Top 6 tips for imaging

osteoporosis

James F Griffith
Department of Imaging and Interventional Radiology
Prince of Wales Hospital
 World population is aging

In 2017, sale of adult

diapers outsold baby
diapers in Japan

“When you’re young, you go out in search of

trouble.
When you’re old, trouble comes to find you”
Beverly Sills, American soprano, 1929–2007
 Osteoporotic (insufficiency) fracture

Hip

Vertebral
Frequency

Distal Radius

Distal Radius
Vertebral
Hip

20 30 40 50 60 70 80 90 100
 # 1: Know significance of an
insufficiency fracture

Presence of insufficiency fracture

provides much stronger, more direct
evidence of bone strenght than DXA
 Why is vertebral fracture important?

 Usually first osteoporotic fracture

 Predicts future fracture
 Absolute measure of reduced bone strength
 # 2: Know the relationship between an
insufficiency fracture and BMD

Most people with vertebral or

other insufficiency fracture have
normal BMD or osteopenia on DXA
 Females aged 50-75 years
50 450
Fracture risk
Fracture Risk (no./1000 person-yr)

45 400

No. of women with fractures

40
35
Fracture 350

300
30 BMD distribution 250
25
200
20
150
15
10 100

5 50

0 0
1.0 -1.0 -2.5
normal low bone mass osteoporosis
‘osteopenia’
 Golfers

Hole-in-one likelihood
Hole-in-one
Hole-in one likelihood

Handicap distribution

35 20 10
Poor golfer Average Good golfer
golfer
 #3. Know how to diagnose a vertebral
fracture
1. Loss of vertebral height 2. Deformity
>20%↓
Scoliosis

Fracture

Fracture
 Physiological wedging & Short
Vertebral Height (SVH)

Physiological wedging SVH

Scheuermann Disease
 Endplate irregularity

 Reduced vertebral height

 Increased AP diameter

 Accelerated disc degeneration

Schmorl’s Node
 Vertebral fracture grading
normal mild moderate severe

<20%↓ 20-25%↓ 25-40%↓ >40%↓

Vertebral Fracture Cascade
 Risk of further fracture is much
greater in those with severe
fractures initially and in those with
multiple fractures
 #4. Recognize osteolysis as feature of
healing of some insufficiency fractures

Intravertebral osteonecrosis Pubic body

“Kummel disease’ osteolysis

Excessive osteolysis of insufficiency fracture

 Rapid destructive arthropathy (RDA)

Excessive osteolysis of insufficiency fracture

 Excessive osteolysis

Pubic body RDA Milwaukee

osteolysis shoulder
Excessive osteolysis of insufficiency fracture
# 5: Recognise exuberant callus as
healing feature in insufficiency fracture
 Insufficiency fracture healing

Presentation 4 months later

 Healing with exuberant callus

Presentation 3 months 10 months

# 6: Know how to distinguish osteoporotic
from malignant vertebral fracture

Osteoporotic Malignant
1/3 of vertebral fractures in patients with metastatic
disease are due to osteoporosis and not malignancy
Difficult to distingish metastatic from
osteoporotic fractures on radiography
 Favour osteoporotic fracture

Fat preservation Triangular-shaped fragment

 Chemical shift imaging Schmeel FC et al
57 patients with vertebral fracture
All fractures < 30 days old, mean 9 ± 8 days
Osteoporotic Malignant
Vertebral fracture fat fraction (%) 24.0 ±12.0 3.5 ±3.5
Normal vertebral body fat fraction (%) 50.5 ±12.0 39.0 ±15.0

Fat fraction ratio (fracture Vs normal) 0.5 ±0.2 0.1±0.1

< 9% fat fraction Sensitivity 96%

Malignant : Specificity 89%
< 0.2 fat fraction ratio

Schmeel FC et al Eur Radiol. 2018

Suh CH, et al (Meta-Analysis). AJR 2018
Examples: mDIXON sequence

Fat fraction 18%

= osteoporotic

Fat fraction 1.8%

= malignant

< 9% fat fraction

Malignant:
< 0.2 fat fraction ratio
 Favour osteoporotic fracture

Fracture line, fluid or gas No pedicle involvement

 MR features of osteoporotic fracture

 Fat preservation
 Fracture line, fluid or gas
 No extension to pedicles
 No large paravertebral mass
 Preservation of trabeculae on CT

benign malignant
 Contrast not helpful

T1 FS + C

Acute and subacute fractures will enhance

 ? Osteoporotic or metastatic

82–year-old
Ca stomach
 Favour osteoporotic fracture

→ severe osteoporotic fracture

Acute & subacute fractures will ↑ metabolic activity

Insuffiency fracture / ↑metabolism
 CONCLUSION
 Insufficiency fracture = absolute measure of
reduced bone strength

 Excessive osteolysis
 Exuberant callus

 MR can distinguish benign versus malignant

fractures with high level of certainly
 Expect healing vertebral fractures to enhance and
show low to moderate levels of metabolic activity
“MSK IMAGING: 2020 VISION”
Thank you
 # 8: Appreciate DXA issues

 Precision error
Lumbar spine 2.0%
Femoral neck 2.5 %
Total hip 2.0%

 Least significant change (precision error x 2.77)

Lumbar spine 5.0%
Femoral neck 7.0%
Total hip 5.0%
 # 8: Appreciate DXA issues

 Typical DXA change 1-2% year

 In women > 65 years, follow-up should be
15 years if T-score is normal
5 years if T-score -1.49 to -1.99
1 year if T-score < -2.0

 Fast losers: steroids, perimenopausal, chronic inflammation,

immobility, depression, hormonal treatment

 Can repeat yearly or if on treatment

#8: Appreciate DXA issues
 Chemical shift imaging (CSI)

 Opposed-phase & in-phase imaging

 mDIXON sequence

 Sensitivity 96%

 Specificity 89%

…..at differentiating benign from malignant fracture