UW MSK Resident Projects
University of Washington, UWMC Roosevelt Clinic, Musculoskeletal Radiology




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Posted by adam_myhre@yahoo.com, 1/20/04 at 8:49:38 AM.

What is it?

Parathyroid hormone is the main hormone that maintains a balance of calcium and phosphate in our bodies.  When released, parathyroid hormone increases the release of calcium from the bone, reabsorption from the kidney, and secondarily stimulates absorption of calcium from the intestines.  It also stimulates secretion of phosphate in the kidney.  Hyperparathyroidism is the abnormal secretion of parathyroid hormone.


Clinical findings:

The classic medical school clinical findings are "Stones, Bones, abdominal moans, and psychiatric overtones," referring to renal calculi, bone pain, peptic ulcers, pancreatitis, and CNS symptoms (confusion lethargy, weakness).  Depending on the etiology, the serum calcium may be elevated and phosphate may be decreased.




Primary Hyperparathyroidism

Excessive parathyroid hormone due to a parathyroid gland abnormality

80% parathyroid adenoma

12% parathyroid hyperplasia (rarely from Multiple endocrine neoplasia)

1-3% parathyroid carcinoma


Secondary Hyperparathyroidism

Excessive parathyroid hormone due to an abnormality elsewhere in the body.

Most often this is from chronic renal failure where elevated phosphate and +/- decreased calcium lead to chronic stimulation of the parathyroid gland. 


Tertiary Hyperparathyroidism

Excessive parathyroid hormone due to autonomous secretion of parathyroid hormone.

Often this is from prolonged secondary hyperparathyroidism from renal failure.  Then, when the patient receives a renal transplant, cause of the secondary hyperparathyroidism is taken away, but the parathyroid glands continue to over secrete parathyroid hormone.


Radiology of Hyperparathyroidism


Osteopenia and bone demineralization are present in all forms of hyperparathyroidism


Subperiosteal resorption is virtually pathognomonic for hyperparathyroidism and is typically seen at the radial aspect of the middle phalanx of the index and middle fingers


Hyperparathyroidism hand1:

Figure 1: Subperiosteal resorption as well as acroosteolysis, the next sign of hyperparathyroidism


Hyperparathyroidism hand8:

Figure 2: Subperiosteal resorption in a child


hyperparathyroidism finger:         hyperparathyroidism finger post:

Figure 3: Compare the finger on a patient with hyperparathyroidism, to his normal appearing finger after treatment


Phalangeal tuff resorption/acroosteolysis


Hyperparathyroidism hand2:

Figure 4: Acroosteolysis (also subperiosteal resorption)


Acroosteolysis differential diagnosis Mnemonic from The Primer:  

(Presented because I can never remember it)



Injury (thermal/frostbite)

Neuropathy (congenital insensitivity to pain, diabetes, leprosy, myelomeningocele)

Collagen vascular disease (Scleroderma, Raynaud's)


Familial (Hadju-Cheney)

Other (Polyvinyl chloride exposure, snake/scorpion venom)


Subchondral resorption

Sacroiliac joints

Distal clavicle

Pubic symphysis




Salt and pepper skull


salt pepper skull:

Figure 5: Salt and pepper skull


salt pepper skull post:

Figure 6: Normal skull in the same patient following treatment of hyperparathyroidism


Brown Tumor

Brown tumors are more common in patients with primary hyperparathyroidism, however, due to the increased prevalence of secondary hyperparathyroidism, there are more brown tumors from secondary hyperparathyroidism than form primary hyperparathyroidism.  It is difficult to differentiate a Brown Tumor from a giant cell tumor or fibrous dysplasia; however, other signs of hyperparathyroidism should be present.


Hyperparathyroidism hand3:

Figure 7:  Brown tumor in the phalanx (also subperiosteal resorption, tuft resorption, and osteopenia)


brown tumor:

Figure 8: Brown tumor in the inferior obturator ramus


Soft tissue calcification 

Primary > Secondary



Secondary > Primary


Triangular fibrocartilage

Symphysis Pubis





Secondary > Primary



Secondary > Primary


Tendon and ligament laxity

May lead to rupture


Renal osteodystrophy

General term for the radiology changes associated with renal failure


Secondary hyperparathyroidism (as describe above)


Also includes:

Osteomalacia (Normal osteoid, abnormal mineralization)

1.  Demineralized coarsened bones

2.  Looser's zones

           Axillary margin of the scapula

           Inner femoral neck


           Pubic and ischial rami


Looser's zones:

Figure 9: Looser's zones in the inferior femoral neck



Rugger Jersey spine


Rugger Jersey:

Figure 10: Rugger Jersey spine


Soft tissue calcification

Vascular calcification





Drs. Escobedo's, Hunter's, and Richardson's teaching files.




Cooper KL.  Radiology of metabolic bone disease.  Endocrinology Metabolism Clinics of North America.  1989; 18(4): 955-76.


Manaster BJ, et al.  Musculoskeletal Imaging: the Requisites. Second Edition.  Mosby, 2002.


Weissleder R, et al.  Primer of Diagnostic Imaging. Second Edition.  Mosby, 1997.





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