Medical Theory on Orthopedics Combining Molecular Imaging with Clinical Practice

Soft tissue is defined as the supportive tissue of various organs,the term soft tissue tumors defines neoplasms derived from soft tissue. At the clinical level, a mass is the most common sign of a soft tissue tumor. However the clinical manifestations and signs of parathyroid adenoma are not in the neck at first. Some patient who's neck was normal at physical examination. Bone pain or dysfunction fractures are always the main reason for the parathyroid tumor patients to the hospital [1, 2]. Parathyroid tumor Figure 1 is an endocrine tumor, mainly associating with bone metabolism, so the patients go to the orthopedic department first. Although the parathyroid tumor is benign, However if patients do not get timely and accurate diagnosis and effective treatment(surgical removal of parathyroid adenoma),they will not only receive the delayed treatment, the decline of life quality,but also the disability, loss of ability to work, Increasing the burden on families and society. Figure2 Whole body bone scan: Parathyroid tumor lead to severe metabolic bone disease which causes the patient disabled.


Introduction
Soft tissue is defined as the supportive tissue of various organs,the term soft tissue tumors defines neoplasms derived from soft tissue.At the clinical level, a mass is the most common sign of a soft tissue tumor.However the clinical manifestations and signs of parathyroid adenoma are not in the neck at first.Some patient who's neck was normal at physical examination.Bone pain or dysfunction fractures are always the main reason for the parathyroid tumor patients to the hospital [1,2] .Parathyroid tumor Figure 1 is an endocrine tumor, mainly associating with bone metabolism, so the patients go to the orthopedic department first.Although the parathyroid tumor is benign, However if patients do not get timely and accurate diagnosis and effective treatment(surgical removal of parathyroid adenoma),they will not only receive the delayed treatment, the decline of life quality,but also the disability, loss of ability to work, Increasing the burden on families and society.Figure2 Whole body bone scan: Parathyroid tumor lead to severe metabolic bone disease which causes the patient disabled.Effective treatment for parathyroid tumors depends on timely, accurate diagnosis.Beijing Ji Shui Tan Hospital Peking University(JST) doctor Peng Jing Jing Primary academic contributions<Advancement in the Application of Nuclear Medicine> was published in Apr.2001 V7N4:59-61 Journal of "China Contemporary Medicine" reported the use of nuclear medicine that is molecular imaging of early diagnosis successful treatment of patients with parathyroid adenoma.The cases in clinical with SPECT for 99m Tc-MDP whole body bone scan and 99m Tc-MIBI parathyroid tumor imaging, in which patients receive timely diagnosis and successful treatment, recover and happy life [3] .In recent years, as the clinic study of new technology and equipment in bone-joint disorders, orthopedic clinical applications of molecular imaging and promotion of the Chinese doctors for parathyroid tumor diagnosis and treatment, as medical science has made a positive contribution [4] .The contribution showed typical diagnostic Imaging of hyperparathyroidism resulted in metabolic bone disease characteristic abnormalities Figure .3:1.The Black skull: increased uptake in calvaria and jawbone.2. Generalized increased uptake with increased contrast between bone and soft tissue due to bone turnover speed and subtracted kidney image.3. Tie sternum and Cage beads.4. Foci of increased uptake due to fracture or brown tumor in rib cage. 5. Decreased uptake brown tumor in the right ilium as doughnut .6. Whole body Bone scan patterns in advanced metabolic bone disease and insufficiency fracture in right neck of femur.There are two main features of metabolic bone disease due to hyperparathyroidism in 99m Tc-MDP bone imaging: (1) Increased uptake in calvaria and jawbone showed "the Black skull".
.Cited by Zhuhai City, Guangdong Province People's Hospital Chen Jiang lin etc. in Anthology of Medicine Apr.2006 [5] , the paper reported a case Qualitative and locational diagnosis with nuclear medicine of primary hyperparathyroidism and successful surgery of parathyroid adenoma: Peng Jingjing et al thought, there are two main features of metabolic bone disease due to hyperparathyroidism in 99m Tc-MDP bone imaging: (1) Bone scan is clear showed total body as "Super Scan"; (2) Increased uptake in calvaria and jawbone for 99m Tc-MDP showed "the Black skull".99m Tc-MIBI parathyroid tumor imaging not only can observe the shape and location, but also display hyper-functional status for parathyroid tumor.Achiever said: Primary hyperparathyroidism is rare in clinic.Because of occult onset and symptoms varied, misdiagnosis is made sometimes.A clear diagnosis of hyperparathyroidism and parathyroid tumors localization is the key for successful treatment.99m Tc-MDP bone scintigraphy and 99m Tc -MIBI parathyroid tumor imaging has certain advantages.To be used clinically, those principal achieves can reduce misdiagnosis of primary hyperparathyroidism.

