Bone Age
 Late Puberty
 Females: 13 years to 15 years of age
 Males: 14 years to 16 years of age

 Assessments of skeletal maturity in this stage are primarily

based on the degree of epiphyseal fusion of the distal phalanges.
Fusion of the epiphyses to the metaphyses in the long bones of
the hand tends to occur in an orderly characteristic pattern, as
follows:
◦ 1) Fusion of the distal phalanges;
◦ 2) Fusion of the metacarpals;
◦ 3) Fusion of the proximal phalanges; and,
◦ 4) Fusion of the middle phalanges.
 Because of their morphologies, the epiphyseal fusion of the
metacarpals is poorly depicted by radiographs and greater
attention is, therefore, placed on the degree of fusion at the
phalanges. Since all carpal bones have now attained their early
adult shape, they are of less value for determination of bone age.
Vicente Gilsanz · Osman Ratib
Hand Bone Age
 Depiction, from left to right, of the rogressive
degrees of fusion of the epiphyses to the
metaphyses,which usually begins at the center
of the physis
 Assessments in late
stages of puberty
and sexualmaturity
are based on the
degree of
epiphyseal fusion of
the distal phalanges
(first) and on the
degree of fusion of
the middle
phalanges (second)
8-month-old boy 10-month-old boy
10-year-old boy 14-year-old boy