BONE [os (PNA, JNA, BNA)] — one of types of connecting fabric making a basis of a skeleton of the person. To. are a framework and the place of an attachment of muscles and many internals, performing in relation to them protective function. In combination with muscles, joints, sinews and other educations they form system of levers and carry out function of a support of a body and the movement (musculoskeletal system). In addition to mechanical To. have biol, the functions connected with participation in a metabolism, in a hemopoiesis.
Studying To. as body and fabric has an old story and it is connected with development of such disciplines as anatomy, physiology, biology, biochemistry, etc. (see. Osteology ).
- 1 Development and growth of a bone
- 2 Anatomy
- 3 Histology
- 4 Physiology
- 5 Biochemistry
- 6 Methods of a research
- 7 Pathological anatomy
- 8 Pathology
- 9 Bones and bone remains in the medicolegal relation
- 10 Tables
Development and growth of a bone
the Bone tissue develops from mesenchymas (see) two ways: directly from a mesenchyma or on site earlier stuffed up cartilage. In this regard distinguish primary (webby), or cover, laid on, To. (os membranaceum) and cartilaginous To., replacing a cartilage (os cartilagineum).
Webby bone formation (osteogenesis membranacea) is characteristic of the coarse-fibered bone tissue forming cover To. skulls. It begins with focal proliferation of mezenkhimny elements, strengthening of vascularization of this site and formation of osteogene islands. In them there is a strengthened formation of collagenic fibers and a differentiation of cells in osteoblasts through a number of intermediate forms (tsvetn. fig. 5). Osteoblasts — large cells (20 — 30 microns) of a round and pyramidal form with the round or oval kernel containing one or several kernels. In cytoplasm the ergastoplazma, mitochondrions and a lamellar complex are well developed; it is a bazofilna owing to high content ribonucleic to - you are a sign of its participation in synthesis of protein. Osteoblasts have enzymatic activity since develop alkaline phosphatase (see), participating in a mineralization To., and other enzymes. In process of further development between osteoblasts collagenic fibers and the amorphous main substance which is sticking together them making osteoid, quickly obyzvestvlyayushchiysya appear. Connecting the shoots, they form osteoblastic sintition and, having appeared in the thickness of interstitial substance, become bone cells — osteocytes. A. V. Rusakov in kosteobrazovatelny process distinguished four phases: proliferation of cells with their differentiation in osteoblasts, fibration, formation of the amorphous substance which is sticking together them, its mineralization. All these phases proceed almost at the same time. In the same time around all future bone in embryonal connecting fabric a large amount of fibers appears. A part of this fabric, directly adjacent to forming To., turns in periosteum (see). Due to osteogene activity of osteoblasts of a periosteum To. at the same time grows also in thickness (a periosteal osteogenesis). Such To., formed at early stages of embryonic development, carries primary webby (coarse-fibered) K. V name later stages it is replaced secondary webby (lamellar) To.
Development To. on the basis of a cartilage — it is the most convenient to study cartilaginous bone formation (osteogenesis cartilaginea) on the example of development long tubular To. On site future To. at first its cartilaginous model consisting of an embryonal hyaline cartilage is formed of a mesenchyma (see. Cartilaginous tissue ), covered with a nadkhryashchnitsa. It occurs on the second month of embryonic development. Substitution of cartilaginous model a bone tissue begins in a middle part of a diaphysis. In deep layers of a nadkhryashchnitsa osteoblasts are differentiated and intercellular substance is formed. Thus, the nadkhryashchnitsa in these sites becomes a periosteum. Such type of ossification received the name of perikhondroostalny (ossificatio perichondroostalis) or periosteal ossification. It occurs on all circle of the middle of a diaphysis, forming a so-called bone cuff, or a perikhondralny bone ring (annulus osseus perichondralis), and gives rise to cortical substance K. At the same time process intra cartilaginous begins (enchondral, or enchondral) ossification (ossificatio enchondralis), in time to-rogo in a cartilage ossification centers are formed. In a diaphysis long tubular To. there is primary osteogene point (gemma osteogenetica primaria), or the diaphyseal center, is later in an epiphysis — ossification centers of an epiphysis (punctum ossificationis epiphysis). Process of an osteogenesis proceeds with participation of a glycogen and number of enzymes. It begins with formation of the diaphyseal center and reaches metaphyses. The border with an epiphysis passes across the so-called line of ossification. This place is especially convenient for studying of details of process of enchondral ossification (tsvetn. fig. 6 and 7).
Directly the belt of reproduction of chondrocytes (cartilaginous cells) borders on an epiphysis. Towards a diaphysis they are flattened and develop in columns. This zone is followed by a belt of the bulked-up large cells — a zone of hypertrophied chondrocytes. On border with a bone tissue in it mineral salts — preliminary calcification are laid. From a diaphysis there is a growing into a cartilage of narrow vascular loops, and capsules of cartilaginous cells are opened, chondrocytes perish, and ossiform fabric is laid for the remaining cartilaginous crossbeams. Endo Hondralnoye ossification gives rise to spongy substance with formation of primary marrowy cavity containing fabric, cells friable, rich with vessels a cut possess various potentialities, including and osteoblastic. The cartilaginous model is replaced with a bone tissue, the cartilage does not turn into a bone tissue, being exposed to processes of destruction. In process of ossification of a diaphysis and an epiphysis between them there is a cartilaginous layer — an epiphyseal plate of growth (fig. 1), or an epiphyseal cartilage (cartilago epiphysialis). Its cells, strenuously breeding, provide growth To. in length. In it the characteristic arrangement of cells, as well as through ossification is observed: zone of proliferation of cells, zone of cellular (cartilaginous) columns, zone of hypertrophied chondrocytes and zone of preliminary calcification. From marrowy cavities vessels grow into a cartilage, chondrocytes perish, their capsules are filled with bone substance of spherical shape, a cut accumulates as well on cartilaginous crossbeams. The epiphyseal cartilage becomes gradually thinner, perforated by vessels and, at last, disappears that leads to merge (synostosis) of an epiphysis and a diaphysis. A. V. Rusakov considered that the main mechanism of growth To. in length its incessantly going reorganization, and an epiphyseal cartilage — only the additional mechanism providing more bystry growth rates To is. Role of reorganization in growth To. it is well visible on the example of growth cover and others To., not having epiphyseal cartilages, and also on the example of lengthening tubular To. at some diseases at adults with the finished growth of a skeleton. Growth To. in thickness occurs by imposing (opposition) of new mass of bone substance from a periosteum — oppositional growth. Thickness of cortical substance at the same time is regulated by its simultaneous rassasyvaniye from an endosteal surface To. Intersticial growth To., similar to that in a cartilage, owing to proliferation of osteocytes and increase in mass of interstitial substance in already created bone tissue does not occur.
Time of emergence of ossification centers and terms of connection of separate parts K. — see. Age bone .
In a bone tissue during all human life the interconnected processes of creation and destruction proceed. Reorganization of osteons (base units of cortical substance) in the course of their formation is always connected with destruction of primary osteons and simultaneous emergence new, formed as on site destroyed, and in a periosteum. Destruction of primary osteons begins after formation of special cells — osteoclasts (tsvetn. fig. 8). Osteoclasts — large many nuclear cells, are derivatives of mezenkhimny cells. Find the incorporated radioisotopes in them and by means of a submicroscopy find crystals of lime and fragments of collagenic fibers. Under the influence of osteoclasts of a plate of osteon are dissolved and on its place the cavity — a rezorbtsionny lacuna (lacuna absorptionis), or a gaushipova a lacuna is formed. Such type of a rassasyvaniye (resorption) of a bone tissue carries the name osteoklastichesky or lacunary. About the mechanism of action of osteoclasts there is no consensus. Assume that they act directly on To., emitting the substances dissolving salts of calcium. A. V. Rusakov, W. Bloom, etc. consider that osteoclasts are of secondary importance, participating in a rassasyvaniye of decomposition products of a bone tissue which occurs without their participation. This situation is confirmed also by data of electronic microscopic examination.
Along with osteoklastichesky type of a resorption many researchers recognize also other types from which distinguish: the smooth resorption which is expressed in «thawing» of bone structures or depression of cortical substance K. without participation of any cells; hallisteresis (see), under the Crimea understand intravital decalcification of a bone tissue, «washing away» of salts of lime at safety of the organic basis remaining in the form of ossiform (i.e. not calciphied) fabrics; the vascular resorption occurring owing to penetration in To. vessels; alar rassasyvaniye (resorption). Autolytic disintegration of bone substance in one step in both components is the cornerstone of it (organic and inorganic), owing to-rogo it turns into liquid state and then resolves, partially under the influence of osteoclasts. Sites of autolytic disintegration of a bone tissue have an appearance of the spaces containing plazmopodobny liquid and delimited from marrowy spaces by an endosteum thanks to what they keep the dimensions at a rassasyvaniye of bone beams (tsvetn. fig. 9 and 10). In cortical substance K. similar spaces have an appearance of bags which A. V. Rusakov called bosoms (fig. 2). Further about bosoms and in bosoms osteoclasts appear. In process of a zapustevaniye of bosoms they grow with fibroretikulyarny fabric. In the 60th 20 century the doctrine about osteocytic appeared ossifluence (see). Supporters of this doctrine explain a rassasyvaniye To. increase in the sizes of osteocytes and expansion of bone lacunas owing to a lysis of the bone substance adjoining to them. All types of a resorption To. gain value in pathology.
