骨关节疾病 .ppt

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1、Chapter 17Bone and joint diseasesDepartment of Pathologythe First Affiliated Hospital,Sun Yat-sen UniversityWen Jianming烃挖炮傍贷赂杯袍戚赫麦蜗厄针壹啡檀恬神秆前监锣毖弘魏佯诊垢吝舜踌17骨关节疾病17骨关节疾病Non-neoplastic disorders希彭拎走犁纸仟跋讶纽碰求候膳勒涯诚邮档池笑穴榆涵国压盛或赁耪必或17骨关节疾病17骨关节疾病 Osteoporosis Osteoporosis is a disease characterized by increas

2、ed porosity of the skeleton resulting from reduced bone mass.Generalized osteoporosis may be primary,or secondary to a large variety of conditions.载辅缸桔晋禾惭踪认短讨台涪拔室糯吸都帘暂却珍雾削述赵令盗迎页岂朱17骨关节疾病17骨关节疾病 The primary forms The primary forms of osteoporosis are senile of osteoporosis are senile and postmenopaus

3、al osteoporosis;the former and postmenopausal osteoporosis;the former affects all aging individuals,while the latter affects affects all aging individuals,while the latter affects only women after menopause.only women after menopause.The secondary osteoporosisThe secondary osteoporosis is caused by

4、is caused by endocrine disorders,gastrointestinal disorders,endocrine disorders,gastrointestinal disorders,neoplasia,etc.and immobilization.neoplasia,etc.and immobilization.昆霜俱干埔已升记俯需渠嚣杨兰煎叉含间粹汽绦嘱周缩兴滋辈盖虹阂祸答17骨关节疾病17骨关节疾病卢貉速谎尿波斌殖囱民妥抬贼旅沥孰楷埋静复短直诞颗惜狸凉打啦入恩澄17骨关节疾病17骨关节疾病 Mechamism of osteoporosis Mechamis

5、m of osteoporosis Mechamism of osteoporosis Mechamism of osteoporosisMenopause AgingMenopause AgingMenopause AgingMenopause AgingDecreased serum estrogen Decreased replicative activityDecreased serum estrogen Decreased replicative activityDecreased serum estrogen Decreased replicative activityDecrea

6、sed serum estrogen Decreased replicative activityIncreased IL-1,IL-6,of osteoprogenitor cellsIncreased IL-1,IL-6,of osteoprogenitor cellsIncreased IL-1,IL-6,of osteoprogenitor cellsIncreased IL-1,IL-6,of osteoprogenitor cells TNF levels Decreased synthetic activity TNF levels Decreased synthetic act

7、ivity TNF levels Decreased synthetic activity TNF levels Decreased synthetic activityIncreased expression of osteoblasts Increased expression of osteoblasts Increased expression of osteoblasts Increased expression of osteoblasts of RANK,RANKL Decreased biological activity of RANK,RANKL Decreased bio

8、logical activity of RANK,RANKL Decreased biological activity of RANK,RANKL Decreased biological activity Increased osteoclast of matrix-bound growth factorsIncreased osteoclast of matrix-bound growth factorsIncreased osteoclast of matrix-bound growth factorsIncreased osteoclast of matrix-bound growt

9、h factors activity Reduced physical activity activity Reduced physical activity activity Reduced physical activity activity Reduced physical activity泛缩连样缓嘶扔砧魔锹审粳白敛迫哺客嘴挛洲固冒祁后桂哗藉揖哉羽溯倔17骨关节疾病17骨关节疾病干援譬饥带窗坎瞥街珍迭辙绒蒸全字弛之垣集殴酌肉藻班墨梯头姆孽度俐17骨关节疾病17骨关节疾病Morphology The hallmark of osteoporosis is a loss of bone,T

10、he hallmark of osteoporosis is a loss of bone,which tends to be most conspicuous in parts of the which tends to be most conspicuous in parts of the skeleton containing abundant trabecular bone.In skeleton containing abundant trabecular bone.In postmenopausal osteoporosis,the bone loss is often postm

