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SBCP Pathology > MSK > Flashcards

MSK Flashcards

1
Q

What are the key features of bone remodelling?

A

It’s a complex balance between bone formation and bone resorption, mediated by several different chemicals

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2
Q

Stages of fracture healing (5)

A
  • Haematoma and inflammation
  • Organisation (granulation tissue forms)
  • Primary callus response (osteoprogenitor cells become osteoblasts)
  • External bridging callus
  • Remodelling stage several months after to streamline the callus formation
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3
Q

What material do osteoblasts form?

A

Osteoid

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4
Q

What happens if a fracture is not properly immobilised?

A

Cartilage is formed instead of bone

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5
Q

Local (early) complications of fractures (5)

A 
Infection
Bleeding
Dislocation of joint
Skin loss/tissue injury
Damage to nerves and vessels
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6
Q

Local (delayed) complications of fractures (5)

A

Damage to epiphyseal growth plates in children

Avascular necrosis of bone

Osteoarthritis

Delayed union

Non-union (no healing at all)

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7
Q

Systemic complications of fractures (8)

A 
Cardiac shock
Fat embolus (within 24-72 hrs)
DIC
Septic shock
Bed sores
DVT/PE
ARDS (even when no injury near chest)
Pneumonia
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8
Q

Factors impairing healing (11)

A 
Age
Diabetes
Malnutrition
Cancer
Radiotherapy
Infection
Ischaemia
Soft tissue injury
Compound fracture
Large fracture gap
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9
Q

Name for infection of bones?

A

Osteomyelitis

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10
Q

Name for infection of joints?

A

Spetic arthritis

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11
Q

Why are bone infections hard to treat?

A

Poor blood supply, hard to get antibiotics to get into the bone

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12
Q

What age group commonly gets acute osteomyelitis

A

Young children and infants

Important DDx of crying child

X rays are no use in diagnosis, therefore have a high index of suspicion and take blood cultures

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13
Q

Most common organism causing acute osteomyelitis?

A

Staph aureus

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14
Q

Most common organism causing acute osteomyelitis <4 yr olds?

A

Haem influenzae

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15
Q

Most common organism causing acute osteomyelitis in sickle cell disease?

A

Salmonella typhi

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16
Q

Aetiology of acute osteomyelitis?

A

Typically a haematogenous spread from minor infection eg tooth or toenail

Can be a complication of open fracture, metal prothesis, or in people who are immunosuppressed

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17
Q

What LATE x ray sign can be seen in osteomyelitis?

A

Sometimes can see a periosteal reaction (fluffiness of periosteum)

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18
Q

Progression of acute osteomyelitis?

A

Bone abscess can exert pressure within bone causing further necrosis, infection, and destruction

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19
Q

How do you prevent a bone infection?

A

Urgent debridement of open fractures

Strict aseptic technique in surgery

Use of prophylactic Abx in open fractures and surgery

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20
Q

Which age group gets chronic osteomyelitis?

A

Usually adults

DOES NOT FOLLOW ON FROM ACUTE OSTEOMYELITIS, DIFFERENT DISEASES

Represents the presence of a smouldering infection which causes bone necrosis and formation.

Causes marked bone deformity

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21
Q

Complications of osteomylitis? (acute and chronic)

A

Sepsis
Bone deformtiy
Osteoarthritis
Skin sinus formation

Squamous carcinoma (Marjolin’s ulcer)

Systemic amyloid (causes liver and renal failure)

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22
Q

What is Marjolin’s ulcer?

A

A squamous carcinoma that can form in long standing chronic osteomyelitis

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23
Q

What causes bone/joint TB?

A

ALWAYS secondary to pulmonary TB (miliary primary TB or reactivation of secondary infection due to immunosuppression)

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24
Q

Where does bone TB arise?

A

Spine, long bones, hips, knees, small bones of hands and feet

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25
Q

Pathology of bone/joint TB: ____ granulomas are seen with necrosis and ___ multinuclear giant cells with the cell distributed in ___ fashion.

A

Caseous

Langerhans

Horseshoe

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26
Q

How can bone TB affect the bones grossly?