Clinical features of parathyroid adenoma 2.1 Definition
Primary hyperparathyroidism incidence rate is about 27/100000 per year, of which 80% is parathyroid tumor, 20% is benign hyperplasia, and parathyroid carcinoma is extremely rare.Because of the parathyroid hormone (PTH) secretes more than the level required to maintain normal serum calcium concentration, bring about laboratory parameters abnormal shows hypercalcemia, hypophosphatemia, elevated alkaline phosphatase and parathyroid hormone increased.Clinical symptoms mainly in four systems 1. Bones--musculoskeletal symptoms: bone pain, dysfunction fractures; 2. Stones--symptoms of urinary system: history of kidney stones with pain; 3. Groans--digestive symptoms: abdominal discomfort, nausea, vomiting, dyspepsia and constipation; 4. Moans-neuropsychiatric symptoms: memory loss, depression, depressed.Diagnostic whole body bone scan image "Super scan" of hyperparathyroidism (HPT) metabolic bone disease Early parathyroid adenoma causing bone metabolism changes in 99m Tc-MDP whole body bone scan image is generalized increased uptake with characterized by the "black skull" and very clearly as "super scan" which give expression to increased contrast between bone and soft tissue due to bone turnover speed and active bone metabolism.Metabolic bone disease with HPTdifferent from metastasis imaging Differential point in whole body bone scan image between "super scan" of HPT metabolic bone disease and wide range of bone metastasis is: HPT metabolic bone disease "super scan" is general uniformity high uptake in the axial skeleton and limb bones (Figure 5); and features of bone metastasis "super scan" are: high uptake of the mainly axial skeleton (Figure 6) and proximal limb bone, with point like lesions of radioactive concentration.Figure 5: "Super scan" with HPT metabolic bone disease Figure 6: "Super scan" with extensive bone metastases Fig. 5. "Super scan" with HPT metabolic bone disease Fig. 6. "Super scan" with extensive bone metastases www.intechopen.com

Fracture and brown tumor
The Patient with proceeding of parathyroid tumors, X-ray radiograph shows bone resorption caused by osteoclast, and lacy cortical thinning leading to subperiosteal bone resorption, typical in middle phalanx radial side of index finger and middle finger.Radiology images can also show brown tumor formed by micro-fracture bleeding, local accumulation of macrophages, and replacement of fibrous tissue.Brown tumor and fractures in the whole body bone scan images showed localized uptake.Large fibrocystic changes (brown tumor) can be expressed as a radioactive defect of the "cold zone" (Figure 2, the anteposition imaging shows: brown tumor in right ilium).

Preoperative localization of parathyroid adenoma
B-ultrasonic examination: after the diagnosis of HPT metabolic bone diseases, neck ultrasound is a simple and preferred method to localize the parathyroid tumors.99m Tc-MIBI parathyroid tumor imaging: after the diagnosis of HPT metabolic bone diseases, the SPECT 99m Tc-MIBI double-phase parathyroid tumor imaging is helpful to the localization diagnosis of parathyroid adenoma (especially ectopic parathyroid adenoma) which is prepared for surgical removal.

Clinical diagnosis of parathyroid adenoma
1. Clinical manifestations of parathyroid adenoma have diversity.There are four mainly symptoms: skeletal system, urinary tract stones, neuropsychiatric system and digestive symptoms.Bone pain and fracture is the most common complained of.Therefore, physicians and surgeons should have a basic consciousness with the diagnosis of parathyroid tumors, such as patients with long kidney stones history, have symptoms of bone pain or fractures.2. Laboratory test is helpful to the diagnosis of hyperparathyroidism: calcium, phosphorus, alkaline phosphatase (AKP) and parathyroid hormone (PTH) was abnormal.3. The recognition characteristic image of the "super scan " of hyperparathyroidism in 99m Tc-MDP whole body bone scan is very important.4. Neck ultrasonography and 99m Tc-MIBI double-phase parathyroid imaging can diagnose and localize parathyroid tumor clearly, which contribute to parathyroid tumor surgery.

