甲狀腺功能減退癥Hypothyroidism：簡稱甲減，是由于甲狀腺激素的合成,，分泌或生物效應(yīng)不足而引起的一種綜合征,。病因較復(fù)雜，以原發(fā)性者多見,，其次為垂體性者,，其他均屬少見?；颊呖赡軙?huì)出現(xiàn)四肢無力、內(nèi)分泌功能減退,、低血壓、眩暈,、肌性肌無力,、體型異常,、呼吸異常等癥狀。

甲狀腺功能減退癥可能是先天性的,，這會(huì)導(dǎo)致嚴(yán)重的骨骼畸形和發(fā)育遲緩,，也可能后天獲得,，這將導(dǎo)致相對(duì)溫和的骨骼異常。獲得性甲狀腺功能減退可能發(fā)生在手術(shù)后或治療后（放射性碘治療）或可能是由于腺性萎縮,，急性或慢性（橋本）甲狀腺炎,，浸潤性疾病如淀粉樣變性或淋巴瘤，某些藥物治療,，碘缺乏癥或垂體紊亂導(dǎo)致甲狀腺激素激素缺乏。在兒童患者中,，骨骼發(fā)育遲緩,，往往伴有缺血性、不規(guī)則或碎片性遠(yuǎn)端股骨和近端脛骨骨骺（圖1）,，類似于多發(fā)性骨骺發(fā)育不良。 牙齒發(fā)育也可能延遲,。

圖1a,。12歲的男孩，先天性甲狀腺功能減退癥,，身材矮小,，發(fā)育遲緩。（a）右側(cè)腕關(guān)節(jié)X線片顯示只有頭狀骨（箭頭）,，鉤狀骨（箭頭）和橈骨（圓）的骨化中心,。骨齡估計(jì)為1.5年。

圖1b,。（b）腰椎橫斷面顯示出發(fā)育不全的椎體,。 L1具有子彈狀椎體（箭頭）。

圖1c,。（c）骨盆前后位置X線照片顯示髖關(guān)節(jié)髖臼變淺（實(shí)心箭頭）,，邊緣不光整,。 股骨頭骨骺（虛線箭頭）小而分散。

圖1d,。（d）右膝的前后X線照片顯示小而不規(guī)則的遠(yuǎn)端股骨和近端脛骨骨骺（箭頭）,。

圖1e。（e）經(jīng)過2年甲狀腺激素替代治療后獲得的左手X線片顯示所有腕骨骨化中心的間歇性骨化,。 骨齡仍然延遲,，但進(jìn)展到約9年（患者年齡，14歲）,。

圖1f,。（f）2年甲狀腺激素替代治療后，獲得的右膝前后X光片顯示骨骺的成熟,，但脛骨和股骨可見殘留不規(guī)則的改變（箭頭）,。 （圖片由Ok-Hwa Kim，MD,，Ajou大學(xué),，韓國首爾）提供。

Woltman征是指深腱反射的延遲松弛階段,，是甲狀腺功能減退癥的神經(jīng)系統(tǒng)表現(xiàn),。

一名53歲的男性前來內(nèi)分泌科診所，有6個(gè)月的進(jìn)行性全身性疲勞和對(duì)感冒的敏感性增加,。在發(fā)表時(shí),，身體檢查顯示彌漫性擴(kuò)大的甲狀腺的存在和踝關(guān)節(jié)反射的延遲放松。實(shí)驗(yàn)室研究顯示,，血清促甲狀腺素水平為200 mIU / L（參考范圍,，0.35至5.50），血清游離甲狀腺素水平為0.05 ng / dl（1 pmol / L）（參考范圍,，每分升0.89至1.76 ng [每升11至23 pmol]）。Woltman征是指深腱反射的延遲松弛階段,，是甲狀腺功能減退癥的神經(jīng)系統(tǒng)表現(xiàn),。這種延遲的放松也可能與懷孕，神經(jīng)性厭食癥,，糖尿病和高齡有關(guān),。患者接受甲狀腺激素替代治療，左旋甲狀腺素治療原發(fā)性甲狀腺功能減退癥,。一個(gè)月后,，血清游離甲狀腺素水平增加到每分升1.23 ng（每升16 pmol），血清促甲狀腺激素水平為每升20.5 mIU,，）,。在隨后的隨訪中,，促甲狀腺素水平歸一化至每升3.2mIU。

資料來源：

• 1. Skowrońska-Jó?wiak E, Lorenc RS. Metabolic bone disease in children: etiology and treatment options. Treat Endocrinol 2006;5(5):297–318.Crossref, Medline, Google Scholar

• 2. Guglielmi G, Muscarella S, Bazzocchi A. Integrated imaging approach to osteoporosis: state-of-the-art review and update. RadioGraphics 2011;31(5):1343–1364.Link, Google Scholar

• 3. O’Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ. The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 1996;11(7):1010–1018.Crossref, Medline, Google Scholar

• 4. Looker AC, Orwoll ES, Johnston CC Jr et al. Prevalence of low femoral bone density in older U.S. adults from NHANES III. J Bone Miner Res 1997;12(11):1761–1768.Crossref, Medline, Google Scholar

• 5. Kanis Jon behalf of the World Health Organization Scientific Group. Assessment of osteoporosis at the primary health care level: technical report. Sheffield, United Kingdom: World Health Organization Collaborating Centre for Metabolic Bones Diseases, University of Sheffield, 2007. University of Sheffield website. https://www./FRAX/pdfs/WHO_Technical_Report.pdf. Accessed November 12, 2015.Google Scholar

• 6. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17(12):1726–1733.Crossref, Medline, Google Scholar

• 7. Kanis JA, Johnell O, Oden A et al. Long-term risk of osteoporotic fracture in Malm?. Osteoporos Int 2000;11(8):669–674.Crossref, Medline, Google Scholar

• 8. Melton LJ 3rd, Atkinson EJ, O’Connor MK, O’Fallon WM, Riggs BL. Bone density and fracture risk in men. J Bone Miner Res 1998;13(12):1915–1923.Crossref, Medline, Google Scholar

• 9. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective: how many women have osteoporosis? J Bone Miner Res 1992;7(9):1005–1010.Crossref, Medline, Google Scholar

• 10. Riggs BL, Melton LJ 3rd. Evidence for two distinct syndromes of involutional osteoporosis. Am J Med 1983;75(6):899–901.Crossref, Medline, Google Scholar

• 11. Kanis JA, Glüer CC. An update on the diagnosis and assessment of osteoporosis with densitometry: Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporos Int2000;11(3):192–202.Crossref, Medline, Google Scholar

• 12. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO study group. World Health Organ Tech Rep Ser 1994;843:1–129.Medline, Google Scholar

• 13. Zebaze RMD, Ghasem-Zadeh A, Bohte A et al. Intracortical remodelling and porosity in the distal radius and post-mortem femurs of women: a cross-sectional study. Lancet2010;375(9727):1729–1736.Crossref, Medline, Google Scholar

• 14. Albright F. Osteoporosis. Ann Intern Med 1947;27(6):861–882.Crossref, Medline, Google Scholar

• 15. Link TM. Osteoporosis imaging: state of the art and advanced imaging. Radiology 2012;263(1):3–17.Link, Google Scholar

• 16. Guglielmi G, Muscarella S, Leone A, Peh WC. Imaging of metabolic bone diseases. Radiol Clin North Am2008;46(4):735–754, vi.Crossref, Medline, Google Scholar

• 17. Sommer OJ, Kladosek A, Weiler V, Czembirek H, Boeck M, Stiskal M. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications. RadioGraphics 2005;25(2):381–398.Link, Google Scholar

• 18. Einhorn TA. Bone strength: the bottom line. Calcif Tissue Int 1992;51(5):333–339.Crossref, Medline, Google Scholar

• 19. Townsend PR, Rose RM, Radin EL. Buckling studies of single human trabeculae. J Biomech 1975;8(3-4):199–201.Crossref, Medline, Google Scholar

• 20. Mosekilde L, Viidik A, Mosekilde L. Correlation between the compressive strength of iliac and vertebral trabecular bone in normal individuals. Bone1985;6(5):291–295.Crossref, Medline, Google Scholar

• 21. Guise TA, Mundy GR. Cancer and bone. Endocr Rev 1998;19(1):18–54.Crossref, Medline, Google Scholar

• 22. Nawanthe S, Nguyen BP, Barzanian N, Akhlaghpour H, Bouxsein ML, Keaveny TM. Cortical and trabecular load sharing in the human femoral neck. J Biomech2015;48(5):816–822.Crossref, Medline, Google Scholar

• 23. Pitt MJ. Rickets and osteomalacia. In: Resnick D, ed. Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 1901–1946.Google Scholar

• 24. Calder AD. Radiology of osteogenesis imperfecta, rickets and other bony fragility states. Endocr Dev 2015;28:56–71.Medline, Google Scholar

• 25. Tiosano D, Hochberg Z. Hypophosphatemia: the common denominator of all rickets. J Bone Miner Metab 2009;27(4):392–401.Crossref, Medline, Google Scholar

• 26. Sabbagh Y, Carpenter TO, Demay MB. Hypophosphatemia leads to rickets by impairing caspase-mediated apoptosis of hypertrophic chondrocytes. Proc Natl Acad Sci U S A 2005;102(27):9637–9642.Crossref, Medline, Google Scholar

• 27. Whyte MP, Zhang F, Wenkert D et al. Hypophosphatasia: validation and expansion of the clinical nosology for children from 25 years experience with 173 pediatric patients. Bone 2015;75:229–239.Crossref, Medline, Google Scholar

• 28. Whyte MP, Greenberg CR, Salman NJet al. Enzyme-replacement therapy in life-threatening hypophosphatasia. N Engl J Med 2012;366(10):904–913.Crossref, Medline, Google Scholar

• 29. Khan A, Bilezikian J. Primary hyperparathyroidism: pathophysiology and impact on bone. CMAJ2000;163(2):184–187.Medline, Google Scholar

• 30. Murphey MD, Sartoris DJ, Quale JL, Pathria MN, Martin NL. Musculoskeletal manifestations of chronic renal insufficiency. RadioGraphics1993;13(2):357–379.Link, Google Scholar

• 31. Resnick D, Deftos LJ, Parthemore JG. Renal osteodystrophy: magnification radiography of target sites of absorption. AJR Am J Roentgenol 1981;136(4):711–714.Crossref, Medline, Google Scholar

• 32. Resnick D, Niwayama G. Subchondral resorption of bone in renal osteodystrophy. Radiology1976;118(2):315–321.Link, Google Scholar

• 33. Brown TW, Genant HK, Hattner RS, Orloff S, Potter DE. Multiple brown tumors in a patient with chronic renal failure and secondary hyperparathyroidism. AJR Am J Roentgenol 1977;128(1):131–134.Crossref, Medline, Google Scholar

• 34. Griffiths HJ, Ennis JT, Bailey G. Skeletal changes following renal transplantation. Radiology 1974;113(3):621–626.Link, Google Scholar

• 35. Mataliotakis G, Lykissas MG, Mavrodontidis AN, Kontogeorgakos VA, Beris AE. Femoral neck fractures secondary to renal osteodystrophy: literature review and treatment algorithm. J Musculoskelet Neuronal Interact2009;9(3):130–137.Medline, Google Scholar

• 36. Resnick D. The sclerotic vertebral body. JAMA 1983;249(13):1761–1763.Crossref, Medline, Google Scholar

• 37. Kuzela DC, Huffer WE, Conger JD, Winter SD, Hammond WS. Soft tissue calcification in chronic dialysis patients. Am J Pathol 1977;86(2):403–424.Medline, Google Scholar

• 38. Naidich JB, Karmel MI, Mossey RT, Bluestone PA, Stein HL. Osteoarthropathy of the hand and wrist in patients undergoing long-term hemodialysis. Radiology 1987;164(1):205–209.Link, Google Scholar

• 39. Naidich JB, Mossey RT, McHeffey-Atkinson B et al. Spondyloarthropathy from long-term hemodialysis. Radiology1988;167(3):761–764.Link, Google Scholar

• 40. Casey TT, Stone WJ, DiRaimondo CR et al. Tumoral amyloidosis of bone of beta 2-microglobulin origin in association with long-term hemodialysis: a new type of amyloid disease. Hum Pathol1986;17(7):731–738.Crossref, Medline, Google Scholar

• 41. Bardin T, Kuntz D, Zingraff J, Voisin MC, Zelmar A, Lansaman J. Synovial amyloidosis in patients undergoing long-term hemodialysis. Arthritis Rheum1985;28(9):1052–1058.Crossref, Medline, Google Scholar

• 42. Bardin T, Lebail-Darné JL, Zingraff J et al. Dialysis arthropathy: outcome after renal transplantation. Am J Med1995;99(3):243–248.Crossref, Medline, Google Scholar

• 43. Gielen JL, van Holsbeeck MT, Hauglustaine D et al. Growing bone cysts in long-term hemodialysis. Skeletal Radiol 1990;19(1):43–49.Crossref, Medline, Google Scholar

• 44. Mitchell DM, Regan S, Cooley MR et al. Long-term follow-up of patients with hypoparathyroidism. J Clin Endocrinol Metab 2012;97(12):4507–4514.Crossref, Medline, Google Scholar

• 45. Shoback D. Clinical practice: hypoparathyroidism. N Engl J Med2008;359(4):391–403.Crossref, Medline, Google Scholar

• 46. Moley JF, Skinner M, Gillanders WE et al. Management of the parathyroid glands during preventive thyroidectomy in patients with multiple endocrine neoplasia type 2. Ann Surg2015;262(4):641–646.Crossref, Medline, Google Scholar

• 47. Resnick D. Parathyroid disorders and renal osteodystrophy. In: Resnick D, ed. Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 2043–2111.Google Scholar

• 48. Steinberg H, Waldron BR. Idiopathic hypoparathyroidism: an analysis of fifty-two cases, including the report of a new case. Medicine (Baltimore)1952;31(2):133–154.Crossref, Medline, Google Scholar

• 49. Taybi H, Keele D. Hypoparathyroidism: a review of the literature and report of two cases in sisters, one with steatorrhea and intestinal pseudo-obstruction. Am J Roentgenol Radium Ther Nucl Med1962;88:432–442.Medline, Google Scholar

• 50. Strom L, Winberg J. Idiopathic hypoparathyroidism. Acta Paediatr1954;43(6):574–581.Crossref, Medline, Google Scholar

• 51. Bronsky D, Kushner DS, Dubin A, Snapper I. Idiopathic hypoparathyroidism and pseudohypoparathyroidism: case reports and review of the literature. Medicine (Baltimore) 1958;37(4):317–352.Crossref, Medline, Google Scholar

• 52. Resnick D. Thyroid disorders. In: Resnick D, ed. Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 2026–2042.Google Scholar

• 53. Hernandez RJ, Poznanski AW, Hopwood NJ. Size and skeletal maturation of the hand in children with hypothyroidism and hypopituitarism. AJR Am J Roentgenol 1979;133(3):405–408.Crossref, Medline, Google Scholar

• 54. Newland CJ, Swift PG, Lamont AC. Congenital hypothyroidism: correlation between radiographic appearances of the knee epiphyses and biochemical data. Postgrad Med J 1991;67(788):553–556.Crossref, Medline, Google Scholar

• 55. Resnick D. Scurvy. In: Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 3459–3463.Google Scholar

• 56. Noordin S, Baloch N, Salat MS, Rashid Memon A, Ahmad T. Skeletal manifestations of scurvy: a case report from Dubai. Case Rep Orthop2012;2012:624628. doi: 10.1155/2012/624628. Published online September 3, 2012.Medline, Google Scholar

• 57. Polat AV, Bekci T, Say F, Bolukbas E, Selcuk MB. Osteoskeletal manifestations of scurvy: MRI and ultrasound findings. Skeletal Radiol 2015;44(8):1161–1164.Crossref, Medline, Google Scholar