A

Can cause kyphosis and scoliosis

Can cross the disc space to involve multiple vertebrae

Psoas abscess

Ankylosis of joints

Systemic amyloid

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27
Q

True/ false: The skeleton is composed of 80% cancellous bone and 20% cortical bone

A

False, other way round

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28
Q

True/false: The bones in the human skull develop by a process of intramembranous ossification

A

False, majority of skull forms this way, but the skull base and jaw bone are fromed through endochondrial ossification

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29
Q

True/ false: PTH raised serum Ca by decreasing renal tubular calcium resorption

A

True, it does this and increases resorption at at the collecting duct

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30
Q

Definition of osteoporosis

A

Reduction in amount of bone

with loss of microarchitecture

LEADING TO weaken bone and pathological fractures

NB** There is normal mineralisation and normal bone cell activity, there is just not enough bone.

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31
Q

Causes of osteoporosis (7)

A 
Idiopathic, post-menopausal
Cushings/ STEROIDS!!
Thyrotoxicosis
Hypogonadism (lack oestrogen)
Hyperparathyoidism
Alcohol abuse
Scurvy
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32
Q

Risk factors in osteoporosis

A 
Female
Age
Caucasian
Early menopause
Family history
SMoking
Alcohol
STEROIDS!!!!!
Previous fractures
Low dietary calcium
Sedentary
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33
Q

Define osteomalacia

A

Uncommon in Europe

Disease due to poor mineralisation of bone

Caused by both low serum calcium and low serum phosphate

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34
Q

Causes of osteomalacia (different to osteoporosis) (7)

A 
Deficient diet
Lack of sun
Malabsorption
Chronic liver disease
Chronic renal disease
!!PHENYTOIN!!
Hypophosphataemia
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35
Q

How will osteomalacia appear with a von Kossa stain?

A

Thickening of unmineralised osteoid (purple) on the surface of mineralised one (black)

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36
Q

What is Paget’s disease? What bones are affected?

A

Due to increased rate of bone remodelling.

Rare under 40 years old

Affects long bones, vertebrae, pelvis and skull

Idiopathic cause but ?slow virus

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37
Q

What is coxa vara in Paget’s disease?

A

When the neck of the femur shifts from 120 degrees to 90 due to bone remodelling

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38
Q

Difference between Paget’s and osteoporosis on histology?

A

Paget’s bone is thickened, osteoporosis bone is thinned

In Pagets you also see greatly increased osteoblasts and osteoclasts. The marrow fat is replaced by loose fibrovascular stroma

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39
Q

Presentation of Paget’s?

A

Mostly asymptomatic

Bone pain
Fractures
Deformity (limb bowing or enlarged skull)
Progressive deafness

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40
Q

Complications of Paget’s disease (5)

A

Fractures
Osteoarthritis
Nerve compression
SARCOMA due to increased blood supply to bone

?high output heart failure (HF is more likely to be due to another cause)

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41
Q

Structure and function of articular cartilage

A

Distributes stress forces around joints

Made up of chondrocytes and matrix which does not regenerate

Matrix is made up of GAGs (polysaccharide polymers which absorb water) and collagen

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42
Q

What can cause secondary osteoarthritis?

A 
Previous fractures
Metabolic bone disease
Hip dislocation
Osteonecrosis
Joint infection
Burnt out RA
43
Q

Pathogenesis of osteoarthritis

A

Wear and repari

Change in composition of GAGs, resulting in splitting and loss of cartilage

Reduction in cartilage, but lots of sclerosis and reactive bone around the joint

44
Q

X ray features of OA

A

Loss of joint space
Osteophytes
Subchondral cysts
Sclerosis

45
Q

Pathology of RA (complex, don’t rote learn)

A

Auto-immune disease

Rhematoid factor IgM reacts with Fc part of sensitised IgG forming an IMMUNE COMPLEX

This activates complement system and interleukins 1 and 6 are released, as well as TNFa.

Increased incidence with HLA-Dr4

46
Q

Who most commonly gets RA?

A

Females>males 4:1

20-50 years

47
Q

Does synovitis or arthrits occur first in RA?

A

Synovitis first (opposite to OA)

Inflamed synovium spreads over articular cartilage and starves it of nutrition

Leads to destruction of cartilage- ARTHRITIS

48
Q

Pathological features found in RA

A

Synovial hyperplasia (thrown up into papillary folds)

Chronic inflammation
Lyphocyte aggregates
Lymphoid follicles

Subcutanous rheumatoid nodules (acellular necrotic collagen granuloma)

49
Q

Systemic effects casued by RA (5)

A 
Vasculitis
Pericarditis
Lung fibrosis
Infection risk
Chronic systemic amyloid
50
Q

Another name for chondrocalcinosis?

A

Pseudogout

51
Q

What cuases gout?

A

Increased sodium urate which comes from breakdown of DNA

If patient is dehydrated, there is a reduction in solvent and this increases urate

Urate crystals in soft tissues causes inflammation

52
Q

Causes of gout

A

Genetics: purine metobolism

Renal failure

THIAZIDE DIURETICS

Increased cell turnover eg form leukaemia etc leading to increased DNA breakdown

53
Q

Histological feature of chronic gout?

A

Giant cells

54
Q

What diseases are sero-negative arthropathies?

A

Ankylosing spondylitis
Psoriatic arthritis
Reiter’s disease
IBD arthritis

They are all NEGATIVE for rheumatoid factor

55
Q

Pathology of sero-negative arthropathies

A

ENTHESITIS (inflammation where a ligament or tendon is attached to bone)

Results in secondary ossification and spondylitis.

Can get large joint synovitis later on

56
Q

What are syndesmophytes?

A

Parallel arrays of bone that cross the intervertebral discs and stiffen the spine

Seen in seronegative arthropathies eg AS, psoriatic arthritis

57
Q

Where do metastatic bone tumours occur?

A

VERY RARE TO OCCUR DISTAL TO KNEE

Skull, ribs, pelvis, spine, humerus, femur

58
Q

What are sclerotic bone metastases?

A

Also called osteoblastic

Induce osteoblast activity

Spread characteristically from prostate and breast

59
Q

Most common primary sites for metastases to bone?

A

Lung, thyroid, breast, kidney, prostate

60
Q

Benign bone forming tumours (3)

A

Osteoma
Osteoid osteoma
Osteoblastoma

61
Q

Malignant bone forming tumour (1)

A

Osteosarcoma

62
Q

What is an osteoma?

A

Benign bone forming tumour
Arises on bone surface
Most common in 40s-60w
M=F

Composed of dense cortical bone

63
Q

Where do osteomas occur?

A

Bone surfaces

Craniofacial skeleton most common

64
Q

What is Gardner syndrome?

A

Multiple osteomas

Increased risk of intestinal adenocarcinoma

65
Q

Treatment of osteoma

A

Observation or simple excision

No reoccurrence usually

66
Q

What is an Osteoid Osteoma?

A

Benign bone forming tumour characterised by:

  • Small size
  • Classic pain pattern worse at night time and relieved by NSAIDS

Occurs in teens and YA males

Treated with radio frequency ablation

67
Q

Where do osteoid ostemoas occur?

A

Most common site is proximal femur

Can occur in small bones of hands and feet or vertebral column

68
Q

Tx for osteoid osteoma

A

Radiofrequency ablation

69
Q

What is an osteoblastoma?

A

Benign bone forming lesion

Similar histology to osteoid osteoma but is >2cm

Occurs in teens and YAs

M>F

Present with pain, swelling, and spinal tumours can cause neurologic symptoms

70
Q

Osteoblastoma location

A

**Posterior part of vertebra (not in the body) and sacrum

Also feet and hands

71
Q

Imaging of osteoblastoma

A

Expansile tumour with circumscribed margins which appear both sclerotic and lytic

72
Q

Treatment of osteoblastoma

A

Surgical: Curettage or en-bloc resection

Excellent prognosis but recurrence rate of 20%

73
Q

What is the most common primary malignant bone tumour? (excluding haematology)

A

Osteosarcoma

74
Q

Age group affected by osteosarcoma?

A

10-20 year olds :(

Second peak >50s

M>F

75
Q

Presentation of osteosarcoma?

A

Enlarging painful mass

Minority have pathological fracture

76
Q

Causes of osteosarcoma

A

Mostly idiopathic

Some arise in diseased bone:

  • Paget’s
  • Radiation
  • Chemo
  • Trauma

Foreign body implants

Genetics: Hereditary retinoblastoma or Li-Fraumeni syndrome

77
Q

Osteosarcoma locations

A

50% in knee region

15% humerous

Also femur, tibia, humerus

78
Q

X ray appearance of osteosarcoma

A

Ill defined
Both lytic and sclerotic

Radiodensity in soft tissues in keeping with soft tissue extension of tumour

79
Q

What is Codman’s triangle on osteosarcoma MRI imaging?