Thanks to constant reorganization of a bone tissue and replacement of former structures with new there is an improvement of mechanical characteristics To. Traces of reorganization remain a long time and can be found at microscopic examination of K. V compact veshchest ve these are so-called detrital structures (tsvetn. fig. 11), and in beams spongy — the drawing of lines of pasting. Formation of bone substance at reorganization To. happens to breaks during which at the edges of bone structures amorphous main substance in the form of a basphilic strip — the line of a stop is laid. Amorphous substance during the imposing of a new portion of bone substance, being located between its two generation, forms the sticking together line. In the area of a rassasyvaniye of bone structure the main substance forming the line of a resorption (fig. 3) is also laid. The quantity, the direction of these lines, distances between them create a certain picture, on a cut it is possible to judge the processes happening in given To.
the Bone system, as well as other systems, throughout all human life undergoes age changes. Age changes in are most expressed To. in the first two years of the post-natal period, at the age of 8 — 10 years and during puberty.
On growth and development To. a significant amount of external and internal factors exerts direct impact. So, living conditions, the postponed diseases, physical. exercises, work, etc. affect development and growth To. Influence of nervous and endocrine systems is very essential; disturbance of their functions leads to disorders of growth and development To., up to formation of uglinesses. M. G. Prives showed close dependence of development To. from circulatory system also planned a number of stages of age variability To., connected with changes of a circulatory bed: 1) a neonatal
stage — at a fruit of the last months of development and the newborn; 2) an infantile stage — at children's age, prior to approach of synostoses of parts K.; 3) a juvenile stage — at young men; 4) a mature stage — at adults when there come synostoses of parts K. and vessels make it uniform system; 5) the senile stage — at old men when vessels become thinner and vascular network is poorer.
At advanced and senile age quite often develops osteoporosis (see) which is usually most expressed in a backbone and long tubular To. It is shown by the depression of spongy and cortical substance happening owing to thinning and reduction of number of bone beams and expansion of vascular channels. Aging of bone substance is expressed in emergence of cracks in it, hl. obr. in structures, it is long not being exposed to reorganization: in inserted systems of compact substance, in subchondral bone plates of large joints. In the same places the bezosteotsitny sites formed owing to a lysis of osteocytes meet. Because of changes of bone substance and osteoporosis there are deformations To. and joints, the most expressed in a backbone and in To. fingers of hands.
Everyone To. has a certain form and size, holds a certain position in a body, it is covered periosteum (see), contains inside marrow (see) it is also supplied circulatory and limf, vessels and nerves. In total To. the bodies connected among themselves by a connecting, cartilaginous or bone tissue form skeleton (see), in Krom at the person apprx. 200 K., part of them unpaired (36 — 40), other steam rooms. To., the bodies making a firm skeleton and connected by mobile joints are set in motion by muscles and together with them form a musculoskeletal system.
An outer surface To. it is covered with a periosteum (periosteum) consisting shch an outside fibrous layer (stratum fibrosum) and internal cambial (stratum cambiale). Its collagenic fibers are included into a cortical layer of a bone perpendicular to its surface in the form of pro-butting, or sharpeevy, fibers (fibrae perforantes).
From a marrowy cavity To. it is covered an endostome (endosteum) — the thin cover formed by the connecting fabric containing osteoblasts and posterior pyramids of collagenic fibers.
Joint surfaces To. are covered with a joint cartilage (cartilago articularis).
To. consists of the compact substance (substantia compacta) located on the periphery, and spongy (substantia spongiosa), which is in a bone and presented by the bone crossbeams located diversely. Distribution of compact and spongy substance depends from funkts, K. V features places To., where special durability at a support and the movement is required, preferential compact substance, and in places where at large volume it is necessary to keep ease and at the same time durability is located, spongy substance is formed. Crossbeams of spongy substance are located naturally, respectively funkts, to appointment, on lines of compression and stretching.
Durability and at the same time elasticity To. it is reached by also certain ratio of the organic and inorganic matters which are a part To. During all human life the structure and chemical structure continuously changes To., what leads also to change it physical. properties.
On features of a form, function and development To. divide into four groups: 1) tubular, 2) spongy, 3) flat and 4) mixed.
Tubular bones consist of compact and spongy substance. A middle part such To. — the body, or a diaphysis (diaphyses), has the form of a tube with a marrowy cavity (cavum medullare) inside. The ends To., or an epiphysis (epiphyses), is thickened and connects with next K. Promezhutochny between a diaphysis and an epiphysis site K. is called a metaphysis (metaphyses). Shoots To., serving for an attachment of muscles, carry the name of apophyses (apophyses). Long tubular To. have the enchondral centers of ossification in both epiphysis (biepifizarny To.) also form a basis of extremities, being the long levers set in motion by muscles. Short tubular To. (To. a shank, a metatarsus, a phalanx of fingers) short levers represent and have the center of an endostosis only in one epiphysis (monoepiphyseal To.).
Spongy To. are formed preferential of spongy substance. Among them distinguish long (edges, a breast), short (To. wrists, tarsi, vertebrae) and sesamoids (see), to the Crimea belong pea-shaped To., patella, etc.
Flat To. are presented by the bones of a calvaria performing preferential function of protection. They are formed by outside and internal plates of compact substance, between to-rymi there is a spongy substance. An internal plate of compact substance flat To. skullcaps at blow easily breaks and therefore received the name of a glass plate — lamina vitrea.
Mixed To. make a base of skull. They have various structure, function and development. Row K. skulls contains the pneumatic bosoms which are reported with the outside environment and carries the name pneumatic To. (ossa pneumatica).
In the bone cells located between crossbeams of spongy substance and in a marrowy cavity of a diaphysis tubular To. marrow which happens red and yellow (medulla ossium rubra et medulla ossium flava) is located.
Surface To. in places of an attachment of muscles differs in roughness. The muscles are more powerful, the muscular shoots K. Tak are developed better, at the adult these shoots are better expressed, than at the child, and at the man they are more considerable, than at the woman. Thus, form K. has age, sexual and individual distinctions. On a surface To., as a rule, one or several feed throats (foramina nutricia) conducting in nutrient canals (canales nutricii), through which in To are found. blood vessels and the nerves accompanying them get.
Detailed data on blood supply, an innervation, a lymphokinesis To. — see. Skeleton .
Variations and anomalies To. are various and can be presented by education additional To., their merge or division, an underdevelopment, change of a form, a deviation in the sequence of emergence of ossification centers, etc. The description of variations and anomalies of separate bones — see in articles devoted to separate parts of a skeleton (e.g., Brush , Backbone , Foot etc.).
Rentgenol, the image of a bone skeleton substantially reminds a picture of a cut To. in the plane parallel to the plane of a x-ray film. However this image is more difficult because of the summatsionny shadow result which is turning out from all thickness To. and other fabrics. The shadow of bone substance is usually well allocated against the background of the fabrics, next to it. It that is more contrast, than more difference between absorbtion coefficients of X-ray bone and other fabrics.
The accepted division To. on tubular, spongy, flat, pneumatic and mixed is confirmed rentgenol, a picture.
Feature tubular To., for rentgenol, studying, existence expressed compact (in a diaphysis) and spongy substance, and also existence of joint surfaces is important. In a diaphysis there is a marrowy cavity, edges is limited in one cases to absolutely smooth endosteal surface of a bast layer, in others — its quite pulled surface because of the bone crossbeams and combs acting in its gleam (fig. 4).
Spongy To. have rather thin and not identical on thickness in different sites a compact enveloping layer, but intervals between to-rymi in various generally consist of continuous network of bone crossbeams, To., as well as in spongy parts tubular To., are not identical by the sizes (fig. 5).
Flat To. are constructed of plates of compact substance and the spongy fabric concluded between them. In some sites spongy fabric can be absent, then opposite plates of a compact layer merge among themselves in one thin compact plate.
Pneumatic To., to the Crimea belong frontal, trellised, wedge-shaped, maxillary and temporal To., in the course of growth are exposed to the pnevmatization accruing to the known limits. The air-vessels arising in them covered by a mucous membrane at different people considerably vary in size and a form.
Mixed To., which cannot be carried to one of the called groups, differ in a big variety of a X-ray anatomic structure (e.g., a mandible, malar, nasal and others To. facial skeleton).
Epiphysis from a diaphysis, growth of a skeleton will not stop yet, separate a metaepiphyseal cartilage which gives a strip of an enlightenment on roentgenograms. Upon termination of growth of a skeleton on site there is no former cartilage left usually traces of their existence, the strips of consolidation clearly reflecting the former borders between an epiphysis and a diaphysis (fig. 6) remain less often.
On some To. (vertebrae, ileal, sciatic, tibial and calcaneal To., the hip, a shovel) are had the additional bone educations, so-called apophyses appearing and merging with To. during certain age periods. The apophyses which did not merge with the main bone can be mistakenly taken on the roentgenogram for a separation of a bone tissue. For the same reason it is necessary to pay special attention and to numerous so-called additional stones in various departments of a skeleton.
Compact substance depending on thickness of its layer on the roentgenogram gives a homogeneous shadow of various intensity. In defined To. in cortical and spongy substance channels of vessels are well visible (a femur, To. shins and forearms, circumarticular department of a shovel, the main phalanxes of fingers, etc.), having in one cases formal looking alike rentgenol, a picture of a crack, in others — with the small centers of destruction.
In places of attachments of sinews, sheaves, joint bags on surfaces To. roughnesses, combs, tuberosity are allocated that gives To. in the respective sites roughness, a roughness and protrusion of a contour. Similarity of these normal morfol, features with patol, states is in some cases possible To., i.e. with manifestations of periosteal imposings or local limited hyperostosis (see). In doubtful cases it is necessary to compare pictures of both parties, however at the same time it is necessary to remember quite often found asymmetry of a skeleton.
The bone tissue differs from other types of connecting fabric in considerable dominance intercellular substance (see), impregnation by its mineral salts, hl. obr. salts of calcium. An organic basis of intercellular substance collagenic fibers (ossein, ossein) and masking them amorphous proteinaceous and carbohydrate (glycoproteins and glikozaminglikana) make the main substance (osseomucoid). Mineral salts are laid not only between fibers, but also in them, forming structure like a hydroxyapatite. Its crystals are very small, but their general surface is very big. It provides ample opportunities of adsorption of other ions on their surface.
Bone cells — osteocytes (tsvetn. fig. 4) are supplied with shoots, their shoots — in bone tubules (canaliculi ossei) lie in the thickness of intercellular substance in bone lacunas (lacunae osseae), and. They have a compact phaeochrous kernel and slabobazofilny cytoplasm, in a cut there is a small amount of mitochondrions and an underdeveloped lamellar complex. The main substance making an inner surface of bone lacunas and tubules forms a boundary matrix (matrix limitans), or a so-called ruzha — a neymannovsky cover.
Distinguish three types of a bone tissue: puchkovy, or coarse-fibered (textus osseus rudifibrosus), parallel and fibrous (textus osseus parallelifibrosus) and lamellar (textus osseus lamellosus). Are constructed of a coarse-fibered bone tissue To. in the embryonal period. On the second year of life it is replaced lamellar and occurs at adults only in places of an attachment of sinews, in seams of a skull or at a bystry osteogenesis, napr, in a bone callosity. Randomly located collagenic fibers form in it the rough powerful bunches impregnated and connected by the main substance.
In a parallel and fibrous bone tissue of fiber are located in parallel, without developing in bunches.
In a lamellar bone tissue fine fibers form parallel ranks, developing in laminas (lamellae osseae). Osteocytes are located between plates in bone lacunas. Plates and their systems are the basic architectural element K. the highest vertebrata and the person in the post-natal period. On thin cross and longitudinal shlifa To. clearly all systems of plates come to light. In each system of a plate densely prilezhat to each other. The bone tubules containing shoots of osteocytes penetrate plates, connect to other tubules and to perivascular spaces inside To. also provide a metabolism between osteocytes and an intercellular lymph. In a superficial zone of compact substance of a diaphysis long tubular To. the layer of outside general plates is located (stratum lamellarum generalium externarum — fig. 7), then the layer of osteons (stratum osteonorum), and then a layer of internal general plates (stratum lamellarum generalium internarum) follows. Outside general plates do not form full rings around a bone, and are blocked by the following layers of plates. In them channels (canales perforantes) in which there pass the blood vessels getting here from a periosteum are located pro-butting, or folkmannovsky. Internal general plates are well developed where compact substance K. limits a marrowy cavity. Between outside and internal layers of general plates the system of plates making the ground mass of cortical substance of a diaphysis and called a layer of osteons is located. In this layer bone plates are located concentrically around the blood vessels included in To. at its development. These systems from 5 — 20 concentrically of the located bone plates are called osteons, or gaversovy systems (fig. 8). The channels located in the center of osteon where there pass blood vessels are called channels of osteon (canales osteoni), or gaversovy channels. In each plate of osteon of fiber are located diversely (fig. 9) that gives special durability To. Osteons are a base unit of compact substance of a tubular bone. Each osteon is delimited from next dark blue during the coloring hematoxylin-eosine by the line (the sticking together line). Osteons are located on length To. According to N. G. The potter-3aikinoy (1977), received by means of a raster submicroscopy, channels of osteons of compact substance have the extent of 300 — 350 microns and can connect among themselves different types of an anastomosis. Between a vascular wall and the endosteum covering the channel of osteon there is a perivascular space. It contains the elements of connecting fabric, osteoblasts, uniform elements of blood and fibrous structures which are interwoven on the one hand into a wall of the channel, and with another — in a vascular wall, located in it, and forming a peculiar framework, on Krom the vessel is as if suspended in a gleam of the channel. Intervals between osteons are filled in parallel going inserted, or intersticial, with systems (systema lamellarum intercalatarum) consisting of inserted plates. Channels of osteons are reported among themselves also by means of the narrow pro-butting (folkmannovsky) channels (fig. 10) going from a periosteum and, unlike channels of the osteons which do not have an environment from special bone plates.
To. has big adaptability to change funkts, loadings that is reached by the corresponding reorganization of bone structures. So, at strengthened physical. activity the working hypertrophy develops, at reduction of mechanical loading — an atrophy To., what is followed by change of the direction of bone beams, arrangements of osteons, etc. M. G. Prives, K. I. Mashkara, N. V. Krylova, D. G. Rokhlin, etc. showed influence of various professions on a structure To. skeleton. Depending on physical. loadings on To. its form, width, length, thickness of compact substance, the sizes of marrowy space, structure of spongy substance changes.
To. in an organism carry out mechanical and biol, functions. Mechanical functions K. are that they form protective rigid frameworks for internals (the vertebral channel, a head cavity, a thorax, area of a basin). Besides, To. are the place of fixing of many internals, serve them as a support. Second important mechanical function K. it is connected with the fact that they in total with muscles and other educations are a part of a musculoskeletal system capable to maintain body weight (and big loadings) and giving the chance to move in space. The movements are possible thanks to a structure of bones in the form of the long and short levers connected by mobile joints (see. Joints ) and set in motion muscles (see).
Mechanical characteristics To. also waters, a ratio of cells and noncellular substance, the course of collagenic fibers, features of a krovenapolneniye and other factors are defined by the content of mineral substances.
Microhardness of osteons is directly proportional to their calcification, making from 29,5 kg/mm 2 at low degree of a mineralization to 38,3 kg/mm 2 — at high degree. With a pressure directed perpendicular to the course of collagenic fibers, the microhardness of a bone decreases by 20 — 25%. Degree of distensibility and the module of elasticity of osteons depend on a degree of wetness: distensibility and elasticity dried up To. decreases. In osteons with a longitudinal arrangement of collagenic fibers they are higher, than at an arrangement of fibers at an angle 90 °.
Mechanical strength is not identical at different parts of a skeleton, varies within one bone, depends on age and a floor. On A.C. To Obysov, for compact substance femoral To. strength on compression makes 15 — 30 kg/mm 2 , for spongy substance of a head — 0,7 — 1,5 kg/mm 2 , spongy substance of a breast — 0,2 — 0,4 kg/mm 2 .
Biol, function of bone system is connected with its participation in a metabolism, especially mineral (see. Mineral metabolism ). This function K. it is caused by extreme mobility To. — its ability to quickly give the connections to blood and that to promote maintenance of a homeostasis of internal environment.
Homeostatic function K. it is carried out by constant exchange of mineral connections between To. and blood. To. — the depot of mineral substances of an organism containing up to 99% of all calcium, 87% of phosphorus, 50% of magnesium, 46% of sodium. Particles of bone minerals at the small sizes have a big general surface that increases contact area To. with an intercellular lymph. An active surface of 1 gram To. reaches 130 — 260 m 2 , and for a skeleton in general — to 2 million m 2 .
Calcium ions and sodium are in To. as in the form of the stable, a little connected with exchange processes fraction, and in the form of labile fraction. From 25 to 68% of the sodium deposited in To., exchanges within four hours. Deposition and exchange of calcium in To. it is controlled by parathyroid, corticosteroid hormones and vitamin D. Hormones of parathyroids influence transfer of calcium and phosphorus from To. in a blood plasma also reduce the return absorption of phosphate in renal tubules, causing a hypophosphatemia and a fosfaturiya. Vitamin D affects absorption of calcium in intestines and directly on To., promoting adjournment of salts * the Cortisone, reducing absorption of calcium in intestines, it is capable to cause osteoporosis (see). Mineral connections K. provide the due level of calcium and phosphorus in blood only at low content of hormones of parathyroids in it. Increase in content of hormones is followed by activation of osteoclasts, destruction of a bone and release of salts of calcium in a blood channel.
In physiology To. a certain value has electric potential it. Proteins of a periosteum, an endosteum, capillaries, the proceeding blood have properties of semi-conductivity. In capillary loops of a growing end To. the narrow arterial link takes a negative charge, place of transition of the arterial site to the extending venous — positive, the Periosteum and the Endosteum are loaded negatively, venules of channels of osteon — is positive. The blood-groove creates the electrochemical potential and electronic conductivity. The alkaline zone is located at the cathode, acid — at the anode. The blood stream increases potential to values at which precipitation of salts is possible. Therefore in a zone of a venous part of a capillary the provisional center of calcification is formed. Increase in a blood-groove activates growth of a bone in length, and easing leads it to decalcification and a resorption To. Such is fiziol, the mechanism of influence of the mechanical loads (stimulating a blood stream) of growth To.
Mechanical deformation To. leads to changes of electric potential. The bent, squeezed sites K. are loaded negatively in relation to the convex sites testing stretching. Emergence of electric effect can be explained with the fact that To. consists of crystal structures — a hydroxyapatite and collagen which conjunction has piezoelectric properties. The changing electric potentials can exert impact on the movement of ions and the loaded molecules on the channels feeding osteocytes.
Physiological mechanisms of blood circulation. Vessels of a diaphysis of tubular bones consist of arteries, veins without valves forming places of expansion like sine, and capillaries which part is reported with sine or takes place in fatty tissue of marrow. Use of radioactive strontium (85Sr) showed that the volume of the blood, general for all skeleton, passing 250 ml, or 5% of cordial emission in 1 min. Speed of a blood-groove in marrow is 1,8 times higher, than in compact substance, and is only twice less, than in a brain. High intensity of a blood-groove is explained by requirements of a hemogenesis here. A blood stream in compact To. provides exchange of ions, especially calcium and phosphorus, between minerals K. both blood and food of a bone tissue.
Tension of oxygen in blood of marrow is equivalent to its content in blood of a jugular vein. Therefore, the blood coming to compact substance has the low tension of oxygen and high carbon dioxide gas, and pH of extracellular liquid K. deviates in the acid party. The high tension of carbon dioxide gas in blood can promote an osteogenesis; activation of education is explained by it To. at venous stagnation.
In compact substance K. 70% of inorganic matters, 20% of organic and 10% of water contain on average. In spongy To. mineral components are made by 35 — 40%, organic 50 — 55%, water — 5 — 15%. More than 95% of an organic matrix To. it is the share of fibrous protein — collagen (see). Collagen K. has strong likeness with collagen of soft tissues; they are close on amino-acid structure, the structure of chains of their molecules and primary structure is identical, but there are also essential distinctions. The bigger maintenance of free amino groups (E-amino groups) of the lizinovy and oksilizinovy remains is characteristic of ossein. In ossein a considerable part of a lysine in not spiral telopeptida on the N-end of a molecule is exposed to a hydroxylation; in other fabrics this process does not happen. Ossein differs also in degree of a hydroxylation of the oksilizinovy remains and type of cross-linking action. At its molecule there are peptides rich with negatively charged amino acids, and organic phosphorus which are absent in collagen of soft tissues. These components are responsible for the beginning of a mineralization and carry out a role of initial factors of calcification.
Contains in the dry demineralized bone matrix apprx. 17% of not collagenic proteins. They have complex structure and at an electrophoresis are divided into several fractions. Glycoproteins (sialoproteids), albumine and residual protein concern to not collagenic squirrels. A glycoprotein To. contains a large number sialine to - you and only traces uranium to - t and sulfate. It is a specific glycoprotein of a bone and differs from sialoproteids of blood serum and sinews. Glikozaminoglikana which main representative is chondroitin-4-sulfate enter an organic matrix of a bone tissue. Chondroitin-6-sulfate, keratansulfat and hyaluronic to - that contain only in small amounts. Glikozaminoglikana take part in formation of a bone framework, they are responsible for biosynthesis of collagen and cause architecture of its bunches. Participation of these connections in stabilization and cementation of fibrous structures defines their value in mechanical function of a bone tissue. Glikozaminoglikana have a direct bearing on ossification. Adjournment of mineral salts in again formed osteons of a bone surely is preceded by synthesis of the sulphated glikozaminoglikan, and 45Ca does not join in a bone after its processing by hyaluronidase. Ossification is followed by qualitative changes of glikozaminoglikan: the sulphated connections give way to not sulphated.
Contents in To. glycogen (see) makes 33 — 80 mkg on 1 g of wet fabric. Presence of a glycogen — a necessary condition for process of a mineralization. The glycogen is localized in mature and hypertrophied cells on site of future crystallization center. The mature osteoblasts surrounded with a mineral bone matrix are deprived of a glycogen.
High concentration of RNA reflects their activity and constant biosynthetic function in bone cells. Amount of RNA in To. equally or exceeds the content of DNA.
Lipids (see) are directly involved in processes of a mineralization. In spongy To. contains — 0,61% of lipids for the dry weight of fabric; from them 0,33% fall to the share of unpolar and 0,28% — on a share of polar lipids.
V K. 8,6 mg of citrate on 1 g of dry weight contain. Citrate has high complexing ability with calcium ions. Except lemon to - you, in To. are found aconitic, amber, fumaric and milk to - you.
V K. a number of the lizosomalny enzymes participating in processes of a resorption contains. Activity of acid hydrolases in bone cells corresponds or even activities of these enzymes in cells of a liver are higher. V K. almost all enzymes of a tricarboxylic cycle, enzymes of carbohydrate metabolism — amylase, zymohexase, a lactate dehydrogenase (LDG), proteases, phosphatases (acid and alkaline), inorganic pyrophosphatase, an adenozintrifosfataza are found, etc.
Thus, the bone tissue is capable to carry out various metabolic transformations directed to biosynthesis and a catabolism of organic components.
V K. heterogeneity of some enzymes, in particular LDG is revealed. The isofermental range of LDG is presented by five fractions: LDG1, LDG2, LDG3 contain approximately in identical quantities (23,0 — 31,5%), LDG4 — on average 13,4 — 15,2%, LDG5 ~ 0,3%. A fermental range To. differs in a number of features in comparison with other fabrics. So, initial scission steps of a glycogen are carried out in a bone tissue of hl. obr. in the amylolytic way. The high activity of an alkaline phosphatase and zymohexase exceeding several times their level in blood serum is characteristic. Activity of alaninaminotranspherase in To. very low, and activity of aspartate aminotransferase in compact substance of tubular bones by 5 times exceeds activity it in blood serum., These data demonstrate that the bone tissue possesses a metabolism, own, specific to it.
Mineral substances K. are presented by oxyapatite and an amorphous kaltsiyfosfat, the ratio between to-rymi changes depending on age and conditions of food. At early age the amorphous phase, in mature — crystal oxyapatite prevails. Amorphous kaltsiyfosfat more we will dissolve, than oxyapatite, and is a labile reserve of calcium ions and phosphorus. Insufficient contents in a diet of calcium, phosphorus and vitamin D promotes accumulation of an amorphous kaltsiyfosfat. Calcium ions in a crystal lattice of oxyapatite can be replaced with radium, strontium, barium, sodium, etc. More than 30 osteotropny microelements are known.
In the course of growth and development To. undergoes the expressed changes: in it the maintenance of organic components decreases and contents mineral increases at decrease in metabolic activity. With age also organic matters K change. It is especially expressed in the embryonal period and in the first decade of life, by the end to-rogo contents, e.g., geksozamin reaches the size characteristic of adults, and remains at this level till an extreme old age.
Interrelation of inorganic and organic matters K. clearly it is shown in the course of a mineralization — at a final stage of education To., Krom is preceded by processes of protein synthesis, glikozaminoglikan, enzymes, makroergichesky connections, etc.
Methods of a research
X-ray inspection takes the important place in complex diagnosis of defeats of the bone and joint device. It is shown in all cases of damages or diseases to K. Osnov of a research make survey pictures in two mutually perpendicular projections. For studying of fine details of structure To. sometimes do pictures with direct increase in the x-ray image. At a research of more complex departments of a skeleton (a skull, a backbone, large joints etc.) on indications make tomography (see) to receive the isolated image of the necessary department To. and to catch even little changes in structure of spongy and cortical substance.
Locomotory function K., including to biomechanic of joints, study by means of X-ray television raying and X-ray cinematographies (see), i.e. series of the pictures removed in different phases of the movement in a joint — a so-called functional X-ray analysis. For assessment of content of mineral salts in To. and definitions of degree of osteoporosis apply X-ray densitometry (see).
A X-ray analysis of diseases To. it is not limited only to definition nozol, forms, but early detection of complications, overseeing by disease, influence includes to lay down. actions, results of operative measures.
Inflammatory diseases To. can be complicated by fistulas. Make for clarification of topography, diagnosis of zatek and a source of fistula fistulografiya (see). Suspicion on damage of a large vessel at an injury of a skeleton can be the indication for urgent arteriography (see). Besides, in hard cases of differential diagnosis of inflammatory and tumoral processes in To. apply arteriography and an osteomedullografiya (administration of contrast medium to the marrowy canal of a long tubular bone — see. Medullografiya ).
