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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

  • 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

  • Spina bifida
  • Osteopetrosis
  • Osteogenesisimperfecta
  • Achondroplasia
  • Congenital Hip Dysplasia
Congenital / Hereditary Disease of Bone
vertebral anomalies

Transitional vertebrae

    • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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 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

  • 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 orgainisms

  • 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 bursae

  • 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

Shoulder- 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

    • 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

  • Osteomalacia
  • Rickets
  • Gout
  • Paget’s
Metabolic Bone Disease
osteoporosis

Generalized, localized deficiency of bone matrix

  • 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

  • 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
slide23

Disorder in metabolism of purine

  • 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

Osteitisdeformans

  • 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

  • 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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