Generalized Increased Bone Density



Generalized Increased Bone Density


Carol L. Andrews, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Physiologic Periosteal Reaction of Newborn (Mimic)


  • Renal Osteodystrophy (Healing)


  • Child Abuse (Mimic)


Less Common



  • Sickle Cell Anemia: MSK Complications


  • Complications of Prostaglandins (Mimic)


  • Congenital Cyanotic Heart Disease


  • Complications of Vitamin A


  • Complications of Vitamin D


  • Scurvy (Mimic)


  • Neuroblastoma (Mimic)


  • Leukemia (Mimic)


  • Osteomyelitis


Rare but Important



  • Caffey Disease (Infantile Cortical Hyperostosis) (Mimic)


  • Idiopathic Hypercalcemia of Infancy


  • Erythroblastosis Fetalis


  • Osteopetrosis


  • Pycnodysostosis


  • Polyostotic Fibrous Dysplasia


  • Hypoparathyroidism


  • Complications of Fluoride


  • Engelmann-Camurati Disease


  • Osteosclerotic Dysplasias


  • Hyperphosphatasia (Juvenile Paget)


  • Melorheostosis


  • Tuberous Sclerosis


  • Van Buchem Disease


  • Ribbing Disease


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Generalized density due to intrinsic alteration of bone vs. dense circumferential overlay of periosteal new bone


  • Hint: Consider age at presentation


  • Hint: May involve diaphysis, metaphysis, &/or epiphysis


Helpful Clues for Common Diagnoses



  • Physiologic Periosteal Reaction of Newborn (Mimic)



    • Seen in 35% of infants age 1-4 months


    • Thin, uniform symmetric periosteal new bone; in humerus, femur, tibia


  • Renal Osteodystrophy (Healing)



    • Patchy sclerosis as unmineralized osteoid (osteomalacia) calcifies and bone resorption (hyperparathyroidism) heals


    • Coarsened trabeculae, periosteal new bone, widened metaphyses


  • Child Abuse (Mimic)



    • Average age: 1-4 years


    • Fractures of varying ages, metaphyseal corner fractures, periosteal new bone


Helpful Clues for Less Common Diagnoses



  • Sickle Cell Anemia: MSK Complications



    • Bone pain begins after age 2-3


    • Multiple bone infarctions may create “bone within bone” appearance


    • Long bone periostitis and generalized patchy increased density


  • Complications of Prostaglandins (Mimic)



    • IV prostaglandins used in ductus-dependent congenital heart disease


    • Soft tissue swelling, periosteal elevation, and extensive periosteal new bone


  • Congenital Cyanotic Heart Disease



    • Represents 2° hypertrophic osteoarthropathy


    • Thick, widespread periostitis in diaphysis, metaphysis, and epiphysis


  • Complications of Vitamin A



    • Excessive intake; occurs after age 1


    • Cortical thickening, soft tissue nodules


    • Involves ulna, metatarsal, clavicle, tibia, other tubular bones, ribs


  • Complications of Vitamin D



    • Excessive intake; given for rickets


    • Dense metaphyseal bands; variable cortical thickening and thinning


  • Scurvy (Mimic)



    • Occurs later than 8 months of age


    • Typically osteopenic but coarsened trabeculae, subperiosteal hemorrhage, and periosteal new bone may dominate


  • Neuroblastoma (Mimic)



    • Typically aggressive osteolytic process but may have periostitis & periosteal new bone


  • Leukemia (Mimic)



    • Similar to neuroblastoma, particularly metadiaphyseal


  • Osteomyelitis



    • Congenital syphilis-transplacental




      • Symmetric diaphyseal periosteal reaction; widened, serrated metaphysis; epiphyses spared


    • Rubella: 1st trimester maternal infection



      • Irregular, alternating sclerotic and lytic areas create “celery stick” pattern


Helpful Clues for Rare Diagnoses

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Generalized Increased Bone Density

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