1. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

2. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Orthopaedic
Pathology
Bone,
cartilage
Soft tissue
nearby
Synoviu
mTendon
Bursa
Fibrous
tissueMuscle

3. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

4. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

5. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Fig. 28 A synovial joint, on section.

6. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rigid endoskeleton
- Supports the body
- Protects viceral organ
- Provides attachments for muscles
Metabolism of calcium and other minerals
Contains hematopoietic marrow
Function of Bone

7. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Fig. 2.1 Embryonic development of a long bone during the first six months

8. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

9. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

10. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

11. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

12. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

13. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

14. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

15. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Normal Rickets

16. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

17. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

18. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

19. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

20. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

21. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

22. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone
marrow
hematopoieti
c lineage
Bone marrow
stromal cell
lineage
BONEBONE

23. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow
hematopoietic lineage
CFM-GM ( colony forming unit
granulocyte-macrophage )
monobl
ast promonocy
te
mon
ocyte
Tissue
macropha
ge
osteoclast

24. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow
stromal cell
lineage
( mesenchymalstem cell )CFU-F(Colony forming
unit fibroblast)
Stromal
osteoblast
precursor cell
Transitory osteoblast
Secretory osteoblast
Osteoblast
( bone lining cell )

25. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
( Receptor activator for
nuclear factor Kappa B)
( Rank ligands )
Osteobl
ast-
osteocla
st
interacti
on

26. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

27. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

28. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

29. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

30. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoblasts
•Secrete interleukin-6 & 11
•Tissue growth factor β
•Activated by parathyroid
hormone; 1,25 vitamin D,
interleukin 1, TNF

31. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Parathyroid hormone
-collagen type 1
-Fibronectin
-Alkaline
phosphatase
-Osteocalcin
-sialoprotein
Osteoblast
Estrogen
interleukin 6

32. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

33. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

34. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

35. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoclast
• Calcitonin-receptor
• Vitronectin receptor
• Tartrate-resistant acid phosphatase
• Cytoplasmic carbonic anhydrase
• Osteopontin

36. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoclast
calcitonin
Integrins
cadherins
N-cam
Vitronectin
Cytoplasmic carbonic anhydrase
calcitonin
Integrins
calcitonin
Integrins
calcitonin
Integrins
cadherins
N-cam
Vitronectin
calcitonin
Integrins
cadherins
N-cam
Vitronectin
calcitonin
IntegrinsIntegrins
calcitonin
Tartrate resistant acid phosphatase
selectin
osteopontin

37. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

38. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Histology of Synovium
•Intimal layer: A thin layer
of synovial cells or
synoviocytes
•Subintimal layer:
arterioles, fat and other
connective tissue cells
such as fibroblasts,

39. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

40. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

41. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

42. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Congenital
anomalies
Developmental
abnormalities:
complex,
variable, genetic
based and
manifest during

43. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Developmenta
l anomalies1) Defect in nuclear proteins and
transcription factor ( dysostosis)
2) Mutations in the hormone and
signal transduction ( dysplasia )
3) Defect in extracellular
structural proteins

44. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

45. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

46. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

47. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

48. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

49. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OSTEOGENESIS IMPERFECTA
A group of distinct clinical syndromes with
various modes of inheritance and having in
common an increased propensity to fracture.

50. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

51. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteogenesis
ImperfectaAbnormal secretion type I
collagen
Decreased synthesis type I
collagen Decreased
Deletion 1(I) gene
Matrix

52. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

53. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

54. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

55. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

56. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

57. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

58. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Ehlers-Danlos
syndrome

59. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Direct inoculations following
compound fracture
Osteomyelitis : caused by
Hematogenous spreading
(staphylococcus aureus, Salmonella)

60. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

61. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OsteomyelitisOsteomyelitis
Involu
crum:
New bone
formation i
n periosteu
m
Seques
trum:
Dead bone

62. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

63. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

64. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

65. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

66. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

67. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

68. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

69. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

70. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Figure 231. Tuberculous osteomyelitis.Figure 231. Tuberculous osteomyelitis.
A sagittal section of a portion of the
vertebral column. Two vertebrae are involved an
d have collapsed, causing kyphotic angulation w
ith compression of the spinal cord.

71. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Spinal tuberculosis (Pott’s disease)
Psoas abscess
Disc destruction
Vertebral collapse
Paraplegia

72. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

73. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

74. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

75. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Commonly affects the spine
Spreads usually from pulmonary
disease via blood stream
Tuberculosis

76. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

77. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
A
B
Figure 244. Congenital syphilis. A, There are
radiolucent defects adjacent to the zones of
provisional calcification and periosteal new
bone around the diaphysis. The defect in the
proximal tibia is symmetrical (Wimberger’s
sign). B, Reexamination of the forearm three
weeks later reveals evidence of healing of the
metaphyseal lesions.

78. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

79. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

80. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Simple fracture
Impacted fracture
Comminuted fracture
Stress fracture
Greenstick fracture
Trauma to normal bone

81. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteoporosis
Osteomalacia
Hyperparathyroidism
Paget’s disease
Osteogennesis imperfecta
Tumors
Pathological fracture

82. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

83. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

84. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Hema
toma

85. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Granulation tissue

86. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Callus-formation
Osseous
callus
Osteo-
cartilaginous
callus

87. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Sequence of bone
healing in fracture
•Hematom
a
•Granulatio
n tissue
•Callus

88. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Complication of
fracture
Delayed
union
Non-
union
pseudarthr
osis
Malunion

89. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

90. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Avascular
necrosis
•Synonym:
Aseptic
necrosisosteonecr
osis

91. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Cause of osteonecrosis
• Idiopathic
• Post fracture
• Fat embolism
• Legg-Calves Perthes
disease
• Steroid induce
• Alcohol

92. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

93. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

94. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Legg-Calves Perthes

95. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

96. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rheumatoid arthritis
• Self-perpetuating , inflammatory joint
disease
• Initially characterized by swelling in
several joints and stiffness
• Roentgenographically show a chronic
inflammatory destruction of the joint
• Laboratory findings: Rheumatoid
factor, ESR

97. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

98. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Terminology in Rheumatoid
arthritis
•Pannus:
inflammed
synovium
attaching on
articular cartilage

99. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rheumatoid
nodule

100. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PATHOLOGY OF SYNOVIUM in
rheumatoid arthritis

101. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Proposed mechanism for
rheumatoid diseases
Robbins and Cotran ( 7th
.
Ed) p. 137

102. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Inflammatory joint
diseases
Seropositive: 1) Rheumatoid
arthritis
2) Juvenile
rheumatoid arthritis
Seronegative: 1) Ankylosing
spondylitis
2) Psoriasis
3) Reactive
arthritis ( Reiter’s syndrome )

103. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

104. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone
tumors• Primary
bone tumors
• Metastatic
bone tumors

105. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

106. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Histologic typing
of bone tumorBone-forming
tumorsCartilage forming
tumorsGiant cell
tumorsBone
marrow tum
ors

107. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone forming tumors
•Benign : OSTEOMA
• Malignant:
OSTEOSARCOMA

108. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Cartilage-forming tumors
• Benign : OSTEOCHONDROMA,
ENCHONDROMA, CHONDROBLASTOMA,
CHONDROMYXOID FIBROMA
• Malignant : CHONDROSARCOMA

109. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone marrow-
forming tumors
• Ewing’s
sarcoma

110. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

111. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

112. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

113. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

114. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

115. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

116. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

117. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

118. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

119. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

120. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

121. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

122. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Chicken-wire
calcification

123. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

124. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

125. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

126. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

127. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

128. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

129. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

130. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

131. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

132. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

133. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Periosteal
reaction

134. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Eosinophilic granuloma
( Langerhans cell granulomatosis,
Langerhans cell histiocytosis )

135. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

136. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

137. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

138. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

139. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

140. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

141. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

142. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

143. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

144. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Bone-
remodeling
unit

145. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

146. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

147. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

148. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Metabolic bone diseases
- Matrix
- Mineralization
- Deposition of waste product
formation
resorption

149. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Matrix formation defect
- Osteogenesis imperfecta
- Paget’s disease
- Mucopolysaccharidosis

150. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Matrix resorption defect
Hyperparath
yroidism
Osteopetrosi
s

151. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

152. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteitis
fibrosa
cystica

153. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

154. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Osteomalacia
Looser’s zone
(pseudofractu
re )Milk-man’s
fracture

155. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

156. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

157. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

158. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rachitic
rosaries

159. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Rickets
Irregularity
of growth
plate
Genu
varusIrregularity
of growth
plate

160. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

161. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

162. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

163. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

164. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..

165. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Table 1. Comparison of two types of involutional osteoporosis.
From Riggs and Melton(1986)with permission.
Type IType I Type IIType II
Age (years) 51-75 > 70
Sex ratio (female : male) 6:1 2:1
Type of bone loss Mainly cancellous Cancellous and compact
Rate of bone loss Accelerated Not accelerated
Fracture site Vertebrae (crush) and Vertebrae (wedge)
distal radius and hip
Parathyroid function Decreased Increased
Calcium absorption Decreased Decreased
Metabolism of 25-OH-D to Secondary decrease Primary decrease
1.25(OH)2D
Main causes Factors related to Factors related to
menopause ageing
25-OH-D = 25-hydroxyvitamin D ; 1.25(OH)2D = dihydroxyvitamin D.

166. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PATHOGENESIS OF OSTEOPOROSISPATHOGENESIS OF OSTEOPOROSIS
ModelModel
Figure 4. Conceptual model of the pathogenesis of fractures relate to osteoporosis.
Modified from Riggs (1988).

167. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Deposition of waste product
- Pseudo - gout
- Gout
- Oxalosis
- Ochronosis

168. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
Gouty

169. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
PseudPseudCalcium
pyrophosphate crystal

170. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
OchroOchro

171. Department of Pathology, Faculty of Medicine, Ramathibodi Hospital…..
ochro
nosis