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
hyperparathyroidism

Osteoporosis

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
(reparative stage)

Fibrogenesis imperfecta

Fluorine poisoning

Cushing syndrome

Intoxication with lead,

bismuth, or phosphorus

Ochronosis (alkaptonuria)

Osteonecrosis

Wilson disease
(hepatolenticular
degeneration)
Hypogonadism

Osteopenia

Osteoporosis

Osteomalacia

Deficient matrix

Normal matrix

Normal
mineralization

Deficient
mineralization

Hyperparathyroidism

Normal matrix and

mineralization
Increased resorption

Foto polos
CT Scan
Scintigraphy
MRI

Radionuclide and X-Ray

Techniques
Single Photon
Absorptiometry
Dual Photon
Absorptiometry

Computed Tomography
Technique
Quantitative Computed
Tomography

Kualitatif

Quantitative Ultrasoud
Techniques

Imaging Techniques for

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,
Gonadal dysgenesis,
Turner syndrome (XO),
Klinefelter syndrome (XXY),
Hypophosphatasia,
Homocystinuria,
Mucopolysaccharidosis
Gaucher disease
Anemias:
Sickle-cell syndromes
Thalassemia
Hemophilia
Christmas disease

Genetic (Congenital)

Hyperthyroidism
Hyperparathyroidism
Cushing syndrome
Acromegaly
Estrogen deficiency
Hypogonadism
Diabetes mellitus
Pregnancy

Endocrine

Scurvy
Malnutrition
Anorexia nervosa
Protein deficiency
Alcoholism
Liver disease

Deficiency States

Myeloma
Leukemia
Lymphoma
Metastatic
disease

Neoplastic

Heparin-induced
Dilantin-induced
Steroid-induced

Iatrogenic

Involutional
(senescent/post
menopausal)
Amyloidosis
Ochronosis
Paraplegia
Weightlessness
Idiopathic

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

Principal Tensile Group

Secondary Tensile Group

Greater Trochanter 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
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
Arise from the lateral cortex below the principal tensile group
Extend superiorly and medially to terminate after crossing the middle of the
femoral neck
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 Ddeficiency 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 vaultthe 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)
2)
3)
4)

Fusion
Fusion
Fusion
Fusion

of
of
of
of

the
the
the
the

distal phalanges;
metacarpals;
proximal phalanges; and,
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