Advancement in fundamental researches
New concept of orthopedic molecular imaging International medical imaging community reached a consensus on the "molecular imaging" definition In June 2007: 1. "Molecular imaging" is the imaging embodiment for the molecular level; 2. "molecular imaging" observed living body (human or animal) in vivo,which can provided dynamic observation time-varying continuously.3. "molecular imaging" can be detected by means of instruments (such as PCT/CT and MRI, etc. equipment) and can be quantitative.The theoretical development of orthopedic molecular imaging was based on the new understanding of bone anatomy and physiology.Bone structure of normal adult bone can be summarized in four categories [6] : Gross level The skeleton consists of two major parts, the axial skeleton includes the skull, spine and rib cage (ribs and sternum), while the appendicular skeleton includes the bones of the extremities, pelvic girdle and pectoral girdle (clavicles and scapulae) Tissue level Bone is divided into two types of tissues forming the skeleton: compact or cortical bone and cancelous, trabecular or spongy bone.The compact bone constitutes 80% of the skeletal mass.The appendicular skeleton is composed predominantly of contical bone.The cortical bone is thicker in the diaphysis.The blood supply to the metaphysic is rich.The spine is composed predominantly of cancellous bone in the body of the vertebra and compact bone in the endplates and posterior elements.The spongy bone has a turnover rate approximately eight times greater than the cortical bones and hosts hematopoietic cells and many blood cells.

Cellular lever
Three types of cells can be seen in bone: osteoblasts, which produce the organic bone matrix; osteocytes, which produce the inorganic matrix; osteoclasts, which are active in bone resorption.Osteoclasts are derived from the hemopoietic system, in contrast to the mesenchymal origin of osteoblasts.Osteocytes are derived from osteoblasts that have secreted bone matrix around themselves.Molecular level At the Molecular level, bone matrix is composed primarily of organic matrix (approximately 35%), including collagen and glycoproteins, and inorganic matrix (approximately 65%), which includes hydroxyapatite, cations (calcium, magnesium, sodium, potassium and strontium) and anions (fluoride, phosphorus and chloride).The calcium in inorganic matrix of bone provid hardness to withstand pressure, and the collagen fibers in organic components provide support and tension.99m Tc-MDP bone scan can embodiment changes in the pathogenesis of the human body on the molecular level, and it is detected by SPECT, three phase imaging for patient examine dynamic change with time varying and may performed semi-quantitative analysis for lesion,so bone scan is part of within the domain of molecular imaging [7] .Orthopedic Nuclear Medicine constitutes an important component of orthopedic molecular imaging.Recent Advances in Orthopedics Combined Medical Imaging with Clinical Practice are important to the development of molecular imaging and rich of content [8,9], [7,10] .For example, using isotopic tracer 99m Tc-MDP as a molecular probe we can tracer the oncology biological behavior of osteosarcoma [11] ,Bone scan can detect multiple lesions of osteosarcoma, show the lung,bone and lymph node metastasis FIGURE.7(A), and provide postoperative follow-up for painful body differential diagnosis recurrence from prosthetic loose FIGURE.7 (B) and efficacy evaluation of chemotherapy.Chemotherapy efficacy for osteosarcoma before operation may be evaluted by quantitative study of 18 F-FDG [12] , and 18 F-FDG imaging (SPECT/CT) to detect what primary carcinoma lesion is from and location for biopsy pathological confirmed diagnosis metastatic carcinoma [10] FIGURE.8, to solve the medical difficult problem.Primary Academic contributions to this project Application of Radionuclide Imaging in Osteosarcoma [11] Cited by Ruijin Hospital, Shanghai Jiao Tong University School of M e d i c i n e F e n g G u o -w e i e t c .t h e p a p e r r e p o r t e d a c a s e b o n e s c a n u p t a k e 99m Tc-MDP increased appearance in aggressive osteosarcoma with pleural,lung metastases demonstrated by operative pathological specimen [13] : Using SPECT Imaging and Molecular probe with tracer 99m Tc-MDP, After following up 133 patients with osteosarcoma,Peng Jingjing et al thought, 99m Tc-MDP SPECT images for detection of pulmonary and bone metastases and recurrent is useful, the usefulness of bone scintigraphy is overall, much earlier and sensitive than radiograph, X-ray and bone scan may complementary in favor of the patients diagnoses, treatment and follow up.Fig. 8. 18 F-FDG SPECT/CT detecting the primary carcinoma lesion and location for pathological confirmed lumbar spine metastatic carcinoma.99m Tc-MDP bone scan (left) seen in single lumbar spine bone tumor which by hospital after operation surgical pathology confirmed metastatic carcinoma, primary tumor is unknown.By 18 F-FDG SPECT / CT imaging (right) to detect the primary lesion, located in the liver, so the patient performed a specific liver therapy.
Of unknown primary tumor of bone metastases performed PET/CT scan is necessary because a variety of 18 F-FDG is a sensitive tracer of malignant tumor, to identify the primary tumor so that patients can receive timely treatment.Unknown primary metastatic tumors occur in approximately 5% to 6.5%, according to report at least 1 / 3 of patients with PET detected the primary lesion, in which patients receive accurate and timely treatment.