A

Reactive bone deposited next to the tumour, usually triangular in shape

80
Q

Osteosarcoma treatment

A

Preoperative chemo (efficacy is determined by histology assessment of tumour necrosis)

Surgery: complete excision or amputation

Radiotherapy if tumour is too large to resect

81
Q

Benign cartilage tumours (2)

A

Osteochondroma

Enchondroma

82
Q

Malignant cartilage tumour

A

Chondrosarcoma

83
Q

What is an osteochondroma

A

Most common primary bone tumour.

Originates in growth plate region. Caused by inactivating mutations of EXT genes

Most patients are in their 20s

M>F

Most are asymptomatic

84
Q

How do osteochondormas present? Solitary vs multiple

A

Can occur sporadically as solitary lesion

Multiple lesions in MULTIPLE HEREDITARY OSTEOCHONDROMATOSIS

Occur in knee, distal femur and proximal tibia

85
Q

Histology of osteochondroma: Characteristic ____ shape with surface _____ cap and an underlying bony stalk

A

Mushroom

Cartilaginous

86
Q

Treatment for osteochondroma

A

Growth ceases at puberty

Treated by excision

Malignant transformation is very uncommon

87
Q

What is an enchondroma?

A

Benign chondrocyte tumour that arises in medulla

Unknown cause

60% in hands and feet

Majority are asymptomatic

Presents in 30s-40s

88
Q

Treatment of enchondroma

A

Slow limited growth

Most require no treatment

If painful: curettage, then packing with bone graft or cement

Multiple lesions occr in Ollier disease and Maffucci syndrome

89
Q

What is a chondrosarcoma?

A

Malignant cartilage producing tumour

idiopathic

Adults in 50s-70s, M>F

Painful enlarging mass, may fracture

90
Q

**Where do chondrosarcomas occur?

A

Pelvis

Proximal femur

RARE to be in hands or feets

91
Q

Treatment of chondrosarcoma

A

Surgery: Aggressive curettage, wide local resection

Radiotherapy if difficult to resect

92
Q

Prognosis of chondrosarcoma

A

Grade 1: 85% 5 year survival

Grade 2 and 3: 50% 5 year survival

93
Q

What is Fibrous Dysplasia?

A

BENIGN fibro-osseus bone neoplasm

Bone lesions develop in childhood and are asymptomatic.

Often in one bone only

Associated with McCune Albright syndrome and Mazabraud syndromes

Affects ribs, femur, tibia, jaw, skull

94
Q

Which bone neoplasm is associate with the bone resembling Chinese figures on low power histology?

A

Fibrous dysplasia

95
Q

Treatment of fibrous dysplasia

A

Benign

Treatment if painful

96
Q

What is a Giant Cell TUmour of Bone?

A

Benign but locally aggressive tumour

Occurs in adults 30s to 50s

FEMALES OVER MALES (unusual)

Occurs in knee, pain and swelling

97
Q

What does RANK ligand do in Giant Cell tumour?

A

Induces formation of osteoclast type giant cells.

Activated by mononuclear cells of the tumour

98
Q

Treatment for Giant Cell Tumour?

A

Surgery: Curettage or en-bloc resection

RANK ligand inhibitor

Radiation

Local recurrance rate is 25%

99
Q

What is Ewing’s sarcoma? How does it present? Who is affected?

A

Malignancy small round cell sarcoma

Most patients between 10-15 yrs

M>F

Painful enlarging mass, mimicing infection

Patients have FEVER and raised WCCs!!

100
Q

Where does Ewing’s sarcoma occur?

A

Mostly in ilium and femur

101
Q

X ray appearance of Ewing’s

A

Ill defined lytic lesion

with periosteal reaction causing new bone formation

102
Q

Which bone lesion is assocaited with a t(11:22)(q24:q12) translocation?

A

Ewing’s sarcoma

Can be detected using FISH or PCR

103
Q

Treament of Ewing’s sarcoma

A

Combo of chemo and surgery:
-pre op chemo (histology, tumour necrosis >90% is good response)

Radiotherapy

50% are cured long term

SBCP Pathology (24 decks)

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