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Ch. 4-DMI 56 Skeletal System. Marilyn Rose RT, RDMS. Physiology of Skeletal System Congenital/ Hereditary Diseases of Bone Inflammatory and Infectious Disorders Metabolic Bone Disease Lead Poisoning. Outline- Part 1.

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Ch 4 dmi 56 skeletal system
Ch. 4-DMI 56 Skeletal System

Marilyn Rose RT, RDMS


Outline part 1

  • Physiology of Skeletal System

  • Congenital/ Hereditary Diseases of Bone

  • Inflammatory and Infectious Disorders

  • Metabolic Bone Disease

  • Lead Poisoning

Outline- Part 1


P hysi ology of skeletal system

  • Composed of two highly specialized connective tissues- Bone and cartilage

  • Bone- organic matrix + inorganic salts- Ca++ and phosphate

  • Perisoteum with blood vessels- covers outer surface- except joints

  • Shaft= diaphysis= medullary cavity (marrow)

  • Ends= ephipysis

  • Compact bone= outer layer- haversian systems

  • Spongy bone= inner weblike marrow space with thin trabaculae

Physiology of Skeletal System


Physiology contd

  • Bones form from hyaline cartilage and cartilage

  • Primary ossification @ 8th week of life is the center of cartilage

  • Entire shaft is ossified at birth

  • Secondary center is at epiphyses

  • Remains separate from diaphysis by epiphyseal cartilage until bone stops growing- then epiphysis an diaphysis fuse- where they meet is the metaphysis.

  • Bones grow in diameter by

    • osteoblasts- form new bone - osification

    • osteoclasts- enlarge cavity- resorption

  • Bone age is determined by the atlas Greulich and Pyle

  • After 40 years- bone loss > bone gain

Physiology contd.


Congenital hereditary disease of bone

  • Vertebral anomalies and cartilage

  • Spina bifida

  • Osteopetrosis

  • Osteogenesisimperfecta

  • Achondroplasia

  • Congenital Hip Dysplasia

Congenital / Hereditary Disease of Bone


Vertebral anomalies

  • Transitional vertebrae and cartilage

    • Has characteristics of both sides of a major division of the spine

  • Occurs @

    • Lumbosacral junction- expanded transverse process- form unilat or bilat joints with the sacrum.

    • C-spine -7th cervical vertebrae- rudimentary rib

  • Both are incidental findings

  • Lumbosacral - degenerative changes in the hip

  • Cervical can compress the brachial nerve plexus or subclavian artery…< blood flow…Thoracic outlet syndrome

Vertebral anomalies


Spina bifida

  • Posterior defect of spinal canal and cartilage

  • Failure of posterior elements to fuse

  • oculta- mild= splitting bony canal at L5-S1

  • Meningocele- herniation of meninges

  • Myelomeningocele- herniation of meninges and portion of the spinal nerve roots.

  • Dimpling or tuft of hair will often be present at the site of the spinal defect.

  • Associated with.. club foot, gait disturbances and bladder/ bowel incontinence (neurogenic)

  • Myelomeningocele has neurologic deficits and almost always associated with Chiari II malformation- caudal displacement of posterior fossa.

  • Hydrocephalus is a common complication

Spina Bifida


O steopetrosis

  • Marble Bone and cartilage

  • Rare hereditary bone dysplasia

  • Failure of resorptive mechanism of calcified cartilage interferes w/ normal replacement by mature bone.

  • Bones are brittle/ stress fractures

  • Anemic

  • Range in severity and age of clinical presentation- fulminant/ fatal – incidental finding.

  • Radiographic- symmetric generalized increase in bone density

  • > mA and kVp

Osteopetrosis


Osteogenesis imperfecta

  • Brittle bones and cartilage

  • Inherited- generalized disorder of connective tissue

  • Characterized by multiple fractures and unusual blue color to the sclera of the eye.

  • Adults are in a wheelchair- skeleton does not support the body weight

  • Radiographic- repeated fx, severe osteoporosis due to thin defective cortex

  • Fx heal with callus- causing bizarre deformities

  • < kVp to compensate for bone loss

  • Wide skull sutures

  • Can be confused with child abuse

OsteogenesisImperfecta


A chondroplasia

  • Most common form of dwarfism and cartilage

  • Diminished proliferation of cartilage in the growth plate (< enchondral bone formation)

  • Autosomal dominant

  • Does not affect membranous bone formation- short limbs with a normal size trunk (axial skeleton)

  • Large head w/ frontal buldging, saddle nose, prognathous (jutting jaw), prominent jaw

  • Radiographic-Erlenmeyer flask deformity, spondylosis

Achondroplasia


Congenital hip dysplasia

  • Incomplete acetabulum formation and cartilage

  • caused by

    • physiologic - > hormone at delivery

    • mechanical – low amniotic fluid or breech

  • After delivery the hips are mechanically rotated and a pop or hip click can be heard

  • The tendons and ligaments are affected

  • Ultrasound is the best method at one month of age

  • If hip dysplasia is diagnosed- a Velcro Pavlik harness is used to realign the joint space

Congenital Hip Dysplasia

3

4

2

1


Inflammatory and infectious disorders

  • Rheumatoid Arthritis and cartilage

  • RA variants-

    • Ankylosing Spondylitis

    • Reiter’s Syndrome

    • Psoriatic Arthritis

  • Osteoarthritis (DJD)

  • Infectious Arthritis

  • Bursitis

  • Rotator cuff

  • Menisci tear

  • Bacterial Osteomyelitis

  • Tuberculous Osteomyelitis

Inflammatory and Infectious Disorders


Rheumatoid arthritis

  • Chronic systemic disease of unknown cause and cartilage

  • Appears as an noninfectious inflammatory (synovial membranes) arthritis of the small joints of the hands and feet

  • 3X more often in females

  • Onset is in 40’s

  • May be very progressive or can undergo spontaneous remissions of variable lengths

  • Symmetric involvement of multiple joints

  • Progressing towards the trunk

  • Synovitis- --excessive exudate---inflamm----synovium to >--- mass of thick tissue cause erosion of articular cartilage- erosion from lytic enzymes

Rheumatoid Arthritis


Ra variants

  • Ankylosing and cartilage Spondylitis

    • Almost always starts in the SI joints

    • Bilat / symmetric involvement

    • Narrow joint space- progress to L spine

    • Ossification in paravertebral tissue / lateral bony bridges/ syndesmophytes- produce the “bamboo spine”

  • Reiter’s Syndrome

    • Reactive arthritis

    • Arthritis, urethritis and conjunctivitis

    • Affects young adult males- post venereal or GI infections

    • SI joints, heel, toes

    • Unilateral SI involvement w/o spine changes

  • Psoriatic Arthritis

    • RA with skin changes of psoriasis

    • Distal interphalangeal joints of hands and feet

    • Erosion and hypertrophic changes at tendon/ lig insertion

RA Variants


Osteoarthritis djd

  • Extremely common and cartilage

  • Loss of joint cartilage and reactive new bone formation

  • Wear and tear of aging

  • Weight-bearing joints- spine, hip, knee and ankle…interphalangeal joints of the fingers

  • Repeated trauma

  • Abnormal stress

  • Result of septic or inflamm arthritis

  • Radiographic: narrow joint space, bony spurs (osteophytes)

  • Erosions can cause cyst-like lesions

Osteoarthritis (DJD)


Infectious arthritis

  • Pyogenic and cartilageorgainisms

  • Hematogenous route or adjacent osteomyelitis or post surgery or trauma of joint

  • Abrupt, high fever

  • Tender, swollen, joint (s)

  • Most common type is migratory arthritis from Lyme disease

  • Radiographic- soft tissue swelling

  • In children- fluid distention of joint capsule

  • 8-10 days after onset- focal erosion in cortex

  • Severe, untreated- extensive destruction and loss of cortical outline

  • Tuberculous arthritis:

    • Chronic, gradual onset- one joint- spine, hip or knee

    • Juxtaarticular osteoporosis precedes bone destruction

    • Joint effussion

    • Disorganization of join

Infectious Arthritis


Bursitis

  • Inflammation of and cartilagebursae

  • Small fluid filled sacs near joints

  • Reduce friction

  • Cause:

    • Repeat physical activity

    • Trauma, RA, gout or infection

  • Tenosynovitis not seen on plain xray

  • Ultrasound is BEST

  • Radiographic: deposits of Ca++ in tendons, frozen joint

  • Early stages shows bursae filled with fluid

Bursitis


Rotator cuff menisci tears

  • Shoulde and cartilager- muscular, tendenous

  • Muscles:

    • Teres minor, infraspinatus, supraspinatus, subscapularis

  • Rupture = communication btw shoulder joint and subacromialbursae - demonstrated by orthrography- Inject contrast into joint space

