Imaging of Musculoskeletal Disorders
Other metabolic bone disease

Key points

  • Pseudofractures (Looser’s zones) are a radiological sign of osteomalacia
  • The main features of Paget’s disease are bone expansion and coarsening of the trabecular pattern
  • Neuropathic arthropathy/Charcot disease most commonly affects the foot in diabetics

Osteoporosis is the most common metabolic disease of bone - see previous page.

Other metabolic diseases affecting the bones and joint include osteomalacia, Paget’s disease, and neuropathic arthropathy (also known as Charcot’s disease).

Osteomalacia

The hallmark sign of osteomalacia is the development of pseudofractures, most commonly seen at the medial edge of the femoral neck. These are lucent lines passing part of the way into the bone, but without crossing the whole bone, and surrounding sclerosis.

Pseudofractures are also known as ‘Looser’s zones’.

Osteomalacia related pseudofracture/Looser’s zone

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Osteomalacia related pseudofracture/Looser’s zone

  • A line passes into the femoral neck, but not across it
  • Increased bone density surrounds this line due to healing
  • The patient had hip pain without a history of trauma
  • These are typical features of a pseudofracture/Looser's zone

Paget’s disease

The cardinal features of Paget’s disease are bone expansion and coarsening of the trabecular pattern. Bones affected may become deformed and they have a higher risk of fracturing and of developing osteosarcoma.

Paget’s is usually seen in its chronic form with involvement of the entire bone it affects. It is most often found incidentally as an asymptomatic finding on an X-ray, but it may be painful in its active stage or if it involves a joint surface.

Paget’s disease - Femur

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Paget’s disease - Femur

  • The femur is expanded with thickening of the cortex and a coarsening of the trabecular pattern
  • The shaft of the femur is deformed
  • Compare with the normal femur (inset)

Paget’s disease – Hemipelvis – Bone scan

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Paget’s disease – Hemipelvis – Bone scan

  • A bone scan was performed in this patient who had an unexplained raised serum alkaline phosphatase
  • The right hemi-pelvis shows increased uptake of the radionuclide marker
  • An X-ray was performed (see image below)

Paget’s disease – Hemipelvis – X-ray

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Paget’s disease – Hemipelvis – X-ray

  • (Same patient as bone scan image above)
  • The entire right hemipelvis appears abnormal – compare with the normal left hemipelvis
  • The cortex is thickened, and the trabecular pattern is coarsened
  • The whole bone is involved

Neuropathic arthropathy/Charcot disease

Peripheral neuropathy causes loss of sensation which can lead to severe secondary degenerative changes in joints.

This neuropathic arthropathy, or Charcot’s disease, is commonly seen in the feet of patients with chronic diabetes. Continued weight-bearing on the insensate foot joints can lead to dislocation and collapse of the arch of the foot.

Charcot foot - Lateral view

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Charcot foot - Lateral view

  • Normal foot shown for comparison
  • The lower image shows collapse of the arch of the foot
  • Despite the severe deformity this diabetic patient had no pain in the foot
  • (Same patient as in image below)

Charcot foot - Dorso-Plantar view

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Charcot foot - Dorso-Plantar view

  • (Same patient as in image above)
  • Normal foot shown for comparison
  • The bones are no longer aligned correctly
  • Arterial calcification is another feature commonly seen on X-rays in patients with diabetes

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Page edited by: Dr Richard Smith BSc MSc MBBS FRCP PGDip - Consultant Rheumatologist (Read bio)

Last reviewed: January 2020