Download - Ap 50 11-12 1 orthopedic pathology
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Orthopaedic Pathology Bone,
cartilageSoft tissue nearbySynoviu
mTendonBursaFibrous tissueMuscle
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Fig. 28 A synovial joint, on section.
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rigid endoskeleton
- Supports the body
- Protects viceral organ
- Provides attachments for muscles
Metabolism of calcium and other minerals
Contains hematopoietic marrow
Function of Bone
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Fig. 2.1 Embryonic development of a long bone during the first six months
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Normal
Rickets
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow
hematopoietic lineage
Bone marrow stromal cell
lineage
BONEBONE
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow hematopoietic lineage
CFM-GM ( colony forming unit granulocyte-macrophage )
monoblast
promonocyte
monocyte
Tissue macrophage
osteoclast
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow stromal cell
lineage ( mesenchymal stem cell )CFU-F(Colony forming
unit fibroblast)
Stromal osteoblast precursor cell
Transitory osteoblast
Secretory osteoblast
Osteoblast( bone lining cell )
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
( Receptor activator for nuclear factor Kappa B)
( Rank ligands )
Osteoblast-
osteoclast
interaction
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoblasts
• Secrete interleukin-6 & 11• Tissue growth factor β• Activated by parathyroid hormone;
1,25 vitamin D, interleukin 1, TNF
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Parathyroid hormone
-collagen type 1
-Fibronectin
-Alkaline phosphatase
-Osteocalcin
-sialoproteinOsteoblast
Estrogen
interleukin 6
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoclast
• Calcitonin-receptor
• Vitronectin receptor
• Tartrate-resistant acid phosphatase
• Cytoplasmic carbonic anhydrase
• Osteopontin
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoclast
calcitonin
Integrins
cadherins
N-cam
Vitronectin
Cytoplasmic carbonic anhydrase
calcitonin
Integrins
calcitonin
Integrins
calcitonin
Integrins
cadherins
N-cam
Vitronectin
calcitonin
Integrins
cadherins
N-cam
Vitronectin
calcitonin
IntegrinsIntegrins
calcitonin
Tartrate resistant acid phosphatase
selectin
osteopontin
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Histology of Synovium
•Intimal layer: A thin layer of synovial cells or synoviocytes
•Subintimal layer: arterioles, fat and other connective tissue cells such as fibroblasts, histiocytes, and occasional mast cells
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Congenital anomalies
Developmental abnormalities:
complex, variable,
genetic based and manifest
during the earliest stages
of bone formation
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Developmental
anomalies1) Defect in nuclear proteins and transcription factor ( dysostosis) 2) Mutations in the hormone
and signal transduction ( dysplasia )3) Defect in extracellular
structural proteins
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OSTEOGENESIS IMPERFECTA
A group of distinct clinical syndromes with
various modes of inheritance and having in
common an increased propensity to fracture.
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteogenesis ImperfectaAbnormal secretion type I
collagen
Decreased synthesis type I collagen Decreased
Deletion 1(I) geneMatrix
Deletion 2 gene
Unstable type I collagen
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Ehlers-Danlos
syndrome
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Direct inoculations following
compound fracture
Osteomyelitis : caused by
Hematogenous spreading
(staphylococcus aureus, Salmonella)
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OsteomyelitisOsteomyelitis
Involucrum:
New bone formation in perioste umSequestrum
:
Dead bone
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Figure 231. Tuberculous osteomyelitis.Figure 231. Tuberculous osteomyelitis.
A sagittal section of a portion of the vertebr
al column. Two vertebrae are involved and have
collapsed, causing kyphotic angulation with co
mpression of the spinal cord.
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Spinal tuberculosis (Pott’s disease)
Psoas abscess
Disc destruction
Vertebral collapse
Paraplegia
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Commonly affects the spine
Spreads usually from pulmonary
disease via blood stream
Tuberculosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
A
BFigure 244. Congenital syphilis. A, There areradiolucent defects adjacent to the zones of provisional calcification and periosteal newbone around the diaphysis. The defect in the proximal tibia is symmetrical (Wimberger’s sign). B, Reexamination of the forearm threeweeks later reveals evidence of healing of the metaphyseal lesions.
