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Cells synthesize, transport and arrange proteins of matrix and initiate process of
mineralisation
Osteoblast have receptors that bind regulatory hormones (PTH, Vit D, Leptin and
estrogen) , cytokines, growth factors, and ECM proteins
In turn express several factors that regulate differentiation and function of
osteoclasts
If osteoblast become surrounded by newly deposited organic matric, transform
into osteocytes
Osteoblast remaining on bone surface may become flattened and quiescent bone
lining cells
o Osteocytes communicate with each other and with cells on bone surface via intricate network of
cytoplasmic processes that traverse tunnels in matric (cannaliculo)
Osteocytes control calcium and phosphate levels in microenvironement and detect
mechanical forces and translate them into biologic activity (mechanotransduction )
o Osteoclasts responsible for bone resorption, derived from same hematopoietic progenitor cells
that also giver rise to monocytes and macrophages
Cytokines and growth factors that regulate human osteoclast differentiation and
maturation include macrophage colony-stimulating factor (M-CSF) , interleukin-1 (IL-1)
and TNF
Mature multinucleated osteoclasts (containing 6-12 nuceli) from fusion of circulating
monoculear precursors and have limited lifespan
Bind to bone surface via integrins
Form underlying resorption pit (self-contained extracellular space analogous to secondary
lysosome )
Cell membranes overlying resoprtion pit thrown into numerous folds (ruffled border)
increasing its digestion products
Osteoclast removes mineral by generating acidic environment utilizing proton pump
system , digest organic component by releasing proteases
Control mechanisms
- Transmembrane receptor RANK receptor activator for NF-KB expressed on osteoclast precursor
- RANKL expressed on osteoblast and marrow stromal cells
- Osteoprotegerin (OPG) secreted decoy receptor made by osteoblast and other types of cells that
can bind RANKL
- When stimulated by RANKL, RANK signaling activates transcription factor NF-KB essential for
generation and survival of osteoclasts
- Second important pathway involves M-CSF produced by osteoblasts and M0CSF receptor, which is
expressed by osteoclast progenitors
o Activation of M-CSF receptor stimulates tyrosine kinase activity that is also crucial for
generation of osteoclasts
o Other notable pathways, WNT/P-catenin pathway
WNT proteins produced by marrow stromal cells bing to LRP5 and LRP6 receptors on
osteoblasts and thereby trigger activation of -catenin and production of OPG
- Bone formation and resoprtion are tightly coupled
o Systemic factors affecting RANKL and OPG expression
Hormones (PTH. Estrogen, testosterone and glucocortoids)
Vit D
IL-1
mechanisms
Growth factors
Paracrine molecular
that regulate
osteoclast formation and function. Osteoclasts are
derived from the same stem
cells that produce macrophages. Osteoblast/stromal
cell membraneassociated RANKL binds to its
receptor RANK located on the cell surface of
osteoclast precursors. This interaction in the
background of macrophage colony-stimulating factor
(M-CSF) causes the precursor cells to produce
functional osteoclasts. Stromal cells also secrete
osteoprotegrin (OPG), which acts as a decay receptor
for RANKL, preventing it from binding
the RANK receptor on osteoclast precursors.
Consequently, OPG prevents bone resorption by
inhibiting osteoclast differentiation.
Proteins of bone
- Type 1 collagen
- Many non-collagenous proteins derived mainly from osteoblasts
Osteoblast deposit collagen either in random weave woven bone or in orderly layered manner
designated lamellar bone
Normally woven bone is seen in sites of rapid bone formation such as fetal skeleton and base of growth
plates
Produced quickly and resist forces equally from all directions
Presence of woven bone in adults is always abnormal
Lamellar bone gradually replaces woven bone during growth, is deposited much more slowly and is
stronger than woven bone
o Similar process occurs at base of articular cartilage, and by this mechanism bones increases in
length and articular surfaces increase in diameter
o In contrast, bones derived from intramembranous formation, such as cranium and lateral portions
of clavicles are formed by osteoblast directly from fibrous layer of tissue that is derived from
mesenchyme
o Because bone tissue is made only by osteoblasts enlargement of bones is achieved by the
deposition of new bone on pre-existing surface
o Mechanism of appositional growth is key understanding bone growth and modeling
Non-neoplastic conditions of bone
Hereditary:
Disease caused by defects in hormones and signal transduction mechanisms
Achondroplasia
- Autosomal dominant disorder (80% from new mutations, most occur in paternal allele)
- Point mutation in the FGF receptor 3 gene
o Normally FGF mediated activation of FGFR3 inhibits cartilage proliferation
o In achondroplasia, mutations cause constitutive activation of FGFR3 Suppress growth
- Most common disease of the growth plate and is a major cause of dwarfism.