Application of molecular imaging in diagnosis of orthopedic diseases
In the difficult diagnosis of puzzle patients and treatment, bring forth diagnostic 99m Tc-MDP bone scan new ideas were a positive contribution to the patient healthcare.20 years ago, bone scan application was limited to multiple metastases.However in clinical practice, patients out of admiration for a famous, from all country came to Beijing JST Hospital whose first symptom are always bone pain and pathologic (or insufficiency) fractures.Difficult diagnosed patients were abnormal in bone scan, X-ray film, CT, or magnetic resonance imaging, but failed to identify problems .What is the real illness cause?Doctor must timely and accurate answers to diagnostic questions.JST' hospital doctors lived through a long period and careful clinical research, the cognitive level of medical images has improved and advancement, bring Molecular Imaging in Diagnosis of Orthopedic Diseases new ideas.We summed up the imaging features diagnosis law of parathyroid tumor, and differentiate diagnosis regular pattern from other some diseases on bone scan, used the scientific theory to guide clinical practice.
The patients complained of bone pain and reasons unknown fracture were diagnosed accurately by the bone scan.Patients diagnosed metabolic bone disease primary hyperparathyroidism were treated with surgically removing of parathyroidoma, metabolic bone diseases by secondary hyperparathyroidism such as renal osteopathy or Rickets went to department of internal medicine treatment.Patients diagnosed with Multiple myeloma were treated in the hematology department.Patients diagnosed with articular disease were treated in the orthopedics [14] or rheumatology department.Patients diagnosed with benign or malignant bone primary tumor or bone disease were treated in bone oncology or pediatrics orthopedic department.Importantly, which eliminate the burden of mind for the patients without serious diseases and let them life tend to happily.Application of the research findings for imaging diagnoses can not only exclude the difficulty and anxiety for patients and get the cure suitable timely, but also provide the effective way for acquire the best economy social performance.
The bone scans imaging differential diagnosis of parathyroid adenoma there are eight of typical image patterns which a doctor should be familiar with in clinical diagnoses.Have you had an knowledge of thereinafter imaging diagnoses Trained continued medical education [4] ?
"Super scan" caused by extensive bone and marrow metastasis is different from the one caused by metabolic bone disease with hyperparathyroidism.The metastasis' Super scan is characterized by diffuse uptake of lesions mainly located in the axial skeleton and proximal limbs, which can be spotty radioactivity concentration.
In hyperparathyroidism resulting in metabolic bone disease, "Super scan" is involving the entire bone."The black skull" is obviously.Radioactivity distributes diffusely and evenly.

Hypertrophic Osteoarthropathy
Hypertrophic Osteoarthropathy caused by Secondary form intrathoracic pathological condition which is a form of periostitis and may be painful.Tubular bones may show periosteal new bone formation.This pathological feature explains the typical bone scan pattern of diffusely increased uptake along the cortical margins of long bones giving the appearance of "parallel tracks".Note the diffusely increased uptake in all bones of the upper extremity and lower extremity with a parallel track pattern in the ulna-radius and tibiae.

