Osteoporosis - Pyogenic Osteomeylitis (98)

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What vitamin deficiency causes rickets in children and osteomalacia in adults?

vitamin D deficiency

Describe the levels of serum calcium, phosphate, vitamin D, and alkaline phosphatase in rickets and osteomalacia.

low serum calcium, phosphate, vitamin D

raised serum alkaline phosphatase

List 3/4 causes of vitamin D deficiency.

poor dietary intake

malabsorption from GI tract

renal disorders causing decreased synthesis of 1,25-dihydroxyvitamin D

rare inherited disorders

List 3/4 ways in which menopause contributes to osteoporosis.

List 3/4 ways in which aging contributes to osteoporosis.

List 3/5 endocrine causes of secondary osteoporosis.

hyperparathyroidism
- most common

hyperthyroidism

diabetes

Addison disease

pituitary tumors

List 3 neoplasia causes of secondary osteoporosis.

carcinomatosis

multiple myeloma

paraneoplastic syndrome

List 3/4 general GI causes of secondary osteoporosis.

malnutrition

hepatic insufficiency

vitamin D or C deficiency

malabsorption

List 3 drugs that can cause secondary osteoporosis.

chemotherapy

corticosteroids

alcohol

What hormone is involved in the pathogenesis of osteoporosis?

parathyroid hormone

- thin bony trabecula

What disorder is associated with a brown tumor?

hyperparathyroidism

- giant cell tumor-like mass
- neo-vascularization, hemorrhage

What disorder is associated with osteitis fibrosa cystica?

hyperparathyroidism

How does chronic renal failure affect phosphate and calcium levels?

hyperphosphatemia

hypocalcemia

- secondary hyperparathyroidism due to decreased vitamin D metabolism in kidneys (inhibition of conversion of vitamin D to active metabolites by phosphate)
- diminished intestinal absorption of vitamin D

How does dialysis (for patients with chronic renal failure) cause renal osteodystrophy?

iron and aluminum from dialysate accumulate on bone and prevents bone deposition

What virus is associated with Paget disease?

Paramyxovirus

- nucleocapsid antigens identified in osteoclasts

What gene mutation is associated with Paget disease?

p62

- increases RANK/RANKL signalling, which leads to increased osteoclastic activity

List 2 cytokines involved in the pathogenesis of Paget disease.

IL-6

M-CSF

- virus stimulates IL-6
- IL-6 and M-CSF activate osteoclasts, making them hyper-responsive to RANKL and vitamin D

List the 3 stages of Paget disease.

osteosclerotic stage: no osteoblastic or osteoclastic activity

- qualitatively weak bone = fractures

Describe the levels of serum alkaline phosphatase and urinary hydroxyproline in Paget disease.

increased serum alkaline phosphatase

increased urinary hydroxyproline

List 3 complications of Paget disease.

- high-output cardiac failure due to increased vascularization
- mix of woven bone and lamellar bone

List 2 tumors associated with Paget disease.

- osteosarcoma seen in elderly (normally 20-40 years of age)

What is the most commonly affected bone in Paget disease?

skull bone

List the 3 phases of fracture healing.

inflammatory phase (1 week)

reparative phase (2-3 weeks)

remodeling phase

Does fracture hematoma favor or retard bone repair and healing?

favors bone repair

What is the name of the soft tissue callus formed towards the end of the inflammatory phase?

procallus

What proteins are responsible for post-fetal differentiation of mesenchymal cells into chondrocytes and osteoblasts?

What type of bone is formed during the early parts of the reparative stage of fracture healing?

woven bone

Describe the location of internal and external callus during the reparative phase.

What term is used to describe the mature lamellar bone that gradually replaces the woven bone of the primary callus?

secondary callus

List 3/4 fracture complications.

List 3 ways in which internal fixation benefits fracture healing.

Fracture complication in which there is cyst formation lined by synovium-like cells

pseudoarthrosis

List 3 systemic complications of fractures.

shock syndrome

myoglobinuria (significant muscle injury)

fat embolization

List 3 determinants of fracture healing.

List 2 routes of osteomyelitis. Which is more common?

hematogenous (seeding from systemic disease)
- more common

direct inoculation

What is the most common bacteria that causes osteomyelitis?

S. aureus

- in 50% of cases, no pathogen is isolated
- receptors for bone matrix components, e.g. collagen

What type of bacteria should be implicated in osteomyelitis associated with genitourinary infection or IV drug abuse?

gram-negative rods (E. coli, Klebsiella, Pseudomonas)

List 2 bacteria that cause osteomyelitis in neonates.

H. influenzae

Group B Strep

What bacteria causes osteomyelitis in sickle cell disease patients?

Salmonella

Acute hematogenous osteomyelitis gender and general age groups (2)

young, growing children or adults > 50

males 2:1

List 4 common locations for acute hematogenous osteomyelitis.

femur, tibia, humerus

vertebral bodies

List 3 predisposing factors for acute hematogenous osteomyelitis.

catheter

trauma

infection

underlying disease

IV abuse

What part of the bone is associated with acute hematogenous osteomyelitis? Explain why this part of the bone is ideal for bacterial growth.

metaphysis

- nutrient arteries terminate in venous sinusoids (ideal lakes for bacterial seeding) rather than forming anastamoses with veins through capillaries
- vascular loops and terminal branches have low oxygen tension and inhibited phagocytosis

What is the name of the necrotic bone that results from acute hematogenous osteomyelitis? What is the name of the new bone that develops around this necrosis?

sequestrum
- necrosis of nearby bony trabeculae due to loss of both endosteal and periosteal blood supply secondary to inflammatory swelling

involucrum

What is the most common site of vertebral pyogenic osteomyelitis?

lumbar spine

List 3 predisposing factors for vertebral pyogenic osteomyelitis.

urinary tract infection

diabetes

IV drug abuse

What part of the vertebrae is affected by vertebral pyogenic osteomyelitis?

begins in vertebral body then spreads through the vertebral end plate to involve the disc

- disc destruction more common in pyogenic than non-pyogenic infections of the spine
- may breach anterior cortex and ligamentous structures to form paravertebral soft tissue abscesses (retropharyngeal abscess, psoas abscess extending to groin and popliteal fossa)
- may spread posteriorly to involve the posterior arch and the neural canal

What is the major problem in treating pyogenic osteomyelitis?

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