JOINT PATHOLOGY www.freelivedoctor.com
www.freelivedoctor.com
Modeling/RE-modeling www.freelivedoctor.com
CELLS of BONE <ul><li>OSTEOPROGENITOR (“STEM”)  (TGF β ) </li></ul><ul><li>OSTEOBLASTS (surface of spicule) </li></ul><ul...
Proteins (organic) of BONE <ul><li>Type 1 collagen (90%) </li></ul><ul><li>Cell adhesion proteins </li></ul><ul><li>Calciu...
Minerals (INorganic) of BONE <ul><li>HYDROXY-APATITE </li></ul><ul><li>Ca5(PO4)3(OH)   </li></ul><ul><li>Ca10(PO4)6(OH)2 <...
ADJECTIVES of BONE <ul><li>Compact </li></ul><ul><li>Spongy </li></ul><ul><li>Cancellous </li></ul><ul><li>Membranous </li...
Woven vs Lamellar www.freelivedoctor.com
www.freelivedoctor.com
- BLASTS/-CLASTS www.freelivedoctor.com
BONE DISEASES <ul><li>1) MALFORMATIONS AND DISEASES CAUSED BY DEFECTS IN  NUCLEAR PROTEINS AND TRANSCRIPTION FACTORS,  pol...
1) MALFORMATIONS AND DISEASES CAUSED BY DEFECTS IN  NUCLEAR PROTEINS AND TRANSCRIPTION FACTORS <ul><li>Congenital absence ...
www.freelivedoctor.com
2) DISEASES CAUSED BY DEFECTS IN  HORMONES AND SIGNAL TRANSDUCTION MECHANISMS <ul><li>Achondroplasia, dwarf (non-lethal) <...
www.freelivedoctor.com
3) DISEASES ASSOCIATED WITH DEFECTS IN  EXTRACELLULAR STRUCTURAL PROTEINS <ul><li>OSTEOGENESS IMPERFECTA TYPES </li></ul><...
Osteogenesis Imperfecta www.freelivedoctor.com
4) DISEASES ASSOCIATED WITH DEFECTS IN  FOLDING AND DEGRADATION OF MACROMOLECULES <ul><li>MUCOPOLYSACCHARIDOSIS (one of MA...
MUCOPOLYSACCHARIDOSES www.freelivedoctor.com
5) DISEASES  ASSOCIATED WITH  DEFECTS IN  METABOLIC PATHWAYS  (ENZYMES, ION  CHANNELS, AND TRANSPORTERS) <ul><li>OSTEOPETR...
OSTEOPETROSIS www.freelivedoctor.com
6) DISEASES ASSOCIATED WITH  DECREASED BONE MASS <ul><li>OSTEOPOROSIS </li></ul><ul><li>“ PEAK” bone mass is early adultho...
www.freelivedoctor.com Categories of Generalized Osteoporosis Primary   Postmenopausal Idiopathic    Senile   Secondary   ...
OSTEOPOROSIS www.freelivedoctor.com
7) DISEASES CAUSED BY  OSTEOCLAST DYSFUNCTION Paget Disease (Osteitis Deformans) <ul><li>Matrix madness, Osteoblasts/-cyte...
PAGET’s DISEASE (of BONE) 85% MONOSTOTIC, WHOLE BONE 15% POLY-OSTOTIC (skull, pelvis) “ JIGSAW”, NOT LAMINAR, BONE CLINICA...
PAGET’s DISEASE www.freelivedoctor.com
8) DISEASES ASSOCIATED WITH  ABNORMAL MINERAL HOMEOSTASIS <ul><ul><li>Ricketts and Osteomalacia </li></ul></ul><ul><ul><ul...
PRIMARY HYPERPARATHYROIDISM www.freelivedoctor.com OSTEITIS FIBROSA CYSTICA “ BROWN” “TUMOR”
RENAL OSTEODYSTROPHY <ul><li>PHOSPHATE RETENTION </li></ul><ul><li>HYPOPHOSPHATEMIA </li></ul><ul><li>HYPOCALCEMIA </li></...
FRACTURES www.freelivedoctor.com
FRACTURES, adjectives <ul><li>Complete, incomplete </li></ul><ul><li>Closed, open (communicating) </li></ul><ul><li>Commun...
FRACTURES <ul><li>THREE PHASES </li></ul><ul><ul><li>HEMATOMA, minutes days   PGDF, TGF- β , FGF </li></ul></ul><ul><ul><...
FRACTURES www.freelivedoctor.com
OSTEONECROSIS <ul><li>Also called AVASCULAR necrosis </li></ul><ul><li>Also called ASEPTIC necrosis </li></ul><ul><li>CAUS...
OSTEONECROSIS www.freelivedoctor.com Disorders Associated with Osteonecrosis Idiopathic Pregnancy Trauma Gaucher disease C...
OSTEONECROSIS www.freelivedoctor.com
OSTEONECROSIS www.freelivedoctor.com
OSTEOMYELITIS <ul><li>Pyogenic: Staph , E. coli, Pseudom, Kleb </li></ul><ul><ul><li>Hematogenous  </li></ul></ul><ul><ul>...
OSTEOMYELITIS <ul><li>DX: X-ray, Bone scan </li></ul>www.freelivedoctor.com
OSTEOMYELITIS <ul><li>DX: Histology </li></ul>www.freelivedoctor.com
OSTEOMYELITIS <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Subperiosteal abscess </li></ul></ul><ul><ul><li>Draining sinus ...
www.freelivedoctor.com
OSTEOMYELITIS <ul><li>Tuberculous </li></ul><ul><ul><li>Usually blood borne </li></ul></ul><ul><ul><li>TB of spine is know...
POTT’s DISEASE www.freelivedoctor.com
SABER SHINS www.freelivedoctor.com
www.freelivedoctor.com Classification of Primary Tumors Involving Bones Histologic Type Benign Malignant Hematopoietic (40...
BONE TUMORS <ul><li>BONE </li></ul><ul><li>CARTILAGE </li></ul><ul><li>FIBROUS </li></ul><ul><li>MISC. </li></ul><ul><ul><...
BONE- BONE TUMORS <ul><li>OSTEOMA </li></ul><ul><li>OSTEOID OSTEOMA </li></ul><ul><li>OSTEOBLASTOMA </li></ul><ul><li>OSTE...
OSTEOMA <ul><li>SOLITARY </li></ul><ul><li>MIDDLE AGE </li></ul><ul><li>FROM SUBPERIOSTEAL or ENDOSTEAL surfaces </li></ul...
FRONTAL SINUS www.freelivedoctor.com
OSTEOID OSTEOMA <ul><li>At least 2 cm in diameter </li></ul><ul><li>Teens, twenties, APPENDICULAR skeleton </li></ul><ul><...
NIDUS www.freelivedoctor.com
OSTEOBLASTOMA <ul><li>AXIAL SKELETON, i.e., SPINE </li></ul><ul><li>NO Nidus </li></ul><ul><li>NO bony reaction </li></ul>...
OSTEOSARCOMA (OSTEOGENIC SARCOMA) www.freelivedoctor.com LATE TEENS KNEES METAPHYSES PAINFUL!!!
TYPES of OSTEOSARCOMAS <ul><li>•  The anatomic portion of the bone from which they arise (intramedullary, intracortical, o...
The most common subtype is osteosarcoma that arises in the metaphysis of long bones; is primary, solitary, intramedullary,...
BONE- CARTILAGE TUMORS <ul><li>OSTEOCHONDROMA (EXOSTOSIS) </li></ul><ul><li>CHONDROMA </li></ul><ul><li>CHONDROBLASTOMA </...
OSTEOCHONDROMA (EXOSTOSIS) <ul><li>Common, Cartilage AND Bone present </li></ul><ul><li>Often MULTIPLE as a hereditary syn...
www.freelivedoctor.com
CHONDROMA <ul><li>Chondroma vs. EN-chondroma </li></ul><ul><li>PURE Hyaline Cartilage </li></ul><ul><li>MULTIPLE enchondro...
CHONDROBLASTOMA <ul><li>RARE, in teenagers </li></ul><ul><li>M>>F </li></ul><ul><li>KNEES, usually </li></ul><ul><li>Epiph...
CHONDROMYXOID FIBROMA <ul><li>RAREST of all </li></ul><ul><li>TEENS, MALES </li></ul><ul><li>“ MYXOID” concept </li></ul><...
CHONDROSARCOMA <ul><li>ANATOMY </li></ul><ul><ul><li>INTRAMEDULLARY </li></ul></ul><ul><ul><li>JUXTACORTICAL </li></ul></u...
CHONDROSARCOMA www.freelivedoctor.com
BONE- FIBROUS TUMORS <ul><li>FIBROUS CORTICAL DEFECT/NON-OSSIFYING FIBROMA </li></ul><ul><li>FIBROUS DYSPLASIA </li></ul><...
FIBROUS CORTICAL DEFECT <ul><li>COMMON, usually LESS THAN 1 CM </li></ul><ul><li>CHILDREN >2 </li></ul><ul><li>IF MORE THA...
FIBROUS DYSPLASIA <ul><li>BENIGN TUMOR </li></ul><ul><li>THREE TYPES </li></ul><ul><ul><li>SINGLE BONE  (70%) </li></ul></...
<ul><li>CURVED spicules </li></ul><ul><li>LACK of osteoblastic rimming </li></ul>www.freelivedoctor.com
FIBROSARCOMA/MFH <ul><li>METAPHYSES of LONG BONES </li></ul><ul><li>PELVIC FLAT BONES </li></ul><ul><li>LYTIC </li></ul><u...
FIBROSARCOMA/MFH www.freelivedoctor.com
MISC. TUMORS of BONE <ul><li>EWING sarcoma/PNET (Primitive NeuroEctodermal Tumor) </li></ul><ul><li>GIANT CELL TUMOR </li>...
EWING/PNET <ul><li>SAME TUMOR </li></ul><ul><li>SMALL ROUND </li></ul><ul><li>NEUROENDOCRINE </li></ul><ul><li>IDENTICAL C...
GCT (Giant Cell Tumor), BONE www.freelivedoctor.com
METASTASES www.freelivedoctor.com MALE: PROSTATE FEMALE: BREAST RENAL, THYROID also seek bone early also LYTIC? BLASTIC?
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SYNOVIAL JOINTS www.freelivedoctor.com
JOINT DISEASES <ul><li>“ ARTHRITIS” </li></ul><ul><ul><li>DEGENERATIVE (OSTEOARTHRITIS) </li></ul></ul><ul><ul><li>RHEUMAT...
DEGENERATIVE ARTHRITIS <ul><li>Etiology/Risk Factors: Age, Trauma, Genes </li></ul><ul><li>Pathogenesis: Progressive EROSI...
www.freelivedoctor.com
HEBERDEN’S NODES DIP, NOT MP or PIP www.freelivedoctor.com
RHEUMATOID ARTHRITIS <ul><li>Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder that may affect many ti...
RHEUMATOID ARTHRITIS <ul><li>Etiology/Risk Factors: Autoimmune </li></ul><ul><li>Pathogenesis: Progressive SYNOVITIS </li>...
The rheumatoid “nodule” shows “palisading” fibroblasts HANDS  WRIST  ELBOWS www.freelivedoctor.com
DIAGNOSIS <ul><li>CLINICAL FEATURES  (1% of population F>>M) </li></ul><ul><ul><li>MORNING STIFFNESS </li></ul></ul><ul><u...
www.freelivedoctor.com
“ JUVENILE” Rheumatoid Arthritis <ul><li>Begins BEFORE age 16, by definition </li></ul><ul><li>Generally LARGER joints tha...
“ SERONEGATIVE” ARTHRITIDES <ul><li>ANKYLOSING SPONDYLITIS (aka, “rheumatoid” spondylitis, or Marie-Strumpell Disease  [HL...
Ankylosing Spondylitis www.freelivedoctor.com
INFECTIOUS ARTHRITIS <ul><li>From OSTEOMYELITIS </li></ul><ul><li>USUALLY SUPPURATIVE </li></ul><ul><li>GC , staph, strep,...
INFECTIOUS ARTHRITIS <ul><li>TB </li></ul><ul><li>LYME Disease, i.e., Borrelia burgdorferi </li></ul><ul><li>VIRAL </li></...
GOUT <ul><li>Endpoint of HYPERURICEMIA from ANY cause resulting in JOINT deposition of Monosodium crystals (TOPHI) </li></...
www.freelivedoctor.com Classification of Gout Clinical Category Metabolic Defect Primary Gout (90% of cases) Enzyme defect...
HYPERURICEMIA   GOUT <ul><li>Age  of the individual and duration of the hyperuricemia are factors. Gout rarely appears be...
FEATURES <ul><li>TOPHACEOUS ARTHRITIS </li></ul><ul><li>GOUTY NEPHROPATHY </li></ul>www.freelivedoctor.com
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GOUTY NEPHROPATHY www.freelivedoctor.com
GOUT <ul><li>Associated with ATHEROSCLEROSIS </li></ul><ul><li>Associated with HYPERTENSION </li></ul>www.freelivedoctor.com
Pseudo-GOUT <ul><li>Gout: Monosodium Urate </li></ul><ul><li>Pseudo-GOUT: Calcium Pyrophosphate </li></ul><ul><li>PSEUDOGO...
GOUT vs. PSEUDOGOUT www.freelivedoctor.com
JOINT TUMORS <ul><li>BENIGN </li></ul><ul><ul><li>GANGLION (SYNOVIAL CYST) </li></ul></ul><ul><ul><li>GIANT CELL TUMOR of ...
GANGLION www.freelivedoctor.com
PVNS/GCT www.freelivedoctor.com
“ SOFT TISSUE” TUMORS <ul><li>FAT </li></ul><ul><li>FIBROUS TISSUE </li></ul><ul><li>FIBROHISTIOCYTIC </li></ul><ul><li>SK...
CAUSES <ul><li>MOSTLY UNKNOWN </li></ul><ul><li>RADIATION association </li></ul><ul><li>CHEMICAL BURN association </li></u...
www.freelivedoctor.com Chromosomal and Genetic Abnormalities in Soft Tissue Sarcomas Tumor Cytogenetic Abnormality Genetic...
SOFT TISSUE TUMORS <ul><li>ALL “SPINDLY” </li></ul><ul><li>Deep (desmoid) vs. Superficial </li></ul><ul><li>Importance of ...
FAT <ul><li>LIPOMA </li></ul><ul><li>LIPOSARCOMA </li></ul>www.freelivedoctor.com NORMAL FAT LIPOMA, encapsulated LIPOSARC...
FIBROUS TISSUE <ul><li>NODULAR FASCIITIS  (pseudosarcomatous) </li></ul><ul><li>FIBROMATOSES  (plantar, palmar, penile) </...
MYOSITIS OSSIFICANS <ul><li>BENIGN FIBROUS TISSUE PROLIFERATION  PLUS OSSEOUS METAPLASIA </li></ul>www.freelivedoctor.com
FIBROHISTIOCYTIC <ul><li>FIBROUS HISTIOCYTOMA </li></ul><ul><li>DERMATOFIBROSARCOMA PROTUBERANS </li></ul><ul><li>MALIGNAN...
SKELETAL MUSCLE <ul><li>RHABDOMYOMA </li></ul><ul><li>RHABDOMYOSARCOMA </li></ul>www.freelivedoctor.com
SMOOTH MUSCLE <ul><li>LEIOMYOMA </li></ul><ul><li>LEIOMYOSARCOMA </li></ul>www.freelivedoctor.com
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VASCULAR  <ul><li>HEMANGIOMA </li></ul><ul><li>LYMPHANGIOMA </li></ul><ul><li>HEMANGIOENDOTHELIOMA </li></ul><ul><li>HEMAN...
PERIPHERAL NERVE <ul><li>NEUROFIBROMA </li></ul><ul><li>SCHWANNOMA </li></ul><ul><li>GRANULAR CELL TUMOR </li></ul><ul><li...
UNCERTAIN <ul><li>SYNOVIAL SARCOMA </li></ul><ul><li>ALVEOLAR “SOFT PART” SARCOMA </li></ul><ul><li>EPITHELIOD SARCOMA </l...
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Diseases of joints

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  • Intramembranous and Endochondral ossification, note: 1 , Reserve zone. 2 , Zone of proliferation. 3 , Zone of hypertrophy. 4 , Zone of mineralization. 5 , Primary spongiosa.
  • Achondroplastic and thanatophoric dwarfs
  • Diffusely DENSE bone with Erlenmeyer Flask deformity of distal humerus
  • Primary = YOUNGER patients, Secondary = OLDER patients
  • Osteochondroma
  • GCT occurs in patients, 20s-40-s, and GCT has a MACROPHAGE lineage
  • Biurate has the OPPOSITE polarization pattern of pyrophosphate. In GOUT, as seen here, the yellow needles are vertical and the blue needles are horizontal, under polarization. IN PSEUDOGOUT, the OPPOSITE is seen.
  • These diseases are related, but PVN appears as shaggy or “villous” projections of synovium, and GCT is a solid tumor. BOTH are regarded as BENIGN proliferations of synovium and reactive cells.
  • What is a herring bone pattern?
  • The MAIN difference between leiomyomas and leiomyosarcomas is the number of mitoses per high power field! How many do you see here?
  • Diseases of joints

    1. 1. JOINT PATHOLOGY www.freelivedoctor.com
    2. 2. www.freelivedoctor.com
    3. 3. Modeling/RE-modeling www.freelivedoctor.com
    4. 4. CELLS of BONE <ul><li>OSTEOPROGENITOR (“STEM”)  (TGF β ) </li></ul><ul><li>OSTEOBLASTS (surface of spicule) </li></ul><ul><li>OSTEOCYTES (completely within spicule) </li></ul><ul><li>OSTEOCLASTS (macrophage lineage) </li></ul>www.freelivedoctor.com
    5. 5. Proteins (organic) of BONE <ul><li>Type 1 collagen (90%) </li></ul><ul><li>Cell adhesion proteins </li></ul><ul><li>Calcium-binding proteins </li></ul><ul><li>Proteins involved in mineralization   </li></ul><ul><li>Enzymes </li></ul><ul><li>Growth factors </li></ul><ul><ul><li>GF-1, TGF-β, PDGF    </li></ul></ul><ul><li>Cytokines </li></ul><ul><ul><li>Prostaglandins, IL-1, IL-6, RANKL </li></ul></ul><ul><li>Proteins Concentrated from Serum </li></ul><ul><ul><li>β2 –microglobulinAlbumin </li></ul></ul><ul><ul><li>IGF, insulin-like growth factor </li></ul></ul><ul><ul><li>TGF, transforming growth factor </li></ul></ul><ul><ul><li>PDGF, platelet-derived growth factor </li></ul></ul><ul><ul><li>IL, interleukin </li></ul></ul><ul><ul><li>RANKL, RANK ligand </li></ul></ul>www.freelivedoctor.com
    6. 6. Minerals (INorganic) of BONE <ul><li>HYDROXY-APATITE </li></ul><ul><li>Ca5(PO4)3(OH) </li></ul><ul><li>Ca10(PO4)6(OH)2 </li></ul>www.freelivedoctor.com
    7. 7. ADJECTIVES of BONE <ul><li>Compact </li></ul><ul><li>Spongy </li></ul><ul><li>Cancellous </li></ul><ul><li>Membranous </li></ul><ul><li>Dense </li></ul><ul><li>Cortical </li></ul><ul><li>Endosteal </li></ul><ul><li>Woven </li></ul><ul><li>Lamellar </li></ul><ul><li>Spicular </li></ul>www.freelivedoctor.com
    8. 8. Woven vs Lamellar www.freelivedoctor.com
    9. 9. www.freelivedoctor.com
    10. 10. - BLASTS/-CLASTS www.freelivedoctor.com
    11. 11. BONE DISEASES <ul><li>1) MALFORMATIONS AND DISEASES CAUSED BY DEFECTS IN NUCLEAR PROTEINS AND TRANSCRIPTION FACTORS, polydactyly, syndactyly, absence of a bone </li></ul><ul><li>2) DISEASES CAUSED BY DEFECTS IN HORMONES AND SIGNAL TRANSDUCTION MECHANISMS, achondroplasia, thanatophoria </li></ul><ul><li>3) DISEASES ASSOCIATED WITH DEFECTS IN EXTRACELLULAR STRUCTURAL PROTEINS </li></ul><ul><ul><li>Type 1 Collagen Diseases (Osteogenesis Imperfecta) </li></ul></ul><ul><ul><li>Types 2, 10, and 11 Collagen Diseases </li></ul></ul><ul><li>4) DISEASES ASSOCIATED WITH DEFECTS IN FOLDING AND DEGRADATION OF MACROMOLECULES </li></ul><ul><ul><li>Mucopolysaccharidoses </li></ul></ul><ul><li>5) DISEASES ASSOCIATED WITH DEFECTS IN METABOLIC PATHWAYS (ENZYMES, ION CHANNELS, AND TRANSPORTERS) </li></ul><ul><ul><li>Osteopetrosis </li></ul></ul><ul><li>6) DISEASES ASSOCIATED WITH DECREASED BONE MASS </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><li>7) DISEASES CAUSED BY OSTEOCLAST DYSFUNCTION </li></ul><ul><ul><li>Paget Disease (Osteitis Deformans) </li></ul></ul><ul><li>8) DISEASES ASSOCIATED WITH ABNORMAL MINERAL HOMEOSTASIS </li></ul><ul><ul><li>Ricketts and Osteomalacia </li></ul></ul><ul><ul><li>Hyperparathyroidism </li></ul></ul><ul><ul><li>Renal Osteodystrophy </li></ul></ul>www.freelivedoctor.com
    12. 12. 1) MALFORMATIONS AND DISEASES CAUSED BY DEFECTS IN NUCLEAR PROTEINS AND TRANSCRIPTION FACTORS <ul><li>Congenital absence of a, usually single, bone: phalanx, rib, clavicle </li></ul><ul><li>Supernumerary digit (polydactyly) </li></ul><ul><li>Syndactyly </li></ul><ul><li>CRANIORACHISCHISIS </li></ul>www.freelivedoctor.com
    13. 13. www.freelivedoctor.com
    14. 14. 2) DISEASES CAUSED BY DEFECTS IN HORMONES AND SIGNAL TRANSDUCTION MECHANISMS <ul><li>Achondroplasia, dwarf (non-lethal) </li></ul><ul><li>Thanatophoria, dwarf (lethal) </li></ul><ul><li>a point mutation (usually Arg for Gly375) in the gene that codes for FGF receptor 3 (FGFR3), which is located on the short arm of chromosome 4. In the normal growth plate, activation of FGFR3 inhibits cartilage proliferation; </li></ul><ul><li>A MUTATION causes FGFR3 to be constantly activated. </li></ul>www.freelivedoctor.com
    15. 15. www.freelivedoctor.com
    16. 16. 3) DISEASES ASSOCIATED WITH DEFECTS IN EXTRACELLULAR STRUCTURAL PROTEINS <ul><li>OSTEOGENESS IMPERFECTA TYPES </li></ul><ul><li>(“Brittle” bone disease, too LITTLE bone), BLUE sclerae </li></ul><ul><li>Mutations in genes which code for the alpha-1 and alpha-2 chains of COLLAGEN 1 </li></ul><ul><li>Mutations of COLLAGEN 2,10, 11 manifest themselves as CARTILAGE diseases, ranging from joint cartilage destruction to fatal </li></ul>www.freelivedoctor.com
    17. 17. Osteogenesis Imperfecta www.freelivedoctor.com
    18. 18. 4) DISEASES ASSOCIATED WITH DEFECTS IN FOLDING AND DEGRADATION OF MACROMOLECULES <ul><li>MUCOPOLYSACCHARIDOSIS (one of MANY lysosome storage diseases) </li></ul><ul><li>DECREASES in ENZYMES which degrade: </li></ul><ul><ul><li>DERMATAN </li></ul></ul><ul><ul><li>HEPAR A N </li></ul></ul><ul><ul><li>KERAT A N </li></ul></ul><ul><li>Chiefly CARTILAGE disorders: short, chest wall, malformed bones </li></ul>www.freelivedoctor.com
    19. 19. MUCOPOLYSACCHARIDOSES www.freelivedoctor.com
    20. 20. 5) DISEASES ASSOCIATED WITH DEFECTS IN METABOLIC PATHWAYS (ENZYMES, ION CHANNELS, AND TRANSPORTERS) <ul><li>OSTEOPETROSIS, 4 types </li></ul><ul><li>One common one has a CARBONIC ANHYDRASE deficiency </li></ul><ul><li>DECREASED osteoclast resorption </li></ul><ul><li>“ MARBLE” bone, brittle, sclerosis </li></ul>www.freelivedoctor.com
    21. 21. OSTEOPETROSIS www.freelivedoctor.com
    22. 22. 6) DISEASES ASSOCIATED WITH DECREASED BONE MASS <ul><li>OSTEOPOROSIS </li></ul><ul><li>“ PEAK” bone mass is early adulthood </li></ul><ul><li>Normal decline, slow </li></ul><ul><li>Osteoporosis is accelerated bone loss </li></ul><ul><li>Factors: </li></ul><ul><ul><li>AGE </li></ul></ul><ul><ul><li>Physical activity </li></ul></ul><ul><ul><li>Estrogen </li></ul></ul><ul><ul><li>Nutrition (Ca++) </li></ul></ul><ul><ul><li>Genetics </li></ul></ul>www.freelivedoctor.com
    23. 23. www.freelivedoctor.com Categories of Generalized Osteoporosis Primary   Postmenopausal Idiopathic    Senile   Secondary   Endocrine disorders Rheumatologic disease Hyperparathyroidism    Drugs Hypo-hyperthyroidism    Anticoagulants    Hypogonadism    Chemotherapy    Pituitary tumors    Corticosteroids    Diabetes, type 1    Anticonvulsants    Addison disease    Alcohol    Neoplasia Miscellaneous Multiple myeloma    Osteogenesis imperfecta    Carcinomatosis    Immobilization    Gastrointestinal Pulmonary disease    Malnutrition, Malbs., Hepatic Insuf., Vit C,D    Homocystinuria    Anemia       
    24. 24. OSTEOPOROSIS www.freelivedoctor.com
    25. 25. 7) DISEASES CAUSED BY OSTEOCLAST DYSFUNCTION Paget Disease (Osteitis Deformans) <ul><li>Matrix madness, Osteoblasts/-cytes gone wild </li></ul><ul><li>THREE PHASES: </li></ul><ul><ul><li>1) Increased osteoclast resorption </li></ul></ul><ul><ul><li>2) Increased “hectic” bone formation (osteoblasts) </li></ul></ul><ul><ul><li>3) Osteosclerosis </li></ul></ul><ul><li>ELEVATED ALKALINE-PHOSPHATASE </li></ul><ul><li>ELEVATED urine HYDROXYPROLINE </li></ul>www.freelivedoctor.com
    26. 26. PAGET’s DISEASE (of BONE) 85% MONOSTOTIC, WHOLE BONE 15% POLY-OSTOTIC (skull, pelvis) “ JIGSAW”, NOT LAMINAR, BONE CLINICAL: PAIN!!! (MICROFRACTURES) www.freelivedoctor.com
    27. 27. PAGET’s DISEASE www.freelivedoctor.com
    28. 28. 8) DISEASES ASSOCIATED WITH ABNORMAL MINERAL HOMEOSTASIS <ul><ul><li>Ricketts and Osteomalacia </li></ul></ul><ul><ul><ul><li>VITAMIN D deficiency/dysfunction </li></ul></ul></ul><ul><ul><li>Hyperparathyroidism, PRIMARY (PTH ADENOMA) </li></ul></ul><ul><ul><ul><li>ENTIRE SKELETON </li></ul></ul></ul><ul><ul><ul><li>OSTEITIS FIBROSIS CYSTICA (von Recklinghausen’s disease (of bone) </li></ul></ul></ul><ul><ul><ul><li>“ BROWN” TUMOR </li></ul></ul></ul><ul><ul><li>Hyperparathyroidism, SECONDARY (RENAL) (NOT AS SEVERE AS 1 º) </li></ul></ul><ul><ul><li>Renal Osteodystrophy = ANY bone disorder due to chronic renal disease </li></ul></ul>www.freelivedoctor.com
    29. 29. PRIMARY HYPERPARATHYROIDISM www.freelivedoctor.com OSTEITIS FIBROSA CYSTICA “ BROWN” “TUMOR”
    30. 30. RENAL OSTEODYSTROPHY <ul><li>PHOSPHATE RETENTION </li></ul><ul><li>HYPOPHOSPHATEMIA </li></ul><ul><li>HYPOCALCEMIA </li></ul><ul><li>INCREASED PTH </li></ul><ul><li>INCREASED OSTEOCLASTS </li></ul><ul><li>METABOLIC ACIDOSIS  release of HYDROXYAPATITES from matrix </li></ul>www.freelivedoctor.com
    31. 31. FRACTURES www.freelivedoctor.com
    32. 32. FRACTURES, adjectives <ul><li>Complete, incomplete </li></ul><ul><li>Closed, open (communicating) </li></ul><ul><li>Communited (splintered) </li></ul><ul><li>Displaced (NON-aligned) </li></ul><ul><li>PATHOGENIC, (non-traumatic, 2 º to other disease, often metastases) </li></ul><ul><li>“ STRESS” fracture </li></ul>www.freelivedoctor.com
    33. 33. FRACTURES <ul><li>THREE PHASES </li></ul><ul><ul><li>HEMATOMA, minutes days  PGDF, TGF- β , FGF </li></ul></ul><ul><ul><li>SOFT CALLUS (“PRO”-CALLUS), ~1 week </li></ul></ul><ul><ul><li>HARD CALLUS (BONY CALLUS), several weeks </li></ul></ul><ul><li>COMPLICATIONS </li></ul><ul><ul><li>PSEUDARTHROSIS </li></ul></ul><ul><ul><li>INFECTION (especially OPEN [communicating] fractures) </li></ul></ul>www.freelivedoctor.com
    34. 34. FRACTURES www.freelivedoctor.com
    35. 35. OSTEONECROSIS <ul><li>Also called AVASCULAR necrosis </li></ul><ul><li>Also called ASEPTIC necrosis </li></ul><ul><li>CAUSE: ISCHEMIA </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Thrombus/Embolism </li></ul></ul><ul><ul><li>Vessel injury, e.g., radiation </li></ul></ul><ul><ul><li>INCREASED intra-osseous pressure  vascular compression </li></ul></ul><ul><ul><li>Venous hypertension too </li></ul></ul>www.freelivedoctor.com
    36. 36. OSTEONECROSIS www.freelivedoctor.com Disorders Associated with Osteonecrosis Idiopathic Pregnancy Trauma Gaucher disease Corticosteroid administration Sickle cell and other anemias Infection Alcohol abuse Dysbarism Chronic pancreatitis Radiation therapy Tumors Connective tissue disorders Epiphyseal disorders
    37. 37. OSTEONECROSIS www.freelivedoctor.com
    38. 38. OSTEONECROSIS www.freelivedoctor.com
    39. 39. OSTEOMYELITIS <ul><li>Pyogenic: Staph , E. coli, Pseudom, Kleb </li></ul><ul><ul><li>Hematogenous </li></ul></ul><ul><ul><li>Contiguous </li></ul></ul><ul><ul><li>Direct implantation </li></ul></ul><ul><li>TB </li></ul><ul><li>Syphilis </li></ul>www.freelivedoctor.com
    40. 40. OSTEOMYELITIS <ul><li>DX: X-ray, Bone scan </li></ul>www.freelivedoctor.com
    41. 41. OSTEOMYELITIS <ul><li>DX: Histology </li></ul>www.freelivedoctor.com
    42. 42. OSTEOMYELITIS <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Subperiosteal abscess </li></ul></ul><ul><ul><li>Draining sinus </li></ul></ul><ul><ul><li>Joint involvement </li></ul></ul><ul><li>SEQUESTRUM vs. INVOLUCRUM </li></ul>www.freelivedoctor.com
    43. 43. www.freelivedoctor.com
    44. 44. OSTEOMYELITIS <ul><li>Tuberculous </li></ul><ul><ul><li>Usually blood borne </li></ul></ul><ul><ul><li>TB of spine is known as POTTS disease </li></ul></ul><ul><li>Syphilis </li></ul><ul><ul><li>CONGENITAL </li></ul></ul><ul><ul><li>TERTIARY, “SABRE” shins </li></ul></ul>www.freelivedoctor.com
    45. 45. POTT’s DISEASE www.freelivedoctor.com
    46. 46. SABER SHINS www.freelivedoctor.com
    47. 47. www.freelivedoctor.com Classification of Primary Tumors Involving Bones Histologic Type Benign Malignant Hematopoietic (40%) Myeloma Malignant lymphoma Chondrogenic (22%) Osteochondroma Chondrosarcoma Chondroma Dedifferentiated chondrosarcoma Chondroblastoma Mesenchymal chondrosarcoma Chondromyxoid fibroma Osteogenic (19%) Osteoid osteoma Osteosarcoma Osteoblastoma Unknown origin (10%) Giant cell tumor tumor Giant cell tumor Adamantinoma Histiocytic origin Fibrous histiocytoma Malignant fibrous histiocytoma Fibrogenic Metaphyseal fibrous defect (fibroma) Desmoplastic fibroma Fibrosarcoma Notochordal Chordoma Vascular Hemangioma Hemangioendothelioma Hemangiopericytoma Lipogenic Lipoma Liposarcoma Neurogenic Neurilemmoma
    48. 48. BONE TUMORS <ul><li>BONE </li></ul><ul><li>CARTILAGE </li></ul><ul><li>FIBROUS </li></ul><ul><li>MISC. </li></ul><ul><ul><li>Ewing’s “sarcoma” </li></ul></ul><ul><ul><li>Giant Cell Tumor </li></ul></ul><ul><ul><li>METASTASES </li></ul></ul>www.freelivedoctor.com
    49. 49. BONE- BONE TUMORS <ul><li>OSTEOMA </li></ul><ul><li>OSTEOID OSTEOMA </li></ul><ul><li>OSTEOBLASTOMA </li></ul><ul><li>OSTEOSARCOMA (OSTEOGENIC SARCOMA) </li></ul>www.freelivedoctor.com
    50. 50. OSTEOMA <ul><li>SOLITARY </li></ul><ul><li>MIDDLE AGE </li></ul><ul><li>FROM SUBPERIOSTEAL or ENDOSTEAL surfaces </li></ul><ul><li>SKULL, FACE, most common </li></ul><ul><li>Totally BENIGN </li></ul><ul><li>To be distinguished from REACTIVE BONE </li></ul>www.freelivedoctor.com
    51. 51. FRONTAL SINUS www.freelivedoctor.com
    52. 52. OSTEOID OSTEOMA <ul><li>At least 2 cm in diameter </li></ul><ul><li>Teens, twenties, APPENDICULAR skeleton </li></ul><ul><li>M>>F </li></ul><ul><li>PAINFUL </li></ul><ul><li>Has a NIDUS </li></ul><ul><li>Responds to aspirin </li></ul><ul><li>Induces a MARKED bony reaction </li></ul>www.freelivedoctor.com
    53. 53. NIDUS www.freelivedoctor.com
    54. 54. OSTEOBLASTOMA <ul><li>AXIAL SKELETON, i.e., SPINE </li></ul><ul><li>NO Nidus </li></ul><ul><li>NO bony reaction </li></ul><ul><li>NOT relieved by aspirin </li></ul>www.freelivedoctor.com
    55. 55. OSTEOSARCOMA (OSTEOGENIC SARCOMA) www.freelivedoctor.com LATE TEENS KNEES METAPHYSES PAINFUL!!!
    56. 56. TYPES of OSTEOSARCOMAS <ul><li>• The anatomic portion of the bone from which they arise (intramedullary, intracortical, or surface) </li></ul><ul><li>• Degree of differentiation </li></ul><ul><li>• Multicentricity (synchronous, metachronous) </li></ul><ul><li>• Primary (underlying bone is unremarkable) or secondary (e.g., osteosarcoma associated with pre-existing disorders such as benign tumors, Paget disease, bone infarcts, previous irradiation) </li></ul><ul><li>• Histologic variants (osteoblastic, chondroblastic, fibroblastic, telangiectatic, small cell, and giant cell) </li></ul>www.freelivedoctor.com
    57. 57. The most common subtype is osteosarcoma that arises in the metaphysis of long bones; is primary, solitary, intramedullary, and poorly differentiated; and produces a predominantly bony matrix www.freelivedoctor.com
    58. 58. BONE- CARTILAGE TUMORS <ul><li>OSTEOCHONDROMA (EXOSTOSIS) </li></ul><ul><li>CHONDROMA </li></ul><ul><li>CHONDROBLASTOMA </li></ul><ul><li>CHONDROMYXOID FIBROMA </li></ul><ul><li>CHONDROSARCOMA </li></ul>www.freelivedoctor.com
    59. 59. OSTEOCHONDROMA (EXOSTOSIS) <ul><li>Common, Cartilage AND Bone present </li></ul><ul><li>Often MULTIPLE as a hereditary syndrome </li></ul><ul><li>M>>>F </li></ul><ul><li>PELVIS, SCAPULAE, RIBS </li></ul>www.freelivedoctor.com
    60. 60. www.freelivedoctor.com
    61. 61. CHONDROMA <ul><li>Chondroma vs. EN-chondroma </li></ul><ul><li>PURE Hyaline Cartilage </li></ul><ul><li>MULTIPLE enchondromas = Ollier’s dis. </li></ul><ul><li>Maffucci synd. if hemangiomas present </li></ul>www.freelivedoctor.com
    62. 62. CHONDROBLASTOMA <ul><li>RARE, in teenagers </li></ul><ul><li>M>>F </li></ul><ul><li>KNEES, usually </li></ul><ul><li>Epiphyses </li></ul><ul><li>MUCH LESS matrix than a chondroma </li></ul>www.freelivedoctor.com
    63. 63. CHONDROMYXOID FIBROMA <ul><li>RAREST of all </li></ul><ul><li>TEENS, MALES </li></ul><ul><li>“ MYXOID” concept </li></ul><ul><li>“ ATYPIA” </li></ul>www.freelivedoctor.com
    64. 64. CHONDROSARCOMA <ul><li>ANATOMY </li></ul><ul><ul><li>INTRAMEDULLARY </li></ul></ul><ul><ul><li>JUXTACORTICAL </li></ul></ul><ul><li>HISTOLOGY </li></ul><ul><ul><li>CONVENTIONAL </li></ul></ul><ul><ul><ul><li>HYALINE </li></ul></ul></ul><ul><ul><ul><li>MYXOID </li></ul></ul></ul><ul><ul><li>CLEAR </li></ul></ul><ul><ul><li>DE-DIFFERENTIATED </li></ul></ul><ul><ul><li>MESENCHYMAL </li></ul></ul>www.freelivedoctor.com
    65. 65. CHONDROSARCOMA www.freelivedoctor.com
    66. 66. BONE- FIBROUS TUMORS <ul><li>FIBROUS CORTICAL DEFECT/NON-OSSIFYING FIBROMA </li></ul><ul><li>FIBROUS DYSPLASIA </li></ul><ul><li>FIBROSARCOMA/MALIGNANT FIBROUS HISTIOCYTOMA </li></ul>www.freelivedoctor.com
    67. 67. FIBROUS CORTICAL DEFECT <ul><li>COMMON, usually LESS THAN 1 CM </li></ul><ul><li>CHILDREN >2 </li></ul><ul><li>IF MORE THAN 5-6 CM, they are then called NON-OSSIFYING FIBROMA </li></ul>www.freelivedoctor.com
    68. 68. FIBROUS DYSPLASIA <ul><li>BENIGN TUMOR </li></ul><ul><li>THREE TYPES </li></ul><ul><ul><li>SINGLE BONE (70%) </li></ul></ul><ul><ul><li>POLY-OSTOTIC (27%) </li></ul></ul><ul><ul><li>POLY-OSTOTIC (3%) with café-au-lait and endocrine disorders, especially precocious puberty </li></ul></ul>www.freelivedoctor.com
    69. 69. <ul><li>CURVED spicules </li></ul><ul><li>LACK of osteoblastic rimming </li></ul>www.freelivedoctor.com
    70. 70. FIBROSARCOMA/MFH <ul><li>METAPHYSES of LONG BONES </li></ul><ul><li>PELVIC FLAT BONES </li></ul><ul><li>LYTIC </li></ul><ul><li>FRACTURES </li></ul><ul><li>OF COURSE, SARCOMATOUS METASTASIS </li></ul>www.freelivedoctor.com
    71. 71. FIBROSARCOMA/MFH www.freelivedoctor.com
    72. 72. MISC. TUMORS of BONE <ul><li>EWING sarcoma/PNET (Primitive NeuroEctodermal Tumor) </li></ul><ul><li>GIANT CELL TUMOR </li></ul><ul><li>METASTASES </li></ul>www.freelivedoctor.com
    73. 73. EWING/PNET <ul><li>SAME TUMOR </li></ul><ul><li>SMALL ROUND </li></ul><ul><li>NEUROENDOCRINE </li></ul><ul><li>IDENTICAL CHROMOSOME TRANSLOCATION </li></ul><ul><li>SECOND most COMMON bone malignancy in CHILDREN </li></ul><ul><li>ARISE IN MEDULLARY CAVITY of BONE </li></ul><ul><li>LOOK LIKE LYMPHOMA </li></ul>www.freelivedoctor.com
    74. 74. GCT (Giant Cell Tumor), BONE www.freelivedoctor.com
    75. 75. METASTASES www.freelivedoctor.com MALE: PROSTATE FEMALE: BREAST RENAL, THYROID also seek bone early also LYTIC? BLASTIC?
    76. 76. www.freelivedoctor.com
    77. 77. www.freelivedoctor.com
    78. 78. www.freelivedoctor.com
    79. 79. www.freelivedoctor.com
    80. 80. SYNOVIAL JOINTS www.freelivedoctor.com
    81. 81. JOINT DISEASES <ul><li>“ ARTHRITIS” </li></ul><ul><ul><li>DEGENERATIVE (OSTEOARTHRITIS) </li></ul></ul><ul><ul><li>RHEUMATOID </li></ul></ul><ul><ul><li>“ JUVENILE” RHEUMATOID </li></ul></ul><ul><ul><li>NON-INFECTIOUS: Ankylosing Spond., Reactive, Psoriasis, IBD </li></ul></ul><ul><ul><li>INFECTIOUS: Supp., TB, Lyme, Viral </li></ul></ul><ul><ul><li>GOUT (URATE) </li></ul></ul><ul><ul><li>PSEUDOGOUT (PYROPHOSPHATE) </li></ul></ul><ul><li>Tumors </li></ul><ul><ul><li>Ganglion (Synovial Cyst) </li></ul></ul><ul><ul><li>Giant Cell Tumor (Pigmented VilloNodular Synovitis[PVNS]) </li></ul></ul><ul><ul><li>Synovial Sarcoma </li></ul></ul>www.freelivedoctor.com
    82. 82. DEGENERATIVE ARTHRITIS <ul><li>Etiology/Risk Factors: Age, Trauma, Genes </li></ul><ul><li>Pathogenesis: Progressive EROSION of articular cartilage </li></ul><ul><li>Morphology: X-Ray, “eburnation”, “joint mice”, osteophytes </li></ul><ul><li>Clinical Expression: PAIN, Limitation of motion </li></ul>www.freelivedoctor.com
    83. 83. www.freelivedoctor.com
    84. 84. HEBERDEN’S NODES DIP, NOT MP or PIP www.freelivedoctor.com
    85. 85. RHEUMATOID ARTHRITIS <ul><li>Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder that may affect many tissues and organs—skin, blood vessels, heart, lungs, and muscles—but principally attacks the joints, producing a nonsuppurative proliferative and inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints. </li></ul>www.freelivedoctor.com
    86. 86. RHEUMATOID ARTHRITIS <ul><li>Etiology/Risk Factors: Autoimmune </li></ul><ul><li>Pathogenesis: Progressive SYNOVITIS </li></ul><ul><li>Morphology: Synovial lymphocytes, macrophages, plasma cells, neutrophils, osteoclasts, “pannus”, hyperemia, rheumatoid “nodules”, vasculitis </li></ul><ul><li>Clinical Expression: PAIN, Limitation of motion, malaise, fatigue, rheumatoid factor IgM-IgGFc, </li></ul>www.freelivedoctor.com
    87. 87. The rheumatoid “nodule” shows “palisading” fibroblasts HANDS  WRIST  ELBOWS www.freelivedoctor.com
    88. 88. DIAGNOSIS <ul><li>CLINICAL FEATURES (1% of population F>>M) </li></ul><ul><ul><li>MORNING STIFFNESS </li></ul></ul><ul><ul><li>ARTHRITIS in MORE THAN 3 JOINT AREAS </li></ul></ul><ul><ul><li>“ TYPICAL” hand findings </li></ul></ul><ul><ul><li>SYMMETRIC ARTHRITIS </li></ul></ul><ul><ul><li>SERUM RHEUMATOID FACTOR </li></ul></ul><ul><ul><li>“ TYPICAL” X-RAY findings </li></ul></ul>www.freelivedoctor.com
    89. 89. www.freelivedoctor.com
    90. 90. “ JUVENILE” Rheumatoid Arthritis <ul><li>Begins BEFORE age 16, by definition </li></ul><ul><li>Generally LARGER joints than RA </li></ul><ul><li>Often POSITIVE ANA </li></ul>www.freelivedoctor.com
    91. 91. “ SERONEGATIVE” ARTHRITIDES <ul><li>ANKYLOSING SPONDYLITIS (aka, “rheumatoid” spondylitis, or Marie-Strumpell Disease [HLA-B27] (M>>F) </li></ul><ul><li>“ REACTIVE” ARTHRITIS (FOLLOWS GU or GI INFECTIONS) </li></ul><ul><ul><li>REITER SYDROME (urethral & conjunctival inflammation too) [HLA-B27] </li></ul></ul><ul><ul><li>Arthritis associated with IBD </li></ul></ul><ul><li>PSORIATIC ARTHRITIS </li></ul>www.freelivedoctor.com
    92. 92. Ankylosing Spondylitis www.freelivedoctor.com
    93. 93. INFECTIOUS ARTHRITIS <ul><li>From OSTEOMYELITIS </li></ul><ul><li>USUALLY SUPPURATIVE </li></ul><ul><li>GC , staph, strep, H. flu, E. coli, (Salmonella in sicklers) </li></ul><ul><li>4 cardinal signs, fever, leukocytosis,  ESR </li></ul>www.freelivedoctor.com
    94. 94. INFECTIOUS ARTHRITIS <ul><li>TB </li></ul><ul><li>LYME Disease, i.e., Borrelia burgdorferi </li></ul><ul><li>VIRAL </li></ul><ul><ul><li>Parvovirus B19 </li></ul></ul><ul><ul><li>Rubella </li></ul></ul><ul><ul><li>Hepatitis C </li></ul></ul>www.freelivedoctor.com
    95. 95. GOUT <ul><li>Endpoint of HYPERURICEMIA from ANY cause resulting in JOINT deposition of Monosodium crystals (TOPHI) </li></ul><ul><ul><li>ACUTE </li></ul></ul><ul><ul><li>CHRONIC </li></ul></ul><ul><li>10% of population has hyperuricemia (>7 mg/dl), but only 1/20 of these has gout </li></ul>www.freelivedoctor.com
    96. 96. www.freelivedoctor.com Classification of Gout Clinical Category Metabolic Defect Primary Gout (90% of cases) Enzyme defects unknown (85%–90% of primary gout) ■ Overproduction of uric acid   Normal excretion (majority)      Increased excretion (minority)      Underexcretion of uric acid with normal    production Known enzyme defects—e.g., partial HGPRT deficiency (rare) ■ Overproduction of uric acid Secondary Gout (10% of cases) Associated with increased nucleic acid turnover—e.g., leukemias ■ Overproduction of uric acid with increased urinary excretion Chronic renal disease ■ Reduced excretion of uric acid with normal production Inborn errors of metabolism—e.g., complete HGPRT deficiency (Lesch-Nyhan syndrome) ■ Overproduction of uric acid with increased urinary excretion HGPRT, hypoxanthine guanine phosphoribosyl transferase.
    97. 97. HYPERURICEMIA  GOUT <ul><li>Age of the individual and duration of the hyperuricemia are factors. Gout rarely appears before 20 to 30 years of hyperuricemia. </li></ul><ul><li>Genetic predisposition is another factor. In addition to the well-defined X-linked abnormalities of HGPRT, primary gout follows multifactorial inheritance and runs in families. </li></ul><ul><li>Heavy alcohol consumption predisposes to attacks of gouty arthritis. </li></ul><ul><li>Obesity increases the risk of asymptomatic gout. </li></ul><ul><li>Certain drugs (e.g., thiazides) predispose to the development of gout. </li></ul><ul><li>Lead toxicity increases the tendency to develop saturnine gout </li></ul>www.freelivedoctor.com
    98. 98. FEATURES <ul><li>TOPHACEOUS ARTHRITIS </li></ul><ul><li>GOUTY NEPHROPATHY </li></ul>www.freelivedoctor.com
    99. 99. www.freelivedoctor.com
    100. 100. www.freelivedoctor.com
    101. 101. GOUTY NEPHROPATHY www.freelivedoctor.com
    102. 102. GOUT <ul><li>Associated with ATHEROSCLEROSIS </li></ul><ul><li>Associated with HYPERTENSION </li></ul>www.freelivedoctor.com
    103. 103. Pseudo-GOUT <ul><li>Gout: Monosodium Urate </li></ul><ul><li>Pseudo-GOUT: Calcium Pyrophosphate </li></ul><ul><li>PSEUDOGOUT is also called CHONDROCALCINOSIS, or CPPD (Calcium Phosphate Deposition Disease) </li></ul><ul><li>IDIOPATHIC, HEREDITARY, SECONDARY </li></ul><ul><ul><li>Secondary  joint damage, hyperparathyroidism, hemochromatosis, hypomagnesemia, hypothyroidism, ochronosis, and diabetes </li></ul></ul>www.freelivedoctor.com
    104. 104. GOUT vs. PSEUDOGOUT www.freelivedoctor.com
    105. 105. JOINT TUMORS <ul><li>BENIGN </li></ul><ul><ul><li>GANGLION (SYNOVIAL CYST) </li></ul></ul><ul><ul><li>GIANT CELL TUMOR of TENDON SHEATH, aka PVNS, Pigmented VilloNodular Synovitis </li></ul></ul><ul><li>MALIGNANT </li></ul><ul><ul><li>SYNOVIAL SARCOMA </li></ul></ul>www.freelivedoctor.com
    106. 106. GANGLION www.freelivedoctor.com
    107. 107. PVNS/GCT www.freelivedoctor.com
    108. 108. “ SOFT TISSUE” TUMORS <ul><li>FAT </li></ul><ul><li>FIBROUS TISSUE </li></ul><ul><li>FIBROHISTIOCYTIC </li></ul><ul><li>SKELETAL MUSCLE </li></ul><ul><li>SMOOTH MUSCLE </li></ul><ul><li>VASCULAR </li></ul><ul><li>PERIPHERAL NERVE </li></ul><ul><li>UNCERTAIN: SYNOVIAL SARCOMA, ALVEOLAR SOFT PART SARCOMA, EPITHELIOD SARCOMA </li></ul>www.freelivedoctor.com
    109. 109. CAUSES <ul><li>MOSTLY UNKNOWN </li></ul><ul><li>RADIATION association </li></ul><ul><li>CHEMICAL BURN association </li></ul><ul><li>THERMAL BURN association </li></ul><ul><li>TRAUMA association </li></ul><ul><li>VIRUS association (HHV8 for Kaposi) </li></ul><ul><li>GENETICS </li></ul><ul><li>Parts of many SYNDROMES </li></ul><ul><li>MANY TRANSLOCATIONS </li></ul>www.freelivedoctor.com
    110. 110. www.freelivedoctor.com Chromosomal and Genetic Abnormalities in Soft Tissue Sarcomas Tumor Cytogenetic Abnormality Genetic Abnormality Extraosseous Ewing sarcoma and primitive neuroectodermal tumor t(11:22)(q24;q12) FLI-1-EWS fusion gene   t(21:22)(q22;q12) ERG-EWS fusion gene   t(7;22)(q22;q12) ETV1-EWS fusion gene Liposarcoma—myxoid and round cell type t(12:16)(q13;p11) CHOP/TLS fusion gene Synovial sarcoma t(x;18)(p11;q11) SYT-SSX fusion gene Rhabdomyosarcoma—alveolar type t(2;13)(q35;q14) PAX3-FKHR fusion gene   t(1;13)(p36;q14) PAX7-FKHR fusion gene Extraskeletal myxoid chondrosarcoma t(9;22)(q22;q12) CHN-EWS fusion gene Desmoplastic small round cell tumor t(11;22)(p13;q12) EWS-WT1 fusion gene Clear cell sarcoma t(12;22)(q13;q12) EWS-ATF1 fusion gene Dermatofibrosarcoma protuberans t(17:22)(q22;q15) COLA1-PDGFB fusion gene Alveolar soft part sarcoma t(X;17)(p11.2;q25) TFE3-ASPL fusion gene Congenital fibrosarcoma t(12;15)(p13;q23) ETV6-NTRK3 fusion gene
    111. 111. SOFT TISSUE TUMORS <ul><li>ALL “SPINDLY” </li></ul><ul><li>Deep (desmoid) vs. Superficial </li></ul><ul><li>Importance of MITOSES </li></ul><ul><li>Importance of STAGING </li></ul><ul><li>Importance of IMMUNOPEROXIDASE </li></ul><ul><li>Importance of CONSULTATION </li></ul>www.freelivedoctor.com
    112. 112. FAT <ul><li>LIPOMA </li></ul><ul><li>LIPOSARCOMA </li></ul>www.freelivedoctor.com NORMAL FAT LIPOMA, encapsulated LIPOSARCOMA, often retroperitoneal
    113. 113. FIBROUS TISSUE <ul><li>NODULAR FASCIITIS (pseudosarcomatous) </li></ul><ul><li>FIBROMATOSES (plantar, palmar, penile) </li></ul><ul><li>FIBROSARCOMA </li></ul>www.freelivedoctor.com
    114. 114. MYOSITIS OSSIFICANS <ul><li>BENIGN FIBROUS TISSUE PROLIFERATION PLUS OSSEOUS METAPLASIA </li></ul>www.freelivedoctor.com
    115. 115. FIBROHISTIOCYTIC <ul><li>FIBROUS HISTIOCYTOMA </li></ul><ul><li>DERMATOFIBROSARCOMA PROTUBERANS </li></ul><ul><li>MALIGNANT FIBROUS HISTIOCYTOMA </li></ul>www.freelivedoctor.com
    116. 116. SKELETAL MUSCLE <ul><li>RHABDOMYOMA </li></ul><ul><li>RHABDOMYOSARCOMA </li></ul>www.freelivedoctor.com
    117. 117. SMOOTH MUSCLE <ul><li>LEIOMYOMA </li></ul><ul><li>LEIOMYOSARCOMA </li></ul>www.freelivedoctor.com
    118. 118. www.freelivedoctor.com
    119. 119. www.freelivedoctor.com
    120. 120. VASCULAR <ul><li>HEMANGIOMA </li></ul><ul><li>LYMPHANGIOMA </li></ul><ul><li>HEMANGIOENDOTHELIOMA </li></ul><ul><li>HEMANGIOPERICYTOMA </li></ul><ul><li>ANGIOSARCOMA </li></ul>www.freelivedoctor.com
    121. 121. PERIPHERAL NERVE <ul><li>NEUROFIBROMA </li></ul><ul><li>SCHWANNOMA </li></ul><ul><li>GRANULAR CELL TUMOR </li></ul><ul><li>MALIGNANT (SCHWANNOMA ) </li></ul>www.freelivedoctor.com
    122. 122. UNCERTAIN <ul><li>SYNOVIAL SARCOMA </li></ul><ul><li>ALVEOLAR “SOFT PART” SARCOMA </li></ul><ul><li>EPITHELIOD SARCOMA </li></ul>www.freelivedoctor.com
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