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Simple fracture
Impacted fracture
Comminuted fracture
Stress fracture
Greenstick fracture
Trauma to normal bone
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoporosis
Osteomalacia
Hyperparathyroidism
Paget’s disease
Osteogennesis imperfecta
Tumors
Pathological fracture
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Hematoma
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Granulation tissue
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Callus-formation
Osseous callus
Osteo-cartilaginous
callus
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Sequence of bone healing in fracture
•Hematoma•Granulation tissue
•Callus formation
•Remodeling
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Complication of fracture
Delayed union
Non-unio
n
pseudarthrosis
Malunion
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Avascular necrosis
•Synonym: Aseptic necrosis
osteonec
rosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Cause of osteonecrosis
• Idiopathic
• Post fracture
• Fat embolism
• Legg-Calves Perthes disease
• Steroid induce
• Alcohol
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Legg-Calves Perthes
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rheumatoid arthritis
• Self-perpetuating , inflammatory joint disease
• Initially characterized by swelling in several joints and stiffness
• Roentgenographically show a chronic inflammatory destruction of the joint
• Laboratory findings: Rheumatoid factor, ESR
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Terminology in Rheumatoid arthritis
•Pannus: inflammed synovium attaching on articular cartilage
•Rheumatoid nodules
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rheumatoid nodule
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PATHOLOGY OF SYNOVIUM in rheumatoid arthritis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Proposed mechanism for rheumatoid
diseases
Robbins and Cotran ( 7th. Ed) p. 137
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Inflammatory joint diseases
Seropositive: 1) Rheumatoid arthritis 2) Juvenile rheumatoid
arthritis Seronegative: 1) Ankylosing
spondylitis 2) Psoriasis 3) Reactive arthritis
( Reiter’s syndrome )
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone tumors• Primary bone tumors
• Metastatic bone tumors
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Histologic typing of bone tumor- Bone forming tu
mors Cartilage formin g tumors Giant cell tu
mors Bone marro w tumors
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone forming tumors
• Benign : OSTEOMA
• Malignant: OSTEOSARCOMA
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Cartilage-forming tumors
• Benign : OSTEOCHONDROMA, ENCHONDROMA, CHONDROBLASTOMA, CHONDROMYXOID FIBROMA
• Malignant : CHONDROSARCOMA
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow-forming tumors
• Ewing’s sarcoma
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Chicken-wire calcification
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Periosteal reaction
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Eosinophilic granuloma
( Langerhans cell granulomatosis, Langerhans cell
histiocytosis )
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone-remodeling
unit
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Metabolic bone diseases
- Matrix
- Mineralization
- Deposition of waste product
formation
resorption
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Matrix formation defect
- Osteogenesis imperfecta
- Paget’s disease
- Mucopolysaccharidosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Matrix resorption defect
Hyperparathyroidism
Osteopetrosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteitis fibrosa cystica
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteomalacia
Looser’s zone
(pseudofracture )
Milk-man’s fracture
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rachitic rosaries
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rickets
Irregularity of
growth plate
Genu varusIrregularit
y of growth plate
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Table 1. Comparison of two types of involutional osteoporosis. From Riggs and Melton(1986)with permission.
Type IType I Type IIType II
Age (years) 51-75 > 70Sex ratio (female : male) 6:1 2:1Type of bone loss Mainly cancellous Cancellous and compactRate of bone loss Accelerated Not acceleratedFracture site Vertebrae (crush) and Vertebrae (wedge) distal radius and hipParathyroid function Decreased IncreasedCalcium absorption Decreased Decreased Metabolism of 25-OH-D to Secondary decrease Primary decrease 1.25(OH)2D
Main causes Factors related to Factors related to menopause ageing
25-OH-D = 25-hydroxyvitamin D ; 1.25(OH)2D = dihydroxyvitamin D.
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PATHOGENESIS OF OSTEOPOROSISPATHOGENESIS OF OSTEOPOROSISModelModel
Figure 4. Conceptual model of the pathogenesis of fractures relate to osteoporosis. Modified from Riggs (1988).
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Deposition of waste product
- Pseudo - gout
- Gout
- Oxalosis
- Ochronosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Gouty tophi
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PseudPseud-o gou-o goutt
Calcium pyrophosphate
crystal
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OchroOchronosisnosis
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Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
ochronosis