Parathyroid hormone in orthopaedics - DNB Orthopaedics MS Orthopedics MRCS Exam GUIDE -

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Monday 16 April 2018

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 POabsorption – 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
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  • 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
  • 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
  • orthopaedic treatment - protecting soft bone from deforming stress and strain
  • # - ORIF
  • after the disease progression arrested – recalcification occurs – deformity corrected by osteotomy
  • good prognosis - after parathyroidectomy – bone pain immediately abolished
  • rapid and progressive healing of bones after removal of tumor
  • 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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