Radiology of Osteoporosis Thomas M. Link, MD, PhD  Canadian Association of Radiologists Journal  Volume 67, Issue 1, Pages 28-40 (February 2016) DOI: 10.1016/j.carj.2015.02.002 Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 1 Lateral chest radiograph of a 71-year-old man with a grade 2 osteoporotic vertebral fracture at T11 with 35% height loss measured by dividing the height of the posterior border of the vertebral body by the anterior height (white lines). These fractures can be easily missed but are clinically very significant as they may be an indication for medical treatment of osteoporosis. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 2 Axial computed tomography of the sacrum obtained more superior (A) and more inferior (B) in a 68-year-old woman with low back pain. The left sacral ala shows areas of increased density, which are consistent with remote insufficiency fractures (long arrows) while the right sacral ala shows fracture lines anterior in the sacrum (short arrows) without significantly increased density superiorly (A) and mildly increased density inferiorly (B). Due to demineralization fracture lines extending through the right sacral ala are not sufficiently visualized. Magnetic resonance imaging would be more sensitive to demonstrate the true extent of the sacral fracture. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 3 Coronal T1-weighted fast spin-echo (A) and short tau inversion recovery (STIR) (B) sequences of the sacro-iliac joints in a 70-year-old woman with bilateral chronic insufficiency fractures of the sacrum. T1-weighted sequences show the fracture lines along with diffusely low signal along the sacro-iliac joints (arrows). STIR sequences show a mix of bright signal (bone marrow oedema pattern, small arrows) and low signal (sclerotic bone, long arrows). Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 4 Sequential radiographs (A, C) and magnetic resonance imaging (MRI) of the pelvis (B) in a 75-year-old woman with a right hip hemiarthroplasty and a left pubic symphysis insufficiency fracture. Initial radiograph (A) was obtained after low energy fall from less than standing height and persistent pain. Suspicion for fracture led to the MRI, which demonstrated a mildly displaced and impacted superior pubic ramus fracture (B). Radiograph obtained 3 months after the fall shows healing pubic symphysis fracture with callus formation. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 5 Anteroposterior, weight-bearing radiograph (A) and coronal fat-saturated intermediated fast spin-echo sequence (B) of the left knee in a 76-year-old man with increasing medial-sided knee pain since 3 months. The radiograph does not show any deformity but medial joint space narrowing and osteophytes, consistent with moderate osteoarthritis. The magnetic resonance imaging shows a subchondral, low intensity line consistent with an insufficiency fracture (arrows) and adjacent, extensive bone marrow oedema pattern. Findings are consistent with increased bone fragility associated with altered biomechanical loading related to medial meniscal abnormality (medial meniscus body is diminutive and torn). Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 6 Anteroposterior left proximal femur radiographs in 72-year-old woman with 8 years of bisphosphonate therapy. Baseline radiograph (A) shows focal cortical prominence consistent with developing, atypical subtrochanteric stress fracture. One month later the subtle cortical thickening has progressed to a complete fracture with the typical medial spike (arrow in B). The atypical subtrochanteric fracture was treated with a long gamma nail with interlocking screw (C). Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 7 Dual-energy x-ray absorptiometry study of the lumbar spine (A), the proximal femur (B) and the distal radius (C) obtained in a 74-year-old woman with osteoporotic bone mineral density (BMD). The diagnosis is made using the lowest t score from L1-4, femoral neck, total femur (consists of femoral neck, trochanteric, and intertrochanteric region, shown in blue), and one-third distal radius regions (shown in blue). In this patient the t score of the lumbar spine was –2.7, of the neck –2.7, of the total femur –2.4, and –2.6 of the one-third distal radius region. Image A also shows previous BMD measurements obtained at age 71 and 73 years; BMD is stable without significant change. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 8 Quantitative computed tomography obtained in a 73-year-old woman with osteopenic bone mineral density (BMD). Image (A) shows the axial CT image with the calibration phantom (arrow) at the level of L1. (B) The oval region of interest (arrow) in the axial image, and (C) the analysed volume in the sagittal plane and (D) in the coronal plane. BMD was calculated as 101.6 mg/mL, consistent with osteopenic BMD. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 9 High-resolution peripheral quantitative computed tomography image of the distal tibia in a 58-year-old woman with type 2 diabetes and fragility fracture. Note high detail of trabecular bone architecture visualization and increased cortical porosity (arrows), which is a typical finding associated with diabetic fragility fractures. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 10 Sagittal short tau inversion recovery sequences of the lumbar spine in a 77-year-old man with osteoporotic vertebral fractures and kyphoplasties. Initially (A) the patient had a L3 osteoporotic fracture (arrow) which was treated with kyphoplasty (asterisk in B). (B) also shows 2 subsequent, new vertebral fractures of L4 and L5 that developed 7 weeks after the initial kyphoplasty. Image C was obtained 5 weeks after the second kyphoplasty (L4 and L5) (asterisks) and demonstrates 2 new fractures at T12 and L1 (arrows). Image D was performed 3 weeks after subsequent T12 and L1 kyphoplasty (asterisks) and shows also mild new T11 fracture with bone marrow oedema pattern along the endplate (arrow). Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 11 Sacroplasty performed with fluoroscopy guidance, bone cement is located in the left sacrum (arrows in A and B). Computed tomography obtained in a prone position demonstrates bone cement in close proximity to the sacro-iliac joint (arrow in C), where insufficiency fractures are typically located. Images courtesy of Dr Peter Munk, Department of Radiology, Vancouver General Hospital, University of British Columbia. Canadian Association of Radiologists Journal 2016 67, 28-40DOI: (10.1016/j.carj.2015.02.002) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions