BONE PATHOLOGY

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="0408dfc3.jpg"> <div> <B> <img src="HTMLobj-209/aniGif.gif" border="0" align="bottom" width="67" height="100">  the osteoporosis by prevention</B></div> <bR> <bR> <div> <B><IMG SRC="0d908790.gif" border=0 width="520" height="377" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" colspan=2 height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0418dfe1esnpes.jpg"> <div> <FONT SIZE="5" COLOR="#336666" FACE="Arial" ><B>BONE PATHOLOGY</B></FONT><B>     </B><B>|</B><B>     </B><A HREF="index.htm" TARGET="_top" TITLE="BONE PATHOLOGY"><U><B>home</B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="bone formation review"><U>bone formation review</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="anatomy"><U>anatomy</U></A>   | 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VSPACE="0"></div> <bR> <div> <B><U>Bone Pathology</U></B></div> <div> <U>Hereditary Disorders</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Infections and Fractures</U></div> <div>  <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Metabolic Diseases</U></FONT> </div> <div> <U>Primary Bone Disease</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Bone Tumors</U></div> <bR> <bR> <bR> <bR> <div> <B>Hereditary Disorders</B><B> </B></div> <bR> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteogenesis imperfecta</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteopetrosis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteochondroma</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Achondroplaisa</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <B> Congenital and Hereditary Bone Disorders</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Achondroplasia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteogenesis Imperfecta (Brittle Bones, Fragilitas Ossium)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteopetrosis (Marble Bone Disease, Osteosclerosis) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hereditary Multiple Exotosis (Osteochondromatosis)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enchondromatosis (Ollier's Disease<FONT SIZE="3" COLOR="#0066FF" FACE="Arial" >]</FONT></div> <bR> <bR> <div> <B><U>Infections and Fractures</U></B></div> <div> <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pyogenic osteomyelitis</U></FONT> [Hematogenous (Pyogenic) Osteomyelitis]</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tuberculosis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis from a Contiguous Infection</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis from an Introduced Infection</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone Tuberculosis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone Syphilis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fungus Infections of Bone</div> <bR> <bR> <div> <B> </B><B><U>Metabolic Diseases</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoporosis Osteoporosis Osteoporosis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tensynovitis</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Scurvy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Paget's Disease</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > [</FONT>Paget's Disease of Bone (Osteitis Deformans]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rickets and Osteomalacia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone Changes in Hyperparathyroidism (Generalized Osteitis Fibrosa Cystica, Von Recklinghausen's Disease of Bone) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Renal Osteodystrophy</div> <bR> <bR> <div> <B><U>Primary Bone Disease</U></B><B> </B></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertrophic Osteoarthropathy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrous Lesions</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cysts</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <B><U>Bone Tumors</U></B></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Plasma Cell Myeloma</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Metastatic Disease</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteogenic Lesions -- Benign</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cartilaginous Tumors</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone-Forming Tumors</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tumors of Unknown Histogenesis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Miscellaneous Tumors and Tumor-like Lesions of Bone</div> <bR> <div> <B><U> Other Nonneoplastic Disorders of Bone</U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrous Dysplasia of Bone</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrous Cortical Defect and Nonossifying Fibroma</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solitary Bone Cyst (Unicameral Bone Cyst)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aneurysmal Bone Cyst</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Eosinophilic Granuloma of Bone</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone Lesions of Gaucher's Disease</div> <bR> <bR> <bR> <div> <IMG SRC="0cd6fdc0.gif" border=0 width="879" height="476" ALT="Microsoft Word Document" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1282" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="LEFT" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF00 > <tR> <tD VALIGN=TOP BGCOLOR=#99FFFF HEIGHT= 19 WIDTH="274"><div> <I><B>Diseases of Growth</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#99FFFF><NOBR><div> <I><B>Repair of Connective Tissuse</B></I></div> </NOBR></tD> <tD VALIGN=TOP BGCOLOR=#99FFFF WIDTH="243"><div> <I><B>Infection</B></I></div> </tD> <tD VALIGN=TOP WIDTH="285"><div> <I><B>Circulatory Disease</B></I></div> </tD> <tD VALIGN=TOP><NOBR><div> <I><B>Metabolic Bone Disease</B></I></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 150 WIDTH="274"><div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Achondroplasia</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteogenesis Imperfecta</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteopetrosis</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epiphysiolysis (Slipped Capital Femoral Epiphysis)</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epiphyseal Separation</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Congenital Pseudarthrosis</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">· <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U>Osteopoikilosis</U></I></FONT></div> </tD> <tD VALIGN=TOP WIDTH="236"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fracture Repair</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fracture Repair Non-union</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Myositis Ossificans</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">· <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Cartilage Repair</U></FONT></div> </tD> <tD VALIGN=TOP WIDTH="243"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis, Pyogenic</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis, Tuberculous</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis, Fungal</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arthritis, Pyogenic</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arthritis, Tuberculous</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">· <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Syphilis</U></FONT></div> </tD> <tD VALIGN=TOP WIDTH="285"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avascular Necrosis, Secondary to Trauma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avascular Necrosis, Nontraumatic</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteochondroses</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteochondritis Dissecans</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> · <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Sickle Cell Disease</U></FONT></div> </tD> <tD VALIGN=TOP WIDTH="214"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Normal Bone Metabolism</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoporosis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomalacia/Rickets</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyperparathyroidism</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> · <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Hypophosphatasia</U></FONT></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1006" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFCC33 > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="298"><div> <I><B>Arthritis</B></I></div> </tD> <tD VALIGN=TOP WIDTH="263"><div> <I><B>Synovial Disease</B></I></div> </tD> <tD VALIGN=TOP WIDTH="425"><div> <I><B>Skeletal Disease</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 133 ><NOBR><div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arthritis, Degenerative</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arthritis, Inflammatory</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gout</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><I><B> </B></I></FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pseudogout</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="263"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Synovitis, Non-Specific</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ganglion</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pigmented Villonodular Synovitis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Giant Cell Tumor of Tendon Sheath</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Synovial Chondromatosis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> <tD VALIGN=TOP WIDTH="425"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrous Dysplasia</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ossifying Fibroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Paget's Disease</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Simple Bone Cyst</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reticuloendothelioses</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1751" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFCC > <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="265"><div> <I><B>Benign Skeletal Lesions</B></I></div> </tD> <tD VALIGN=TOP><NOBR><div> <I><B>Benign Cartilaginous Lesions</B></I></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <I><B>Benign Osseous Lesions</B></I></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="336"><div> <I><B>Malignant Lesions of Bone</B></I></div> </tD> <tD VALIGN=TOP WIDTH="220"><div> <I><B>Benign Lesions of Soft Tissue</B></I></div> </tD> <tD VALIGN=TOP WIDTH="439"><div> <I><B>Malignant Lesions of Soft Tissue</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 508 ><NOBR><div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Non-Ossifying Fibroma</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Desmoplastic Fibroma</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aneurysmal Bone Cyst</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Giant Cell Tumor</U></B></I><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Exostosis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Periosteal Chondroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enchondroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondroblastoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondromyxoid Fibroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="213"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enostosis (Bone Island)</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoid Osteoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoblastoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> <tD VALIGN=TOP WIDTH="336"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Myeloma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lymphoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ewing's Sarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Metastatic Carcinoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Clear Cell</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Dedifferentiated</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Juxtacortical</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Mesenchymal</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Secondary to Enchondroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chondrosarcoma, Secondary to Exostosis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Low-Grade Intramedullary</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma in Paget's Disease</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Parosteal</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Periosteal</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Small Cell</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Soft Parts</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Wing0a73006f00f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteosarcoma, Telangiectatic</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chordoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adamantinoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> <tD VALIGN=TOP><NOBR><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Angiolipoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lipoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibromatosis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemangioma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neurilemoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neurofibroma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="439"><div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Soft Tissue Sarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Liposarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Leiomyosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malignant Fibrous Histiocytoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neurosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rhabdomyosarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Synovial Sarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vascular Sarcoma</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <B>Bone pathology</B></div> <bR> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="885" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BELOW" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#800000 HEIGHT= 33 WIDTH="167"><div> <I><B>Diseases of Growth</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="168"><div> <I><B>Repair of Connective Tissuse</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="162"><div> <I><B>Infection</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="174"><div> <I><B>Circulatory Disease</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000><NOBR><div> <I><B>Metabolic Bone Disease</B></I></div> </NOBR></tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="885" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="HSIDES" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFCC HEIGHT= 284 WIDTH="167"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/achondro.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Achondroplasia</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/oi.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Osteogenesis Imperfecta</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/osteopet.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Osteopetrosis</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/scfe.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Epiphysiolysis (Slipped Capital Femoral Epiphysis)</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/episepa.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Epiphyseal Separation</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/congpseu.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Congenital Pseudarthrosis</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect02/osteopoi.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Osteopoikilosis</B></I></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="168"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect03/fracrepi.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Fracture Repair</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect03/fracnonu.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Fracture Repair Non-union</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect03/myositis.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Myositis Ossificans</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect03/cartrepa.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Cartilage Repair</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="162"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/ostpyoge.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteomyelitis, Pyogenic</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/osttuber.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteomyelitis, Tuberculous</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/ostfunga.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteomyelitis, Fungal</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/arthpyog.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Arthritis, Pyogenic</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/arthtube.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Arthritis, Tuberculous</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect05/syphilis.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Syphilis</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="174"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect06/avntraum.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Avascular Necrosis, Secondary to Trauma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect06/AvnNonTr.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Avascular Necrosis, Nontraumatic</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect06/ochondro.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteochondroses</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect06/ostdiss.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteochondritis Dissecans</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect06/sickcell.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Sickle Cell Disease</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="198"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect07/bonemet.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Normal Bone Metabolism</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect07/ostporos.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteoporosis</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect07/ricket.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteomalacia/Rickets</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect07/hypara.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Hyperparathyroidism</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect07/hypophos.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Hypophosphatasia</B></U></A></div> </tD> </tR> </TABLE></B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </U></B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B><U>Achondroplasia</U></B></FONT> </div> <bR> <div> <B>General Considerations</B><FONT SIZE="3" COLOR="#0000CC" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> congenital and often hereditary (<B>autosomal dominant</B>) skeletal disorder</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> characterized by a unique form of <B><U>dwarfism</U></B> and <B><U>bone deformity r</U></B>esulting in a disproportinate shortness of the extremities relative to the trunk. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> caused by a <FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><I><B><U>failure of proliferation and column formation of epiphysial cartilage cells</U></B></I></FONT>, that is, by a <FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B><U>defect in endochondral bone formation which impairs the longitudinal growth of the tubular bones</U></B></FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Point mutations in the<B> FGR3 gene</B> (encoding fibroblast growth receptors) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">on human chromosome 4 p segregate with disease in achondroplasia families</div> <bR> <bR> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" > </FONT></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> various degrees of expression. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The severest cases result in fetal or neonatal death, and milder cases survive and comprise the commonest type of adult dwarfism. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The adult height in achondroplasia is usually less than four feet. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The extremities (legs, arms, fingers, toes) are very short (micromelia) relative to the trunk which is only slightly shortened. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intramembraneous ossification is not affected. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The head (cranial vault) is large. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The root of the nose is depressed. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The skeletal deformities just noted along with normal intelligence and sexual development distinguish achondroplasia from dwarfism resulting from endocrine and nutritional deficiencies and other causes. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The microscopic changes in achondroplasia are best shown by a section of the epiphysis of a long bone during the neonatal period. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The epiphysial growth plate is thin.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There are few cells in the zone of proliferating cartilage. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The hypertrophic cartilage cells form extremely irregular columns, if any, and as a result the zone of provisionally calcified cartilage is small and does not provide an adequate scaffolding for bone matrix deposition by metaphysial osteoblasts. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Periosteal new-bone formation by osteoblasts is not impaired. </B></div> <bR> <bR> <bR> <div> <B><U>2. Osteogenesis Imperfecta (Brittle Bones, Fragilitas Ossium)</U></B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B><U> </U></B></FONT></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">O</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B>steogenesis imperfecta (OI) is a rare heritable and often congenital disorder of skeletal development .</B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">characterized by bone fragility which predisposes to fractures and deformity and by connective-tissue .</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">abnormalities which may involve the eyes (blue sclerae), ears, teeth, joints, and skin. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The underlying cellular defect lies in abnormal collagen synthesis by osteoblasts and fibroblasts. (Collagens are the major protein constituents of connective tissue, and type I collagen is the main collagen of bone, tendon, and skin.)</B></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B></FONT><I><B>Molecular studies indicate that the primary biochemical defect in OI is defective synthesis and secretion of collagen I caused by mutations (deletions, insertions, substitutions) in the two structural genes which encode the alpha1- and alpha 2- peptides of this triple helix molecule. Many, if not all, of the OI phenotypes are mutants of the two collagen 1 structural genes. Inheritance may be dominant, reces</B></I><I><B>sive, or sporadic. </B></I></div> <bR> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">O<FONT SIZE="3" COLOR="#000000" FACE="Arial" >I is divisible into two main clinical groups based upon the age of onset and the clinical severity: </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">OI congenita with multiple fractures usually present at or before birth and often fatal. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">OI tarda in which disease expression is less severe and often not apparent at birth. </div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is a broad range of disease expression within each group. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The chief clinical features are:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> fragility of bones,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> multiple fractures (of long bones), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bone deformities,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> (caused by fracture healing with poor alignment and weak callus): </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and shortness of stature or dwarfism (in the congenita group). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bones of the extremities are shorter, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">smaller, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and thinner than normal. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A general decrease in bone mass (osteopenia/osteoporosis) is seen radiographically. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The teeth may be fragile and discolored as a result of dentin imperfection (dentinogenesis imperfecta). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A striking feature is the presence of blue sclerae caused by a thin or defective fibrous layer which is translucent to the underlying choroid and vitreous.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Ligamentous laxity of joints and thin fragile skin also reflect a defective fibrous structure.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Progressive impairment of hearing, more common in the tarda group, is caused by otosclerosis. </div> <bR> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The typical microscopic changes of OI can be seen in a section of a long bone of a severely affected child.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The bone cortex is thin and porous. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bone trabeculae are thin, delicate, and widely separated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many osteoblasts and osteocytes are present, but the formation and organization of osteoid is deficient. There is less bone tissue than normal and most of it is woven or non-lamellar bone with collagen fibers of small size and random distribution. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The woven bone has an increase in basophilic ground substance (shown by blue staining in H.&E. sections): </div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Replacement of immature by mature bone with circumferential lamellae and Haversian systems is delayed or incomplete. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The woven bone in OI may persist into adolescence, whereas in normal children woven bone usually occurs only in the embryo or early childhood ( or in fracture repair). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The proliferation of epiphysial cartilage cells is normal, but the formation of osteoid by osteoblasts is impaired and delays the process of endochondral bone formation. </div> <bR> <bR> <bR> <bR> <div> <B><U>3. Osteopetrosis (Marble Bone Disease, Osteosclerosis) </U></B></div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> rare hereditary,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> usually congenital, disorder of skeletal development characterized by massive but<B><U> fragile bones, </U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">with marked thickening of cortical and medullary bone and concomitant reduction of the marrow space, and resulting in some cases in severe, even <B><U>fatal</U></B>,<B><U> anemia</U></B> and in <B><U>blindness and deafness. </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The cause of osteopetrosis is unknown</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> but the pathogenesis appears to be related to a defect in the function of osteoclasts in bone resorption and remodeling. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There are two different genetic and clinical forms of the disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The autosomal recessive form runs a "malignant" course and is fatal in utero, infancy or young adult life as a result of bone marrow obliteration, profound anemia, or other hemopoietic abnormalities.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The autosomal dominant form has a more benign course marked by repeated fractures on slight trauma, a near normal normal life expectancy, and the absence of hemopoietic abnormalities. </div> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">R</FONT>adiographically and pathologically, <B><U>all bones are affected, </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">but the most significant changes in osteopetrosis occur in the bones which are preformed in cartilage. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The long bones of the extremities, vertebrae, pelvic bones, and base of the skull show a </div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">great increase in the density and thickness of the cortex,</U></B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">an increase in the number and size of bony trabeculae, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> marked reduction or obliteration of the marrow spaces and haversian systems. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The reduction in the total amount of bone marrow leads to anemia and extramedullary hemopoiesis, resulting in enlargement of the spleen, liver, and lymph nodes. </div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bone overgrowth at the base of the cranium causes narrowing of the optic foramina and pressure on the optic nerves, resulting in primary optic atrophy and blindness. </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other cranial nerves, such as the auditory nerves, are similarly involved.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition to the increased density and mass of the long bones,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> the most characteristic microscopic change in <B><U>medullary and cortical bone is the presence and persistence into adult life of spicules of calcified cartilage which normally would have been resorbed,</U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> replaced, and remodeled preparatory to endochondral ossification. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These changes apparently reflect a basic defect in the function of osteoclasts in the resorption and remodeling of mineralized epiphysial cartilage. </div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteoclasts and active osteoblasts are few in number. </U></B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bone tissue formed is largely woven bone, and very little of it is remodeled and replaced by lamellar bone</U></B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Although massive, the bone structure is of poor structure and easily fractured. </div> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B>4. Hereditary Multiple Exotosis (Osteochondromatosis)</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> </B></FONT></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >his is an hereditary developmental disorder of the skeleton in which multiple cartilage-capped bony outgrowths (exostoses/osteochondromas) </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">protrude from the bone cortex in the metaphysial region of bones </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">preformed in cartilage, such as the long bones of the extremities particularly in the region of the knee, ankle, or shoulder</div> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</FONT>he exostoses tend to have a <B><U>bilateral and symmetrical distribution.</U></B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The scapulae, ribs, inominate bones, vertebrae, and metacarpal and metatarsal bones may also be involved.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Although not common, hereditary multiple exostosis is the most frequently seen systemic disorder of skeletal development. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is apparently inherited as an autosomal dominant, but there is an unexplained 3:1 preponderance of affected males compared to females.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The precise origin of the cartilage-capped lesions is uncertain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The usual explanation is that the exostoses arise from foci of misplaced or misdirected epiphysial cartilage which grows outwardly rather than longitudionally, abetted by a lack of normal restraint from the covering perichondrium.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The exostoses grow by endochondral ossification of the cartilage cap, and growth of the exostoses ceases at or prior to the skeletal maturation of the individual. </div> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">P<FONT SIZE="3" COLOR="#000000" FACE="Arial" >athologically and radiographically, the exostoses are seen as sessile or stalked bony protuberances, with various shapes (knobby, hemispherical, conical) and sizes (1-10 cm. in diameter), protruding from the metaphysial region of the involved bones </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The exostoses of long bones characteristically point away from the joint because the epiphysial site of origin of the exostoses lags behind the advancing epiphysial growth plate as the long bones increase in length. Grossly, the exostoses are covered with periosteum and capped with a thin layer of cartilage </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In some ( 3-5%) cases of hereditary multiple exostosis, the cartilage cap or remnants of it undergoes malignant transformation to a sarcoma, most often a peripheral chondrosarcoma. </div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malignant transformation is less often seen in solitary exostosis which, although microscopically similar and much more common than multiple exostosis, does not have an hereditary basis and is not a systemic disorder of skeletal development. </U></B></div> <bR> <bR> <bR> <div> <U>5. Enchondromatosis (Ollier's Disease)</U><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><U> </U></FONT></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rare disorder of skeletal development characterized by the presence of <B>multiple circumscribed foci or masses of cartilage in the interior of bones preformed in cartilage, particularly the long and short tubular bones of the extremities.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The disorder does not appear to be hereditary.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Clinical manifestations of the condition</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> may first appear in early childhood. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Swellings of the fingers and toes, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bone deformities,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> leg length discrepancies, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and pathological fractures may be caused by the presence of the enchondromas</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Skeletal involvement tends to be greater on one side of the body than the other.</div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Multiple hemangiotama of the soft tissues and muscles is sometimes associated with enchondromatosis (Maffucci syndrome). </U></B></div> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he characteristic radiographical </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> multiple, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">central, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">well circumscribed areas of radiolucency, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">often striped with calcification, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">located in the short or long tubular bones, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and frequently causing thinning and bulging of the cortex. </div> <div> Microscopically, the multiple enchondromas are composed :</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">of lobules of cartilage cells of benign but richly cellular appearance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> forming a hyaline matrix. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The morphological appearance is similar to that of solitary enchondroma, a benign cartilage growth that involves only a single bone in an individual ( discussed under Bone Tumors). </div> <bR> <bR> <div> compared to the solitary enchondroma, the cartilaginous lesions in enchondromatosis are more cellular histologically and more prone to malignant transformation to chondrosarcoma, which may appear near midlife as a complication of enchondromatosis at a reported incidence, variously, of 5-50%. </div> <bR> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><U>Bone Infections</U></B></div> <bR> <bR> <bR> <div> O<FONT SIZE="3" COLOR="#000000" FACE="Arial" >steomyelitis (literally an inflammation of bone and bone marrow) is the generic term for bone infections. Pathogenic microorganisms (pyogenic bacteria, mycobacteria, fungi) can spread to bone by one of three routes: hematogenous spread; direct extension from a contiguous site of infection; and direct introduction. The most serious bone infections are pyogenic osteomyelitis and tuberculosis; also to be noted are rare cases of syphilis and fungus infections. The clinical course of osteomyelitis depends on the characteristics of the causative organism, the route of the infection, and the age of the patient. </FONT></div> <bR> <bR> <div> <B>2. Hematogenous (Pyogenic) Osteomyelitis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> just remember a patient that had an injury is susceptible to to osteomyelitis, so bone pain in this case = osteomyelitis first and avoid giving corticosteroid which can and will worsenn the case.</div> <bR> <bR> <bR> <div> <B>Etiology and Pathogenesis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A<FONT SIZE="3" COLOR="#000000" FACE="Arial" >cute hematogenous osteomyelitis occurs predominately in children and before the age of epiphysial closure (<21 yrs), </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">typically originates in the metaphysis of long bones in the region of most rapid growth and greatest vascularity, and involves, in order of frequency, the lower end of the femur, the upper end of the tibia and humerus, and the radius.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Hematogenous osteomyelitis of children sometimes results from the blood-borne spread to bone of an extraskeletal focus of infection (skin, ear, pharynx) , but most often such a source of infection is not clinically demonstrable. In that event it is generally assumed that transient "trivial" bacteremia arising from "trivial" trauma, such as ordinary cuts and bruises of the skin, is the original source of infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hematogeneous osteomyelitis of children is most often caused by S. aureus which accounts for 60-90% of cases. Osteomyelitis of neonates is also frequently caused by group B streptococci and E. coli. Children with sickle cell disease are prone to acquire Salmonella infections and to develop Salmonella osteomyelitis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Osteomyelitis of children usually begins in the metaphysis of long bones. The blood-borne bacteria are carried to the marrow space by way of the nutrient artery. The initial site of infection within a particular bone is determined by the vascular anatomy as related to the epiphysial growth plate. In children of more than 1 year of age (who account for most cases, about 80%, of hematogenous osteomyelitis), the metaphysial branches of the nutrient artery do not penetrate the growth plate. The vessels turn back upon themselves just proximal to the plate and enter venous sinusoids in the marrow space of the metaphysis. The venous sinusoids are much larger than the arteries feeding them, have a slower blood flow, and provide a medium favorable for bacterial growth. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hematogenous osteomyelitis in adults rarely involves the long bones but usually occurs in the vertebrae which are generally highly vascular. The hematogenous spread of infection can occur by way of the nutrient branches of the spinal artery or by flow from the pelvic veins to the lumbar veins and, under conditions of increased abdominal pressure, retrograde flow through the paravertebral venous plexus of Batson. The vertebral infection is usually secondary to a primary bacteremia caused by genitourinary tract infection, soft tissue and respiratory infections, and those contracted by i.v. drug abusers. S. aureus accounts for about 55% of adult bone infections, and Gram-negative bacteria and streptococci for much of the remainder. The complications of vertebral osteomyelitis include extension of the infection to the adjacent disk space and extension to retropharyngeal, mediastinal, peritoneal, and meningeal sites depending on the vertebrae involved. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b7011800000000.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he bacterial infection causes a fulminant acute inflammation of the marrow space and an exudation of polymorphonuclear leukocytes. The presence of an inflammatory exudate within the rigid limits of the marrow space causes an increase in intramedullary pressure, reduced blood flow, local vascular occlusion, and thrombosis. Local ischemic injury and cell necrosis of marrow and osseous tissue occur, and the bacteria, pus cells, and necrotic debris comprise a septic focus of purulent inflammation. At the early stage of the infection, no specific bone changes are seen by radiography. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The infection may then spread rapidly by way of vascular channels through the medullary cavity and the bone cortex which is thin in the region of the metaphysis and provides easy access to the periosteum. The purulent material may elevate the periosteum and form abscesses beneath it or penetrate the periosteum as sinus tracts which drain into the soft tissue or extend to the skin surface. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The stripping away of the periosteum further impairs the blood supply to the cortical and medullary bone, and larger areas of ischemic bone tissue become necrotic. The areas of bone destruction may be seen in the radiograph as patchy areas of radiolucency. After several days a sizeable portion of the necrotic bone tissue may separate from the viable bone as an avascular bone fragment termed a sequestrum, which may be seen in the radiograph as a radioopaque sequestrum</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With continuation of the bone infection, chronic inflammatory cells (lymphocytes, histiocytes, plasma cells), proliferating fibroblasts, and reactive new bone formation contribute to the microscopic picture of chronic osteomyelitis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The elevated periosteum is stimulated to form new bone which surrounds the underlying infected and inflammed bone with a bony envelope termed an involucrum. </div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b7011800000000.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clinical Course</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he onset of hematogenous osteomyelitis is usually sudden in children (but often insidious in adults). </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The early symptoms of childhood osteomyelitis are those of infection and inflammation: fever, bone pain often throbbing and severe and referred to the metaphysis, tenderness to pressure, limitation of movement which in the extreme may render the limb immobile ("pseudoparalysis"), local erythema, swelling, and heat. Blood cultures are positive in about 50% of pediatric cases . </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The clinical diagnosis of early osteomyelitis can be supported by a bone scan ( with technicium diphosphonate): increased tracer uptake reflects the inflammatory process in the bone lesion. Plain radiographs usually do not reveal changes until about 10 or more days after the onset of symptoms, because a substantial (30-50%) reduction in bone calcium content is required for the demonstration of an osteolytic destructive lesion. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The course of acute hematogenous osteomyelitis is age-dependent. In neonates (< 3 months of age), bone infections are often fulminant but rarely necrotizing, because the spongy bone and thin cortex adapt to increased intraosseous pressure without compromising the blood supply. In infants (3-12 months) and adults, capillaries extend from the metaphysis to the epiphysis and can spread the infection to the adjacent joint, causing suppurative arthritis and septic joint effusion. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In children (>1 yr.) who have an intact epiphysial plate without capillary penetration, a sterile "sympathetic" effusion may occur, indicating a barrier between the infection and the joint space. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The pathological picture in hematogenous osteomyelitis may occasionally differ from the spreading and destructive pattern previously described. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The initial focus of bone infection may become circumscribed by a fibrous capsule and bone sclerosis to form a localized abscess <B><U>(Brodie's abscess) </U></B>which may undergo sterilization or become a chronic focus of infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rarely, in other circumstances, exuberant periosteal new-bone formation dominates the pathological picture, resulting in a non-purulent sclerosing osteomyelitis (Garre's sclerosing osteomyelitis). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A prompt clinical diagnosis and the institution of a potent and protracted regimen of antibiotic therapy have greatly decreased the mortality rate of osteomyelitis which reached as high as 20-40% of cases in the pre-antibiotic era. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nevertheless, even now a sizeable number of bone infections may be undiagnosed or inadequately treated. In chronic osteomyelitis, the avascular dead tissue, pus and bacteria may remain isolated within an area of bone fibrosis and sclerosis and give rise to recurrent episodes of acute osteomyelitis. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The treatment of chronic bone infections usually requires , in addition to antimicrobial therapy, surgical intervention to drain abscesses and remove necrotic tissue. </div> <bR> <bR> <div> <B><U>3. Osteomyelitis from a Contiguous Infection</U></B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B><U> </U></B></FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">B<FONT SIZE="3" COLOR="#000000" FACE="Arial" >urns, </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sinus disease, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">peridontal infection, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">soft tissue infection, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and skin ulcers </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">caused by peripheral vascular disease (arteriosclerosis, diabetes, vasculitis) are among the adjoining sites of microbial infection that may spread to bone. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The onset is often insidious, and the symptoms are those of infection and inflammation of the involved bone.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The pathological and radiological changes are similar to those seen in chronic hematogenous osteomyelitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The treatment usually requires surgical intervention (debridement of necrotic tissue, drainage of abscesses, etc.) combined with bacteriological cultures and appropriate antimicrobial therapy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood cultures are positive in about 10% of cases. </div> <bR> <bR> <bR> <div> <B>4. Osteomyelitis from an Introduced Infection</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> P<FONT SIZE="3" COLOR="#000000" FACE="Arial" >enetrating wounds, compound fractures, simple fractures treated surgically with open reduction and internal fixation, prosthetic joint replacements, and other orthopedic appliances (plates, nails, screws, pins) may introduce microbial infection directly into bone. The pathological changes in the involved bone include suppurative inflammation, ischemic necrosis, fibrosis, and reactive new-bone formation as occur in hematogenous osteomyelitis. </FONT></div> <bR> <bR> <bR> <div> <B>5. Bone Tuberculosis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >uberculous osteomyelitis is almost always caused by the hematogenous spread of organisms from an active focus of tuberculosis elsewhere in the body, usually the lung and occasionally some other site (mediastinal or aortic lymph nodes, kidney, bowel, etc.). </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bone infection may occur at any age but is most commonly seen in children. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The vertebrae and the long bones of the extremities are most frequently involved. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In many cases the infection also spreads to contiguous joints such as the hip, knee, and intervertebral joints. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bones and joints of the hands, feet, shoulder, elbow, and ribs are also sometimes involved. In some patients, it may be impossible to determine whether the infection originated within the cancellous bone of the metaphysis or the joint. </div> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he onset of tuberculous osteomyelitis is usually insidious. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The infection is unrelenting, necrotizing, and destructive of bone, cartilage, and soft tissue. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The tuberculous exudation and the inflammatory necrosis may extend through the medullary and cortical bone, penetrate through the periosteum, and progress through the epiphysial and articular cartilage (radiographic joint space). Tunneling sinuses may extend into the adjoining soft tissue and drain to the skin surface. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sequestration and the formation of an involucrum are uncommon. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tuberculosis of the spine (Pott's disease) most commonly involves the thoracic and lumbar vertebrae and usually comprises both tuberculous osteomyelitis and tuberculous arthritis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tuberculosis of spine (Pott's disease) with vertebral collapse and acute kyphotic angulation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The infection often begins in the anterior part of the vertebral body and extends into the intervertebral disc: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The tuberculous destruction and collapse of the vertebral bodies and discs result in serious deformities (kyphosis and kyphoscoliosis) of the spine. The kyphotic angulation along with the inflammation and edema of the dura caused by vertebral collapse may compress the spinal cord and nerve roots, resulting in pain, muscle spasm and weakness, and paralysis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The tuberculous exudate emerging from a bone or joint may spread through sinuses in the soft tissue or dissect along fascial planes and muscle sheaths and present at a more remote site as a "cold" abscess, socalled because there is a milder degree of heat compared to a pyogenic abscess and few, if any, acute inflammatory cells. In this way, tuberculous exudation from the thoracolumbar spine may spread along paravertebral muscles and the psoas muscle sheath and localize in the inguinal region (psoas abscess). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Microscopically, tuberculosis of bone and joint is characterized, as are all tuberculous lesions, by the presence of epithelioid granulomas (tubercles) with central caseous necrosis and Langhans' multinucleate giant cells: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For a definitive diagnosis, tubercle bacilli must be demonstrated microscopically in the lesions or cultured from bone, joint, or synovial fluid. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tubercle-like (tuberculoid) granulomas may be seen in some other inflammatory diseases of bone such as coccidioidomycosis and Boeck's sarcoid, which is characterized by granulomas that rarely, if ever, caseate or calcify. </div> <bR> <bR> <div> <B><U>6. Bone Syphilis</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> </U></B></FONT></div> <bR> <bR> <bR> <div> S<FONT SIZE="3" COLOR="#000000" FACE="Arial" >yphilitic infection may be acquired in-utero (congenital syphilis) or postnatally (acquired syphilis). Bone syphilis is produced by the hematogenous spread of Treponema pallidum during the secondary or tertiary stages of the disease. In congenital syphilis, the infection is spread to the fetus by way of the placenta. The spirochetes localize at active sites of endochondral ossification in the metaphysis of long tubular bones. </FONT></div> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b7016800000000.gif" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he two chief bone lesions of congenital syphilis are osteochondritis and periostitis.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Syphilitic osteochondritis involves the metaphysial-epiphysial junctions of long bones and the costo-chondral junctions.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Microscopically, the lesions reveal little evidence of osteoblast activity or endochondral bone formation, the epiphysial zone of provisional calcification is widened (as also shown radiologically), and syphilitic inflammatory granulation tissue extends across the metaphysis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The connection between the metaphysis and epiphysis may be loosened and result in epiphysial separation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The inflammatory granulation tissue permeating the metaphysis contains an abundance of proliferating capillaries and a prominent perivascular infiltrate of mononuclear inflammatory cells, with large numbers of plasma cells. In florid cases, spirochetes may be demonstrated in the lesions by silver stains. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Syphilitic periostitis is usually seen in early childhood and is characterized by the infiltration of inflammatory granulation tissue between the periosteum and the bone cortex and by subperiosteal new-bone formation. The tibia is most often affected. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The deposition of new bone along the anterior cortical surface produces a forward bowing and sharpening of the tibia, the "saber shin" deformity of congenital syphilis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acquired syphilis of bone occurs in the tertiary stage of the disease and involves the long tubular bones, the skull, and the vertebrae.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The lesions include syphilitic osteochondritis, periostitis with extensive subperiosteal new-bone formation, and osteomyelitis, usually caused by the formation of gummas in the medullary cavity. </div> <bR> <bR> <div> <B>7. Fungus Infections of Bone</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > [very frequent and can masque other thing]</FONT></div> <bR> <div> M<FONT SIZE="3" COLOR="#000000" FACE="Arial" >ycotic osteomyelitis is rare and usually occurs from the spread of a contiguous infection of soft tissue or sometimes by hematogenous spread. The fungus diseases most often reported as a cause of skeletal infection are coccidioidomycosis (San Joaquin Valley Fever), actinomycosis, blastomycosis, cryptococcosis, and sporotrichosis.</FONT></div> <bR> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="658" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BELOW" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#800000 HEIGHT= 18 WIDTH="194"><div> <I><B>Arthritis</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="251"><div> <I><B>Synovial Disease</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="203"><div> <I><B>Skeletal Disease</B></I></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="658" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="HSIDES" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFCC HEIGHT= 160 ><NOBR><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect08/arthritd.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Arthritis, Degenerative</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect08/arthritI.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Arthritis, Inflammatory</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect08/gout.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Gout</B></I></U></A><I><B> </B></I></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect08/psedgout.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Pseudogout</B></I></U></A></div> </NOBR></tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="251"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect09/synovnon.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Synovitis, Non-Specific</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect09/ganglion.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Ganglion</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect09/pvs.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Pigmented Villonodular Synovitis</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect09/gctts.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Giant Cell Tumor of Tendon Sheath</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect09/synchondr.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Synovial Chondromatosis</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC><NOBR><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect10/fibdyspl.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Fibrous Dysplasia</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect10/ossyfibr.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Ossifying Fibroma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect10/pagets.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Paget's Disease</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect10/sbc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Simple Bone Cyst</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect10/reticulo.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Reticuloendothelioses</B></U></A></div> </NOBR></tD> </tR> </TABLE></B></div> <div> <B> </B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="945" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BELOW" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#800000 HEIGHT= 63 WIDTH="137"><bR> <div> <I><B> Benign Skeletal Lesions</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="159"><div> <I><B>Benign Cartilaginous Lesions</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="148"><div> <I><B>Benign Osseous Lesions</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="197"><div> <I>Malignant Lesions of Bone</I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="137"><div> <I><B>Benign Lesions of Soft Tissue</B></I></div> </tD> <tD VALIGN=TOP BGCOLOR=#800000 WIDTH="148"><div> <I>Malignant Lesions of Soft Tissue</I></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="945" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="HSIDES" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFCC HEIGHT= 871 WIDTH="137"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect11/nonossif.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Non-Ossifying Fibroma</B></I></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect11/desfibro.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Desmoplastic Fibroma</B></I></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect11/abc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Aneurysmal Bone Cyst</B></I></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect11/gct.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><I><B>Giant Cell Tumor</B></I></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="159"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect12/exostos.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Exostosis</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect12/perichon.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Periosteal Chondroma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect12/enchondr.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Enchondroma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect12/chondrob.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondroblastoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect12/chondfib.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondromyxoid Fibroma</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="148"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect13/enostosi.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Enostosis (Bone Island)</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect13/osteoma.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect13/ososteom.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteoid Osteoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect13/osblasto.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteoblastoma</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="197"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/myeloma.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Myeloma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/lymphoma.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Lymphoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/ewings.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Ewing's Sarcoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/mets.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Metastatic Carcinoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/chonsarc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/clearcell.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Clear Cell</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/dediffer.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Dedifferentiated</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/juxtacor.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Juxtacortical</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/mesenchy.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Mesenchymal</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/secencho.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Secondary to Enchondroma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/secexost.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chondrosarcoma, Secondary to Exostosis</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/osteosar.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/lowgrade.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Low-Grade Intramedullary</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/ospagets.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma in Paget's Disease</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/parost.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Parosteal</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/periost.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Periosteal</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/smllcell.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Small Cell</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/softpart.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Soft Parts</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/telangie.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Osteosarcoma, Telangiectatic</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/chordoma.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Chordoma</B></U></A></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect14/adamanti.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Adamantinoma</B></U></A></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC><NOBR><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/angiolip.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Angiolipoma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/lipoma.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Lipoma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/fibromat.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Fibromatosis</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/hemangio.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Hemangioma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/neurolem.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Neurilemoma</B></U></A><B> </B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect15/neurofib.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B>Neurofibroma</B></U></A></div> </NOBR></tD> <tD VALIGN=TOP BGCOLOR=#FFFFCC WIDTH="148"><div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/sts.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Soft Tissue Sarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/fibrosar.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Fibrosarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/liposarc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Liposarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/leiomyos.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Leiomyosarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/mfh.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Malignant Fibrous Histiocytoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/neurosar.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Neurosarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/rhabdomy.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Rhabdomyosarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/synosarc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Synovial Sarcoma</U></B></U></A><B><U> </U></B></div> <div> <A HREF="http://imc.gsm.com/integrated/msk/mspath/enneking/sect16/vascsarc.html" TARGET="_top" TITLE="http://imc.gsm.com/integrated/msk/mspath"><U><B><U>Vascular Sarcoma</U></B></U></A></div> </tD> </tR> </TABLE></B></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><U>Metabolic Bone Diseases</U></B></div> <bR> <bR> <bR> <bR> <div> M<FONT SIZE="3" COLOR="#000000" FACE="Arial" >ature bone consists of: an organic matrix (osteoid) composed mainly of type 1 collagen formed by osteoblasts; a mineral phase which contains the bulk of the body's reserve of calcium and phosphorus in crystalline form (hydroxyapatite) and deposited in close relation to the collagen fibers; bone cells; and a blood supply with sufficient levels of calcium and phosphate to mineralize the osteoid matrix. </FONT></div> <div> Bone turnover and remodeling occurs throughout life and involves the two coupled processes of bone formation by osteoblasts and bone resorption by osteoclasts and perhaps osteolytic osteocytes. </div> <div> The metabolic bone diseases may reflect disturbances in the organic matrix, the mineral phase, the cellular processes of remodeling, and the endocrine, nutritional, and other factors which regulate skeletal and mineral homeostasis.</div> <div>  These disorders may be hereditary or acquired and usually affect the entire bony skeleton. </div> <div> The acquired metabolic bone diseases are the more common and include: osteoporosis, osteomalacia, the skeletal changes of hyperparathyroidism and chronic renal failure (renal osteodystrophy), and osteitis deformans (Paget's disease of bone). </div> <div> The diagnosis of metabolic bone diseases requires a careful history and physical examination, specific radiographic examination, and appropriate laboratory tests. Bone biopsy may be indicated in some cases. The ilium is the standard biopsy site for the evaluation of metabolic bone diseases. The preparation of undecalcified bone sections permits a distinction to be made between osteoid and mineralized bone and thus the histological identification of disorders of bone mineralization. </div> <bR> <bR> <bR> <bR> <div> <B>2.Osteoporosis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <bR> <div> O<FONT SIZE="3" COLOR="#000000" FACE="Arial" >steoporosis is the most common bone disease in the U.S. and is increasing in prevalence with the aging of the population. Presently, an estimated 10 million people, mainly postmenopausal women, in the U.S. have osteoporosis, and an additional 18 million have low bone mass, a 'silent' risk factor for bone fracture. Osteoporosis is a major cause of the hundreds of thousands of fractures (of hip ~300,000, spine, and wrist) occurring annually in the U.S. in women over the age of 45. Estimates are that approximately 10-20% of women die within 1 year following osteoporotic hip fracture. </FONT></div> <div> Osteoporosis is defined as a decrease in bone density (mass per unit volume) of normally mineralized bone, resulting in thinning and increased porosity of the bone cortices and trabeculae. The bone that remains, although diminished in amount, is normally mineralized and lacks the wide osteoid seams which are typical of osteomalacia and other disorders of bone mineralization. Osteoporosis is also a broadly used clinical term for a generalized loss of bone density resulting in skeletal fragility, bone pain, and pathological fractures (of the spine, wrist, hip, and ribs), particularly in postmenopausal women and both sexes with increasing age. </div> <div> Osteopenia ("too little" bone) is a descriptive term for a loss of bone density observed radiologically. Osteopenia may be local (as in disuse atrophy of an immobilized limb) or generalized. There are many causes of generalized osteopenia, among them: osteoporosis unrelated to other disease, endocrinopathies (hypercortisolism, hypogonadism, hyperparathyroidism, hyperthyroidism), deficiency states (rickets/osteomalacia, scurvy, malnutrition), neoplastic diseases ( multiple myeloma, metastatic carcinoma, leukemia), chronic diseases (malabsorption syndromes, chronic renal failure), drugs (glucocorticoids, heparin, alcohol), and hereditary diseases (osteogenesis imperfecta, homocystinuria). </div> <div> Primary osteoporosis, unrelated to other disease, is classified by age groups into postmenopausal, senile, idiopathic (premenopausal women and younger men), and juvenile forms. Postmenopausal osteoporosis is the most frequent form of osteoporosis and is the commonest metabolic bone disease. The term involutional osteoporosis encompasses osteoporosis occurring in postmenopausal women and in both sexes with increasing age. Osteoporosis is an underlying factor in most of the hundreds of thousands of fractures seen annually in the U.S. in women over 45 years of age. </div> <bR> <bR> <div> <B>Etiology and Pathogenesis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> T<FONT SIZE="3" COLOR="#000000" FACE="Arial" >he immediate causes of common postmenopausal and senile osteoporosis are uncertain. The predisposing factors are suggested by the clinical profiles of patients who are at risk (Table, modified after Vigorita, V.J.). </FONT></div> <bR> <div> <B>Risk Factors Associated with Osteoporosis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF00 > <tR> <tD VALIGN=CENTER BGCOLOR=#99FFCC HEIGHT= 19 WIDTH="171"><div> PROFILE</div> </tD> <tD VALIGN=CENTER BGCOLOR=#99FFCC><NOBR><div> BODY HABITUS</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#99FFCC WIDTH="164"><div> DIETARY</div> </tD> <tD VALIGN=CENTER BGCOLOR=#99FFCC WIDTH="142"><div> LIFE STYLE</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="171" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="138"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="138" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="164"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="164" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><div> Caucasian</div> </tD> <tD VALIGN=CENTER WIDTH="138"><div> Low weight</div> </tD> <tD VALIGN=CENTER><NOBR><div> Low calcium intake</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><div> Inactivity</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><div> Nulliparity</div> </tD> <tD