Sherif Elsobky

Cannot teach you all about bones The aim of the lecture is to highlight topics you need to know Emphasise the basic principles that will help you pass your exam Test what you know

Bone:
Composition Structure Function

Ca2+ Osteoporosis Other clinic topics

Mechanical Mineral storage Haemopoietic

What are the three main components the form the bones microstructure??

Matrix, organic and inorganic Organic Type 1 collagen Non organic carbonated hydroxyapatite Matrix cells
Osteoclasts, osteocytes and osteoblasts

Cells OsteoBlasts: Broduce bones Osteocytes: Maintains bones -most numerous stuck in lacunae, stellate processes OsteoKlasts: Kills bone

Compact tissue - the harder, outer tissue of bones Cancellous tissue - the sponge-like tissue inside bones. Subchondral tissue - the smooth tissue at the ends of bones covered with cartilage.

Layer of spongy bone sandwiched between parallel layers of compact bone b. Periosteum covers compact bone c. Endosteum covers spongy bone Hematopoietic tissue: Red marrow Red marrow cavities i. Spongy bone of long bones In adults, fat containing medullary cavity extends into epiphysis i. Little red marrow

Outline the difference between woven and lamellar bone???

LAMELLAR Arrangement of Type I collagen parallel Osteocytes in matrix few Osteocyte morphology uniform Deposition/production slow Tensile strength strong Present in adult skeleton Normal Found in bone forming tumor rare Pathologic formation Reaction to persistent stress and slowly growing tumors

WOVEN Irregular Numerous Pleomorphic Rapid Low Abnormal Usual Reaction to rapidly growing tumor or virulent infection

 Outline

the 5 distinct zones of endochondral ossification?

From cartillage to bone

"Real People Have Calcified Osses": Resting zone (reserves) Proliferation Hypertrophy Calcification Ossification

1. 2.

Bone needs to be replaced. Resorbs and reforms Osteoblasts and Osteoclasts work together PTH +Osteoblasts + Collagenase & Osteoclasts Bone reabsorbed Remodelling Osteoblasts Osteoid --> Bone formed Osteoid= collagen

PTH stimulates Osteoblasts Osteoblasts stimulates Osteoclasts and Collagenase which reabsorb bone Coupling signals stimulate Osteoblasts to form Osteoid (mineralization). Osteoblasts flatten and deactivate

Physiology

What is the normal Ca2+ range? 5 functions of calcium ?

Normal range of calcium is 2.1-2.6 mmol/

Function of Calcium Contractility of cardiac muscles depends on extracellular Ca2+ (ligand for cell membrane depolarisation) Contractility of skeletal muscles depends on intracellular Ca2+ (actual mechanism for contraction) Plasma membrane ion channel activities Transmission of nervous impulses Enzyme activities Maintenance of bones and teeth Blood clotting Calcium Regulation 99% found in bones and 1% soluble in cells and blood plasma (in dynamic equilibrium)

Parathyroid hormone (parathyroid gland)

Calcitonin (thyroid gland) PTH released in response to low ionic calcium in blood

Osteoclasts are activated to digest bone matrix and release calcium into blood Calcitonin is released in response to high calcium in blood Calcium salts are deposited into bone

40% of eaten Ca++ is absorbed through the small intestine Through epithelial receptor called Calbindin
Sats depend on 1,25-dihydroxvitamin D

Excretion mainly though kidneys

Secreted by thyroid gland lower plasma calcium Effects:

Kidneys Decrease calcium reabsorption Bones Inhibits bone resorption by osteoclasts Less potent than PTH

What are the six characteristics of synovial joints??

1There is a joint cavity 2.The parts of the bones in contact with each other are covered by smooth articular cartilage. 3. The joints are surrounded by a connective tissue capsule 4. The inner surface of the capsule and the non-articular surfaces of the bones are covered with synovial membrane 5. The capsule is reinforced by ligaments 6. The joint is capable of movement

Synovial joint Three joint in one (Medical tibiofemoral joint, later TFJ and patellofemoral joint) Unstable (due to weight) hence susceptible to injury Ligaments and meniscus

Flexion Extension Rolling Rotation

Which muscles provide knee stability?

Four ligaments: Collaterals (M+L), Cruciate (A+P) Functions:

Stability Limiting movements Protect the articular capsule

Meniscus:
Fibrocartilage discs Medial and lateral Shock absorbers Reduce friction

Menisci attachments in knee Each meniscus has something attached to it. The medial meniscus has the medial collateral ligament The lateral meniscus is attached to the popliteal muscle.

Cruciate ligaments: insertions PAMS APPLES: Posterior [passes] Anterior [inserts] Medially. Anterior [passes] Posteriorly [inserts] Laterally.