Thus, techniques rentgenol, researches K. are very various. They allow to judge situation, a form, size, contours and a structure To., about relationship of their joint ends, about a condition of the closing plates, kernels of ossification, surrounding a bone of soft tissues. They provide a razgr nicheny norms and pathologies taking into account age, standard and specific features of a structure and function of the bone and joint device and give the chance to objectively estimate a condition To. at various diseases.
Rentgenol, semiotics of bone pathology is diverse. From a normal picture treat the main deviations: changes of situation, a form, size and relationship To.; changes of a surface To. — regional defects, exostoses (see), periostites (see), periostoses and so forth; changes of degree of density To. and its structures — osteoporosis (see), osteomalacy (see), osteosclerosis (see); reorganization To. at hyperparathyreosis (see), osteodystrophies (see), fibrous osteodysplasias (see), etc.; destruction To. — ossifluence (see), osteonecrosis (see), sequestration (see. Sequester, sequestration ); growth disorder and development To. At the same time different diseases can be shown similar rentgenol, signs, and the same disease sometimes causes changes not similar at each other at various patients. Therefore rentgenol, data shall be analyzed taking into account all complex a wedge, pictures of a disease and results histologic and others a lab. researches.
Conduct microscopic examination of the bone tissue received it is intravital at operations and biopsies (see), and also at autopsy.
Microscopically To. investigate on the decalcified cuts painted according to research problems. Submicroscopy (see), especially in combination with autoradiography (see), reveals details of ultrastructure of osteocytes and interstitial substance, in particular the sizes and localization of crystals of bone apatite, a ratio of cells and interstitial substance, degree funkts, activities of osteogenetic cells.
By method microx-ray analysis (see) distribution of mineral salts in various bone structures and degree of their mineralization (fig. 11) is established. On the thin decalcified sections it is possible to study distribution of organic components of bone substance.
It is possible to determine by method of a stereomicrox-ray analysis thickness of bone plates, a spatial relationship of bone cells.
The method macro - and microfractions of X-ray is applied to studying of crystal structures of a bone tissue — character of mineral salts, the sizes of crystals, a crystal lattice of bone apatite.
The method of culture of fabrics found out important details of development of a bone tissue, destiny of bone transplants.
A method of impregnation by caustic silver of the decalcified cuts To. apply to a research of its microcirculator bed.
The great value got radio-gramophones. a research of diseases To. Radio-gramophones, technique of a research K. consist in various ways of registration and measurement of radiations of the radioactive nuclides which are artificially entered into an organism replacing stable microelements of bone substance (a radio isotope research), or in registration and measurement of the induced activity of microelements of the bone arising at influence of neutrons (the neutron and activation analysis — NAA).
The radio isotope research
the Radio isotope research is based on ability of radioactive materials to join in ion exchange and to be besieged on a surface of crystals of calcic apatite of a bone. The excessive accumulation of isotope found at a radio isotope research can be caused various patol, the processes which are followed by disturbance of an osteogenesis and reorganization of bone structure, napr, inflammatory, tumoral and dystrophic processes, and also the posttraumatic phenomena, disbolism, etc.
For radio isotope diagnosis use big group of osteotropny radionuclides, however the greatest application was found by strontium-85, strontium-87, gallium-67 and pyrophosphates.
The main and most widespread techniques of a radio isotope research of bones are radiometry (see) previously revealed at rentgenol, a research patol, the centers in a bone and similar sites of a symmetric bone, plane scanning (see), radio isotope review of a skeleton and stsintigrafiya (see). Skanogramma gives the chance to judge distribution in bones of the osteotropny radionuclide entered into an organism, the number of its accumulation in patol, the center and in healthy fabric, and also location of the center, its form and the sizes. At fractures of bones the research helps to establish intensity of process of healing or its absence. At inflammatory diseases of bones accumulation of radionuclide in area patol, is more than center of subjects, than process of healing of the destructive center and than more intensively reaction of an osteogenesis is more active from a periosteum, an endosteum and bone substance. At dysplastic and dystrophic diseases To. data of a radio isotope research differ in big diversity and inconstancy. To receive the picture to some extent displaying the course of a disease repeated researches within several weeks (are necessary at single introduction to an organism of strontium-85) and comparison of the received results to data rentgenol, researches.
At osteogene malignant tumors, in particular the osteoblastic and mixed forms of an osteosarcoma, increase in accumulation of a nuclide in comparison with the symmetric site of a healthy bone by 5 — 10 times, and sometimes is observed more (tsvetn. fig. 1 — 3). Often observed inclusion of a nuclide in ekstraossalny tumoral fabric is the reason that the extent of borders of the tumoral center on a skanogramma it is frequent 2 — 4 cm more, than on the roentgenogram. At benign tumors and metastasises of a malignant tumor in a bone extremely insignificant or total absence of accumulation of radionuclide in the tumoral center is noted.
A contraindication to a radio isotope research of bones and joints is serious condition of the patient, fervescence higher than 37,5 °, pyelonephritis and stones in uric ways, and also pregnancy and the entire period of a lactation. The research at women in childbearing age is recommended to be conducted at once after the termination of periods.
The Neutron and Activation Analysis (NAA) — a highly sensitive way of definition of mineral composition of any fabric, including bone. The technique of a research is based on radiation of fabrics by a neutron flux (by means of the reactor, the generator and other sources) that is followed by transition of a part of kernels of microelements of fabrics to excited state with their subsequent transformation into stable nuclides and radiation of gamma quanta, alpha and beta particles, etc. Mineral composition is defined on the basis of identification of the radiation specific to each nuclear reaction, and measurement of its intensity. Distinguish NAA in vitro and NAA in vivo.
NAA in vitro can be applied to studying of maintenance of any element and its exchange in a bone tissue, but in a wedge, to practice the technique of determination of quantitative content of calcium, phosphorus and sodium and a ratio of their concentration in was repaid To. at recognition of various bone tumors and their differential diagnosis with hron, atypically proceeding osteomyelitis, dystrophic and dysplastic processes. Subject to neutron radiation the sample of fabric weight apprx. 1 g received by means of a puncture biopsy or an operational way. The sample is dried up in the thermostat at t ° 80 — 90 °, crushed in powder and packed into a polyethylene sack. Along with a bone irradiate also the standard prepared from dry salt of calcium phosphate, acetic to - you and fiziol, solution of sodium chloride. The maintenance of elements in a sample is defined by comparison of their areas of photopeaks in gamma ranges with a standard. The obtained data compare to the average content of calcium, phosphorus and sodium, and also to a ratio of their concentration in normal bones (table 1).
Comparison of results of NAA to data kliniko-rentgenol, in most cases leads researches to the correct solution of a diagnostic task.
NAA in vivo is connected with radiation of all body of the person or his large departments (extremities, a backbone, etc.) also it is applied to studying of balance of calcium at the diseases which are followed by a rassasyvaniye of bone substance and loss of calcium, napr, at osteoporosis, osteomalacy and other inborn and acquired general diseases. Such research, having big sensitivity, allows to catch little changes of content of calcium in a skeleton in dynamics with an accuracy of ±2% that is especially necessary for assessment of efficiency of medicinal therapy. Much attention is paid abroad to NAA in vivo which is carried out on a backbone which at system osteoporosis first of all and more intensively, than other departments of a skeleton, is exposed to change.
At diseases To. there are certain biochemical, changes as in most To., and in other fabrics.
At patients with imperfect bone formation the change of amino-acid composition of collagen which is expressed in substantial increase of quantity of a lysine, oxylysine, a histidine, arginine and proline is noted; content of metabolic active soluble collagen is reduced. Along with change of biosynthesis of collagen disturbance of metabolism of glikozaminoglikan takes place; at the same time ability of connecting fabric to utilize aminosugar decreases. Accumulation of glikozaminoglikan in To. can cause a delay of formation of crystallization nuclei. At this pathology there is a deep demineralization of a bone tissue.
The patients with a hyperparathyreosis along with the increased excretion of oxyproline and high activity of an alkaline phosphatase of blood serum characterizing active disintegration of bone substance have strengthening of anabolic processes. In fragments of the bones taken from such patients during operation find the increased oxygen consumption, the strengthened utilization of proline from incubating medium and intensive education milk to - you.
At Pedzhet's disease in To. high activity of an alkaline phosphatase, a lactate - and malate dehydrogenases, the increased maintenance of a hondroitinsulfat is found. These data confirm intensively proceeding processes of biosynthesis of components of an organic matrix of a bone tissue. Their mineral metabolism amplifies; the affected bone by 10 times absorbs strontium-85 in comparison with healthy more intensively.
At rickets To. richer with water and is poorer in mineral substances; especially sharply the content of calcium decreases. The fraction of salt-soluble collagen decreases by 4 times at increase in total protein due to accumulation of insoluble collagen. Collagen of a bone tissue shows high sensitivity to a lack of vitamin D. About chemical structure To. it is possible to judge by data of table 2.
To. is structure unusually dynamic, constantly renewed due to reorganization. Braking or lack of reorganization is followed by deterioration in mechanical characteristics To. also leads to emergence macro - or microfractures, napr, at a marble disease, a hypothyroidism, a Lorain's disease.
Microscopically in cortical substance braking of reorganization is shown in weak expressiveness of an osteonny structure. At periodically arising braking of reorganization and a regrowth in a diaphysis To. there are so-called lines of a stunt seen on the roentgenogram (fig. 12). They are caused by formation of bone plates of a compact osteonny structure.
Usually idea of durability To. connect with its hardness depending on contents in To. mineral salts. Actually durability To. it is caused as well by its internal very tectonics. E.g., at a marble disease, at Pedzhet's disease, despite big, than normal, hardness, To. are subject patol, to changes (see) since bone masses forms the chaotic heaps which are not corresponding funkts, to appointment.
At some diseases the nature of reorganization and character of the most bone substance are so typical that they allow to establish sometimes on one microscopic drug the diagnosis or at least to assume a certain group of diseases. E.g., abundance of so-called detrital structures, especially in cortical substance K., it is typical for acromegalias (see), small fancy mosaicity of bone structures characterizes a bone disease of Pedzhet (tsvetn. fig. 13), wide ugly lines of pasting — an osteomyelodisplasia (tsvetn. fig. 14). The expressed mosaicity of bone beams without their disturbance funkts, very tectonics is inherent to a hyperparathyreosis (see) and a nephrogenic osteodystrophy (see. Nephrogenic osteopathy ). The heap of a peculiar bone substance without any funkts, very tectonics characterizes marble disease (see).
The ratio of osteocytes and interstitial substance matters. Normal in neogenic unripe (not lamellar) bone substance osteocytes are located unevenly, quite often small groups. Osteocytes are usually large, lacunas their wide, thus existence of large osteocytes in itself and wide lacunas cannot be a sign of osteocytic ossifluence (a rassasyvaniye of bone substance under the influence of osteocytes — see. Ossifluence ).
The pathological osteogenesis is expressed in discrepancy between quantity of osteocytes and interstitial substance, napr, in relative abundance of osteocytes owing to insufficient production of interstitial substance at imperfect bone formation (see. Bone formation imperfect ), in scanty quantity of osteocytes in ossiform fabric at rickets (see), osteomalacy (see), in patol, a condition of interstitial substance, napr, at a marble disease.
Interstitial substance can have character of osteoid, i.e. not mineralized organic basis of K. Fiziologicheski it meets at the edges of bone beams, on walls of channels of osteons in the form of the narrow strips which are not exceeding width of one plate of osteon. At patol. states osteoid is laid on old bone structures in the form of zones, uneven on width, or forms the chaotic glybchaty heaps which are not corresponding funkts, very tectonics at all To. Collagenic fibers in it are also located randomly. This already in itself demonstrates that osteoid always is neogenic, but is not intravital the decalcified organic basis preexisting To. Therefore it appears in places of the most intensive growth or reorganization To.: in the field of an epiphyseal cartilaginous rostkovy plate (rickets), at pregnant women — in pelvic bones is (osteomalacy), at diseases of kidneys, digestive organs — in bodies of vertebrae, in edges. Feature of osteoid is that it is not exposed to a rassasyvaniye, its calcification will not begin yet. Fiziol, osteoid (as well as a dentinogenny layer of teeth similar to it), bordering bone structures, protects them from a rassasyvaniye. Obviously, in the course of a mineralization To. connection of an organic component with inorganic creates new biol, properties at bone substance. At the diseases which are followed by the expressed formation of osteoid discrepancy rentgenol, characteristics of process from pathoanatomical takes place. Radiological osteoporosis while there is an intensive new growth of the not mineralized bone substance (which is not defined radiological) that it is more correct to carry to an osteosclerosis is defined.
Bone beams in different cases of pathology can be located separately, being not connected in uniform network as is normal, and patol. bone structures can have the different form: roundish, branchy, rhabdoid.
Heterotopic formation of a bone (ectopic, heterologous, extra bone) occurs in fastion, cartilages, skin, mucous and serous membranes, a firm meninx, walls of vessels, limf, nodes, internals, in muscles at the long repeating injuries (e.g., in pectoral muscles of shooters, adductors of a hip at equestrians, in muscles of athletes — fig. 13), in hems, especially front abdominal wall, in lungs on site of calciphied primary tubercular affect, in para-articular fabrics at patients with damage of a spinal cord owing to neurotrophic disturbances.
In an experiment the heterotopic osteogenesis naturally arises at change of an epithelium of a bladder and urethra, gall bladder in soft tissues. In the place of change there are cysts covered by the epithelium corresponding to type of an epithelium of a transplant, and in connecting fabric of a wall of a cyst the bone tissue closely adjacent to an epithelium develops.
The necrosis of a bone occurs at disturbance of blood circulation, at inflammatory processes in it or in the fabrics surrounding it, at influence on To. thermal factors (burn, freezing injury), etc. It is characterized by a karyorrhexis (dissolution of kernels) of osteocytes. At the same time usually there is a necrosis of fabric of vascular channels and a marrowy cavity.
The necrosis only of osteocytes is not a sign of death of a bone tissue since vital properties can remain in interstitial substance and after dying off of osteocytes. Morphologically directly dead it is impossible to define a condition of interstitial substance — live it or. An indirect indicator of a condition of a bone fragment with nekrotizirovanny osteocytes is reaction of surrounding fabric: around obviously dead not infected bone fragment, napr, prokipyachenny To., the fibrous capsule is formed. Meanwhile the free bone splinters formed at a change To., take up with each other is To., and on their basis there are processes of an osteogenesis. Probably, these splinters kept viability.
The osteanabrosis consists in a decrease of its substance (bone structures) owing to disturbance fiziol, ratios between a rassasyvaniye of bone substance and its creation, i.e. its rassasyvaniye prevails. The atrophy can extend to all To. or to be focal. In the first case distinguish an atrophy concentric and eccentric. At a concentric atrophy there is a reduction of thickness To. with a normal ratio between a cortical layer and a marrowy cavity; at an eccentric form process of an atrophy goes generally from a marrowy cavity, leading to expansion it and to thinning of a cortical layer, without disturbance of the sizes and the general configuration To. Atrophy To. usually the hl is followed by expansion vascular. obr. osteonew, channels and a marrowy cavity at the expense of a rassasyvaniye of their walls and beams of spongy substance that leads to a picture of osteoporosis. The focal atrophy arises depending on local patol, processes, napr, with a pressure of a tumor, aneurism of a vessel. However the focal atrophy is not purely local process: structural changes To. directly in the field of influence of a disturbing factor are followed by reorganization and other departments To. as adaptation to the conditions of loading which changed in the course of an atrophy. The atrophy of a cortical layer is expressed in its uniform thinning and in a spongization, i.e. loss of a compact structure owing to expansion of vascular channels.
The term «spongization» means only superficial looking alike spongy substance, but not change of a structure by the principle of the last. In spongy substance there is a thinning of the most part of bone beams (fig. 14) up to total disappearance of a part them that leads to expansion of marrowy spaces. First of all the beams testing the smallest funkts, loading disappear. The beams located according to the main power lines remain longer and often not only do not atrophy, but become more powerful. Processes of creation of a new bone tissue, but poorly expressed continue also at the strongest atrophy.
Distinguish the following types of an atrophy. Senile (senile osteoporosis) all skeleton, but unevenly as concerning various takes To., and various departments same To. It is, as a rule, an eccentric atrophy, it is most strongly expressed in spongy To., especially in vertebrae, and in spongy substance tubular To. The decrease in processes of an osteogenesis connected with reduction of processes of assimilation is the cornerstone of it. The general structure To. becomes simplified. The senile atrophy can cause deformation of a backbone (usually in the form of a kyphosis of chest department owing to microfractures of bodies of vertebrae) and easy developing of fractures, most often necks femoral To. A senile atrophy To. skulls it is expressed in expansion K. owing to their reorganization and expansion diploe or in sharp thinning To., hl. obr. at the expense of an outside cortical plate. Thinning in the field of both parietal is most characteristic To. The atrophy of bone structures at senile osteoporosis occurs slowly by a resorption at the same time of both of its components — organic and inorganic, i.e. there is deossification, but not decalcification (decalcification) as designate this process in rentgenol, literature. A senile atrophy To. it is impossible to consider as a result of falling of kosteobrazovatelny ability of cellular elements. At senile reorganization To. the mosaicity of bone beams similar to that at Pedzhet's disease can be expressed. A senile atrophy To. arises owing to the reorganization caused by the general decrease in exchange processes and connected also with less mobile way of life, but not owing to changes of properties of osteogene cells.
The atrophy from a divergence is observed in To. at considerable decrease or a long absence of their function, napr, at a long immobilization of an extremity, in amputating stumps, in alveolar shoots of jaws at loss of teeth. In the first case it is usually eccentric atrophy which is not sharply expressed. In bones of amputating stumps, at long stumps it is observed eccentric, and at short — a concentric atrophy. In essence such atrophy To. also has adaptive character.