Multiple Myeloma (MM)
Bone scan of MM shows "the same disease with different characteristics images".The patient's image can have many manifestations: multiple uptake Increase strip or banding, decreased uptake cold spot lesions [15] , which mainly distribute in the spine, pelvis, ribs, skull and proximal long bone.
In clinical work, some MM bone scan image does not show the bone destruction, so bone scan revealed no abnormalities.Imaging physicians and orthopedic surgeons should pay attention to the patient's complain for bone pain, considering for multiple myeloma.

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Patient's relevant laboratory tests, bone pain, anemia, infection and renal dysfunction and related organ or tissue damage (ROTI) should be recorded.Fig. 13.Multiple Myeloma (MM) multiple striping or banding increased uptake with Spinal is the most common image pattern and the typical image pattern of decreased uptake "Cold spot" lesions on 99m Tc-MDP Bone scan (Note the "Cold spot" lesions in sternum)

Fibrous dysplasia
Fibrous dysplasia is a benign bone disorder which remains essentially unchanged and can be seen in lesion of long duration.The lesions cause thining of the bone cortex and replacement marrow.The condition may present as solitary lesion (monostotic) or with multiple foci (polyostotic).
Polyostotic fibrous dysplasia may be associated with café-au-lait pigmentation and multiple endocrine hyperfunction, most commonly seen as precocious puberty in girls, Cushing's syndrome, and is called the McCune-Albrightzonght syndrome.
Standard radiographs show lucent areas with various amounts of ossification and cyst formation and may show expansion.Fibrous dysplasia, in general appears as an area of markedly increased uptake on 99m Tc-MDP bone scan.Whole body bone scan used for overlook the Fibrous dysplasia condition present as solitary lesion (monostotic) or with multiple foci (polyostotic).

Rheumatoid Arthritis
Rheumatoid Arthritis is the autoimmune disease causes inflammation of the connective tissue mainly in the joints.Synovitis activity is the dominant clinical variable that determines the therapeutic approachin patients with rheumatoid arthritis.99m Tc-MDP bone scan used for overlook the all joint to measure the condition present of synovitis activity and differential diagnosis from other diseases result in bone-joint pain.

Fig. 15. Rheumatoid Arthritis Synovitis activity
A 52 years old female patient, suffered from rheumatoid arthritis 4 years.The left knee was painful and deformed for six months.TKA was done.Whole body bone scan showed that left knee joint was after treated by replacement surgery, and rheumatoid arthritis (active phase) violated elbows, wrists, hands, hips, knees, feet and thoracic and lumbar spine with Increase uptake in the areas of the joints affected Synovitis activity.

Rickets
A 41-year-old male patient suffered from joint pain and back pain more than 5 years and lower limbs were weakness gradually 1 year.He could not go on the working.The patient suffered from intermittent back pain with no obvious incentive for 5 years, more severe in morning .It was also accompanied by joint stiffness, which reduced after the event, and did not affect the activities.Initially he was treated at a local hospital as rheumatoid arthritis, the pain releived.But in the past 2 years, the pain gradually got worse, double shoulder, hips, chest, leg were painful and weak.He was bound to bed, get up on stage difficultly.He was 7cm lower than he was young.

Paget's disease (Osteitis deformans)
A 54 years old male patient, complained of "left knee pain, glided into varus deformity leg 4 years, left muscle atrophy, walking inconvenience", were diagnosed as Paget's Osteitis by pathology.
Whole body bone scan showed characteristic bone expansion changes: left tibia was bending deformity; T4 vertebral body, left pelvis and tibia in the active stage of osteolysis which osteogenesis showed increased uptake.The radioactivity distribution of the left humerus was mild and uniform in sclerotic phase.Bone scintigraphy scan shows increased uptake in the left tibia with bending deformation, T4 and left pelvis with enlargement and bending deformans of the bones affected with lytic the active phase.The Left humerus shows no abnormal uptake of the radiopharmaceuticals with time on the sclerotic phase indicating a relatively inactive lesion.

