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Musculoskeletal DiseaseMusculoskeletal Disease

Long Bone FormationLong Bone Formation Long Bone FormationLong Bone Formation

Membranous BoneMembranous Bone Articular Joint FormationArticular Joint Formation

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Articular Joint FormationArticular Joint Formation

Lamellar Bone vs. WovenLamellar Bone vs. Woven

Lamellar BoneLamellar Bone Bone StructureBone Structure

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Bone MetabolismBone Metabolism

Congenital ProblemsCongenital Problems

Matrix problemsMatrix problems Premature Premature

epiphyses closureepiphyses closure PituitaryPituitary MalabsorptionMalabsorption

Osteogensis ImperfectaOsteogensis Imperfecta

Brittle Bones Dis.Brittle Bones Dis. Multiple SubtypesMultiple Subtypes

Auto DominantAuto Dominant Auto RecessiveAuto Recessive

Collagen defectCollagen defect Bad bone matrixBad bone matrix

Blue scleraBlue sclera

Osteogenesis ImperfectaOsteogenesis Imperfecta OsteopetrosisOsteopetrosis

RockRock--like boneslike bones Actually ‘Chalk’Actually ‘Chalk’ Osteoclast defectOsteoclast defect Can’t resorbCan’t resorb Many FrxsMany Frxs

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Lamellar Bone vs. WovenLamellar Bone vs. Woven AchondroplasiaAchondroplasia

Premature Premature closure of closure of epiphysesepiphyses

Auto dominantAuto dominant Homozygous is Homozygous is

lethallethal

EnchondromaEnchondroma

Small rest of Small rest of hyaline cartilagehyaline cartilage

DevelopmentalDevelopmentalBony defectBony defect Bony defectBony defect

FracturesFractures Syndrome of Syndrome of

multiple multiple enchondromasenchondromas

Very disfiguringVery disfiguring

Multiple EnchondromasMultiple Enchondromas

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Nonossifying FibromaNonossifying Fibroma

Very commonVery common DevelopmentalDevelopmental Fibrous cortical Fibrous cortical

defectdefectdefectdefect Size determines Size determines

what we call what we call them.them. 55--6 cm6 cm

OsteoporosisOsteoporosis

Loss of bone Loss of bone massmass

Not problem of Not problem of calciumcalciumcalcium calcium metabolismmetabolism

Peak bone massPeak bone mass WomenWomen FracturesFractures HRTHRT

OsteoporosisOsteoporosis

OsteoporosisOsteoporosis

Collapse of vertebral Collapse of vertebral bodiesbodies

KyphosisKyphosis Loss of heightLoss of height Hip fracturesHip fractures Peak bone massPeak bone mass Physical activityPhysical activity GeneticsGenetics

RANK & OPGRANK & OPG

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Vitamin D DeficiencyVitamin D Deficiency

RicketsRickets Developing boneDeveloping bone Can’t convert cartilage Can’t convert cartilage

d l t bd l t bmodel to bonemodel to bone Permanent deformityPermanent deformity

OsteomalaciaOsteomalacia AdultsAdults Can’t remodelCan’t remodel Softening of boneSoftening of bone

HyperparathyroidismHyperparathyroidism

HyperparathyroidismHyperparathyroidism Renal OsteodystrophyRenal Osteodystrophy

Paget’s DiseasePaget’s Disease

Viral infectionViral infection Destructive and Destructive and

proliferativeproliferativeS l i fS l i f Sclerosis of marrow Sclerosis of marrow spacespace

Skull and pelvisSkull and pelvis Increased incidence Increased incidence

of primary bone of primary bone tumortumor

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Paget’s DiseasePaget’s Disease ClubbingClubbing

Hypertrophic Hypertrophic osteoarthropathyosteoarthropathy

Soft tissue and Soft tissue and periosteal boneperiosteal bone

COPDCOPD Pure emphysema, rarePure emphysema, rare

Lung cancerLung cancer Heart defectsHeart defects

OsteomyelitisOsteomyelitis

Direct infection of Direct infection of bone.bone.

Bacterial most oftenBacterial most oftenSt h lSt h l StaphylococcusStaphylococcus

SalmonellaSalmonella Sickle Cell DiseaseSickle Cell Disease

TuberculosisTuberculosis Spine firstSpine first

SyphilisSyphilis PeriosteumPeriosteum

Avascular Necrosis, Avascular Necrosis, Legg-Perthes

Weight bearing jts.Weight bearing jts. Developmental?Developmental? Physically active.Physically active.

Compression andCompression and Compression and Compression and necrosis of bone and necrosis of bone and articular cartilage.articular cartilage.

Legg-Perthes FracturesFractures

AnthropologyAnthropology ForensicsForensics

IdentificationIdentification Pattern in child Pattern in child

abuseabuse Bumper heightBumper height PathologicalPathological

TumorTumor GummaGumma Developmental Developmental

defectdefect

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Greenstick FractureGreenstick Fracture PseudoarthrosisPseudoarthrosis

Bone TumorsBone Tumors

Benign vs. MalignantBenign vs. Malignant Primary vs. MetastaticPrimary vs. Metastatic

SymptomsSymptoms SymptomsSymptoms PainPain EnlargementEnlargement Fracture at site of tumorFracture at site of tumor

OsteochondromaOsteochondroma

Mechanical injury to growth line.Mechanical injury to growth line. Continues to grow as a unit for years.Continues to grow as a unit for years. Problem of diagnosis.Problem of diagnosis.

Fibrous DysplasiaFibrous Dysplasia

DevelopmentalDevelopmental MonostoticMonostotic PolyostoticPolyostotic BonesBones

Ribs, femur, jaw, Ribs, femur, jaw, , , j ,, , j ,humerus….humerus….

McCuneMcCune--AlbrightAlbright PolyostoticPolyostotic CaféCafé--auau--lait spotslait spots Sexual precocitySexual precocity HyperthyroidismHyperthyroidism Pituitary adenomasPituitary adenomas

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McCuneMcCune--AlbrightAlbright Bone CystsBone Cysts

Fairly commonFairly common BenignBenign RibsRibs Weakened area tends Weakened area tends

to fractureto fracture

Osteoid OsteomaOsteoid Osteoma

TibiaTibia Injury?Injury? CorticalCortical

V i f lV i f l Very painfulVery painful AspirinAspirin

Malignant tumors, metastaticMalignant tumors, metastatic

From practically any From practically any cancercancer BreastBreast ProstateProstate LungLung

To any boneTo any bone VertebraeVertebrae Long bonesLong bones

Osteosarcoma, Primary MalignancyOsteosarcoma, Primary Malignancy

Weight bearingWeight bearing Long bonesLong bones Young peopleYoung people Osteoblast is malignant Osteoblast is malignant

cellcellcellcell Genetics of tumor being Genetics of tumor being

unraveledunraveled Rb geneRb gene P53P53 MDM2MDM2 St. Bernards and Great St. Bernards and Great

DanesDanes

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Osteosarcoma, Primary MalignancyOsteosarcoma, Primary Malignancy Codman’s TriangleCodman’s Triangle

XX--Ray findingRay finding Lifting of periostium Lifting of periostium

by tumorby tumor

ChondrosarcomaChondrosarcomaEwing SarcomaEwing Sarcoma

‘Small blue tumor’‘Small blue tumor’ Primitive neuroectodermal Primitive neuroectodermal

tumor (PNET)tumor (PNET)Children and young adultsChildren and young adults Children and young adults.Children and young adults.

Oseous and extraOseous and extra--oseousoseous ‘Fusion genes’‘Fusion genes’ t(11;22)(q24;q12)t(11;22)(q24;q12)

Giant Cell TumorGiant Cell Tumor

OsteoclastsOsteoclasts BenignBenign Locally destructiveLocally destructive EpiphysesEpiphyses

AdolescentsAdolescents

MetaphysesMetaphyses KneeKnee SolitarySolitary

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ArthritisArthritis Inflammation of the jointsInflammation of the joints

Articular surface and/or joint capsule.Articular surface and/or joint capsule. InfectiousInfectious

GCGCL & thL & th Lyme & othersLyme & others

Immune mediated, rheumatic feverImmune mediated, rheumatic fever Streptococcal triggerStreptococcal trigger

Autoimmune, rheumatoid arthritisAutoimmune, rheumatoid arthritis Wear and Tear, osteoarthritisWear and Tear, osteoarthritis Crystal arthritis, goutCrystal arthritis, gout

Rheumatic Heart DiseaseRheumatic Heart Disease

Rheumatoid Arthritis Rheumatoid Arthritis –– Systemic DiseaseSystemic Disease

Genetically Genetically susceptiblesusceptible

TriggerTrigger Virus? EBVirus? EB

AutoimmuneAutoimmune Autoimmune Autoimmune destructiondestruction Rheumatoid factorRheumatoid factor

Loss of articular Loss of articular cartilagecartilage

Joint fusionJoint fusion

Rheumatoid ArthritisRheumatoid Arthritis Rheumatoid FactorsRheumatoid Factors Present in about 80% of casesPresent in about 80% of cases Some healthy people and other CT diseasesSome healthy people and other CT diseases RA need titer (Don’t screen with this)RA need titer (Don’t screen with this) IgMIgM generated against persons generated against persons IgGIgG

Rarely Rarely IgGIgG or or IgAIgAT d iT d i FF i f ib di f ib d Targeted against Targeted against FcFc portion of antibodyportion of antibody

SelfSelf--associate to form immune complexesassociate to form immune complexes Activate complement, causing cartilage destructionActivate complement, causing cartilage destruction These circulating immune complexes bring about These circulating immune complexes bring about

many of the extramany of the extra--arthritic symptomsarthritic symptoms TNF, ILTNF, IL--1, IL1, IL--6, IL6, IL--1515 CCP antibodies (cyclic CCP antibodies (cyclic citrullinatedcitrullinated proteins)proteins)

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Rheumatoid FactorRheumatoid Factor

CitrullineCitrulline generationgeneration Cyclic Cyclic citrullinatedcitrullinated proteins antibodies proteins antibodies

PanusPanus FormationFormation Rheumatoid ArthritisRheumatoid Arthritis

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Rheumatoid ArthritisRheumatoid ArthritisRheumatoid NodulesRheumatoid Nodules

Rheumatoid NoduleRheumatoid NoduleJuvenile Idiopathic ArthritisJuvenile Idiopathic Arthritis

Number of subtypesNumber of subtypes Some RF Some RF ––

Some RFSome RF ++ Some RF Some RF ++ ANA +ANA + All are systemicAll are systemic <16 years old<16 years old

Ankylosing SpondylitisAnkylosing Spondylitis Reiter’s SyndromeReiter’s Syndrome

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OsteoarthritisOsteoarthritis

Wear and tear on Wear and tear on joint cartilagejoint cartilage

Normally there is very Normally there is very little friction.little friction.

Minimal damage leads Minimal damage leads to cartilage fractures.to cartilage fractures.

Synovial fluid into Synovial fluid into underlying bone.underlying bone.

Microcysts and bone Microcysts and bone necrosis.necrosis.

OsteoarthritisOsteoarthritis

Weight bearing Weight bearing jointsjoints

Injury to Injury to cartilagecartilage

ProgressiveProgressive MiddleMiddle--age and age and

olderolder

OsteoarthritisOsteoarthritis

The The Boston Molasses DisasterBoston Molasses Disaster, also known as the , also known as the Great Molasses FloodGreat Molasses Flood or or The Great Boston Molasses The Great Boston Molasses TragedyTragedy, or the "Molasses Spill" occurred on January 15, 1919, in the North End neighborhood of Boston, , or the "Molasses Spill" occurred on January 15, 1919, in the North End neighborhood of Boston, Massachusetts in the United States. A large molasses tank burst and a wave of molasses rushed through the Massachusetts in the United States. A large molasses tank burst and a wave of molasses rushed through the streets at an estimated 35streets at an estimated 35 mph (56mph (56 km/h), killing 21 and injuring 150. The event has entered local folklore, and km/h), killing 21 and injuring 150. The event has entered local folklore, and residents claim that on hot summer days the area still smells of molasses.residents claim that on hot summer days the area still smells of molasses.

MolassesMolasses or or treacletreacle is a thick syrup byis a thick syrup by--product from the processing of the sugarcane or sugar beet into sugarproduct from the processing of the sugarcane or sugar beet into sugar

Crystal ArthritisCrystal Arthritis

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GoutGout Crystal ArthritisCrystal Arthritis

GoutGout Uric acid crystalsUric acid crystals Genetics and dietGenetics and diet Crystals in joint space Crystals in joint space

and soft tissuesand soft tissues Tophi in soft tissueTophi in soft tissue

Intense inflammatory Intense inflammatory reaction in jointreaction in joint

Very PainfulVery Painful

GoutGout GoutGout

GoutGout GoutGout

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PseudogoutPseudogout

Similar symptomsSimilar symptoms Calcium pyrophosphateCalcium pyrophosphate SmallerSmaller

Gout or Pseudogout?Gout or Pseudogout?

Tumors of Soft TissueTumors of Soft Tissue

Nodular FasciitisNodular Fasciitis FasciitisFasciitis

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Myositis OsificansMyositis Osificans

LegsLegs PalmsPalms

Auto mechanicsAuto mechanics

Hematoma that becomesHematoma that becomes Hematoma that becomes Hematoma that becomes calcifiedcalcified

Overt bone formationOvert bone formation Even bone marrowEven bone marrow

DesmoidDesmoid

LiposarcomaLiposarcoma RhabdomyosarcomaRhabdomyosarcoma

FibrosarcomaFibrosarcoma Malignant Fibrous HistiocytomaMalignant Fibrous Histiocytoma

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Synovial SarcomaSynovial Sarcoma