Msk final 16 04-2014

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Msk final 16 04-2014

  1. 1. Musculoskeletal System PART-1. 120-08-2014
  2. 2. • The skeletal system is vital during life. • Essential role in mineral homeostasis, houses the hematopoietic elements, provides mechanical support for movement, protects viscera, and determines body size and shape. • Bones are largely made up of an organic matrix (osteoid) and the mineral calcium hydroxyapatite, which gives the bones strength and hardness. • Stony hard structure, bone is a dynamic tissue that is continuously resorbed, renewed, and remodelled. 220-08-2014
  3. 3. • Parts of a long bones: • Diaphysis (shaft), physis (growth plate), • Epiphysis (ends of bone, partially covered by articular cartilage), • Metaphysis (junction of diaphysis and epiphysis, most common site of primary bone tumors) • Cross section: Periosteam, cortex (composed of cortical bone or compact bone), • Medullary space (composed of cancellous or spongy bone) 320-08-2014
  4. 4. 420-08-2014
  5. 5. Normal histology • Bone: mineralized osteoid; either lamellar bone or woven bone. • Lamellar bone: layered bone with concentric parallel lamellae; gradually replaces woven bone; normal type of bone found in adult skeleton; stronger than woven bone 520-08-2014
  6. 6. • Osteoblasts: arise from marrow mesenchymal cells; when active, are plump and present on bone surface; eventually are encased within the collagen they produce. • Osteoblasts control osteoclast activity via parathyroid hormone. 620-08-2014
  7. 7. 720-08-2014
  8. 8. • A, Active osteoblasts synthesizing bone matrix. • The surrounding spindle cells represent osteoprogenitor cells. • B, Two osteoclasts resorbing bone. 820-08-2014
  9. 9. 920-08-2014
  10. 10. • Osteomyelitis • Avascular necrosis, osteonecrosis • Skeletal dysplasias , achondroplasia, osteogenesis imperfecta, osteopetrosis, • Metabolic and endocrine diseases • Osteoporosis • Osteitis fibrosa cystica 1020-08-2014
  11. 11. • Renal osteodystropy • Skeletal fluorosis • Paget's disease of bone, osteitis deformans • Tumour like lesions of bone. 1120-08-2014
  12. 12. 1220-08-2014
  13. 13. OSTEOMYELITIS: • Denotes inflammation of bones and marrow and the common use of the term virtually always implies infection. • May be a complication of any systemic infection but frequently manifests as a primary solitary focus of disease. • All types of organisms ,including viruses, parasites, fungi and bacteria can produce osteomyelitis, but infections caused by certain pyogenic bacteria and mycobacteria are the most common. 1320-08-2014
  14. 14. 1420-08-2014
  15. 15. 1520-08-2014
  16. 16. 1620-08-2014
  17. 17. 1720-08-2014
  18. 18. 1820-08-2014
  19. 19. • Resected femur in a person with draining osteomyelitis. • The drainage tract in the sub periosteal shell of viable new bone (involucrum) reveals the inner native necrotic cortex (sequestrum). 1920-08-2014
  20. 20. PYOGENIC OSTEOMYELITIS: is almost always caused by bacteria. 1. Hematogenous spread. 2. Extension from a contiguous site. 3. Direct implantation. 2020-08-2014
  21. 21. • E.coli, Klebsiella and Pseudomonas are more frequently isolated from patients with genitourinary tract infections or with intravenous drug abusers. • Mixed bacterial infections can be seen in the setting of direct spread during surgery or open fractures. • Salmonella infections for unknown reasons common in sickle cell patients. 2120-08-2014
  22. 22. • In 50% of the cases no organisms can be isolated. 2220-08-2014
  23. 23. Sites of involvement: • Influenced by the vascular circulation, which varies with age. • Neonates: the metaphysical vessels penetrate the growth plate, resulting in frequent infection of the metaphysis, epiphysis or both. • In children: metaphysical. • Adults: epiphyses and subchondral regions. 2320-08-2014
  24. 24. Stages : • Acute • Sub acute • Chronic , On clinical duration of disease SEQUENCE OF INFECTION: Once localized in bone, the bacteria proliferate and induce an acute inflammatory reactions and causes cell death. 2420-08-2014
  25. 25. • Necrosis of the bone within first 48hrs. • Spread of bacteria and inflammation within the shaft of the bone and may percolate through the haversian systems to reach the periosteum. • In children ,the periosteum is loosely attached to the cortex; therefore sizable sub periosteal abscess formation occurs. 2520-08-2014
  26. 26. • Further ischemia and bone necrosis occurs. 2620-08-2014