- Premature closure of the growth plate due to reduced chondrocyte proliferation with normal appositional
bone formation.
o Affected individuals have shortened proximal extremities
o Trunk of relative normal length
o Enlarged head with lubing forehead
o Conspicuous depression of root of nose
o Skeletal abnormalities not associated with changes in longevity, intelligence or reproductive
status
X4329B. Lower limb bones from a
Tyrion lannister
man aged 68 with achondroplasia.
- Large head
Death was due to myocardial
- Frontal bossing of head
infarction. See the short and
- Forearm is relatively normal sized, proximal arm
disproportionately thick bones
bones shortened
- Trunk is relatively normal sized
Cortical bone thickness is increased
- Have intelligence and life span
Affected patients have normal intelligence and life-span.
Thanatophoric dwarfism most common lethal form of dwarfism
- Gain of function mutation in FGFR3 (differ from those in achrondroplasia)
- Affected individuals have micromelic shortening of limbs, frontal bossing, relative macrocephaly, small
chest cavity and bell-shaped abdomen
- Underdeveloped thoracic cavity leads to respiratory insufficiency
- Individuals frequently die at birth or soon after
Disease associated with defects in extracellular structural proteins
Importance of structural bone proteins exemplified by diseases associated with deranged metabolism of
collagens important in bone and cartilage formation
Clinical manifestations highly variable
Skeletal
radiogram of a
fetus with lethal
type II OI. Note
the numerous
fractures of
virtually all
bones,
resulting in
accordion-like
shortening of the
limbs.
Osteopetrosis
Radiogram of the
- Aka marble bone disease and Albers-schoneberg disease
upper extremity in
rare genetic disease that are characterized by reduced
an individual with
bone resoprtion and diffuse symmetric skeletal sclerosis
osteopetrosis. The
due to impaired formation or function of osteoclasts
bones are diffusely
- Osteopetrosis stonelike quality of bones
sclerotic, and the
o Bones are abnormally brittle and fracture easily
distal
o Autosomal recessive and dominant forms
metaphyses of the
Mild
ulna and radius are
poorly formed
Severe
Pathogenesis
- Interfere with process of acidification of osteoclast
resorption pit, required for dissolution of calcium
hydroxyapatite within matrix
o Eg: CA2 encodes enzyme carbonic anhydrase II
o Required by osteoclast and renal tubular cells to generate protons from carbon dioxide and water
o Lack of CAII Prevents osteoclast from acidifying
resoprtion put and solubilizing hydroxyapatite
o Blacks acidification of urine by renal tubular cells
Morphology
- Due to deficient osteoclast activity
- Bones lack medullary canal and ends of long bones are
bulbous (Erlenmeyere fask deformity) and misshapen
- Neural foramina are small and compress exiting nerves
Primary spongiosa normally removed during growth, persists and fills medullary cavity no room
for hematopoietic marrow and preventing formation of mature trabeculae
Deposited bone not remodeled
o Woven in architecture
Section of proximal tibial diaphysis
o Intrinsic abnormalities cause bone to be brittle and
from a fetus with osteopetrosis. The
predisposed to fracture
cortex (1) is present, but the
o Histologically number of osteoclast may be normal,
medullary cavity (2) is filled with
increased or decreased depending on underlying
primary spongiosa, which replaces
genetic defect
the hematopoietic elements.
Clinical features
- Severe infantile malignant osteopetrosis autosomal recessive
- Becomes evident in utero and facial paralysis , repeated often fatal infections because of inadequacies
of marrow produced in extramedullary sites also causes prominent hepatosplenomegaly
- Mild autosomal dominant begin
Osteoporosis
- Disease characterized by porous bones and reduced bone mass
- Causes
o Primary
Post menopausal
Senile
o Secondary
Endocrine disorders
Hyperparathyroidism
Hyperthyroidism
Hypothyroidism
Pituitary tumors
DM 1
Addisons disease
Neoplasia
MM
Carcinomatosis
GIT
Malnutrition
Malabsorption
Hepatic insufficiency
V C,D, deficiencies
Drugs
Antico-agulants
Chemo
Corticosteroids
Anticonvulsants
Osteoporotic vertebral body (right) shortened by
OH
compression fractures compared with a normal
Pathogenesis
vertebral body. Note that the osteoporotic vertebra
- Peak bone mass archived during young
has a characteristic loss of horizontal trabeculae
adulthood
and thickened vertical trabeculae
Magnitude determined hereditary factors polymorphisms in genes that influence bone metabolism
Physical activity, muscle strength, diet hormonal state also make important contributions
Imbalance between bone resopriton and bone formation
Accordingly, age-related bone cells and matrix and strong impact on bone metabolism
o Osteoblast from elderly individuals have reduced proliferative and biosynthetic potential
o Proteins bound to extracellular matrix (such as growth factors, which are mitogenic to
osteoprogenitor cells and stimulate osteoblastic synthetic activity)
Losing biologic punch over time
o Net result is diminished capacity to make bone
o This form osteoporosis, known as senile osteoporosis low-turnover variant
Reduced physical activity increases the rate of bone loss in experimental animals and humans
o Because mechanical forces stimulate normal bone remodeling
o Bone loss in an immobilized or paralyzed extremity
o Load magnitude influences bone density more than number of load cycles
o Muscle contraction is dominant source of skeletal loading (resistance exercise impt)
Genetic factors RANKL, OPG, RANK
Bodys calcium nutritional state impot
o Calcium deficiency occurring during period of rapid growth stunt peak bone mass
o Calcium deficiency increase PTH conc reduced levels of vitamin D
Hormonal influences decade after menopause poste menopausal osteoporosis
o Hormone-dependent acceleration of bone loss that occurs during decade after menopause
o Effects of estrogen mediated by cytokines
Decreased estrogen levels increased secretion of inflammatory cytokines by blood
monocytes and bone marrow cells
Cytokines stimulate osteoclast recruitment and activity by increasing RANKL and
diminish OPG
3 main
- Inadequate peak bone mass mechanism
- Excessive bone resorption
- Inadequate formation of bone during remodeling
Morphology entire skeleton affected in postmenopausal and senile osteoporosis
- Post menopausal osteoporosis inc osteoclast activity affects mainly bones or portions of bones
that have increased surface area cancellous compartment of vertebral bodies
- Trabecular plates become perforated, thinned and lose interconnections leading to progressive
microfractures and eventual vertebral collapse
- Senile osteoporosis cortex thinned by subperiosteal and endosteal resorption
- Haversian systems widened
Clinical course
- Clinical manifestations of osteoporosis depend on which bones involve
- Vertebral fractures that frequently occur in thoracic and lumbar regions are painful
o Multiple cause significant loss of height and various deformities
o Including lumbar lordosis and kyphoscoliosis
o Complications of fractures of femoral neck, pelvis or spine PE, pneumonia
- Osteoporosis cannot be reliably detected until 30-40% of bone mass is lost and measurement of blood
levels of calcium, phosphorus and alkaline phosphatase are not diagnostic
Infections:
Osteomyelitis 2288
Most commonly affects children with pain in a long bone.(but may present in any form, mild fever)
Spread
1) Haematogenous spread most cases in children
2) Extension from contiguous site
3) Direct implantation often in adults open fracture, surgical complication, diabetic infections
Usually bacterial Staphylococcus Aureas 80-90% as a result of direct entry (compound fracture, complication
of internal fixation of fracture) or haematogenous (septicaemia).
