Metabolic Bone Disease – Histopathology Flashcards
What are the 4 main functions of bones?
Mechanical – support and site for muscle attachment
Protective
Metabolic – reserve of calcium
Structural
What are the two main components of bone and what are their relative proportions?
Inorganic (65%) – calcium hydroxyapatite (store of 99% of the body’s calcium, 85% of the phosphorous and 65% of Na and Mg)
Organic (35%) – bone cells and protein matrix
Describe the classification of bone as cortical and cancellous.
Cortical Long bones 80% of skeleton Appendicular skeleton 80-90% calcified Mainly mechanical and protective role Cancellous Vertebrae and pelvis 20% of skeleton Axial 15-25% calcified Mainly metabolic Large surface
What are the indications for bone biopsy?
Evaluate bone pain or tenderness Investigate abnormality seen on X-ray For bone tumour diagnosis To determine the cause of unexplained infection To evaluate therapy
What are the two types of bone biopsy?
Closed – needle – core biopsy with Jamshidi needle
Open – for sclerotic or inaccessible lesions
What are the three types of bone cell?
Osteoblast – build bone by laying down osteoid
Osteoclast – multinucleate cells of the macrophage family that resorb bone
Osteocyte – osteoblast like cells
Where are osteocytes found?
Lacunae
What cytokine is important for stimulating the differentiation of osteoclast precursors into pre-osteoclasts?
M-CSF (this is produced by osteoblasts)
Which cells produce RANKL and what is its effect?
Pre-osteoblasts
It stimulates the maturation of osteoclasts
What do mature osteoblasts produce that blocks the RANK/RANKL binding?
Osteoprotegrin
How are bones classified anatomically?
Flat
Long
Cuboid
What type of ossification leads to the formation of:
a. Long Bones
b. Flat Bones
a. Long bones
Endochondral ossification
b. Flat bones
Intramembranous ossification
How else can bone be classified?
Trabecular (cancellous) or compact (cortical)
Woven (immature) or lamellar (mature)
What is metabolic bone disease?
Disordered bone turnover due to imbalance of various chemicals in the body (vitamins, hormones, minerals etc.)
Overall effect is reduced bone mass (osteopaenia) often resulting in fractures from little or no trauma
What are the primary causes of osteoporosis?
Age
Post-menopause
What is osteomalacia and what can it be caused by?
Condition of defective bone mineralisation that can be caused by: Vitamin D deficiency Phosphate deficiency (usually related to chronic renal disease)
What are the metabolic and endocrine consequences of vitamin D deficiency?
Secondary hyperparathyroidism –> increased bone resorption
Hypocalcaemia – neuronal excitability causing muscle twitching
Describe the histology of osteomalacia.
No calcification of bone
More uncalcified osteoid
Bones are very bendy and cannot carry musculature very easily
What are the clinical consequences of osteomalacia?
Bone pain/tenderness
Fracture (horizontal fractures at Looser’s zone at the neck of the femur are commonly seen)
Proximal weakness
Bone deformity
What are the consequences of hyperparathyroidism?
Hypercalcaemia
Hypophosphataemia
Osteitis fibrosa cystica
List the four organs that are directly or indirectly affected by parathyroid hormone to control calcium metabolism.
Parathyroid glands
Bones
Kidneys
Proximal small intestine
State some causes of primary hyperparathyroidism.
Parathyroid adenoma
Chief cell hyperplasia
State some causes of secondary hyperparathyroidism.
Chronic renal insufficiency
Vitamin D deficiency
What are the symptoms of hyperparathyroidism?
Stones, Bones, Abdominal Groans and Psychic Moans Stones – calcium oxalate renal stones Bones – osteitis fibrosa cystica Abdominal Groans – acute pancreatitis Psychic Moans – psychosis and depression
What is the most important investigation for hyperparathyroidism and what will it show in someone with hyperparathyroidism?
X-ray of the hand
Subperiosteal bone erosions
Brown cell tumours – small areas of resorption in the long bones of the fingers that are filled with osteoclasts
What are the five features of renal osteodystrophy?
Increased bone resorption (osteitis fibrosa cystica) Osteomalacia Osteoporosis Osteosclerosis Growth retardation
What are the consequences of renal osteodystrophy on phosphate and calcium levels?
Hyperphosphataemia as failure to excrete phosphate
Hypocalcaemia as a result of a decrease in vitamin D metabolism
Secondary hyperparathyroidism
What is Paget’s disease?
Disorder of bone turnover (there is a lack of proper communication between the cells)
What are the three stages of Paget’s disease?
Osteolytic - focal bone loss
Osteolytic-osteosclerotic- bone responds to the mass bone loss
Quiescent osteosclerotic- osteoblasts begins response to bone loss and is weakened disorganised bone structure
Describe the histology of Paget’s disease.
Prominent reversal lines
Masses of osteoclasts in the same site as osteoblasts
Which sites does Paget’s disease most commonly affect?
Skull
Spine
What is a Haversian canal?
Channel that blood vessels run in within bone
Pits in the bone surface where osteoclasts are found (also called resorption bays)
Howships lacunae
Main internal structure of bone
Periosteum most superficial
Cortex deeper which is compact cortical bone
Medulla inside
What is bone mainly in metaphysis
Trabecular
Different types of bone anatomically
Flat- protective such as ribs skull
Long- mechanical such as femur
Short/cuboid- carpals which stabilise movement
Irregular- complex shapes to protect organs such as pelvis
Sesamoid- embedded in tendon
Macroscopic division of bone
Cancellous
Cortical
Microscopic classification of bone
Mature woven
Immature lamellar
Micro anatomy of cortical bone
Lamellar organised in rod shaped osteons with central canal for vessels
Osteocytes dotted around with a dendritic network involved in signalling
Multi nuclear bone cell
Osteoclast
Standard bone biopsy site
Transiliac as site of all types of bone
Most common bone disorders
Osteoporosis Osteomalacia Primary hyperparathyroidism Renal osteodystrophy Paget’s disease
Define osteoporosis
Defined as bone density less than -2.5 on DEXA
Osteomalacia in children
Rickets
Signs of rickets
See bowing of bones and widen growth plates
