okay we'll talk a little bit about skeletal pathology and we've got a big long list of things that we're gonna be looking at here so we'll briefly review anatomy and physiology of the skeletal system particularly different types of joints and things like that well detail the occurrence signs symptoms diagnosis treatment of the following pathology oh I or osteogenesis imperfecta achondroplasia osteopetrosis hand-and-foot malformations vertebral and cranial anomalies osteomyelitis various arthritis is that's a very broad term ankylosing spondylitis injury to the vertebral column which we've pretty much already discussed in the last lecture the woods to a quick recap of that and then belong benign versus malignant neoplasms so I've shortened some of the considerations for this chapter down to just those things that I imagined would be most likely to be seen in general x-ray right and we'll also discuss very briefly radiographic technique required for these different pathologies so the human skeletal system has 106 separate bones 126 bones and the appendicular skeleton and 80 bones and the axial skeleton most commonly they're composed of calcium and phosphate with a few other things thrown in there and their main function is support protection movement and blood cell production so bone marrow bread bone marrow is a significant part of where our blood comes from so in terms of looking at the bone we have a compact outer portion sometimes just called compact bone and the cancellous bone within that inner portion often types on x-ray the cancellous bone appears is what we call trabecular patterns on the x-ray and it's a sign that we have sufficient technique review what we need to view there's a medullary canal within the longer bones which is where the red blood cells are and contains a yellow marrow and then there's a trabecular pattern there particularly we can see it on this image around the head of the bone the tip flowy someone remind me what does that mean cancellous bone located within the skull so the heart bone no.8 the inner portion of the bone within the skulls diplo II cancellous bone of the skull and then that red bone marrow within the long bones of the body so bone cells are largely defined as osteoblasts which are those bone forming cells which line the medullary canal there's first and so we talked about them helping with fracture repair and then osteoclasts are specialized bones that are used to break down the bone by specialized cells used to break down the bone largely to enlarge the medullary cavity there's different types of bone classifications I'm not necessarily interested in that for our purposes here but we do need to be able to identify these different areas of ossification as being the diathesis which a lot of times I think about as the main shaft of the bone is the diathesis the epiphysis so we talked about the pith of steel plates right these areas of additional growth and then metathesis you know it's not labeled on that but it's that growth zone between the epiphysis the metathesis the growth sone between the epiphysis and the diathesis in addition to understanding those different types of bones it's good to have an idea of these different types of joints and almost all the registry questions that I've seen and there's at least one question in there about the joints so I've got some really basic definitions of joints here but fibrous or centaur throw niall which means it doesn't move centaurs rodeo means without movement so futures of the skull or a classic example of that cartilaginous or Antioch arf-arf oh my goodness cartilaginous or ant feet are throw do means that it moves slightly but not that much so move slightly but not that much and an example of that is the intervertebral joint spaces they don't move that much and we wouldn't want them to move that much and the synovial or die are throaty or those do move they're the movable joints like the knee so fibrous cartilaginous synovial or if we want to get fancy sin our priority or an fie Arthur Oriole or die Arthur audio probably totally mispronouncing that okay the first disorder that we'll talk about is osteogenesis imperfecta sometimes called brittle bone disease this is mutations in the gene you don't necessarily need to know where those mutations occur but there's two different forms of this disease one is osteogenesis congenita which is a parent at birth and it leads to deformity and often early death versus osteogenesis tardo which just means later or slower this is starts seven years after birth so the fracture generally stops at adulthood has anyone had a chance to do images like this this is osteogenesis imperfecta tarda Campbell's clinic is a place where people are treated for disorders like this so again genetic congenital disorder oftentimes if it's a parent at birth we're going to call it a congenita if it occurs five to fifteen five to 15 years of age we're going to call it tartar and I want to share this with y'all real quick because a kid president is someone who has osteogenesis imperfecta has anyone seen his videos I think he's really cool and a very interesting guy so I'm just going to share some of his video with y'all real quick yeah I wish they could bottle that energy up and share it by continuing on with the congenital and hereditary diseases achondroplasia as a bone deformity and sometimes called dwarfism right it's the most common inherited disorder it is recessive in nature so you could have two siblings two brothers for example one of them has it manifest and the other one that's it's it's late and it's not a parent so the treatments related to it largely have to do with stabilizing the individual making sure that they're not outpacing themselves in terms of the bone growth and distribution of weight and stuff like that here's some evidences of it that we'd see on egg day and our textbook talks about how this bone age that's done here on the Left shows this kind of abnormal flaring appearance at the metathesis so within the growth space between the epiphysis and the diathesis of the fingers we see a flare kind of almost like trumpet shape and the and the phalanges themselves are broader right so they're wider another thing that the CT image shows us is called mid-face hypoplasia which just means that the skull has continued to grow but the face the facial bones have not right so it is is a characteristic of achondroplasia that the skull would continue to grow because the brain still needs that space right but it has outpaced the growth of the face and so an example of that is Peter Dinklage actors in Game of Thrones has achondroplasia he's made videos about his thoughts on it but rather than show you all the video about his thoughts on a condor plays yeah I want y'all just to see him interacting with with with someone just an interviewer just so you get a feeling for what are his everyday kinds of thoughts that he has again my point with showing you these videos is just to underscore the fact that as we look at these congenital deformities and things like that that every day of this person's life is shaped by this but it doesn't have to shape our interactions with them right and they can still be a tremendous blessing they have their own perspective on things and I think that treating them as a human being as an equal is is going to just be very refreshing for some of them right and and and it may be something that I thought was interesting towards the beginning of his interview he says are you nervous right and the interview did seem nervous to me right and I'm sure it's something that he's watching those cues constantly like am i making this person so nervous right now and that's part of his life all right osteoporosis which if you remember in the in the middle of it so it says osteo that means bone peach roses it comes from the I came from if it's Latin or Greek word for rock right so like Peters name means rock and Christ says on on this rock I will build my church right so right there inside this it's telling us this is marble bone or sometimes called stone bone it means that there's an increased blood of inky's increased bone density and defect in bone contour and the bones are heavy but they're also more brittle all right so they're more dense this will require increased radiographic technique right and this is what a classic example of one of these congenital diseases that's commonly asked Registry questions about because it's it's both a medical terminology question and also a radiographic technique type question but if you're wondering about what the density is I mean these almost look bright white on this image we can't see any trabecular pattern because it's been annihilated by the density of the bone but we also do see these contour deformities where there's the bone is of a different shape than what we would typically expect hand and foot malformations I've only included one of them on here but the ones that are of interest to us and that we will see examples of in our work are syndactyly which is failure of the fingers or toes to separate that means that they have fingers that look more or less like this and toes as well that look more or less like this they have not separated there might be a web-like type material between the digits right the bones are not necessarily fused but the skin around the bones is polydactyly means extra digits and there's certain genetic types out there one of them I think about in particularly there's a gene strain in Russia where people have five fingers right and that's part of some a gene that's passed down from generation generation in clubfoot which sometimes also called talipes it's very more common in males than in females and typically it's just treated with casting and splinting of the three this one is probably the more registry ready because there's actual if you look back in your Merrill's there's actual positioning requirements for talipes so maybe refresh your memory of how we can assist with imaging of this in order to prepare the casting and the splinting and if we're looking for someone I asked Tom if he could if I could mention this Tom Wolfe was born with with this and it was corrected with casting and splinting so again just everyday folks you know that struggle with these things and and when we could we can just go about our business yes yes okay as an American thank you for your clarification of that yeah yeah and that's a sin I don't know vertebral anomalies I mean forward along here scoliosis abnormal lateral curvature of the spine generally not apparent until adolescence we work quite a bit with these patients getting a baseline image and then follow-up images the incidence is higher in females than males so it's going to be important that we get appropriate images of this that we're aware of the radiation that we're using and then we do things to shield the patient and reduce the number of exposures that we need for any given exam and also to encourage the patient because it's particularly if they're adolescent that's a key part of someone's development of someone's sense of self and so we might be one of the few people they can talk to about this and we might see them from month to month and so there's opportunities to encourage people their transitional vertebra this is usually at the lumbar sacral juncture sometimes we see cervical ribs at c7 and that means just what it is that there are ribs coming off of c7 occasionally we see what's called lumbar ribs where the like l1 has ribs coming off of the lumbar spine and then spina bifida is an incomplete closure of the vertebral canal and again that's common in a lumbar sacral region and generally there'll be some kind of outpouching or like a bulge there at the base of the spine it's a parent without any x-ray so here's some of those congenital anomalies we can see there's a lumbar rib neither side spina bifida cervical rifts oc7 has an additional rib this typically needs to be removed surgically because it even cares people's breathing the scoliosis yeah and one of the reasons I wanted to include this I'm glad you said something is make sure you're counting your vertebral on everyone because they we do have a percentage of the population to have additional vertebra they have percentage of the population that have ribs in these transitional vertebra so continue to count your vertebra on every x-ray that you take because of the spine because these anomalies are fairly common okay continue on with these congenital anomalies diseases the cranial anomalies cranial stenosis is early closure of the cranial sutures so we can see that on the x-ray above the sutures have closed which has caused this irregular formation of the skull now because the brain still needs to grow even though the sutures are closed and encephalo the brain and cranial vault do not form this is incompatible with life so generally this is diagnosed with ultrasound but we can see here is an x-ray image of a woman late term in pregnancy and there is no there's a formation of facial bones but no formation of the skull osteomyelitis just means infection of the bone or bone marrow if it's a matter Genesis that means it occurred at the ends of the long bones so it happened at the end a lot of times that's related to things like staph or a coli infection we can have contiguous infections which is a lot of times associated with burns or sinus diseases or even periodontal infections so these can get pretty bad pretty quick so you'll see particularly this when I think about periodontal infection I think about if you're working in a hospital that serves people who are under resourced a lot of people who come in with tube to that cesses and now they've got infectious spread to facial bones and things that get really nasty really quick right just started out as a tooth infection and now we've got infection all through the skull so that's osteomyelitis the terms that are helpful to think about in terms of what's happening in the bone as the infection spreads through the bone is the sequester which is an area of dead bone tissue at the center right it's devascularized it's necrotic there's no the infection has caused a complete destruction of the bone and that sequester generally it's at the center it's at the center of it and then there'll be an invoke room which is a shell of new bone that's trying to support that area of death right so the osteoclasts are going to work to tear out the parts that's diseased and became and this vault room is formed to continue to the structure and the support and the protection protective purposes of the skeleton around the area of infection arthropathy czar disorders of the joints so anything joint related as the umbrella term is arthropathy so arthritis bursitis tendinitis tense and I Tim sin of itis these are just in inflammations within the joint either of the tendons or the bursa sac around the joint and we'll talk more about them here briefly if it's arthritis we're talking about joint inflammation so I don't want to stress that there's a bunch of different kinds of arthritis out there so it's going to be important for us to identify what's causing the inflammation of the joint because that's normally the first word in arthritis so remember Tornai thread is very very different from other forms of arthritis so looking at RNA this is a chronic autoimmune disease generally triggered by some kind of exposure to an antigen so the body's immune response is triggered and it starts to attack at some joint spaces this requires oftentimes some kind of surgical intervention you can see this one has an idiopathic fracture here as well as subluxation of the first digit so we see a compounding of problems that are coming out of the rheumatoid arthritis incredibly painful and we also have a reduced life expectancy of about five to seven years for these individuals if you wondering what could be worse than rheumatoid arthritis juvenile rheumatoid arthritis is about as bad as it gets stills disease and there's a CR criterion for this which is that it's the patient's younger than 16 years of age at onset of disease we're gonna see symptoms of arthritis and one or more joints for at least three weeks onset of the sign to these different types of arthritis you don't necessarily need to know these types but just know that this criteria here is just defining what it is as opposed to Rivet aureus right and specifically it's happening when people are younger it's the same autoimmune process but it's happening with a younger individual ankylosing spondylitis sometimes also called bamboo spine every strombel disease this mainly involves the vertebral column although as the bone is demineralized the calcium deposits can wind up in other parts what we're what we're seeing is demineralization of the spine and the calcium is going other places like into ligaments or into joint spaces so where we see it most acutely is if we missed this here you'll see bilateral fuzziness of the SI joints as that calcium exits the spine it's pooling up and hardening the SI joints closing off that joint also ossification of the ligaments along the spine and then fusion of the bones themselves this is treated with in SADS and exercise which is the case with a lot of these inflammatory joint diseases that we're going to look at osteoarthritis sometimes called degenerative joint disease or DJP is the most common type of arthritis there's deterioration of the joint cartilage in this instance in the formation of osteophytes our bone spurs Goudy arthritis is an inherited metabolic disorder so I just want to again stress there's all these different types of arthritis it just means inflammation of the joints all of these processes are correct in different directions some of them are congenital some of them are malformations some of them are just wouldn't wear and tear and things like that the gouty arthritis causes an excess the positive uric acid within the joint space and bone and what one term that's worth familiarize yourself with is a topi which is these crystalline deposits as the uric acid crystallizes we can do serum blood analysis and the VAT and see that there's this presence of uric acid but it's difficult sometimes to detect on x-ray so I want Joe share this image with y'all this is a very interesting new development in the field so here's GOG arthritis on a hand x-ray I cannot see unremarkable hand x-ray on typical CT we have maybe some kind of flare-up or something going on that might be one of those tophi one of those little tiny crystal deposits right the uric acid this is dual-energy CT so with dual-energy CT we can actually do a crystallography where we can assess the different types of minerals that are deposited in this area and so you can see the iridescence shows up bright green on this image and that's a positive sign of gout so by being able to differentiate different mineral deposit types based on their linear profiles dual-energy CT shows a lot of promise for the diagnosis of something like out right which is completely invisible on the x-ray it would be what we would call a cult so just future considerations things to continue to think about as the field progresses tendinitis is inflammation of a tendon tense so tennis and of I can't say that one can anyone say it tenosynovitis I'll take tenosynovitis inflammation of both the tendon and the sheath the tendon and the sheath we get the complicated word bursitis is the inflammation of the bursa or that sac around the joint space that holds the synovial fluid and the ganglion is cystic swelling and the tendons sheath it may not necessarily be in the area of the joint but it could be right they can be quite painful when we're looking at the vertebral column we have some special considerations to think about like what we talked about with the trauma section there's these whiplash type injuries and in general when we're talking about whiplash we're talking about soft tissue neck injuries they can be quite painful there's not a fracture involved but the bones were involved in damaging the soft tissue due to the whiplash action of the spine spondylolisthesis is a slipping of the vertebra it's tippet most typical at l5 s1 and it is sometimes surgically corrected a spondylolysis is an erosion of the vertebral body itself and this is one of the reasons why we do Bleek used up the lumbar spine if we see that collar on the spot on the Scottie dog not not readily apparent in this I magnify this there'll be a dark a dark line across the Scottie dogs net that's indicative of spondylolysis one of the reasons why we do obliques in terms of neoplastic diseases I just kind of singled out these three benign ones and three malignant ones an osteoma is dense bone in the skull so the skull itself just becomes more dense it's benign in nature and we don't generally surgically resect it or anything like that osteochondroma is along the metathesis of the long bones the taxes of the long bones so we start to see it increase hardening at that point giant cell tumor is not as bad as it sounds although it can occasionally be a metastatic or malignant in nature but there's numerous osteo plastic giant cells some of which may be malignant but if you remember from our vocabulary earlier osteo plastic that's not good it means it breaks down bone so this tumor eats bone basically in general efforts to resect it sometimes we're successful sometimes it caught it crops up somewhere else the malignant ones osteosarcoma awry arises from osteoblasts so we have additional very strange-looking bones that form out of this tumor then the tumor is actually in the bone viewing tumors this happens between ages 5 and 15 and it's within the medullary canal and we'll see extensive lesions as it spreads throughout different bones in the body the most common form of malignant bone cancer though is metastases from other sites so metastatic prostate cancer no static breast cancer metastatic lung cancer bones are a common sight of metastases so they are the most common malignant tumor within the skeleton in general Mero that are most often effective as well as the spine and for this slide here just I for this section you'll notice we are actually super interested in additive versus subtractive every question for the most part on the registry that it deals with additive or subtractive is interested in the skeletal system with some exceptions like we talked about with cirrhosis and stuff like that but I do feel like this is helpful to just kind of think through this list use it as a way to refresh your memory of what the pathology was and how that might affect the actual impact in terms of getting patient history and preparing for the examination thank you so much