Organisms express receptors for bone matrix components such as collagen
- Facilitates adherence to bone tissue
E.coli, pseudomonas, klebsiella more frequently isolated from individuals with gentiurinary tract infections
or IV drug users
Mixed bacterial infection seen in direct spread or inoculation of organisms during surgery or open fractures
Haemophillus influenza ad Group B strep neonatal period
Salmonella sickle cell disease
Location of infection within bone influenced by osseos vascular circulation varies with age
Age
Location
Neonates
Metaphyseal vessels penetrate growth plate
- Infection of metaphysis, epiphysis or both
Children
Localization of micro-organisms in metaphysis is typical
Adults after growth plate closure Metaphyseal vessels reunite with epiphyseal counterparts provide route
for bacteria to seed epiphyses and subchondral regions
Morphology Depends on
Stage
- Acute
- Subacute
- Chronic
Location of infection
Once in bone, bacteria proliferate and induce acute inflammatory reaction
Entrapped bone undergo necrosis within first 48 hours bacteria and
inflammation spread within shaft of bone
- May percolate within haversian system to reach periosteum
- In children periosteum loosely attached to cortex
o Sizable subperiosteal abscess may form (may track for long distances
along bone surface)
- Lifting of periosteum further impairs blood supply to affected region
o Suppurative and ischemic injury cause segmental necrosis
- Necrotic bone forms the inner sequestrum
- Rupture of periosteum soft tissue abscess and eventual formation of
draining sinus
- After 1st week chronic inflammatory cells become more numernous
release cytokines
o Stimulate osteoclastic bone resprtion
o Ingrowth of firous tissue
In infants, epiphyseal
infection spreads
through Articular
surface or along
capsular and
tendoliagmentous
insertions
producing septic
arthritis
Pathogenesis brief: bacteria focus of acute inflammation compression of blood vessels necrosis of bone
fragments reactive new bone formation. Hervation system bacterial can travel
Pus underneath periosteum and can be lifted of causing multiple segments of bone necrosis
Osteoclast engulf necrotic bone and release growth factor within necrotic bone formation of new bone
around necrotic bone (involucrum)
Clinical course
- Haematogenous osteomyelitis manifests as acute systemic illness
o Malaise
o Fever
o Chills
o Leukocytosis
o Marked to intense throbbin pain over affected region
Radioogical Finding
- Lytic focus of bone destruction surrounded by zone of sclerosis
Treatment antibiotics + surgical drainage
Chronicity may develop
- Delay in diagnosis
- Extensive bone necrosis
- Inadequate antibiotic therapy or surgical debridement
- Weakened host defenses
- Other complications
o Pathological fracture
o Secondary amyloidosis
o Endocarditis
o Sepsis
o Development of squamous cell carcinoma in sinus tract
o Sarcoma in infected bone
Pagets Disease (Osteitis Deformans)
Chronic disease of unknown aetiology. Some people say may be related to
measles virus (paramaxyal virus)
Characterised by the presence of regions of major osteoclastic bone
resorption followed by periods of uncoordinated bone formation.
May affect part of one bone, an entire bone or many bones.
Patients have few symptoms.
3 stages :
1. initial osteolytic stage
Mosaic pattern of
lamellar bone
pathognomonic of
Paget disease.
Hyperparathyroidism with
osteoclasts boring into center of
the trabeculum (dissecting
osteitis).
2. Debris removed and releases local growth factors attracting fibroblast fibroblast in growth and
angiogenesis new blood vessels
3. Provisional fibro-cartilaginous callus
4. Osseous callus- women bone Spongy structure (can try to weight bear now, so that osteoclast can
reabsorb disorganized bone
5. Remodeling lamellar bone
Fractures
- Classification
o Complete or incomplete
o Closed when overlying tissue is intact
o Compound fracture site communicates with skin surface
o Comminuted bone is splintered
o Displaced ends of bone at fracture site not aligned
o Pathological fracture break occurring in bone already altered by disease process
o Stress fracture slowly developing fracture follows period of increased physical activity where
bone is subjected to new repetitive loads
Repair process
- Immediately after fracture
o Rupture of blood vessels hematoma
Fills fracture gap and surrounds area of bone injury
Clotted blood provides fibrin mesh
Helps seal off fracture site + framework for influx of inflammatory cells and
ingrowth of fibroblast and new capillary vessels
Degranualted platelets and migrating inflammatory cells release PDGF, TGF-B,
FGF and interleukins , which activate osteoprogenitor cells in periosteum,
medullary cavity and surrounding soft
A, Recent fracture of the fibula. B, Marked
tissues
callus formation 6 weeks later.
Simulate osteoclastic and
osteoblastic activity
By end of first week, hematoma is organizing adjacent tissue is being modulated for
future matrix production
Fractured ends of bones are being remodeled
Fusiform and uncalcified tissue soft-tissue
or procallus provides anchorage between
ends of fractured bones but offers no
structural rigidity for weight bearing
- Activated osteoprogenitor cells deposit subperiosteal
trabeculae of woven bone that orients perpendicular to
cortical axis and within medullary cavity
- In uncomplicated fracture, repair tissue reaches maximal
girth at end of second or third week
o Helps stabiles fracture site
o Newly formed cartilage along fracture line undergoes
enchondral ossification (which normally occurs at
growth plate)
Forms network of bone that connects to reactive trabeculae deposited elsewhere in
medullary cavity and beneath periosteum
Fractured ends are bridged by bony callus, as it mineralizes, stiffness and strength of
callus increases
o In early stages of callus formation excess fibrous tissue, cartilage and bone produced
If bone nor perfectly aligned, volume of callus greatest in concave portion of fracture site
As callus matures , subjected to weight bearing forces , portions that are not physically
stressed are resorbed
Callus is reduced in size until shape has been re-established
Medullary cavity also restored
Deadbone empty lacunae, surrounded by necrotic adipocytes that frequently rupture, releasing fatty
acids
o Ding calcium and form insoluble calcium soaps that may persist for life
- Healing response osteoclast reabsorb necrotic trabeculae
o Those that remain act as scaffolding for deposition of new bone creeping substitution
- In subchondral infarcts, pace of this substitution is too slow to be effective so there is eventual collapse
of necrotic cancellous bone and distortion, fracture and even sloughing of articular cartilage
Clinical course
- Symptoms depend on location and extent of infarction
- Typically subchondral infarcts cause chronic pain initially associated with activity
o Then becomes progressively more constant as secondary changes supervene
o Often collapse and may predispose to severe, secondary osteoarthritis
- Medullary infarcts clinically silent except for large ones occurring in gaucher disease, dysbarism and
sickle cell anemia
- Cause
o Pain
o Bone collapse
o Arthritis
Pre-reading Ankle sprain
Anterior talo-fibular ligament
- Spans anterior lateral ankle joint
- Originates from anterior edge of fibula
lateral to articular cartilage of lateral
malleolus and insert into talus
Posterior tibiofibular ligament
- Arises form medial surface of lateral
malleolus and courses medially in
horizontal fashion to posterior aspect
of talus
Calcenofibular ligament
- Attahced on anterior edge of distal
fibula
- Calcenal insertion
Injuries
- Inversion injury lateral ligament damage
- Eversion injury medial ligament strains or ruptures
- Injuries that involve jumping or compression osteochondral damage
- Important to ask if pt can weight bear afterwards indicates more severe injury
Examination
- Degree of swelling generally correlates with soft tissue damage , distribution indicates site of maximal
trauma
- Anatomical factors what can predispose to injury
o Hind foot varus or cavovarus foot should be noted
- Direct tenderness important clinical sign in ankle injury
- Initially tenderness may be less localized after a few days finely localizing specific area of tenderness
correlates closely with damage to specific underlying structure
Osteochondral lsisons
- Damage o cartilage of talus generally caused by trauma
- Lateral lesions caused by ijuies during inversion and dorsiflexion
- Medial lesions eversion and plantar flexion (more common)
- Not diagnoised at time of trauma but present later with continuing ache , generally felt deep in ankle
- Swelling common adter weight bearing
Impingement lesions
- Soft-tssue or bony impingement lesions persisting pain at extremes of movement
- Fibrotic scar tissue may develop in lateral gutter after inversion injury
- Scar tissue may become chronically inflamed causing reactive hyperplastic synovitis
- Synovitis forms meniscoid lesion that can become trapped between lateral malleolus and talus during
dorsiflexion
Exercise and lower-limb related pain
Clinical assessment everyone asks for detailed history
Pain history
- Focal tibial pain raise suspicion of stress injury
- Diffuse pain compartment syndrome or medial tibial stress syndrome or referred pain
Nature of pain
- Deep aching pain somatic in nature
- Sharp shooting pain in narrow band radicular pain radicular pain
- Both somatic referred pain and radicular pain can arise from lumbosacral and pelvic structures
Address red and yellow flag conditions
- Neoplastic disease (primary and secondary)
- Vascular compromise (DVT, arterial obstruction)
- Osteomyelitis/septic arthritis
- Inflammatory arthritis
o Longitudinal stress fractures and chornic non-union proximal medial stress fractures surgery
Other stress fractures
- Tibial stress fracture most common
- Low risk fractures
o Metatarsal shaft
o Femoral shaft
o Tibial shaft
o Fibula
o Calcenus
o Sacrum
o Pubic rami
- High risk prone to non-union and progression to complete fracture
o Femoral neck
o Patella
o Anterior cortex of tibia
o Navicular
o Talus
o Medial malleolus
o Base of 5th metatarsal
o Sesamoid
Tendinosis
- Non-inflammatory condition that results in intra-tendinous degerneation related to ageing, decreased
vascular supply and microtrauma
- Needs to be distiguised from tendinitis and paraptenonitits
o Tendinitis associated inflammatory disorder (RA)
o Paratenonitis inflammation of ouerlayer of tendon (paratenon)
Responsible for crepitus felt with movement
- Tendinosis responsible for 30% of all overuse sports injuries: most common persistent forms
o Achilles running activities
May be insertional or mid-tendon
Insertional associated with haglunds deformity, prominence of posteror superior
calcaneal tuberosity that contributes to irritation of overlying tissues and Achilles tendon
o Mid-tendon Achilles tendinosis most commonly seen in recreational atheletes (30-50)
Men more risk than women (3xs)
Pain starts insidiously with some discomfrit after exercise
As it progressed pt notice pain during exercise and stiffness after inactivity
CLinicallu tneder nodular thickening in mid-tendon
o Paratenonitis
Swelling is more sausage-like
Stays fixed when foot is plantar or dorsiflexed
Thompson test performed if concern of complete tear of tendon
o Patellar tendinosis jumping activities
Insidious condition that often presents late
Tenderness to palpation usually in inferior pole of patella
Tendon may be thickened, often associated patella-femoral dysfunction
Fapina ggravated by decline squats
Chronic exertional compartment syndrome
Compound fractures
Clinically deformed fractures
Fractures with axial rotation, significant angulation or displacement
Actual or high risk vascular complication
Neurological compromise
Compartment syndrome indicated by
o Increasing pain in first few hours
o Tightness of muscle compartment (forearm and calf particularly vulnerable
o Pain on passive extension
o Impaired capillary refill
o Abscess of pulses (occurs late)
Suspicion of non-accidental injury
All dislocations requiring reduction under anesthesia
Complications
Early
Arterial injury
Absent or reduced pulse
Temp or color difference
Compartment syndrome
Severe pain
Worse with passive extension of digits
Nerve palsy
Sensory
Motor
LATE
Volkmann Ischemic Contracture
<1%
ischemic muscle becomes
scarred & fibrotic Malunion
usually cubitus varus or
gunstock deformity
o Malignancy
o Hypercoagulability
Clot(thrombus forms in veins due to stasis and injury to vein
Clinical
o Local pain tenderness
o Swelling
o If calf thrombosis increased pain on dorsiflexion Homans sign
Inc. Temp and pulse
Treatment
o Prophylaxis
Early movement
Compression stockings
Sequential mechanical compression
Partial anti-coagulation
Aspirin
Clexane
Low-dose heparin
Established
Full anticoagulation
o Heparin
o Warfarin
PE
- 2-5% pt get PE
- Dislodgement circulation lung
- Most commonly from proximal leg or pelvic vein thrombosis
- Large thrombus may occlude pulmonary bifurcation sudden death
Clinical signs
- Chest pain-pleuritic
- Dyspnea
- Hemoptysis
- Cyanosis
- Tachycardia
- Shock
- Rales and friction rubs
Fat Embolism
1) Multiple fractures release marrow fat (and marrow)
into circulation. Globules are >7u in size
2) Fat globules filtered out in lung causing acute
respiratory syndrome
a. Some globules pass through lung and
disseminate in systemic circulation and are
filtered out in
i. Skin (petechial rash)
ii. Brain (Confusion, coma)
iii. Kidney (Haematuria, lipiduria)
Chondrogenic (22%)
Osteogenic (19%)
Unknown origin (10%)
Histiocytic origin
Fibrogenic
Osteochondroma
Chondroma
Chondroblastoma
Chondromyxoid fibroma
Osteoid osteoma
Osteoblastoma
Giant cell tumor
Fibrous histiocytoma
Metaphyseal fibrous defect
(fibroma)
Notochordal
Vascular
Hemangioma
Lipogenic
Neurogenic
Lipoma
Neurilemmoma
Chondrosarcoma
Dedifferentiated chondrosarcoma
Mesenchymal chondrosarcoma
Osteosarcoma
Ewing tumor
Giant cell tumor
Adamantinoma
Malignant fibrous histiocytoma
Desmoplastic fibroma
Fibrosarcoma
Chordoma
Hemangioendothelioma
Hemangiopericytoma
Liposarcoma
