• Clinical bone disease occurs in less than half of the patients with hyperparathyroidism.
  • Hyperparathyroidism tends to present either with bone disease or with renal stones, but not both.

Parathyroid hormone and bone:

  • The parathyroid hormone acts directly on the bone.
  • Release calcium into the extra-cellular fluid by stimulating osteoclastic resorption.


  • The hyperparathyroidism may be classified as:
  1. Primary: Due to adenoma of the parathyroid.
  2. Secondary: Due to persistent hypocalcemia, e.g. renal rickets.
  3. Tertiary:The secondary hyperplasia remains and becomes autonomous.
  • All types are associated with excessive secretion of parathormone.


  • Age: 3rd to 5th decade
  • Male: Female ratio 1:3

Common presenting complaints:

  1. Bone pains

  2. Pathological fracture:

  • Common sites of fractures are dorso-lumbar spine, neck of the femur and pubic rami.

  3. Brown’s tumour:

  4. Anorexia, nausea, vomiting and abdominal cramps

  5. Renal colics with haematuria, because of renal calculus


1. In the Hand

  • Classical subperiosteal cortical resorption of the middle phalanges. 

2. In the Spine

  • Biconcave vertebral body due to the bulging of the disk, ‘Cod fish spine’.

3. In the Long Bones

  • Generalized rarefaction with cystic lesions
  • osteitis fibrosa cystica and brown tumors. 

4. In the Skull

  • Stippling calcification.
  • ‘Pepper pot skull’ (also known as salt pepper appearance). 

Laboratory Investigations

  1. Elevated serum calcium, low serum phosphorus.
  2. Elevated serum alkaline phosphatase.
  3. Elevated serum parathormone levels.


  • It consists of:
  1. removal of the basic cause
  2. orthopaedic treatment
  3. urologic treatment.

Exam Important

  • Most common cause of hyperparathyroidism is Adenoma.
  • A common cause of Primary hyperparathyroidism is Solitary parathyroid adenoma.
  • Chronic renal failure  is associated with secondary hyperparathyroidism.
  • Secondary hyperparathyroidism due to Vit D deficiency shows Hypophosphatemia.
  • Tertiary hyperparathyroidism is Secondary hyperparathyroidism with chief cell adenoma.
  • Subtle presentation of hyperparathyroidism is Asymptomatic hypercalcemia.
  • Pathognomic feature of hyperparathyroidism is Sub periosteal resoption of phalynges.
  • Characteristic subperiosteal bone resorption in Hyperparathyroidism is best seen at Radial border of middle phalanx.
  • Salt-pepper skull is a feature of primary hyperparathyroidism.
  • Osteitis fibrosa cystica is seen with Primary hyperparathyroidism.
  • Brown tumor is seen in Hyperparathyroidism.
  • Absence of lamina dura seen in Hyperparathyroidism.
  • Floating teeth is seen in Hyperparathyroidism.
  • Increased plasma concentration of calcium is associated with Primary hyperparathyroidism.
  • The initial treatment of choice for secondary hyperparathyroidism in renal osteodystrophy is Phosphate binders.
  • Adenoma  is the most common surgically repairable cause of hyperparathyroidism.
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