At an atrophy from pressure there is a disappearance of bone structures, sometimes on a considerable extent. E.g., at an aortic aneurysm big defects in bodies of vertebrae, in their shoots, sometimes before opening of the spinal channel are formed (tsvetn. fig. 16).
The neurotic atrophy is observed at diseases central and peripheral nervous systems: a hemiplegia, poliomyelitis, at disturbance of an integrity of nervous trunks. Injury of the mixed nerves is followed by stronger atrophy, than defeat of motive. The pathogeny of bone changes in all these cases is difficult; a part them is caused by a divergence of body, a part — the vascular disorders developing after damage of a nervous system.
Hyperplastic processes in To. have various origin. They can have adaptive character as, e.g., a working hypertrophy To. It is expressed in strengthening funkts, structures, in a thickening of a cortical layer due to formation of new mass of bone substance of an osteonny structure, in formation of powerful beams of spongy substance. Such To. are very dense. The working hypertrophy develops in connection with features of a profession or when on To. the increased loading owing to absence another falls To. or at patol, process (fig. 15) in it. Focal hyperplastic processes can result. disturbances of development To., napr, at melocheostosis (see), owing to reactive, inflammatory processes (see. Osteomyelitis ). A diffusion thickening To. carries the name hyperostosis (see), thickenings in the form of focal bone outgrowths are called exostoses (see), or osteophytes (see). Senile hyperostoses To. skulls arise most often on an inner surface frontal To. owing to their reorganization. A pathogeny of a hyperostosis of inner surfaces of frontal bones (see. Morganyi syndrome ), arising sometimes at pregnancy, it is not found out. Hyperostoses are characteristic at such patol, processes as a hypervitaminosis And, Bamberger's periostosis — Mari (see. Bambergera — Mari a periostosis ).
Increase in mass of bone structures carries the name osteosclerosis (see). The reasons of development of an osteosclerosis and extent of its distribution are various. Cases of an osteosclerosis of a skeleton of constitutional character (a genuinical osteosclerosis) are observed. Skeleton structure at the same time is correct, but To. are very dense, thick, massivna. Their compact substance is thickened, channels of osteons are considerably narrowed owing to formation of new bone plates on their walls (eburnation).
Development of a generalized osteosclerosis (a milk and alkaline syndrome of Burnett) is observed on the soil hron, an alkalosis at the long use of large amounts of milk and alkalis at a peptic ulcer (see. Burnett syndrome ).
The focal osteosclerosis can result from the inflammatory processes specific and nonspecific, and also around any dense deposits, tumors, parasites.
Circulatory disturbances. Both the osteogenesis, and a rassasyvaniye of bone structures as is normal, and in pathology proceed against the background of the strengthened blood supply, degree to-rogo is various. It is usually difficult to define what degree of a hyperemia favors to an osteogenesis and what — to a rassasyvaniye of bone substance.
The hyperemia and an angiomatosis at a peculiar angioneyrodistrofichesky process are especially sharply expressed — a spontaneous rassasyvaniye To. (see. Ossifluence ). At it partially or entirely resolve separate To. or several bones: femoral, bones of a pelvic or shoulder girdle, front, thorax (vertebras, edges).
At a caisson disease (see. Compressed-air disease ) in To. the changes described under the name of bone heart attacks are observed. The essence and a pathogeny of these changes cannot be considered found out. Features of blood supply To., wide network of an anastomosis between systems of their vascular network are that, as in an experiment it is almost not possible to reproduce a heart attack To.
Inflammatory processes always proceed in the fabric containing vessels. V K. the angienchyma contains in its internal departments (a marrowy cavity of a diaphysis, marrowy spaces of spongy substance), in vascular channels of cortical substance. In these fabrics K. also inflammatory processes proceed. An inflammation To. almost never only the periosteum, only cortical or spongy substance is limited to defeat, and everything captures them. However preferential defeat of this or that department To. with the corresponding features a wedge, manifestations and pathoanatomical changes gave the grounds to divide inflammatory processes on periostitis (see), or osteoperiostitis (see), osteomyelitis (see), osteitis (see).
In addition to the pyogenic microorganisms causing different types of osteomyelitis, inflammatory processes in To. develop also at specific infections — tuberculosis (see), syphilis (see), brucellosis (see), actinomycosis (see) and at fungal infections (see. Mycoses ).
The bone tissue has big ability to regeneration. The last is carried out at the expense of the same fabric elements which participate in reorganization of a bone tissue: elements of a periosteum, fabric of channels of osteons and spongy substance. In reparative regeneration at a change To. also parostalny (okolokostny) fabric takes part. Osteocytes do not participate in regeneration. Depending on conditions in which process of regeneration proceeds formation of a new bone tissue happens on connective tissue or hondralny type.
From a periosteum most intensively there is a formation of cartilaginous tissue. It has big fiziol, value, t. to, provides the bystry immobilization of bone fragments necessary for their further union; cartilaginous tissue is formed much quicker, than bone, and has sufficient density initially to fix fragments. Fixing of fragments provides the condition of rest necessary for basic process of reparative regeneration To. — formations of intermediary bone callosity (see) directly in the area of a change.
Dystrophic changes of a bone tissue — various patol, leads the states connected with disturbance of exchange in K. Nedostatok in food of vitamin A (Retinolum) to delay of growth of a skeleton owing to disturbance of an enchondral and periosteal osteogenesis. In an epiphyseal cartilaginous plate proliferation of cartilaginous cells decreases, the regularity of an arrangement of cells in a kolonkovy zone, education bone balochek is broken. Are formed by Balochki not along cartilaginous columns, and parallel to an epiphyseal plate owing to what under it the switching bone plate is prematurely formed.
Morfol, changes in To. at avitaminosis With consist in a growth disorder and an osteanagenesis (see. Scurvy ). At a lack of a calciferol (D-avitaminosis) of change To. are expressed in shape rickets (see) and osteomalacy (see). The hypervitaminosis And is observed at overdose of vitamin A and shown by formation of small periosteal hyperostoses in the field of a diaphysis To. Hyperostoses at a hypervitaminosis And develop at children 1 years (more often at the age of 2 — 3 years), unlike the so-called children's cortical hyperostoses which are developing at children up to 6 months and followed, as a rule, by defeat of a mandible are more senior.
The overdose of vitamin D at treatment of rickets (especially at use of the irradiated ergosterol and a calciferol) can cause development of osteoporosis (in the presence of a hypercalcemia, a hyperphosphatemia, a hypercalcuria).
Dystrophic bone changes are brightly expressed at some endocrine diseases: acromegalias (see), hypopituitarism (see), hyper - and a hypothyroidism, hyperparathyreosis (see). At a hypopituitarism epiphyseal cartilaginous rostkovy plates are not closed up to an extreme old age, cranial seams also not of a zarashchena; reorganization To. it is slowed sharply down. Therefore in To. till an extreme old age there is no updating of bone structures.
At a hyperthyroidism (see. Thyrotoxicosis ) in To. the processes connected with strengthening of exchange develop. To. are exposed to the strengthened reorganization that it is easy to catch on a mosaic structure of bone beams. At a long hyperthyroidism processes of a rassasyvaniye of a bone tissue are more intensive that leads to development of osteoporosis, sometimes very sharply expressed.
At hypothyroidism (see), caused by an underdevelopment of a thyroid gland, the growth disorder is observed To., leading to dwarfism. At microscopic examination To. sharp delay of processes fiziol, reorganizations of a bone tissue is noted. V K. the structures which were not replaced for many years remain. It leads to decrease in its durability both owing to aging of these bone structures, and owing to insufficient fitness of internal very tectonics To. to the changing conditions. Therefore in To. dwarfs at an inborn hypothyroidism it is possible to see microfractures bone balochek spongy substance that quite often is the reason of deformation To.
Typical changes To. are observed at a hyperparathyreosis — primary (see. Parathyroid osteodystrophy ), secondary and tertiary. The last two forms are, as a rule, connected with diseases of kidneys and concern to group of nephrogenic osteodystrophies (see. Nephrogenic osteopathy ). V K. at the same time the changes close to a picture of primary hyperparathyreosis develop. A part of cases proceeds at children with a picture of rickets, at adults — with a picture of osteomalacy or with a picture of an osteosclerosis.
Long diseases of the digestive system — a pancreas, a gall bladder, a stomach, intestines, in particular a high enterectomy, to a spr (see) — can be complicated by the osteomalacic syndrome which is quite often acting into the forefront. An example of a pulmonary osteodystrophy is Bamberger's syndrome — Mari.
Diseases are allocated To., the fermentoobrazovaniye caused by disturbance — hypo - and a giperfosfataziya. At hypophosphatasias (see) bone substance remains ossiform owing to inability of cells of an organism to develop the alkaline phosphatase participating in a mineralization To. This rare hereditary disease is shown vnutriutrobno, at the birth or in the early childhood and is expressed in heavy changes of a skeleton — like rickets.