Ensure patient safety preventing traumatic complication Acute Pulmonary Embolism (APE)
Beijing Ji Shui Tan Hospital is a large modern comprehensive hospital which focuses on 99m Tc-MAA Lung perfusion Imaging showed lung with morphologic abnormalities.Right lung was lobe and segmental perfusion defects, and left lung shows segmental perfusion defects (figure 18).With normal X-ray before surgery (Nov.18), V / Q diagnosis was doneacute pulmonary embolism.In the ICU ward the patient received anticoagulation and thrombolytic therapy. 2 weeks later (Dec.4), pulmonary perfusion imaging (Figure 19) was reviewed, the original lobe and segmental perfusion defects had been seen the distribution of perfusion and lung morphology was normal after effectively treatment.X-ray and ECG were normal too.The patient was pulled through by accurate diagnoses and effective treatment.This paper inspired Beijing Ji Shui Tan Hospital on the understanding and study of acute pulmonary embolism [16] .Doctors can see directly from the image: lower limb Thrombosis bring about post-traumatic pulmonary embolism is an important research topic.Early diagnosis and treatment for APE patients can prevent recurrent thromboembolism.It can improve the cure rate, reduce mortality and ensure medical safety of patients before and after surgery.The development of molecular imaging in China to follow simple, efficient, accurate principles, accuracy is the key [4] .The first time in the Hospital for patients with accurate diagnosis and effective treatment, cost savings, improved quality of life, to enjoy the development of medicine and science and technology progress in health benefits for the people.

Fig. 1 .
Fig. 1.Parathyroid adenoma The neck SPECT/CT scan function-anatomy fused Imaging reveals A focus of increased 99m Tc-MIBI activity at the posterior inferior of the right lobe of the thyroid which consistent with parathyroid adenoma

Figure 2 :
Figure 2: metabolic bone disease which causes the patient disabled

Fig. 2 .
Fig. 2. A 39 years-old woman complained of painful bone and joint for a long time with occurred fracture time and again.99m Tc-MDP Bone Scan shows: metabolic bone disease which causes the patient disabled.Her diagnosis is Parathyroid adenoma and she was performed a parathyroid adenoma ectomy in surgical operation.

Fig. 3 .
Fig. 3. Diagnostic Imaging of hyperparathyroidism resulted in metabolic bone disease characteristic abnormalities.

FIGURE. 7 Fig. 7 .
Fig. 7. Bone scan showed Osteosarcoma focus for 99m Tc-MDP positive imaging tracing metastases in bone and lymph node with surgical pathology confirmed (A) and recurrence indication after operation (B).

Fig. 10 .
Fig. 10.99m Tc -MIBI parathyroid tumor imaging 99m Tc-MIBI double-phase parathyroid tumor imaging: Early image (A)shows, the position and morphology of double-leaf thyroid were normal.The abnormal radioactive uptake can be seen on the right side below thyroid, the lower edge of which was close to the level of sternum .The size is about 3.8cm × 2.4cm.Delayed image (B) showed the thyroid image faded, and the oval-shaped abnormal lesion is still visible below the right side of thyroid.

Fig. 12 .
Fig. 12. Hypertrophic Pulmonary Osteoarthropathy:The parallel track pattern Hypertrophic Pulmonary Osteoarthropathy in a patient with left lung hilum mass.Note the diffusely increased uptake in all bones of the upper extremity and lower extremity with a parallel track pattern in the ulna-radius and tibiae.

Fig. 14 .
Fig. 14.Fibrous dysplasia (A) monostotic the right femur (B) polyostotic for whole body bone Bone scan image show intensely increased uptake in lesion bones.Whole body bone scan used for overlook the Fibrous dysplasia condition present as solitary lesion (monostotic) or with multiple foci (polyostotic).
Tests carried out and The results showed Serum calcium (Ca) 2.4mmol / L (2.25-2.75)Serum phosphorus (P) ↓ 0.53mmol / L (0.8-1.6) Alkaline phosphatase (AKP) ↑ 480 IU / L (25-90) Rheumatoid factor (RF)-negative HLA-B27-negative A/G were normal, renal function BUN, CRE, UA mused in the normal range.Spine X-ray showed osteoporosis.MRI reported suspected pelvis bone destruction.Whole body bone scan (Figure16) shows skeletal clearly: Bilateral ribs show multiple hot spots, as "beaded ribs"; the spine shows multiple vertebral collapse as strip change; The agent 99m Tc-MDP uptake in shoulders is increased, and the left is more; There are ribbon-like zones increased uptake in rib cage, pelvis, femora, tibia and metatarsals.Bone scintigraphy scan shows metabolic bone disease: A specific abnormality of the rickets is the presence of Looser's zones, also called Pseudofractures or Milkman's fractures.