Benign
1. Osteochondromas (exostosis) benign cartilage capped tumor attached to underlying skeleton by
bony stalk 2302
- Most common benign tumor 85% solitary
- Remainder part of multiple hereditary exostosis syndrome (autosomal dominant hereditary disease)
- Hereditary exostoses due to germline loss of function mutations in EXT1 or EXT2 genes
- EXT1 and 2 results in defective endochondral ossification sets stage for abnormal growth
- Age usually under 20 years
- But multiple Osteochondromas apparent during childhood
- Men (3) > women
- Only develop in bones of endochondral origin and arise from metaphysis near growth
plate of long tubular bones esp the jaw
- Site near epiphyses of limb bones
- Benign outgrowth of normal bone with cartilage cap
Morphology
- Sessile or mushroom shaped
- Range in size (1-20cm)
- Cap composed of benign hyaline cartilage varying in thickness
- Covered peripherally by perichondrium
- Cartilage has appearance of disorganized growth plate and undergoes enchondral ossification
- Newly made bone forming inner potion of head and stalk
- Cortex of stalk merges with cortex of host bone
o Medually cavity of Osteochondroma and bone are in continuity
Osteochondroma. A, X-ray of an osteochondroma arising off the posterior surface of the tibia. B,
Axial CT scan shows continuity of the cortex of the bone and the center of the osteochondroma. The
fibula is adjacent to the mass. C, Gross specimen of sessile osteochondroma composed of a cap of
hyaline cartilage undergoing enchondral ossification. D, The cartilage cap has the histologic
appearance of disorganized growth plate-like cartilage
Clinical course
- Osteochondroms slow-growing masses
- Can be painful If imping of nerve or if stalk is fractures
- Detectable as incidental finding
Chondromas benign tumors of hyaline cartilage usually in bones of enchondral origin
- Can arise within meduallary cavity (encondromas)
- Surface of bone (Subperiosteal or juxtacortical condromas)
Enchondromas most common of intraosseous cartilage tumors
- Age range 20-40 years
- Arise in medullary cavity
- Commonly solitary metaphyseal lesion of tubular bones
o Favoured sites short tubular bones of hands & feet
- may be part of syndrome eg Olliers disease or Mafucci.
Olliers disease or Mafucci.
- Olliers All have multiple Enchondromas
- Mafucci lots of Enchondromas + multiple hemangiomas
within enchondromas
Morphology Multiple lesion within medullary cavity Nodular
and translucent
Enchondroma with a nodule of hyaline
- Usually smaller than 3 cm grossly gray-blue and translucent
cartilage encased by a thin layer of
- Composed of well-circumscribed nodules of cyto logically
reactive bone.
benign hyaline cartilage
- Peripheral portion of nodules may undergo encondral
This is an example of
ossification
enchondromatosis or Olliers
o Centre can calcify and die
disease in a boy, 15 years old,
- Chrondomas in olliers disease and Maffuci syndrome
with multiple enchondromas
sometimes more cellular
(arrows) present.
o Can exhibit cytologic atypia (makes it dififcult to
distinguish from chondrosarcoma)
Clinical Features
- Mostly asymptomatic, detected incidentally
Enchondroma of
the phalanx with a
pathologic
O ring sign)
fracture. The
radiolucent
nodules
of hyaline
remain stable
cartilage scallop
transformation
the endosteal
more
surface.
of developing
and brain
Malignant
1. Osteosarcoma malignant mesenchymal tumor in which cancerous
cells produce bone matrix
- Most common primary malignant tumor of bone
- 20% of primary bone cancers can occur in all age range BUT
Age range 75% under 20 years common In young men
- SECOND PEAK OCCURS IN ELDERLY
o Usually associated with Pagets disease, infarcts or past
irradiation
Bone location in young people
- Metaphyseal region of long bones of extremities
- Knee most common (50%)
But In persons beyond 25 incidence in flat bones and long bones equal
Pathogenesis
- 70% acquired genetic abnormality (ploidy changes,
chromosomal aberrations)
o RB gene (retinoblastoma)
o P53
- Tend to grow at sites of bone growth as proliferation makes
osteoblastic cells prone to acquire mutations that could lead to
transformation
Pathology: several subtypes of osteosarcoma recgonised
- Site or origin(intramedullary, intracortical or surface
- Degree of differentiation
- Multicentricity (syndrobous, metachoronous)
- Primary (underlying bone unremarkable) secondary (pre-existing dosorders)
- Histologic features
Most common subtype arise in metaphysis of long bone primary, solitary, intramedullary
and poorly differentiated
- Osteosarcomas are generally big, bulky tumours
- gritty and tan-white, with areas of hemorrhage and cystic degeneration.
- Often grow through cortex, producing a soft tissue mass.
- Spread extensively in medullary canal, infiltrating and replacing marrow surrounding
osteosarcoma
pre-existing bone trabecular
(arrows) of the
- When joint invasion occurs tumor grows into it along tendoligamentous structures
femur
or through attacjemtn site of joint capsule
- Tumour cells vary in shape and size frequently have hyperchromatic nuclei
- Formation of bone by tumor cells characteristic
o Neoplastic bone coarse, lace-like architecture
o May also be deposited in broad sheets
o Primitive trabeculae
Other matrices, including cartilage or fibrous tissue may be present in varying amounts
o When malignant cartilage abundant called chondroblastic osteosarcoma
Vascular invasion conspicuous 50-60% of individual tumor may be necrotic
Osteosarcoma of
upper end of tibia.
The tan-white
tumor fills most of
medullary cavity of
metaphysis and
proximal diaphysis.
infiltrated through
cortex, lifted
periosteum, and
formed soft-tissue
masses on both
sides of bone
Clinical course
- Typically presents as painful, progressively enlarging masses
- Sometimes sudden fracture of bone is first symptoms
- Radiogram: desctructive, mixed lytic and blastic mass with infiltrative
margins
- Tumor frequently breaks through cortex and lifts periosteum resulting in
periosteal bone formation
- Triagular shadow between cortex and raised ends of periosteum codman
triangle
o Characteristic but not diagnostic of tumor
- Aggressive neoplasms demonstrable pulmonary metastasis (90%)
osteosarcoma with
prominent bone formation
extending into soft tissues.
periosteum, has been
lifted, has laid down a
proximal triangular shell
of reactive bone aka
Codman triangle
2. Chondrosarcoma 2308
Produces neoplastic cartilage
Second most common malignant matrix-producing bone tumor Chondrosarcoma skeleton is 50% as common
as osteosarcoma.
Age range pt generally >40
Male to female ratio 2:1
Most cases denovo, remainder associated with pre-existing Enchondromas or Osteochondroma
Most common sites central parts of skeleton particularly in pelvis, shoulder and wrist (distal extremities
rarely involved)
Presentation
- Painful progressively enlarging masses
- Radiologically
o Endosteal scalloping
o Flocculent-appearing matrix calcifications
- Slow growing tumors can cause reactive cortical thickening
- High-grade neoplasm destroy cortex and form soft-tissue mass
Treatment wide surgical excision and chemotherapy
Lung and skeleton favored metastatic sites
Morphology
- Malignant hyaline and myxoid cartilage
- Large bulky tumors
o Lobulated, nodules of gray-white translucent glistening tissue
o Necrosis may create cystic spaces
o Spotty calcification common
Microscopically
o Classified by histologic type and as intramedullary or juxtacortical
o 90% intramedullary conventional (hyaline or myxoid) chondromas
o Most tumors low-grade
Grade 1 or 2 5 year survival of 90 -81%
Mild hypercellularity,
Chondrocytes have plump vesicular nuclei with small nucleoli
Grade 3 43% 5 year survival
Marked hypercellularity, extreme pleomorphism , bizzare tumor giant cells and
mitoses
X4291. This is a chondrosarcoma of the scapula in a woman aged 35.
She suffered from multiple hereditary exostoses and a mass arising
from the shoulder blade had recently increased in size and become
painful. This is an operative surgical specimen. Note the white
translucent appearance of the tumour.
Clinical Case
A 80 year old man who is in hospital for radiotherapy complains of pain in his left upper arm. During the night
he turned over and felt his arm crack. On examination the Humerus is tender and swollen at about midshaft.
Q. How would you proceed? Take a Hx, imaging,
Olf X0RAY and x ray from humerus
Hx of lung Ca and metastasis to bone
X-ray shows hairline fracture of left humerus
Pathological fracture especially as no significant history of trauma and known cancer with metastases
Pt complains also complain of nausea, abdominal pain and constipation
What is possible explanation for these symptoms
- Multiple metastases causing raised serum calcium
In the same ward is a 16 year old boy with a tender swelling above his knee. He has been admitted for
haemoptysis.
Q. What is the most likely diagnosis? osteosarcoma (bimodal presentation)
- Possible metastasis to lung
This is his Xray.
X2874.