  • MRI is the modality of choice

    • Tear= high signal intensity

  • US is preferred initially to see tear of tendon

  • Knee pain

  • Acute trauma, more frequently degenerative

  • Inherent in human knee function

  • MRI modality of choice (90-98% accuracy)

    • Tear sharp line of high signal intensity

    • Crosses normally dark triangular meniscus

    • Show ACL/ PCL and changes in the underlying bone

  • US may demonstrate tenosynovitis- thick fluid filled

Rotator Cuff/ Menisci Tears


Bacterial tuberculous osteomyelitis

  • Bacterial and cartilage

    • Inflammation of bone and bone marrow

    • Hematogenous- adjacent infection/ direct intro of organisms (OR)

    • Acute – rich red marrow

      • Infants- metaphysis- femur/ tibia- staf/ strep

      • Fever/ tender

      • Adult- vertebrae- localized back pain and back spasm- rarely long bones

    • Decreased with antibiotics

    • Complication of IV drug use

    • Diabetic- soft tissue infection spread from skin abscess- cellulitis- osteomyelitis

    • Radiographic- deep soft tissue swelling adjacent to metaphysis, displacement of fat planes

  • Tuberculous

    • Very rare today

    • Thoracic or lumbar spine

    • Pott’sdz- TB of spine- irregular, bone destruction

    • Eventual vertebral collapse

Bacterial/ Tuberculous Osteomyelitis


Metabolic bone disease

  • Osteoporosis and cartilage

  • Osteomalacia

  • Rickets

  • Gout

  • Paget’s

Metabolic Bone Disease


Osteoporosis

  • Generalized, localized deficiency of bone matrix and cartilage

  • Mass of bone per unit volume is decreased

  • Accelerated resorption of bone-

  • decreased bone formation

    • Cushings syndrome

    • Prolonged steroid

    • Disuse or immobilization (cast)

  • Loss of mineral salts- more lucent

  • 50-70% lost before lucent areas are seen on radiographs

  • Use LOWEST kVp – short scale to look for lucency

  • DEXA is often used- measure bone mineral content

  • Radiographic- cortical thinning- spine/pelvis- anterior wedging or compression fractures

Osteoporosis


Osteomalacia rickets

  • Insufficient mineralization adult skeleton and cartilage

  • Failure of calcium/ phosphorus deposition

    • From inadequate intake

    • Failure of absorption

    • Vitamin D necessary for intestinal absorption

  • Chronic renal failure

  • Renal cause for calcium lost in urine

  • Radiographic- loss of bone density due to nonmineralized osteoid

  • Thin but prominent cortex

  • Bones bend and display bowing deformity

  • Rickets is systemic disease of infancy / childhood that is equivalent to osteomalacia

  • Lack of UV rays for vitamin D

  • Radiographic- increase in distance between ossified epiphysis and end of shaft

  • Bowing of weight bearing bones

Osteomalacia/ Rickets


  • Disorder in metabolism of purine and cartilage

  • Increase in blood level of uric acid

  • Deposition of uric acid crystals in joints, cartilage and kidney

  • Causes of hyperuricemia

    • Metastatic carcinoma

    • Myeloma

    • Hemolytic anemia

    • Drugs- chemo/ HTN

    • Kidney failure

  • Radiographic- painful arthritis

  • Single joint- first metatarsophalangeal joint

  • “rat bite” erosions

  • Large soft tissue swelling- tophi

Gout


Paget s

  • Osteitis and cartilagedeformans

  • Common chronic metabolic disease of the skeleton

  • Destruction of bone

  • Repair

  • Weak, deformed, thick structures that fracture easily

  • 2x in men

  • Pelvis and weight bearing bones

  • Radionuclide bone scan is most efficient method to see extent of lesions

  • Radiographic- mottled, cotton- wool appearance- cold (destructive) hot (repairative)

  • Increased trabeculation

  • Picture frame vertebrae

Paget’s


Lead poisoning

  • Especially lead paint and cartilage

  • Occupational inhalation of fumes

  • Drinking water with lead pipes

  • Eating food prepared, processed, stored in lead containers

  • Number one environmental pollutant worldwide

  • Chronic- mental retardation, seizures, behavioral disorders or delayed development

  • Radiographic- in children lead is deposited in growing portions of skeleton- metaphyses- lead lines

  • Pica kids may eat the paint and find abdominal opacities like barium (CT)

Lead Poisoning


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