Fig. 17 .
Fig. 17.Diagnostic Imaging of Paget's disease Orthopedic and traumatology.The surgical volume reached 35000 in 2009.Clinical research in medical imaging make a positive contribution for the protection of medical quality and patient safety, during the process of exploring critical and difficult orthopedic patients and optimize the efficacy of the diagnosis.The treatment of post-traumatic critically ill patients with acute pulmonary embolism (APE) In Nov. 10, 2000, a 56-year-old man fell from 3 meters high and got multiple traumas (Right hip fracture, fracture of the right pubis ischium branch, open comminuted fracture of the right olecranon).On Nov. 20, when the patient received second operation of open reduction and plate fixation for the right fracture acetabular under general anesthesia, he had chest tightness, shortness of breath, PaO 2 critical situation of declining.Orthopedic surgery was stopped and the rescue was implement in the ICU ward immediately.ECG shows sinus tachycardia and SⅠQⅢ T Ⅲ & V 1 rsr 'wave, which was believed to be acute pulmonary embolism.Lung perfusion ECT was done for the patient immediately in nuclear medicine department.

Fig. 18 .
Fig. 18.Lung perfusion imaging of post-traumatic acute pulmonary embolism Abnormal secretion of parathyroid hormone PTH leads to changes in bone metabolism in parathyroid tumor patients .Bone pain or dysfunction fracture are always the reason for patients to the hospital.There were many patients initially diagnosed with unilateral bone cyst (Brown tumor of fibrocystic changes in local radiology images), or misdiagnosed as bone metastases (bone scan imaging features were not yet understand).In order to accurate diagnosis and effective treatment for parathyroid tumor, it is very important to familiar with the differential diagnosis of bone scan, advances of orthopedic medical imaging basic research in molecular imaging and clinical application in bone tumors and disease as a starting point, the next section focus on the bone scan imaging features and differential diagnosis between parathyroid tumor metabolic bone disease and multiple myeloma, rickets etc. eight diseases, with the aim of doctor comprehend typical characteristic distinction.
Bone scintigraphy scan shows metabolic bone disease.Note there are ribbon-like zones multiple foci increased uptake in rib cage caused by pseudofractures on bone scans mimicking metastatic bone disease.This characterstic pseudofractures is one of specific abnormality of Rickets.The patient was diagnosed as hypophosphatemic rickets based on the fact of middle-aged male patients with chronic process.The bone pain and muscle weakness was the main manifestation, which progressively increased and lead to movement disorder.Laboratory tests: normal calcium, hypophosphatemia and elevated ALP.Bone scan with pseudo fractures are the characteristic of bone scan imaging finding prompted rickets.The diagnosis of hypophosphatemic rickets was established.Increased PTH caused by hyperparathyroidism was secondary to rickets.After three years of out-patient and hospital treatment, this patient has been able to work properly.The patient's 99m Tc-MDP bone scan image shows the pseudofeatures of metabolic bone disease: rib pseudofracture site showed local radioactivity uptake; ribbon-like zones increased uptake in spine, pelvis and lower extremities which embodiment Osteomalacia reflect the pathological changes of pseudofracture in rickets.Rickets refers that bone matrix of adults whose epiphyseal growth plate has been closed mineralized impediently.It is a metabolic bone disease that newly formed bone matrix is not mineralized in the normal manner.There are many causes responsible for decreased extracellular calcium phosphate product, and resulted in bone mineral deposition obstacles.The clinical manifestations of rickets are mainly bone pain and muscle weakness, fractures and deformities.Metabolic bone disease, pseudo fractures are the characteristic of bone scan imaging finding.Rickets belongs to endocrine and metabolic diseases.Now there are many related diseases, including seven sets of issues: Associated with vitamin D endocrine system diseases, phosphate balance abnormalities, metabolic acidosis, abnormal calcium balance, bone matrix abnormalities, lack of primary mineralization, some factors leading to the inhibition of mineralization.Although the clinical presentation is similar, but the pathogenic mechanisms are different, relating biochemical laboratory examination and treatment are also different.Therefore, in the diagnosis of rickets, we need the systematic, in-depth inspection and analysis to clarify the etiology.Diagnosis and treatment guide of rickets refers to Cecil Medicine.