Diagnostic Imaging of Paget's Disease

1. Musculoskeletal
Paget's Disease

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Paget's Disease (Osteitis
Deformans)
a) Incidence
b) Location
c) Types
d) Radiographic Features

7. a) Incidence :
-Chronic bone disorder characterised by
excessive abnormal bone remodelling
-It is relatively common in older adults, can
affect up to 4% of individuals over 40 and
up to 11% over the age of 80
-Usually polyostotic and asymmetrical

8. b) Location :
-Pelvis
-Spine
-Skull
-Proximal long bone

9. c) Types :
1-Active phase (lytic phase, osteoclastic activity):
-Aggressive bone resorption : lytic lesions with
sharp borders that destroy cortex and advance
along the shaft (candle flame, blade of grass)
2-Inactive phase (quiescent phase, osteoblastic
activity) :
-New bone formation and sclerosis : thickening of
cortex and coarse trabeculations
3-Mixed pattern (lytic and sclerotic phases
coexist) :
-Bowing of bones becomes a prominent feature

10. d) Radiographic Features :
1-Classic Triad
2-Pelvis
3-Spine
4-Skull
5-Long Bones

11. 1-Classic Triad :
-Thickening of the cortex
-Accentuation of the trabecular pattern
-Increased size of bone

12. 2-Pelvis :
-Thickening of iliopubic (iliopectineal),
ilioischial lines (early signs)
-Thickening of trabeculae
-Protrusio acetabuli (acetabular protrusion),
intrapelvic displacement of the medial wall
of the acetabulum

15. Cortical thickening of the pelvic bones seen more along the bilateral ilioischial
lines as well as thickening of trabeculations

16. Normal Pelvis Protrusio Acetabuli

17. Bilateral acetabular protrusio (white arrows) , the femoral head should not extend medial to a line
drawn from the lateral aspect of the pelvis and the lateral aspect of the obturator foramen (blue
line) , The distance between the acetabulum and the ilioischial line (yellow arrow) should not be >
3mm in males and >6 mm in females

18. -N.B. :
Causes of Protrusio Acetabuli :
My PROTRUSIO
1-Marfan syndrome
2-Paget’s disease , Primary protrusio acetabuli
3-Rheumatoid arthritis
4-Osteogenesis imperfecta
5-Trauma
6-Rickets
7-Unknown (idiopathic)
8-S , Psoriatic arthritis
9-Inflammatory arthritis (ankylosing spondylitis)
10-Osteomalacia

19. 3-Spine :
-Picture frame vertebral body : enlarged
square vertebral body with peripheral thick
trabeculae and inner lucency (increased
opacity of the cortex on all sides of the
vertebral body whereas the characteristic
sclerosis of the rugger jersey spine is seen
only at the superior and inferior endplates)
-Ivory vertebra

20. Picture frame vertebral body

21. Picture frame Rugger jersey

22. Sandwich vertebra Rugger-jersey picture frame
(Osteopetrosis) (HPT) (Paget’s)

23. 4-Skull :
-Osteoporosis circumscripta : osteolytic phase,
commonly seen in frontal bone (radiolucent
regions of the skull on plain film)
-Cotton-wool appearance : mixed lytic-sclerotic
lesions
-Inner and outer table involved : diploic widening
-Basilar invagination with narrowing of foramen
magnum : cord compression
-Neural foramen at base of skull may be
narrowed : hearing loss, facial palsy & blindness

24. *N.B. :
Causes of basilar invagination :
a) Congenital :
1-Osteogenesis imperfecta
2-Achondroplasia
3-Cleidocranial dysplasia
4-Chiari I & II malformations
5-Klippel-Feil syndrome
b) Acquired : (HOPR)
1-Rheumatoid arthritis
2-Paget's disease
3-Hyperparathyroidism
4-Osteomalacia / rickets

25. Osteoporosis circumscripta of frontal bone is lytic phase of Paget's disease

26. Osteoporosis circumscripta

27. Lateral skull radiograph shows a large geographic, lytic lesion in the left
frontal bone (blue arrows). Also seen are islands of bone (white
arrows) producing a "cotton-wool" appearance

28. Osteoporosis circumscripta

29. Cotton wool sign

30. Cotton wool sign

34. 5-Long Bones :
-Thickening of cortex and enlargement of
bone
-Candle flame (Blade of grass) : V-shaped
lytic lesion advancing into diaphysis
-Lateral curvature of femur
-Anterior curvature of tibia (commonly
resulting in fracture)

35. V-shaped lucency (white arrow) in metaphysis of femur from the lytic phase of
Paget disease