Parathyroid hormone in orthopaedics

Parathyroid hormone in orthopaedics

• regulator of calcium exchange
• fall in plasma ionized calcium stimulates production – vice versa
• Target organs
• Kidney
  • renal tubules
    • decreases PO₄ absorption – inhibits reabsorption
    • increases Ca absorption
  • renal parenchyma
    • Vit D hydoroxylation from 25 OH to 1.25 OH increased
• bone
  • bone erosion – osteoclasts – release Ca, PO₄ into blood
• gut
• increased Ca absorption d/t to increased 1.25OH in kidney

Pathology

• hypercalcemia – increase GFR of Ca – hyper calciuria – calcinosis – stone formation – recurrent infection – impaired kidney function
• hyper phosphaturia
• bones
  • osteoporosis and erosions

Clinical features

• General
  • tiredness – dehydration - depression
• Bone
  • bone pain
• Renal
  • renal colic – polyuria - nocturia
• Others
  • abdominal pain – chondro calcinosis – corneal calcification – ectopic calcification

Hyperparathyroidism

• Causes
  • primary
    • parathyroid adenoma
  • secondary
    • to compensate for long standing hypocalcemia ( renal failure, Vit D deficiencies) turning – raised PTH – S. Ca but normal or decreased
      • PTH normal when hypocalcemia corrected
  • tertiary
    • autonomous parathyroid hyperplasia – after long standing secondary hyperparathyroidism ( renal failure)
      • plasma Ca and PO₄ elevated
      • treated by parathyroidectomy
• Bony changes in parathyroidism
  • increased in ratio of osteoclast to osteoblast
  • decreased collagen by osteoblast
  • resorption of osseous tissue
• Types of resorption
  • subperiosteal
  • intra cortical
  • endosteal
  • subligamentous
• subperiosteal erosion
  • diagnostic
  • most frequent along radial aspect of II phalanx of middle finger and index finger
  • medial aspect of proximal tibia, femur, humerus, margin of rib,laminar dura
• intra cortical erosion
  • osteoclastic
  • X ray – intra cortical linear striations
  • II MC is most common site
  • salt and pepper skull ( granular appearance with loss of trabecular detail) – difference between outer and inner table of skull lost
  • Brown tumors
    • localized accumalation of fibrous tissue and giant cells
    • replaces bone and produce osseous expansion – also may undergo necrosis, liquefaction producing cyst
    • single or multiple well defined lesion – axial or appendicular – eccentric or cortical
    • facial bones, pelvis, ribs, femur
    • Rugger jersy spine
• Endosteal bone resorption
  • osteoclastic resorption
  • endosteal surface of hand bones
  • localized – scalloped – along inner margins of cortex
• Subligamentous bone resorption
  • multiple sites – frequent in joints of axial skeleton – sacroiliac, sternoclavicular, acromioclavicular
  • knee joint may be

Treatment

• orthopaedic treatment - protecting soft bone from deforming stress and strain
• # - ORIF
• after the disease progression arrested – recalcification occurs – deformity corrected by osteotomy

Prognosis

• good prognosis - after parathyroidectomy – bone pain immediately abolished
• rapid and progressive healing of bones after removal of tumor

Hypoparathyroidism

• hereditary or primary
• acquired
  • removal of parathyroid gland in thyroidectomy
• pseudo
  • deficiency of end organ response to PTH
  • hyperplasia of PTH gland – increased PTH
• Symptoms and signs

• hypocalcemic tetany
• muscle excitability
• Chovstik's or Troussoeu sign positive

• Treatment
  • administering PTH and calciferol
  • milk restriction
  • calcium supplementation – parenteral in tetany

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