Intended for healthcare professionals

Endgames Picture Quiz

A woman with raised alkaline phosphatase and forearm deformity

BMJ 2011; 342 doi: (Published 15 June 2011) Cite this as: BMJ 2011;342:d3435
  1. Joanne K Y Lam, resident ,
  2. Karen S L Lam, professor ,
  3. Annie W C Kung, professor ,
  4. Kathryn C B Tan, professor ,
  5. Wing-Sun Chow, associate consultant ,
  6. Annette W K Tso, assistant professor
  1. 1Queen Mary Hospital, Pokfulam Road, Hong Kong
  1. Correspondence to: J K Y Lam kyjoanne414{at}

A 71 year old Chinese woman was referred from the general outpatient clinic to our endocrine clinic for evaluation of raised serum alkaline phosphatase (ALP), which had been measured as part of a routine check-up. Apart from a history of hypertension and gout, she was well. For the past two years her blood tests had shown a raised ALP (183-277 U/L; reference range 47-124). Liver enzymes, renal function tests, thyroid function tests, and adjusted calcium and phosphate concentrations were all within normal ranges.

Examinations of the abdomen, cardiovascular system, and respiratory system were normal. She was noted to have a deformity of the right forearm (fig 1). She denied a history of trauma or fracture. The deformity had been present for three years, but she had not sought medical advice because it did not affect her hand function and was not painful. A radiograph of the right forearm was taken (fig 2).

Fig 1 Deformity of the right forearm

Fig 2 Radiograph of the right forearm


  • 1 What is the diagnosis?

  • 2 Describe the radiological abnormalities that confirm the diagnosis

  • 3 How would you treat this condition?


1 What is the diagnosis?

Short answer

The diagnosis is Paget’s disease of bone.

Long answer

Paget’s disease of bone was first described by James Paget, who named this skeletal condition “osteitis deformans” in 1877.1 It is a disease of bone remodelling and is characterised by excessive bone resorption at affected skeletal sites, followed by disorganised bone formation. The overproduced bone is sclerotic and of poor quality, and it is susceptible to deformity and fracture.2 Paget’s disease of bone is the second most common metabolic bone disease in European countries. The prevalence of Paget’s disease in the United Kingdom has been estimated at 5% in people over 55 years of age.3 Paget’s disease, …

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