FRACTURES, adjectives

Complete, incomplete
Closed, open (communicating)
Communited (splintered, greenstick)
Displaced (NON-aligned)
Pathogenic, (non-traumatic, 2 to other
disease, often metastases)
 FRACTURES
THREE PHASES
HEMATOMA, minutes days PGDF, TGF-, FGF
SOFT CALLUS (PRO-CALLUS), ~1 week
HARD CALLUS (BONY CALLUS), several weeks

COMPLICATIONS
PSEUDOARTHROSIS
INFECTION (especially OPEN [communicating]
fractures)
FRACTURES
 OSTEONECROSIS
Also called AVASCULAR necrosis
Also called ASEPTIC necrosis
CAUSE: ISCHEMIA
Trauma
Steroids
Thrombus/Embolism
Vessel injury, e.g., radiation
INCREASED intra-osseous pressurevascular
compression
 OSTEONECROSIS
Disorders Associated with Osteonecrosis
Idiopathic Pregnancy

Trauma Gaucher disease

Corticosteroid Sickle cell and other

anemias
administration
Infection Alcohol abuse
Dysbarism Chronic pancreatitis
Radiation therapy Tumors
Connective tissue Epiphyseal disorders
disorders
OSTEONECROSIS
 JOINTS
Joints are constructed to provide both
movement and mechanical support
classified as solid (nonsynovial) and cavitated
(synovial)
SYNOVIAL JOINTS
 Diseases of the Joints
Osteoarthritis
Also termed degenerative joint disease
Is the most common disorder of the joints
characterized by the progressive erosion of
articular cartilage
May arise without any obvious predisposing
factors (primary)
Secondary osteoarthritis refers to degenerative
changes developing in a previously deformed
joints or in some metabolic disorders
Pathogenesis
Normally balanced articular cartilage degradation
and replacement
In osteoarthritis, this process is disturbed by a variety
of influences
genetic defects in proteoglycan and type 2
collagen
mechanical stress
age
increasing bone density
increased estrogen level===
=========imbalances in signaling
pathway
decreased chondroblast proliferation
increased chondrocyte apoptosis
 The most important of these influences are aging
and mechanical effects
OA is characterized by significant changes in both
the composition and the mechanical properties of
cartilage
Early changes include , increased water and decreased
proteoglycans
Attempts for repair
Morphology
Fibrillation (splitting) at the articular surface
Erosion of the articular cartilage
Thickened subchondral bone
Fragments of cartilage and bone are often
dislodged to form free-floating "joint mice
Bone proliferation occurs at the margins of the
joints to produce bony excrescences, termed
osteophytes
chondromalacia
Clinical features
Signs and symptomes develop gradually
The joints commonly involved include the hips,
knees, lower lumbar and cervical vertebrae,
proximal and distal interphalangeal joints of the
fingers aside from complete inactivity no way to prevent progress of osteoarthritis

May be asymptomatic ,common complaints

include joint stiffness and deep, aching pain, exacerbated by
use
particularly in the morning
Some degree of joint swelling is common, and
small effusions may develop
tpn222
ccp
resulting in t4 cell activation and release of cytokines which recruit mphages .actiivates synovial cells
chondrocytes and fibroblasts resulting in production of collagenase,pge2,elastase ,=destruction of bone
cartilage and tendons.rank t cell
activatin of fibroblasts chondrocytes and synovial cells-proliferation-panus ,fibrosis and ankylosis
panus with fibrosis and
ossification
HANDSWRISTELBOWS

