Bone degenerative disorders


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Bone degenerative disorders

  2. 2. O STEOPOROSIS <ul><li>Decreased b one mass ( o steopenia.) r esulting in thin,fragile bones that are susceptible to fracture. </li></ul><ul><li>Most common bone disorder in U.S.A.(about 15 million individuals have primary type) </li></ul><ul><li>Most commonly occurs in postmenopausal Caucasian women and the elderly. </li></ul>
  3. 3. Primary Postmenopausal Senile Secondary Endocrine disorders Hyperparathyroi-dism Hypo-hyperthyroidism Hypogonadism Pituitary tumors Diabetes, type 1 Addison disease
  4. 4. Neoplasia Multiple myeloma Carcinomatosis Gastrointestinal Malnutrition Malabsorption Hepatic insufficiency Vitamin C, D deficiencies Idiopathic
  5. 5. Rheumatologic disease Drugs Anticoagulants Chemotherapy Corticosteroids Anticonvulsants Alcohol Miscellaneous Osteogenesis imperfecta Immobilization Pulmonary disease Homocystinuria Anemia
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  7. 7. O STEOPOROSIS(cont.) <ul><li>Patients may experience bone pain and fractures. </li></ul><ul><li>Weight bearing bones are predisposed to fractures </li></ul><ul><li>Vertebrae ( compression fractures) </li></ul><ul><li>Femoral neck ( h ip fracture) </li></ul><ul><li>Distal radius ( Colles fracture) </li></ul><ul><li>Pulmonary embolization </li></ul>
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  9. 9. O STEOPOROSIS(cont.) <ul><li>Loss of height , kyphos coliosis, lordosis </li></ul><ul><li>X-rays: generalized radiolucency of bone ( osteopenia ) </li></ul><ul><li>Dual Energy X Ray Absorptiometry ( DEXA.) </li></ul><ul><li>NORMAL SERUM CALCIUM,PHOSPHORUS,and ALKALINE PHOSPHATASE. </li></ul><ul><li>Micro: t hinned cortical and trabecular bone </li></ul><ul><li>Treatment : e strogen replacement therapy , w eight bearing exercise,Calcium and Vitamin D , Biphosphonate ( Alendro nate) , Calcitonin. </li></ul>
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  14. 14. O STEOMALACIA and R ICKETS <ul><li>Both diseases are characterized by decreased mineralization of newly formed bone, usually caused by deficiency or abnormal metabolism of vitamin D. </li></ul>
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  16. 16. O STEOMALACIA and R ICKETS . <ul><li>Etiology: d ietary deficiency of Vitamin D </li></ul><ul><li>Intestinal malabsorption ( bilis,pancreatic insuff.,celiac sprue,regional enteritis) </li></ul><ul><li>Lack of sunlight </li></ul><ul><li>Renal and liver disease </li></ul><ul><li>Chronic use of antacids(Al OH binds to P) </li></ul><ul><li>Drugs(incr.rate of degradation of sterols:phe nytoin,phenobarbital,rifampin) </li></ul>
  17. 17. R ICKETS ( Children) <ul><li>Prior to closure of the epiphyses </li></ul><ul><li>Both remodeled bone and bone formed at the epypheseal growth plate are undermineralized </li></ul><ul><li>Enchondral bone fromation is affected leading to skeletal deformities. </li></ul>
  18. 18. R ICKETS (children) <ul><li>Craniotabes and frontal bossing: skull deformities. </li></ul><ul><li>Rachitic rosary: deformity of the chest wall as a result of an overgrowth of cartilage at the costochondral junction </li></ul><ul><li>Pectus carinatum ( pigeon breast deformiy); outward protrusion of the sternum. </li></ul><ul><li>Lumbar lordosis: s pinal curvature </li></ul><ul><li>Bowing of the legs: c urvature of femur, tibia due to weight bearing </li></ul><ul><li>Fractures may also occur. </li></ul>
  19. 19. O STEOMALACIA . ( Adults) <ul><li>Impaired mineralization of the osteoid matrix results in thin, fragile bones that are susceptible to fracture. </li></ul>
  20. 20. O STEOMALACIA ( Adults) <ul><li>Clinical p resentation: </li></ul><ul><li>-- Bone pain </li></ul><ul><li>-- Fractures of the vertebrae, hips and wrist. </li></ul><ul><li>-- X-rays : diffuse radiolucency of bone (osteo </li></ul><ul><li>penia ) </li></ul><ul><li>--Lab: l ow serum calcium and phosphorus and/or </li></ul><ul><li>raised alkaline phosphatase </li></ul>
  21. 21. B ONE I NFECTIONS . O STEOMYELITIS ,TB, Syphilis. <ul><li>P YOGENIC O STEOMYELITIS . </li></ul><ul><li>Routes of infection: </li></ul><ul><li>Hematogenous spread : Most common  seeding of bone after bacteremia, commonly affects the metaphysis. </li></ul>
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  24. 24. O STEOMYELITIS (cont . ) <ul><li>Routes of Infection: </li></ul><ul><li>Hematogenous: from skin pustule,infected gums/teeth,IV puncture, UTIs, urologic procedures  ends of long bones </li></ul><ul><li>Direct inoculation </li></ul><ul><li>Spread from an adjacent site of infection </li></ul><ul><li>Microbiology:Syaphylococcus aureus, ( m ost common), Escherichia coli, Streptococci,Gonococci, Haemophilus influenzae, Salmonella (common in sickle cell disease) Pseudomonas ( common in intravenous drug abusers and diabetics ) </li></ul>
  25. 25. O STEOMYELITIS (cont.) <ul><li>Clinical features: f ever , localized pain, erythema and swelling, leukocytosis </li></ul><ul><li>X-ray : m ay be normal for up to 2 weeks , </li></ul><ul><li>but it m ay initially show periosteal elevation </li></ul><ul><li>Later: l ytic focus with surrounding sclerosis. </li></ul>
  26. 26. O STEOMYELITIS (cont . ) <ul><li>Pathology: s uppurative i nflammation </li></ul><ul><li>Vascular insufficiency </li></ul><ul><li>Ischemic necrosis of bone </li></ul><ul><li>Sequestrum: necrotic bone. </li></ul><ul><li>Involucrum: n ew bone formation that surrounds the sequestrum </li></ul>
  27. 27. O STEOMYELITIS(cont.) <ul><li>Diagnosis: </li></ul><ul><li>Blood culture. </li></ul><ul><li>Bone biopsy and culture </li></ul><ul><li>Treatment: Antibiotics:+ s urgical drainage. </li></ul>
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  30. 30. O STEOMYELITIS(cont.) <ul><li>Complications: </li></ul><ul><li>Fracture </li></ul><ul><li>Intraosseous ( Brodie) abscess. </li></ul><ul><li>Amyloidosis </li></ul><ul><li>Sinus tract formation </li></ul><ul><li>Squamous cell Ca. o f the skin at the site of persistent draining sinus tract </li></ul><ul><li>Osteogenic sarcoma ( rare. ) </li></ul>
  31. 31. T B O STEOMYELITIS . <ul><li>Affected individuals : adolescents or young adults, inmigrants. </li></ul><ul><li>U.S.A : V ictims tend to be older, excepting I mmunosupressed. </li></ul><ul><li>Occurs in 1% of cases of TB. </li></ul>
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  39. 39. T B O STEOMYELITIS(cont.) <ul><li>Pain or tenderness, fever, night sweats, weight loss. </li></ul><ul><li>Caseating granulomas with extensive destruction of the bones. </li></ul><ul><li>Common site : Thora c ic and lumbar vertebrae ( Pott ´s Disease) </li></ul>
  40. 40. T B O STEOMYELITIS(cont.) <ul><li>Complications. </li></ul><ul><li>Vertebral compression fracture </li></ul><ul><li>Psoas abscesses </li></ul><ul><li>Amyloidosis </li></ul>
  41. 41. S KELETAL S YPHILIS <ul><li>Infrequent. </li></ul><ul><li>Congenital : 5th month of gestation </li></ul><ul><li>Fully developed at birth. </li></ul><ul><li>Osteochondritis </li></ul><ul><li>Periostitis </li></ul><ul><li>Acquired syphilis: Involvement of the bone in the tertiary stage. </li></ul>
  42. 42. S KELETAL S YPHILIS(cont.) <ul><li>2-5 years after the infection. </li></ul><ul><li>Bones involved: Nose, palate, skull and extremities.( Saber shin) </li></ul><ul><li>Histology: Edematous granulation tissue , plasma cells and necrotic bone </li></ul><ul><li>Gummata </li></ul><ul><li>Silver stain for spirochetes. </li></ul>