  27. 27. • Dead pieces of bone are known as the sequestrum. • Rupture of the periosteum→soft tissue abscess formation→draining sinuses. • In infants epiphyseal infection may spread to the adjacent joint and causes septic or suppurative arthritis.; may lead to permanent disability. 2720-08-2014
  28. 28. • After the first week chronic inflammatory cells become more numerous with the release of cytokines and deposition of new bone formation at the periphery. • New bone may be deposited as a sleeve of living tissue known as the Involucrum. 2820-08-2014
  29. 29. • Brodies abscess: • Small intraosseus abscess that frequently involves the cortex and is walled off reactive bone. • Sclerosing osteomyelitis of Garre typically • develops in the jaw. 2920-08-2014
  30. 30. • Clinical Course: • Fever ,chills, malaise, marked to intense throbbing pain over the affected region. Diagnosis; • Sign/symptoms. • X-ray • Blood cultures • Biopsy.-HISTOPATHOLOGY. 3020-08-2014
  31. 31. Complications: • Acute bacterial arthritis. • Pathologic fracture. • Secondary amyloidosis • Endocarditis • Septicaemia. • Squamous cell carcinoma. • Rarely sarcoma in the affected bone 3120-08-2014
  32. 32. Tuberculous osteomyelitis: Routes of entry; • Usually blood borne and originate from a focus of active visceral disease. • Direct extension (e.g. from a pulmonary focus into a rib or from tracheobronchial nodes into adjacent vertebrae) or spread via draining lymphatics. 3220-08-2014
  33. 33. • In patients with AIDS frequently multifocal. • Pott disease is the involvement of Spines. • Thoracic and lumber vertebrae followed by the knees and hips are the most common sites of skeletal involvement. • The infection breaks through the invertebral discs and extends into the soft tissues forming abscesses. 3320-08-2014
  34. 34. Clinical features and complications: • Pain • Fever , Weight loss • May form an inguinal mass ‘which represents a cold fluctuant psoas abscess. • Bone destruction. • Tuberculous arthritis. • Sinus tract formation • Amyloidosis. 3420-08-2014
  35. 35. Osteonecrosis • Fracture dislocation • Corticosteroids administration • Radiation therapy • Sickle cell disease. 3520-08-2014
  36. 36. 3620-08-2014
  37. 37. • Femoral head with a subchondral, wedge- shaped pale yellow area of osteonecrosis. • • The space between the overlying articular cartilage and bone is caused by trabecular compression fractures without repair. 3720-08-2014
  38. 38. Osteogenesis imperfecta • Autosomal dominant disorder of synthesis of type 1 collagen that constitutes to 90-95% of bone matrix. • Sclera,eyes,joints,ligaments, teeth, skin. • Too little bone. • Type-1. 2, 3, 4. 3820-08-2014
  39. 39. 3920-08-2014
  40. 40. • Skeletal radiogram of a fetus with lethal type II osteogenesis imperfecta. • Note the numerous fractures of virtually all bones, resulting in accordion-like shortening of the limbs. 4020-08-2014
  41. 41. Osteopetrosis • Marble bone disease. • Autosomal disorder, characterised by increased skeletal mass or osteosclerosis caused by hereditary defect in osteoclast dysfunction. 4120-08-2014
  42. 42. • Failure of normal osteoclast dysfunction of bone resorption coupled with continued bone formation and endochondral ossification results in net overgrowth of calcified dense bone. • Too much bone 4220-08-2014
  43. 43. 4320-08-2014
  44. 44. • Radiogram of the upper extremity in an individual with osteopetrosis. • The bones are diffusely sclerotic, and the distal metaphyses of the ulna and radius are poorly formed (Erlenmeyer flask deformity). 4420-08-2014
  45. 45. 4520-08-2014
  46. 46. • Section of proximal tibial diaphysis from a fetus with osteopetrosis. • The cortex (1) is present, but the medullary cavity (2) is filled with primary spongiosa, which replaces the hematopoietic elements. 4620-08-2014
  47. 47. Metabolic and Endocrine bone diseases. • Osteoporosis • Osteomalacia and rickets • Scurvy. • Hyper parathyroidism • Thyroid dysfunction • Renal osteodystropy • Skeletal fluorosis. 4720-08-2014
  48. 48. OSTEOPOROSIS. • COMMOM CLINICAL SYNDROME, involving multiple bones in which quantitative reduction of bone tissue mass but the bone tissue mass is otherwise normal. • Elderly, post menopausal women. • Backache . • Radiologicaly 30% of bone mass. 4820-08-2014
  49. 49. 4920-08-2014
  50. 50. • Pathophysiology of postmenopausal and senile osteoporosis . 5020-08-2014
  51. 51. 5120-08-2014
  52. 52. • Osteoporotic vertebral body (right) shortened by compression fractures compared with a normal vertebral body. • Note that the osteoporotic vertebra has a characteristic loss of horizontal trabeculae and thickened vertical trabeculae. 5220-08-2014