The rheumatoid nodule shows palisading

fibroblasts
uvetus and keratoconjuctivits-jogren
 JUVENILE RHEUMATOID ARTHRITIS (JRA)
Heterogeneous group of chronic arthritides that is a
major cause of functional disability
Types of JRA
oligoarticular (<5 joints involved)
polyarticular (5 or more joints involved) and
systemic variants
2:1 female predominance
By definition, it begins before age 16 and the
arthritis must be present for a minimum duration
of 6 weeks
 JRA differs from RA in adults in the following
ways:
oligoarthritis is more common
systemic onset is more frequent
large joints are affected more often than small
joints
rheumatoid nodules and rheumatoid factor are
usually absent, and
antinuclear antibody seropositivity is common
 Commonly targeted joints in JRA are the knees,
wrists, elbows, and ankles
They become warm and swollen and are often
involved symmetrically
Pericarditis, myocarditis, pulmonary fibrosis,
glomerulonephritis, uveitis, and growth
retardation are potential extra-articular
manifestations
 Clinical Features
Four steps in the clinical course
1. Asymptomatic hyperuricemia
-precedes clinical evident gout by many yrs
2. Acute gouty arthritis
-Initially monoarticular involvement later
polyarticular with fever
3. Intercritical period
Asymptomatic interval b/n attacks
4. Tophaceous gout
 In untreated patients in the form of tophi in
the cartilage, synovial membrane tendons and
soft tissue.
Tophus is a chalky yellow white deposit of
monosodium urate crystals
Classic locations are ear, heads, olecranon
bursa and in the Achilles tendon
h.influenzae-childrens<2 yrs old
s.aures-older children and adults
gonococcus -older adolescents and
young adult
salmonella-sca at any
both sexes equally but gonococcus
women of reproductive age
 JOINT TUMORS
BENIGN
GANGLION (SYNOVIAL CYST)
GIANT CELL TUMOR of TENDON SHEATH, aka
PVNS, Pigmented VilloNodular Synovitis
MALIGNANT
SYNOVIAL SARCOMA
GANGLION
 Soft tissue tumors
Benign, malignant and intermediate
Classification according to their differentiation
lines (e.g. liposarcoma is not a tumor arising
from lipoblast but exhibiting lipoblastic
differentiation)
 Classification of soft tissue tumors
Lipomatous tumors Fibrohistiocytic tumors
Lipoma Benign fibrous histiocytoma
Liposarcoma Malignant fibrous histiocytoma
Smooth muscle tumors Vascular tumors
Leiomyoma Hemangioma
Leiomyosarcoma Angiosarcoma
Skeletal muscle tumors Tumors of peripheral
nerves
Rhabdomyoma Schwannoma
Rhabdomyosarcoma Neurofibroma
Fibroblastic tumors Malignant peripheral nerve
Nodular fasciitis sheath tumor
Fibromatoses Tumors of uncertain
Fibrosarcoma origin
Synovial sarcoma
 Lipoma
Very common benign tumor
Subcutaneous tissue of the trunk and limbs in the middle-
aged and elderly
Soft, slowly growing mass
Microscopic features: well-defined lobules of mature adipose
tissue
are solitary but multiple in familial cases.
are mobile and pain less masses but pain
full in angiolipomas.
complete excision is curative.
histologically no pleomorphism
 Liposarcoma
Adults (peak incidence 40-60 years)
Site: lower limb and retroperitoneal space
Key diagnostic feature: multivacuolated lipoblast (two
or more lipid droplets within the cytoplasm)
Subtypes:
Well-differentiated, lipoma-like liposarcoma
(atypical lipomatous tumor):
aggressive ,recur after excision and metastasize to
Myxoid liposarcoma: lung
Pleomorphic liposarcoma:
lipoblasts having cytoplasmic lipid vacuoles that scallop the
nucleus and the appearance recapitulating that of fetal fat cells.
Leiomyoma
Skin, subcutaneous tissue, uterus, gastrointestinal
tract
Microscopic features: interlacing bundles of well-
differentiated smooth muscle cells ----well circumscribed
Leiomyosarcoma
Mesentery, retroperitoneal space, wall of large
veins, skin, subcutaneous tissue, deep soft tissues
of limbs
Signs of malignancy: large size, high mitotic rate,
areas of necrosis, marked cellular pleomorphism
liomyosarcoma- adults and females
-firm painless mass
-spindle cells with cigar shaped nuclei arranged in interwoven
fasicles
retroperitoneals are large ,difficult to exciseand cause death by invasion and
extension
Leiomyoma
Rhabdomyoma
Extremely rare lesions ---common in heart
Rhabdomyosarcoma
most common malignant soft tissue tumour in infants
and young children <20
Diagnosis depends on the demonstration of
rhabdomyoblasts (round, elongated or oval cells with
eccentric eosinophilic cytoplasm, in which fibrillated
appearance may be noted tadpole cells, strap cells,
racket cells)
 Subtypes of rhabdomyosarcoma:
Embryonal rhabdomyosarcoma:
most common, early childhood, head and neck region
and genitourinary system, small rounded or spindle-
shaped cells within a myxoid matrix
Bothryoid rhabdomyosarcoma (grape-like):
embryonal rhabdomyosarcoma with polypoid configuration
and myxoid consistency, occur in mucosa-lined organs
Alveolar rhabdomyosarcoma:
ages of 10 to 20 years, muscles of limbs and trunk
Pleomorphic rhabdomyosarcoma:
limbs of adults, large cells with eosinophilic cytoplasm
and either single or multiple highly atypical nuclei
Nodular fasciitis
Benign fibroblastic proliferation
Adolescents and young adults
Rapidly growing nodule within subcutaneous
tissue, forearm is the most common site
Microscopic features: plump immature
fibroblasts arranged in short bundles,
numerous mitoses, cellular pleomorphism not
present
Superficial fibromatoses
Palmar fibromatosis (Dupuytrens contracture): middle-aged
men, nodular thickening of palmar aponeurosis leading later
to flexion deformities of fingers
 Plantar fibromatosis (Ledderhoses disease):
nodular thickening of plantar aponeurosis
 Penile fibromatosis (Peyronies disease):
abnormal curvature of penis
 Microscopic features: nodules of well-
differentiated fibroblasts arranged in long
sweeping bundles