  43. 43. Paget´s disease(Osteitis deform.) <ul><li>Begins after 40´s and is commonly seen in caucasians(3%), with some hereditary predisposition(autosomal dominant trait) </li></ul><ul><li>Paramyxovirus may have a role as cause of the disease showing 2 forms of presentation a. Localized in tibia, femur, iliac, humerus, vertebrae & skull(monostotic) in 15% of cases. b. Localized in several bones(polyostotic) in 85% of cases. </li></ul>
  44. 44. Paget´s disease(Osteitis deform.) <ul><li>Pathology. There are 3 stages: --Osteolytic --Osteolytic-osteoblastic --Osteosclerotic(“cold” stage) </li></ul><ul><li>Micro: --Thickened trabecular & cortical bone --Abnormal arrangement of lamellar bone (mosaic pattern) --Woven(reactive) bone --Giant multinucleated osteoclasts(w/viral incl.) --Fibrotic marrow </li></ul>
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  46. 46. Paget´s disease(Osteitis deform.) <ul><li>Complications. --Myelophthisic anemia --Optic & auditory nerve compression --Fx. --Cardiac failure(high output due to large A/V shunts from blood vessels in fibrotic marrow --Malignancies(about 1% of cases)  osteo genic sarcoma, fibrosarcoma(jaw,femur, pelvis) </li></ul>
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  53. 53. BONE & DEGENERATIVE DISORDERS <ul><li>There are 206 bones diverse in size & shape that have a role in mineral homeostasis, contains hematopoietic elements, determine the body size/shape and provide support for movement and protection. Long bones have </li></ul><ul><li>- Epiphysis - Epiphysial plate </li></ul><ul><li>- Metaphysis - Diaphysis(shaft) </li></ul>
  54. 54. BONE & DEGENERATIVE DISORDERS <ul><li>Also, a bone shows 2 gross anatomical forms in proportion to a particular function: </li></ul><ul><li>1. Compact bone:dense outer shell(cortex) with basic units(osteons) arranged in vertical columns and lamellar structure that contain osteocytes & capillaries forming a haversyan system. </li></ul><ul><li>2. Cancellous bone(spongious) arranged in trabecules(osteocytes+osteoblasts+capillaries) along with marrow </li></ul>
  55. 55. BONE & DEGENERATIVE DISORDERS <ul><li>3. Woven bone(non-lamellar), a primitive form laid down in fetal development, with irregular trabecula in a primitive matrix. In adult life this type is seen in bone regeneration(later replaced by lamellar bone) and tumors </li></ul>
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  58. 58. BONE & DEGENERATIVE DISORDERS <ul><li>Bone cells constitute about 2% of bone weight: </li></ul><ul><li>Osteoprogenitor(STEM) cells in vacinity of surfaces </li></ul><ul><li>Osteoblasts in surface of bones(synthesis& arrange of proteins) w/receptors for hormo nes, GFs </li></ul><ul><li>Osteocytes(control of Ca++, P) </li></ul><ul><li>Multinucleated osteoclasts(from granulocyte-mo nocyte precursor in marrow) with resorption pits (Howship´s lacunae) </li></ul>
  59. 59. BONE & DEGENERATIVE DISORDERS <ul><li>Bone proteins include type I collagen(90% of organic component) and non-collagenous proteins derived from osteoblasts  matrix </li></ul><ul><li>Bone is a blend of organic matrix(35%)and inorganic(65%) </li></ul><ul><li>Inorganic components are:Ca++hydroxyapa tite(stores 99% of body Ca++, 80% of P and 65% of Na & Mg) </li></ul>
  60. 60. BONE & DEGENERATIVE DISORDERS <ul><li>BONE DEPOSITION. - From rows of osteoblasts laying down lamellar collagen matrix  incorporated into the bone and housed in small lacuna as osteocyte  non-calcified osteoid in the centre of the osteon/surface of trabecula. Normally calcification follows very quickly -During osteoblastic activity ALKALINE PHOSPATASE is liberated into blood flow </li></ul>
  61. 61. BONE & DEGENERATIVE DISORDERS <ul><li>Bone & calcium homeostasis: - parathyroids </li></ul><ul><li>blood Ca++ PTH </li></ul><ul><li>blood Ca++  bone (osteocyte rel/Ca++ </li></ul>
  62. 62. BONE & DEGENERATIVE DISORDERS <ul><li>MINERAL HOMEOSTASIS. 1. PTH in parathyroid glands Ca++ PO++++ 2. 1.25(OH2)D3 in proximal conv.& straight tubules Ca+++ PO++++ 3. Calcitonin in “C” cells Ca++ PO++++ </li></ul>