VALIGN=CENTER WIDTH="138"><div> Small frame</div> </tD> <tD VALIGN=CENTER><NOBR><div> High protein intake</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><div> Smoking</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><div> Scoliosis</div> </tD> <tD VALIGN=CENTER WIDTH="138"><div> Leanness</div> </tD> <tD VALIGN=CENTER><NOBR><div> High phosphorus intake</div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> High alcohol intake</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> Positive family history</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="138"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="138" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> Lactase deficiency</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="618"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="618" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="171" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=2 WIDTH="303"><div> OTHER</div> </tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="171" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=2><NOBR><div> Low bone mass at skeletal maturity</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="171" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=2><NOBR><div> Early or surgically induced menopause</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="171"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="171" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=2><NOBR><div> Steroid or anticonvulsant medication</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="142"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="142" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> O<FONT SIZE="3" COLOR="#000000" FACE="Arial" >f the potential predisposing factors in postmenopausal and senile osteoporosis, low bone mass at maturity, estrogen (and androgen) deficiency, and negative calcium balance are the most notable. </FONT></div> <div> The conventional wisdom suggests that postmenopausal and senile osteoporosis is a disorder of coupling of bone formation and resorption, resulting in a net excess of resorption and a decrease in bone mass, as influenced by aging, lack of gonadal hormones, negative calcium balance or other dietary deficiency, environmental and genetic factors. </div> <div> Bone turnover and remodeling occurs throughout life and involves the tightly coupled processes of bone formation by osteoblasts and bone resorption by osteoclasts. The total bone mass increases with skeletal growth as bone formation exceeds resorption, remains constant for several years during skeletal maturity when bone formation and resorption are nearly equal, and begins to decline after the age of 40 to 50, at a faster rate in women than in men, as bone resorption exceeds formation. The progressive bone loss over the ensuing decades may amount to 30-50%, or more, of the initial skeletal mass. The detrimental effect of progressive bone loss tends to be greater in those who are genetically or constitutionally predisposed to have a smaller bone mass at maturity. The osteoporosis may be asymptomatic for a time and perhaps only recognized by clinical x-rays taken for some other purpose. At some critical point, the fracture threshold is reached, the fragile skeleton fails to meet mechanical demands, and bone pain, microfractures, and overt fractures of the vertebrae and other bones ensue. This condition of symptomatic osteoporosis occurs most frequently in postmenopausal and aging white females, less commonly in white males, and rarely in blacks of either sex. </div> <div> In theory, the net loss of bone in osteoporosis can be caused by either decreased bone formation relative to resorption or increased bone resorption relative to formation. An early hypothesis suggested that postmenopausal osteoporosis was caused primarily by a decreased rate of bone formation apparently without a change in the rate of bone resorption. Kinetic studies of bone turnover using radioactive calcium and quantitative bone radiography show otherwise. The bone formation rate in most osteoporotic subjects is at the normal adult level although low rates are sometimes found, whereas the bone resorption rate is often high. Although there is always a net excess of bone resorption in osteoporosis, the absolute amounts of bone formation and resorption can vary from case to case. </div> <div> Although not the only consideration in pathogenesis (see: Risk Factors), sex hormone deficiency is a major factor associated with the development of postmenopausal osteoporosis. Briefly, estrogens apparently react with and signal osteoblasts directly through high-affinity estrogen-receptors. In women with a balanced state of bone mass, bone formation by osteoblasts normally offsets parathyroid hormone (PTH)- and local cytokine (IL-1, TNF-alpha, IL-6, etc.)-induced stimulation of bone resorption by osteoclasts. With a deficiency of estrogen (or of androgen, an estrogen precursor, in men), osteoclast activity predominates, resulting in an increased resorption and loss of bone. </div> <bR> <bR> <bR> <bR> <div> <B>Pathology</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" >T</FONT>he excessive bone loss in postmenopausal and senile osteoporosis produces thinning and increased porosity of the trabecular bone of the axial skeleton (vertebrae, ribs, and pelvis). The cortices of cylindrical bones are also thinned from the inside by endosteal resorption, resulting in enlargement of the medullary cavity without a change in the outside diameter of the bone. The vertebral bodies, particularly in the thoracolumbar region of the spine, may be weakened by microfractures and collapse anteriorly, resulting in compression fractures and wedging of the vertebrae, a loss of stature, and kyphotic deformity of the spine <B><U>("dowager's hump"). </U></B></div> <bR> <bR> <div> The bony end plates of the osteoporotic vertebrae are thinned and may be cupped inwardly by the force of adjacent, expanding intervertebral discs</div> <div> The corresponding clinical x-ray picture is termed "codfished vertebrae".The ribs in osteoporosis are fragile and brittle. The most common sequelae of osteoporosis are compression fractures of the spine and fractures of the femoral neck and distal radius (Colles' fracture). </div> <div> Histologically, the amount of cortical and cancellous bone in osteoporosis is decreased compared to the normal for a similar site, sex, and age. The bone that remains has a lamellar structure and osteoid seams of normal width. The bone cortices are thinned, and the haversian canals are widened. The trabeculae of cancellous bone are decreased in size and number. The trabeculae are thin, discontinuous, and widely separated</div> <div> Osteoblasts are not numerous. Resorptive surfaces of trabecular and endosteal bone may be smooth (graded "inactive") or irregular and scalloped ("active") by resorption cavities (Howship's lacunae) corresponding to the actual or previous locations of osteoclasts. </div> <div> Both cortices are thinned. The trabeculae of cancellous bone are thinned and are no longer continuous from cortex to cortex. The osteoid seams are of normal width. </div> <div> Osteoporosis is accelerated bone loss. Normally, there is loss of bone mass with aging, perhaps 0.7% per year in adults. However, bone loss is greater in women past menopause than in men of the same age. The process of bone remodelling from resorption to matrix synthesis to mineralization normally takes about 8 months--a slow but constant process. Bone in older persons just isn't as efficient as bone in younger persons at maintaining itself--there is decreased activity of osteoblasts and decreased production of growth factors and bone matrix.</div> <bR> <div> This diagram illustrates changes in bone density with aging in women. The normal curve (A) steepens following menopause, but even by old age the risk for fracture is still low. A woman who begins with diminished bone density (B) even before menopause is at great risk, particularly with a more accelerated rate of bone loss. Interventions such as postmenopausal estrogen (with progesterone) therapy, the use of drugs such as the non-hormonal compound alendronate that diminishes osteoclast activity, and the use of diet and exercise regimens can help to slow bone loss (C) but will not stop bone loss completely or restore prior bone density. Diet and exercise have a great benefit in younger women to help build up bone density and provide a greater reserve against bone loss wiht aging.</div> <bR> <bR> <bR> <div> Risk factors for osteoporosis include:</div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Female sex</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age > 70 years</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Caucasian or Asian race</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Early onset of menopause</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Longer postmenopausal interval</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inactivity, especially lack of weight bearing exercise</B></div> <bR> <bR> <bR> <div> Osteoporosis can be classified as primary or secondary. Primary osteoporosis is simply the form seen in older persons and women past menopause in which bone loss is accelerated over that predicted for age and sex. Secondary osteoporosis results from a variety of identifiable conditions that may include:</div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Metabolic bone disease, such as hyperparathyroidism</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neoplasia, as with multiple myeloma or metastatic carcinoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malnutrition</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Drug therapy, as with corticosteroids</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prolonged immobilization</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Weightlessness with space travel</B></div> <bR> <bR> <bR> <bR> <div> Modifiable risk factors that may potentiate osteoporosis include: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Smoking</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alcohol abuse</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive caffeine consumption</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive dietary protein consumption</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom"