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Findings: Bone Scan: Increased radiopharmaceutical uptake along cortical margins of the bilateral femurs and tibias. No evidence of bony metastases.
Diagnosis: Hypertrophic Osteoarthropathy
Discussion:Hypertrophic osteoarthropathy can be primary or secondary. The primary form represents 3-5% of all cases of hypertrophic osteoarthropathy and is also called pachydermoperiostosis. The predominant radiographic feature is periostitis.
The secondary form occurs in association with multiple conditions: the clinical syndrome includes clubbing of the fingers and toes, subperiosteal new bone formation, synovitis, and autonomic disorders. Between 1 and 12% of patients with bronchogenic carcinoma develop hypertrophic osteoarthropathy. It is also associated with other pulmonary processes, such as abscess, bronchiectasis, emphysema, Hodgkin's disease and metastasis. It is also common in pleural mesothelioma. Other associated conditions include cyanotic congenital heart disease as well as abdominal processes, such as ulcerative colitis and Chrone's disease. Periostitis can also be seen in thyroid acrophachy, venous stasis, hyper-vitaminosis A and Caffey's Disease.
Periostitis is seen on Bone Scintigraphy as increased radiopharmaceutical uptake along the cortical margins of long bones. Patchy uptake can be seen when synovitis is present. Common sites of involvement are, in descending order, the radius and ulna, tibia and fibula, humerus and femur, metacarpals and metatarsals, and the proximal and middle phalanges. Bone scintigraphy is more sensitive for hypertrophic osteoarthrapathy then radiography. After treatment of the associated disease there is usually a rapid remission of clincal signs and symptoms. Bone scans may return to normal in 1 to 6 months. The reversal of radiographic findings lags behind the scintigraphic findings.
References:
1) Ali A, Tetalman MR, Fordham EW et al. Distribution of hypertropic pulmonary
osteoarthropathy. Am J Radiol 1980; 134: 771-780.
2) Rosenthall L, Lisbona R. Skeletal Imaging. Appleton-Century-Crofts, 1984.
3) Resnick D. Bone and Joint Imaging. W.B. Saunders, 1989.
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