Small fluid filled sac that reduces friction Prepatellar bursa: Between the patella and skin Infrapatellar bursa: Between tibia and patellar ligament Suprapatellar bursa: Inf femur and quads muscle

Knee

injuries

Which menisci is more likely to get damage and why?

Medial meniscus is torn more often than the lateral lateral meniscus is smaller in diameter, thicker in periphery,

wider in body and more mobile

Damage usu due to mechanical stresses produced from: Acceleration and deceleration Coupled with sudden change in direction and landing after a jump (eg basketball and football)

Injuries commonly occur usually when the knee is flexed and there is significant rotation between the femur and tibia

Ligaments can be damaged together or in isolation Occurs when a joint is loaded in the direction in which the ligament resists movement: MCL snaps when forcing knee into valgus LCL snaps when forcing knee into varus

Valgus outward angulation of the distal segment of a bone or joint (causing knee to point medially) Varus inward angulation of the distal segment of a bone or joint (causing knee to point laterally)

In young people with strong bones, the ligaments are usually relatively weaker and will be the first to be injured The converse is true in elderly people with weak bones

ACL damage Medial meniscus damage

MCL damage

Fractures around the knee can be associated with injuries to other structures
Transverse fractures in the patella may occur due to quadriceps contracting suddenly against a resistance

May predispose to osteoarthritis (especially when articular surfaces are involved)

How would you test for an Anterior cruciate ligament tear clinically?
Anterior draw test, Lachmans test

How would you test for menisci tear

McMurrays test If you cant remember the name in exam describe how you do it

Occurs when a force exceeds the compressive or tensile strength of the bone
highest incidence is seen in young males between ages 1524 (tibia, clavicle and distal humerus) and usually the result of trauma. In the elderly, fracture of proximal femur, proximal humerus, vertebrae, distal radius, or pelvis are often associated with osteoporosis.

Stage of Haematoma Blood vessels break and leaking blood produces a haematoma Stage of Subperiosteal and Endosteal Cellular Proliferation osteoblasts and chondroblasts are activated and proliferate at periosteum and endosteum Stage of Callus Chondroblasts lay down hyaline cartilage & Osteoblasts lay down collagen fibres which then calcifies to form woven bone Stage of Consolidation Osteoblasts lays down lamellar bone at the expense of woven bone

Stage of Remodelling Bone is gradually remodelled to original state

Osteoporosis

Define osteoporosis

A bone mineral density that is 2.5 SDS or more below the mean peak bone mass (average of young, healthy adults) as measured by DEXA scan

Osteoporosis is a bony disorder characterized by progressive decrease in bone density and mass Osteon is bone and porosis is hole in Greek

Female male ratio 4:1 and higher incidence of male osteoporosis Up to 50% postmenopausal women affected One in ten older women with a previous fragility fracture has a referral for bone density assessment in her electronic medical record

Describe the risk factors of osteoporosis?

History of fracture as an adult and in an immediate (first-degree) relative Low body weight Lifelong low calcium intake Current cigarette smoking Alcoholism Advanced age Early menopause Asian

Clinical picture Serological Se Calcium, Phosphorus and Alkaline Phosphatase. Other markers from blood and urine Gold standard- DXA

Two X-ray beams with differing energy levels are aimed at the patient's bones a method of estimating the strength of bones and the likelihood of bone fractures with minimal or no trauma On X-ray you will see changes only after 3040% bone loss

Define T score and Z scores??

T score number of standard deviations above or below the mean for a similar healthy 30 year old Z score number of standard deviations above or below the mean for the patients age, sex and ethnicity

Clinical
Loss of bone mass sufficient to significantly increase the risk of fracture

Diagnostic
T score number of standard deviations above or below the mean for a similar healthy 30 year old
Normal BMD = Osteopenia BMD = Osteoporosis BMD = T: 0 to -1 T: -1 to -2.5 T: less than -2.5

Z score number of standard deviations above or below the mean for the patients age, sex and ethnicity

Are as important as any medication Nutritional

Calcium Vitamin D Vitamin A

Lifestyle
Smoking Exercise

Falls risk reduction

Bisphosphates- Most effective Parathyroid hormone

Selective Oestrogen Receptor Modulators

Denosumab

Excessive uncontrolled destruction of bone by abnormally large and active osteoclasts Concurrent inadequate attempts at haphazard new bone formation by osteoblasts Produces physically weak woven bone Very high alk phos, normal Ca2+ and Po4

Vitamin D deficiency Normal collagen production but mineralization is inadequate Leads to trabecular bone that is only partially mineralised and is therefore soft and weak Low Ca++, high PO4, Normal Alk Phos, High PTH