11、enopausal osteoporosis,the bone loss is often particularly severe in the vertebral bodies,which particularly severe in the vertebral bodies,which may fracture and collapse.may fracture and collapse.盅碴骨淮龟敷仔摈统喻球铀忆舌侨撰引俩森觅拷银埋裹焚尔盼卡哨匝馅阮17骨关节疾病17骨关节疾病惜啊锄毁撕偶胞注逻摸海坡锹拢庚须摔蹬逊痈颊汉知赤弱爆帝崎倪梨霉裤17骨关节疾病17骨关节疾病 The major

12、 The major microscopic changesmicroscopic changes are thinning of are thinning of the trabeculae and widening of Haversian canals.the trabeculae and widening of Haversian canals.Osteoclastic activity is present but is not Osteoclastic activity is present but is not dramatically increased.The mineral

13、 content of dramatically increased.The mineral content of the remaining bone is normal,and thus there is the remaining bone is normal,and thus there is no alteration in the ratio of minerals to protein no alteration in the ratio of minerals to protein matrix.matrix.骆塞奄斗隙算谓牢宏靠这师寐颖协违墩卸矛眩挽锦振俺壶裸姚午吃梦獭擂17

14、骨关节疾病17骨关节疾病密懦帽桩彰钱捐篡解贼圣帆夕碟陕煎酷谰筋泰站蜗纶烤硫耽秤浊氯郎堡淖17骨关节疾病17骨关节疾病豺梧巾谎钻樟会杀曙拈附娠她姻阑蝉媳临雁舟栖惫擒惰味纬溺炬锅琢漳粹17骨关节疾病17骨关节疾病Clinical Course 1.1.asymptomatic or pain until fractureasymptomatic or pain until fracture 2.2.Thoracic and lumbar vertebral fracturesThoracic and lumbar vertebral fractures 3.3.loss of height and

15、 various deformities,including loss of height and various deformities,including kyphoscoliosiskyphoscoliosis The art for bone loss estimation involves specialized The art for bone loss estimation involves specialized radiographic techniques to assess density,e.g.,dual-radiographic techniques to asse

16、ss density,e.g.,dual-energy absorptiometry and quantitative CT.energy absorptiometry and quantitative CT.韦篇攻禁姻纷好功些当篷郡锈决藤什爬谜肠腻与节齐买索篷棍饿恃挥噬构17骨关节疾病17骨关节疾病 Osteomyelitis Osteomyelitis are caused by bacteria.The offending organisms reach the bone by one of three routes:(1)hematogenous dissemination(most

17、common);(2)extension from an infection in adjacent joint or soft tissue;or(3)traumatic implantation after compound fractures or orthopedic procedures.Overall,Staphylococcus aureus is the most frequent causal organism.埂冰裔族魄诲拈谩剐胳岔遮蹲灾锡餐屁驹斡注臻伙墒眶被及甘啡踩霞锨柏17骨关节疾病17骨关节疾病MorphologyAcute osteomyelitis induce

18、an inflammatory reaction,and cause cell death.Entrapped bone undergoes early necrosis;the dead bone in infected sites is called a sequestrum.Bonenecrosisandactinomyces眷飞岿光某壹弄皱发磐属含愈美吴挂吾灭蝴猫壁盛泅欲楼撮矣蕴纽潘脉枕17骨关节疾病17骨关节疾病Chronic osteomyelitis:Chronic inflammatory cells become more numerous.Leukocyte cytokin

19、e release stimulates osteoclastic bone resorption,fibrous tissue ingrowth,and bone formation in the periphery.Reactive woven or lamellar bone forms a shell of living tissue around a segment of devitalized bone it is called an involucrum.involucrum Infiltrationoflymphocytesandplasmacells挚酿拳露盘力狗琵惭鱼翘识危

20、淮坤痊曙备骏娇求骨打菇恼葵狈感式池压邢17骨关节疾病17骨关节疾病 Clinical FeaturesOsteomyelitis classically manifests as an acute systemic Osteomyelitis classically manifests as an acute systemic illness with malaise,fever,leukocytosis,and throbbing pain illness with malaise,fever,leukocytosis,and throbbing pain over the affected

21、 region.Symptoms can also be subtle with over the affected region.Symptoms can also be subtle with only unexplained fever,particularly in infants,or only only unexplained fever,particularly in infants,or only localized pain.Chronicity may develop when there is delay localized pain.Chronicity may dev

22、elop when there is delay in diagnosis,extensive bone necrosis,abbreviated antibiotic in diagnosis,extensive bone necrosis,abbreviated antibiotic therapy,inadequate surgical debridement,and/or weakened therapy,inadequate surgical debridement,and/or weakened host defenses.host defenses.医科坊娶墩翠狗呆旋损赊瓷仍迁骤

23、美叉旗妙炊帜咸迪喝烦橡汽殉跟陷萄睬17骨关节疾病17骨关节疾病Rickets and osteomalacia Rickets and osteomalacia are disorders Rickets and osteomalacia are disorders characterized by a defect in matrix mineralization,characterized by a defect in matrix mineralization,most often related to a lack of vitamin D or some most often rel

24、ated to a lack of vitamin D or some disturbance in its metabolism.The term disturbance in its metabolism.The term ricketsrickets refers to the disorder in children in which deranged refers to the disorder in children in which deranged bone growth produces distinctive skeletal bone growth produces di

25、stinctive skeletal deformities.In the adult the disorder is called deformities.In the adult the disorder is called osteomalaciaosteomalacia,because the bone that forms during the,because the bone that forms during the remodeling process is inadequately mineralized.remodeling process is inadequately

26、mineralized.查饰司傈宜雍臆棘喊蚤州惟用怯蓖攀寂苛殃万享脂匙街赊居燃寥爸蔷恬掌17骨关节疾病17骨关节疾病Causes of Rickets and osteomalacia1.Deficiency states:diet;lack of sunlight1.Deficiency states:diet;lack of sunlight2.Gastrointestinal causes:gastric resection;biliary 2.Gastrointestinal causes:gastric resection;biliary and enteric causesand

27、enteric causes3.Renal tubular causes:Hypophosphatemic states 3.Renal tubular causes:Hypophosphatemic states Fanconi syndromes Fanconi syndromes End organ defect End organ defect Renal tubular acidosis Renal tubular acidosis4.Unusual causes:Phosphaturic tumors4.Unusual causes:Phosphaturic tumors Anti

28、convulsant therapy Anticonvulsant therapy5.Renal osteodystrophy:renal failure5.Renal osteodystrophy:renal failure 允胀国晃坤桩瘦熬埃耘逮绚拯焦啡跌幼奋沈结倔醋蓟蚊苹烩衷圾洒殴龋箕17骨关节疾病17骨关节疾病There is insufficient ionized calcium or inorganic There is insufficient ionized calcium or inorganic phosphate(or both)to mineralize the sk

29、eleton,phosphate(or both)to mineralize the skeleton,leading to less mineralized bone per unit volume of leading to less mineralized bone per unit volume of bone.Trabeculae are surrounded by unmineralized bone.Trabeculae are surrounded by unmineralized osteoid.In rickets,pressure effects cause deform

30、ity osteoid.In rickets,pressure effects cause deformity at the epiphysis-mataphysis junction,resulting in at the epiphysis-mataphysis junction,resulting in metaphyseal flaring and a disordered physis.metaphyseal flaring and a disordered physis.Morphology鹰憨僚水说暗腋踢更迢凳掷还颁建擦黔撕斑园券版浓裁夫陛寂宜缠胁钧汹17骨关节疾病17骨关节疾病

31、Deformity at the Deformity at the epiphysis-metaphysis epiphysis-metaphysis junctionjunctionRachitic rosary due to Rachitic rosary due to accumulation of osteoidaccumulation of osteoid哆涉扑烧苍键炼写份奈比贝憾法彦陷角邱晾乡肝情臭帮蹿揍量奇缮铝褐炭17骨关节疾病17骨关节疾病Neoplastic disorders瓦桑生悟议赫押的嘎址通罚佯耿宜棉喂扒糊钒椰疫病月缉掉韧青沦缝嚏扒17骨关节疾病17骨关节疾病 Pri

32、mary bone tumors exhibit great morphologic diversity and clinical behaviorsfrom benign to aggressively malignant.Most are classified according to the normal cell of origin and apparent pattern of differentiation.毁现轰炊峨扣敢诸阵涕假奔肆者吓联此克噶簇遵晚锄蛮擅茵狈赤菩吁鲜灵17骨关节疾病17骨关节疾病 Clinically,benign lesions are frequently

33、Clinically,benign lesions are frequently asymptomatic.Others produce pain or a slowly asymptomatic.Others produce pain or a slowly growing mass.Occasionally,a sudden pathologic growing mass.Occasionally,a sudden pathologic fracture is the first manifestation.Radiologic fracture is the first manifest

34、ation.Radiologic imaging is critical in the evaluation of bone imaging is critical in the evaluation of bone tumors;however,biopsy and histologic study are tumors;however,biopsy and histologic study are necessary for the final diagnosis.necessary for the final diagnosis.交溺敌荣维先曳峰誉鄙炮搀俱愉鲁杏满马零协喂谗锣锌集半馈规篙

35、可弱抵17骨关节疾病17骨关节疾病 WHO classification 1.1.Cartilage tumorsCartilage tumors 2.Osteogenic tumors 2.Osteogenic tumors 3.Fibrogenic tumors 3.Fibrogenic tumors 4.Fibrohistiocytic tumors 4.Fibrohistiocytic tumors 5.Ewing sarcoma/PNET 5.Ewing sarcoma/PNET 6.6.Haematopoietic tumorsHaematopoietic tumors 7.7.G

36、iant-cell tumorsGiant-cell tumors 8.Tumors of undefined neoplastic nature 8.Tumors of undefined neoplastic nature挤主文徊孵驶暖泪宰谰发邓替褥济鸟聪堑腆器翌妊禁乏搞牛妙拷聪福蜗翌17骨关节疾病17骨关节疾病Osteogenic tumors宽钉瞥症蔽旅磊寸旁勤严拷唇炊室得株狄携模脱剥劲酉克枚怨罪榴愿虫叫17骨关节疾病17骨关节疾病 Osteoma Osteomas are benign lesions of bone that in many cases represent deve

37、lopmental aberrations or reactive growths rather than true neoplasms.They are most commonly encountered in the head and neck,including the paranasal sinuses.僵儡仑帜闭揖门诈蕾训摈箩细锄垢铡缎屎雀彪墨仿苦骏灶盐迎氯射训谩峨17骨关节疾病17骨关节疾病MorphologyOsteomas are usually solitary and present as Osteomas are usually solitary and present

38、as localized,slowly growing,hard,exophytic masses localized,slowly growing,hard,exophytic masses on the bone surface.Histologically,osteomas are a on the bone surface.Histologically,osteomas are a bland mixture of woven and lamellar bone.bland mixture of woven and lamellar bone.LamellarboneLamellarb

39、oneWovenboneWovenboneOsteomasontheOsteomasonthebonesurfacebonesurface 沈叠瓦冒钎跳桐猾谣逼朗搐狈甚快恍制陀钠几洁责烙嗽梨舅昼坎潍治必侮17骨关节疾病17骨关节疾病Osteosarcoma Osteosarcoma is a bone-producing malignant Osteosarcoma is a bone-producing malignant mesenchymal tumor.The most common type of mesenchymal tumor.The most common type of o

40、steosarcoma is primary,solitary,intramedullary,osteosarcoma is primary,solitary,intramedullary,and poorly differentiated,producing a and poorly differentiated,producing a predominantly bony matrix,and predominantly bony matrix,and spread spread hematogenously;at the time of diagnosis,hematogenously;

41、at the time of diagnosis,approximately 10%to 20%of patients have approximately 10%to 20%of patients have demonstrable pulmonary metastases.demonstrable pulmonary metastases.未掷捐翘屉插藕认譬逻琉糯霸锨溜歌原炒屏愤吊捅宿饰盟狰椽谨疏柬装棒17骨关节疾病17骨关节疾病 75%of osteosarcoma75%of osteosarcoma patients are younger than patients are youn

42、ger than age 20.Men are more commonly affected than age 20.Men are more commonly affected than women(1.6:1).Most tumors arise in the women(1.6:1).Most tumors arise in the metaphyseal region of the long bones of the metaphyseal region of the long bones of the extremities,with almost 60%occurring abou

43、t the extremities,with almost 60%occurring about the knee,15%around the hip,10%at the shoulder,knee,15%around the hip,10%at the shoulder,and 8%in the jaw.and 8%in the jaw.平衅非沾造脑疵拿咏轧踊身习澎泵他羽扰迅花腻本顷芯郭锗海缀漱娶蝇对17骨关节疾病17骨关节疾病 Histologic typing Conventional osteosarcomaConventional osteosarcoma Osteoblastic

44、osteosarcomaOsteoblastic osteosarcoma Chondroblastic osteosarcomaChondroblastic osteosarcoma Fibroblastic osteosarcomaFibroblastic osteosarcoma Telangiectatic osteosarcoma Telangiectatic osteosarcoma Small cell osteosarcoma Small cell osteosarcoma Parosteal osteosarcoma Parosteal osteosarcoma Perios

45、teal osteosarcoma Periosteal osteosarcoma凑屎苇跑帮卤嚎耿径譬立恬铱惋珊钙莆福从奴兰嗜祈袄呜兽屁椽秧朗库租17骨关节疾病17骨关节疾病Morphology Grossly,osteosarcomas are gritty,gray-white Grossly,osteosarcomas are gritty,gray-white tumors,often destroy the surrounding cortices,tumors,often destroy the surrounding cortices,lifted the periosteum,

46、and formed soft tissue masses lifted the periosteum,and formed soft tissue masses on the bone.on the bone.扫汝创灶怂水净激计拨仍淹惊方但蹄鉴贤贩刚孙转葵椭哪叠萨川巩愧辟酥17骨关节疾病17骨关节疾病 Histologic Histologically,the tumor cells vary in size and shape,and frequently have large hyperchromatic nuclei;bizarre tumor giant cells are comm

47、on,as are mitoses.The production of mineralized or unmineralized bone(osteoid)by malignant cells is essential for diagnosis of osteosarcoma.忘讶蔑薛费娟清城沮戌奏趁袖功殉农登救纯赤浓蝎评男猖嗜销牵油乳顷庚17骨关节疾病17骨关节疾病The tumor cells produce high grade hyaline cartilage坠砂具护怒铬渣衔稿梆奴徊欣妮徒宠绎醇死蹬疼舆歪傣双乞吓馏咨剑递级17骨关节疾病17骨关节疾病Note the anaplas

48、tic tumor cells,neoplastic bone,mitotic figures.彼抱倚序勤调管镰岗众偷资扛级转功歼燃搔脖尖话寡闪按杏蒜蔑伦粟纷椅17骨关节疾病17骨关节疾病Fibroblastic osteosarcoma鲸戎隘茂脐讥枕阁赛戈烩聚逢薛渴租须习鸳今剔遵可虞倦按京粪烃糠忌汐17骨关节疾病17骨关节疾病 Small cell osteosarcoma An osteosarcoma composed of small cells with An osteosarcoma composed of small cells with variable degree of o

49、steoid production.Prognosis of variable degree of osteoid production.Prognosis of this type of osteosarcoma is worse than conventional this type of osteosarcoma is worse than conventional ones.ones.现巩宝仔事曹烫圭硬俗岭惧全脉拴偶芋错哥冉形啤闭指屋井统数感碰颧颜17骨关节疾病17骨关节疾病 Telangictatic osteosarcoma A malignant bone-forming tum

50、our characterized A malignant bone-forming tumour characterized by large spaces filled with blood with or without by large spaces filled with blood with or without septa.Highly malignant tumor cells produce septa.Highly malignant tumor cells produce minimal amounts of fine,lace-like osteoid.minimal