  53. 53. OSTEOPOROSIS • Many diseases and disorders have been associated with osteoporosis • In general, immobilization causes bone loss (following the 'use it or lose it' rule). • Hypo gonadal states can cause secondary osteoporosis • These include Turner syndrome, Klinefelter syndrome, Kallmann syndrome, anorexia nervosa, hypothalamic amenorrhea 5320-08-2014
  54. 54. OSTEOPOROSIS • A bilateral oophorectomy (surgical removal of the ovaries) or a premature ovarian failure • Endocrine disorders that can induce bone loss include Endocrine disorders that can induce bone loss include Cushing's syndrome, hyperparathyroidism, thyrotoxicosis, hypothyroidism, diabetes mellitus type 1 and type 2. 5420-08-2014
  55. 55. 5520-08-2014
  56. 56. OSTEOPOROSIS Is a term that denotes increased porosity of the skeleton resulting from reduction in the bone mass. It may be localized →disuse osteoporosis of a limb. or may involve the entire skeleton, as a metabolic bone disease. 5620-08-2014
  57. 57. OSTEOPOROSIS • Primary • Secondary PRIMARY: Post menopausal Senile 5720-08-2014
  58. 58. OSTEOPOROSIS • Secondary: immobilization, Endocrine Disorders chronic anemia, medications. 5820-08-2014
  59. 59. OSTEOPOROSIS 5920-08-2014
  60. 60. 6020-08-2014
  61. 61. OSTEOPOROSIS 6120-08-2014
  62. 62. Vertebral bone with osteoporosis demonstrates a compressed 6220-08-2014
  63. 63. OSTEOPOROSIS Pathophysiology: • AGING • ↓ replicative activity of the osteoprogenitorcells • ↓ synthetic activity of the osteoblasts. • ↓ activity of the matrix bound growth factors. 6320-08-2014
  64. 64. OSTEOPOROSIS • Menopause: • ↓ serum estrogen • ↑ IL-1,IL-6 levels • ↑ osteoclast activity Genetic factors Nutritional effects 6420-08-2014
  65. 65. OSTEOPOROSIS • The two main biochemical markers for bone formation are • serum alkaline phosphatase and serum osteocalcin. • Markers for bone resorbtion include urinary calcium and urinary hydroxyproline 6520-08-2014
  66. 66. OSTEOPOROSIS Prevention Strategies • The best long-term approach to osteoporosis is prevention. • Children and young adults, particularly women, with a good diet (with enough calcium and vitamin D) and get plenty of exercise, will build up and maintain bone mass. • This will provide a good reserve against bone loss later in life. Exercise places stress on bones that builds up bone mass 6620-08-2014
  67. 67. Osteitis fibrosa cystica • Skeletal manifestation of hyperparathyroidism. • Hyper calcaemia. • Brown tumour or reparative gaint cell granuloma of hyperparathyroidism. • Demineralization, bone resorption. 6720-08-2014
  68. 68. • Hyperparathyroidism with osteoclasts boring into the center of the trabeculum (dissecting osteitis). 6820-08-2014
  69. 69. 6920-08-2014
  70. 70. • Resected rib, harboring an expansile brown tumour adjacent to the costal cartilage. 7020-08-2014
  71. 71. 7120-08-2014
  72. 72. • A, Recent fracture of the fibula. • B, Marked callus formation 6 weeks later. 7220-08-2014
  73. 73. Metabolic bone disease. • Renal osteodystropy • Skeletal abnormalities in cases of chronic renal failure, • Patients treated by dialysis. 7320-08-2014
  74. 74. 7420-08-2014
  75. 75. Skeletal fluorosis. • High sodium fluoride content in soil and water. • Endemic fluorosis: Panjab , Andhra Pradesh. • Nonendemic fluorosis: Aluminium,megesium,superphosphate. 7520-08-2014
  76. 76. JAMES PAGET IN 1877 • Pagets diseases of bone or osteitis deformans. • Osteolytic and osteosclerotic disease of bone of uncertain aetiology involving one bone or more bones. • Age 50 yrs. 7620-08-2014
  77. 77. 7720-08-2014
  78. 78. • Diagrammatic representation of Paget disease of bone demonstrating the three phases in the evolution of the disease. 7820-08-2014
  79. 79. 7920-08-2014
  80. 80. • Mosaic pattern of lamellar bone is pathognomonic of Paget disease. 8020-08-2014
  81. 81. 8120-08-2014
  82. 82. • Severe Paget disease. • The tibia is bowed and the affected portion is enlarged, sclerotic, and exhibits irregular thickening of both the cortical and cancellous bone. 8220-08-2014
  83. 83. 8320-08-2014
  84. 84. Fibrous dysplasia • Fibrous dysplasia is a common benign fibro-osseous lesion, which • occurs sporadically during the period of skeletal growth (ages 10 to25). • It is a hamartoma and is characterized by the intramedullary location. • There are two forms of the disease: monostotic (80% of cases) and polyostotic. • Polyostotic involvement may be a part of • McCune-Albright syndrome (fibrous dysplasia, patchy cutaneous • pigmentation, and precocious puberty), or Mazabraud's syndrome • (fibrous dysplastic lesions in close proximity to soft tissue 8420-08-2014
  85. 85. • Most common locations include the long bones (femur, tibia andhumerus), the ribs, cranio-facial bones and pelvis. • In the long bones, the lesion is found in the metaphysis or diaphysis. • The hallmark of fibrous dysplasia is inability of tissue at the affected site to produce mature lamellar bone 8520-08-2014
  86. 86. Fibrous dysplasia • Typical Clinical Picture: • A 22-year-old female was seen in consultation for a lesion in the proximal femur. • She complained of chronic mild to moderate pain in her right hip and was walking with a noticeable limp. • Physical examination revealed hip deformity and minimal limb length discrepancy. • There were no other abnormal findings. 8620-08-2014
  87. 87. 8720-08-2014
  88. 88. • A very characteristic feature is "ground glass" (homogenous) density. • Remember that when this disorder involves the long bone, it commonly produces what is called "long lesion in the long bone" with • Three key features: • lucency, sclerotic rim and cortical expansion. 8820-08-2014
  89. 89. 8920-08-2014
  90. 90. • Three characteristic histologic features of this entity: • a) thin, wavy spicules of woven bone ("chinese characters"); • b) lack of osteoblastic rimming or osteoclastic activity; • c) moderately cellular bland fibrous background. • In children, stromal mitoses may be frequent, 1 to 5 per hpf 9020-08-2014
  91. 91. • Non-Ossifying Fibroma (NOF) OR • (Fibrous cortical defect, or Metaphysical cortical defect) 9120-08-2014
  92. 92. • NOF is a common, non-neoplastic, self-healing lesion occurring in skeletally immature individuals, usually between the ages of 5 and 20 years. • Small lesions are usually incidental radiological findings. • The larger lesions occupying more than a half of the bone diameter may present with a pathologic fracture. • l Location. • In most cases, NOF presents as a solitary lesion in the metaphysis or meta-diaphysis of the long bone at the knee (distal femur, proximal tibia or fibula), distal tibia and proximal humerus. 9220-08-2014
  93. 93. • Typical Clinical Presentation: • An incidental finding of a bone lesion in the distal tibial meta-diaphysis of an 13-year-old male. • The lesion was totally asymptomatic. • l As always, pay attention to the patient's age. The fact that the lesion did not produce symptoms and was found incidentally suggests benignancy. 9320-08-2014
  94. 94. 9420-08-2014
  95. 95. • Plain radiograph shows a sharply demarcated, lucent, loculated, metadiaphyseal lesion surrounded by a rim of sclerotic bone. Note the eccentric location along the long axis of the bone. 9520-08-2014
  96. 96. 9620-08-2014
  97. 97. Solitary Bone Cyst (SBC) • Typical Clinical Presentation: • A 12-year-old boy presented with a short history of pain in his thigh. 9720-08-2014
  98. 98. 9820-08-2014
  99. 99. Plain radiograph demonstrates a well- defined ,symmetric ,expansile, intramedullary lytic lesion of the proximal femur. 9920-08-2014
  100. 100. • Solitary bone cyst is relatively common, non- neoplastic lesion, typically occurs in the skeletally immature patients, in the first and second decades of life (80% of cases). • It is usually a unicameral cyst, which does not have an epithelial lining (hence not a true cyst) and is filled with serous fluid. About 80% of cases are diagnosed in two locations: humerus and proximal femur. In the long bone, SBC characteristically involves the metaphysis and diaphysis. • Other possible skeletal sites are the ilium, talus, and calcaneus. 10020-08-2014
  101. 101. 10120-08-2014
  102. 102. Aneurysmal Bone Cyst (ABC) • Aneurysmal Bone Cyst (ABC) is a rapidly growing, locally aggressive, intramedullary, vascular lesion, which characteristically produces blowout expansion of the affected portion of the bone. ABC can be primary (de novo) or secondary. • Secondary ABC may develop in a pre-existing benign lesion such • as chondroblastoma, chondromyxoid fibroma, giant cell tumour, and fibrous dysplasia, or be superimposed on a malignant tumor (osteosarcoma). • Although ABC can occur at any age, the majority of patients are younger than 25. 10220-08-2014
  103. 103. • Typical Clinical Presentation: • A 17-year-old male presented with a slowly enlarging, painful lesion of the right • clavicle 10320-08-2014
  104. 104. 10420-08-2014
  105. 105. 10520-08-2014
  106. 106. 10620-08-2014

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