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Presented by Edward McCarthy, M.D. and prepared by Angelique W. Levi, M.D.
Case 6: A 50 year old woman fell and fractured her hip.
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1. Question
Week 41: Case 6
A 50 year old woman fell and fractured her hip. A radiograph of her hand (Image 1, shown below) was done at that time to rule out a fracture, but instead it showed resorption of the tufts of the distal phalanges and subperiosteal resorption along the boarders of the phalanges. A total hip was done. Histologic analysis was performed on the femoral head.images/5.14.01.EMCxray6.jpg
images/5.14.01.EMCcase6a.jpg
images/5.14.01.EMCcase6b.jpgCorrect
Answer: Hyperparathyroidism
Histology: The radiograph of the hand shows subperiosteal resorption, consistent with tunneling resorption. The histology of the femoral head shows increased osteoclastic activity in the pattern of tunneling resorption. This pattern of tunneling resorption is diagnostic of hyperparathyroidism, either primary or secondary. Most patients with primary hyperparathyroidism are diagnosed early and do not develop clinical bone disease. However, all patients with chronic renal disease develop secondary hyperparathyroidism and eventually develop brittle bones. This patient has chronic renal disease. The severity of her tunneling resorption indicates severe secondary hyperparathyroidism. Many patients in renal failure require four-gland total parathyroidectomy to prevent the dissolution of their skeletons.
Discussion: It is not normal to see osteoclastic resorption in bone. If extensive osteoclastic resorption can be seen by light microscopy, the diagnosis of hyperparathyroidism must be strongly suspected.
The histologic findings of osteoporosis include thinning of bone trabeculae, but subperiosteal or “tunneling resorption” is not a feature of osteoporosis.
Incorrect
Answer: Hyperparathyroidism
Histology: The radiograph of the hand shows subperiosteal resorption, consistent with tunneling resorption. The histology of the femoral head shows increased osteoclastic activity in the pattern of tunneling resorption. This pattern of tunneling resorption is diagnostic of hyperparathyroidism, either primary or secondary. Most patients with primary hyperparathyroidism are diagnosed early and do not develop clinical bone disease. However, all patients with chronic renal disease develop secondary hyperparathyroidism and eventually develop brittle bones. This patient has chronic renal disease. The severity of her tunneling resorption indicates severe secondary hyperparathyroidism. Many patients in renal failure require four-gland total parathyroidectomy to prevent the dissolution of their skeletons.
Discussion: It is not normal to see osteoclastic resorption in bone. If extensive osteoclastic resorption can be seen by light microscopy, the diagnosis of hyperparathyroidism must be strongly suspected.
The histologic findings of osteoporosis include thinning of bone trabeculae, but subperiosteal or “tunneling resorption” is not a feature of osteoporosis.