Giperfosfataziya (synonym: the family osteoectasia, a desmalny family ectasia, hron, a progressive osteopathy with a giperfosfataziya, etc.) is characterized by the progressing deformations long To., expansion of a cortical layer of these bones and To. skulls, reminding Pedzhet's disease. Patients have a big head with outstanding frontal hillocks, a short neck and a thorax. In urine the content of hydroxyproline is increased. At biopsies lack of an osteonny structure is revealed To.
Crucial importance in diagnosis of diseases To. (especially tumoral) belongs to histologic methods of a research. Material for this research is received in the way biopsies (see), edges can be open (a synonym intsizionny, operational), puncture, trepanation.
As many bone diseases have no specific symptoms, the great value is gained by the anamnesis, results of survey, assessment of the general condition of the patient, his age, localization patol. process, character and intensity of pains. Data on course of disease therefore they are necessary a detailed wedge, data and roentgenograms received at the previous investigation phases are extremely important.
Studying of the anamnesis gives the chance to establish prescription of a disease, it is correct to estimate a role of an injury if it took place. Often the injury is the provocative moment revealing is hidden proceeding patol, process (tumors of a bone, dysplastic defeats, etc.). At usual injury before of a normal bone the swelling, dysfunction come at once. At patol, process in a bone these signs usually appear through a nek-swarm time. For diagnosis of separate types of displaziya (ekzostozny a chondrodysplasia of imperfect bone formation, etc.) clarification of heredity matters. Data on earlier postponed diseases (osteomyelitis, tuberculosis, syphilis, etc.) quite often help with establishment of the nature of a bone disease.
An early symptom of a bone disease is pain, edges can be various on character and localization. So, the acute, suddenly arising for no apparent reason pains or pains connected with the minimum injury indicate an opportunity patol, a change. Incremental pains are characteristic of inflammatory process in a bone (e.g., tuberculosis). Dull, long aches of arching character are quite often observed at tumoral process. The exhausting, precisely localized night pains — a characteristic sign of an osteoid osteoma and the isolated abscess. Often pains do not correspond to the location patol, the center, and are reflected. So, at defeat of a hip joint they are quite often localized in a knee joint etc. The patient
is examined in a lying and sitting position and in the movement; at the same time compare symmetric body parts. Patol, conditions of a bone tissue (a thickening, deformation, surface irregularities, shortening, etc.) are palpatorno defined easier if To. it is located close to a surface (a brush, foot, a tibial bone, a clavicle, a skull). Sometimes at survey it is possible to define a form, prevalence of bone defeat (e.g., tumors), and also puffiness, a swelling or consolidation of soft tissues. The condition of joints is established at a detailed research of all extremity and each joint separately, and the volume of movements in a joint — by means of a goniometer (see. Goniometriya ). Increase or reduction of the sizes of an affected area of a bone reveal by measurement of a circle patol, a segment taking into account thickness of soft tissues.
the Standard classification of diseases To. no. The most widespread is A. V. Rusakov's classification, the etiological and pathogenetic principles, with instructions of separate similar groups on morphology patol, processes without transfer nozol, forms are the basis a cut. Classification included four basic groups patol, processes: injuries, inflammatory, dysplastic and dystrophic diseases. In a wedge, M. V. Volkov's classification bone defeats at children constructed on the same principles as classification And. V. Rusakova, the most often found diseases are specified To. and separate nozol, their forms that is important for the correct and timely diagnosis and the choice of a rational method of treatment.
Damages — one of the most numerous groups of pathology To. in peace and wartime, arise owing to various reasons, are followed by various complications (shock, blood loss, suppurative processes, etc.) and have a wide arsenal of methods of treatment (see. Changes ).
Inflammatory diseases. More often they are called by pyogenic microorganisms — a streptococcus, staphylococcus (see. Osteomyelitis ), and also activators of so-called specific inflammations — tuberculosis, syphilis, a brucellosis, etc.
The infection gets into a bone tissue in the hematogenous way, at Krom of a bacterium get into marrow through feed vessels, or a periosteal way — from a joint, at wounds, open fractures, etc. At cortical localization inflammatory process is defined as osteitis (see), defeat of marrowy spaces of spongy substance is called osteomyelitis, in case of distribution of process on both departments of a bone spoken about a panosteitis.
Inflammatory diseases of a bone tissue have long, is frequent hron, the current with characteristic recurrence of process — the period of an aggravation alternates with remission. The beginning of a disease quite often acute with the expressed symptoms of intoxication. The local center comes to light more often not at once. Damage of a bone is followed by morbidity, forced position of an extremity, a contracture of the next joint, puffiness of soft tissues. At osteomyelitis and tuberculosis fistulas with allocation of bone sequesters are quite often formed (see. Sequester, sequestration ). To complications of inflammatory processes To. secondary damages of the next joints belong up to anchylosis (see), growth disorder of an extremity (lengthening or shortening), patol, changes. In metafizarny and diaphyseal departments long tubular To. the isolated abscess, napr, a Brodie's abscess is quite often localized (see. Brody abscess ), hron, sclerosing osteomyelitis of Garre. For a wedge, pictures of these diseases inertly current inflammation K.
Rentgenol, a picture of inflammatory defeats is characteristic To. it is extremely various that is connected with their various etiology, age of the patient, localization of process and other factors. During an initial stage and in a phase of a heat of osteomyelitis rentgenol. the syndrome of an inflammation is shown by the following signs: local osteoporosis, centers of destruction of a bone tissue, bone sequesters, periostitis. In a phase of a zatikhaniye in pictures signs of an otgranicheniye of the inflammatory centers and a reparation come to light.
Differential diagnostic characters of the most frequent forms of inflammatory diseases To. are provided in table 3.
it is necessary to understand the disease process leading to absence or ugly development To As a dysplasia of a skeleton., and also to the wrong formation of the fabric components which are their part. Dysplastic diseases of a skeleton are divided into three groups:
I. Malformations — the diseases connected with disturbance of an embryogenesis or pathology of pregnancy.
II. Actually a dysplasia of a skeleton — the diseases of inborn character connected with various funkts, disturbances of mesenchymal fabric and its derivatives — connecting, cartilaginous and braids pus of fabrics. Carry to displaziya of a skeleton also hyperostoses and bone eozinofilez.
III. Tumors To. a skeleton, relating, according to A. V. Rusakov, T. P. Vinogradova and M. V. Volkov, to group of dysplastic diseases of a skeleton.
Malformations are extremely various. Owing to disturbance of an embryogenesis To. the child also the sizes can have irregular shape that easily comes to light on roentgenograms. Pictures allow to establish localization, degree and the nature of defect (inborn defect of an extremity, increase in number or change of a ratio of separate elements of the bone and joint device or their merge, increase or reduction of separate parts of a skeleton, a delay of their development etc.). The description of malformations separate To. — see in articles devoted to separate parts of a skeleton (e.g., Brush , Backbone , Foot , Skull ).
Actually a dysplasia — the diseases of inborn character combined by the general term «system dysplasia». Carry a dysplasia of cartilaginous tissue to them (a chondrodysplasia, a dysplasia of regions of growth, epiphyseal a dysplasia) and a dysplasia of a bone tissue. Many of them have family and hereditary character (an imperfect osteogenesis, an ekzostozny chondrodysplasia), being the chromosomal, genetically caused diseases. One dysplasia are connected with disturbance of normal process of ossification of a cartilaginous and bone tissue (a chondrodysplasia, an osteodysplasia) and quite often remind tumors. In other cases the wrong formation of a skeleton is caused by a growth disorder of a bone in length owing to a dysplasia of region of growth of a bone (fizarny a dysplasia) or disturbance of development of an epiphysis (an epiphyseal dysplasia). A number of dysplastic diseases is connected with a malformation of bone and hemopoietic systems that leads to hyperostoses of bones.
System a dysplasia in the x-ray image are characterized by generalized changes of the bone and joint device. They are found at the birth of the child or, in any case, before the end of growth of a skeleton and to this term can progress. Roentgenograms allow to differentiate defects of an endostosis (multiple epiphyseal a dysplasia, a spondiloepifizarny dysplasia, a spider finger, multiple cartilaginous exostoses, the Chondromatosis), defects of periosteal ossification (imperfect bone formation), defects of endosteal ossification (see. Melocheostosis , Osteopoikilosis ).
Chondromatosis of bones (see) — the malformation of cartilaginous tissue, is for the first time described by the Lyons surgeon L. Oilier in 1899. The essence of a disease consists in the slowed-down and perverted ossification of an embryonal cartilage. Coming normal on 3 — 4 months of embryonal life substitution of a cartilaginous skeleton a bone tissue does not happen therefore in metafizarny departments of bones, and sometimes throughout a diaphysis or a body of a flat bone there are large centers of an embryonal cartilage. Often tibial, femoral and humeral bones, ossicles of brushes and feet, pelvic bones are surprised. The disease comes to light at early age.
From the beginning of walking there are deformations of bones, lameness, the progressing shortening of an extremity. Patol, fractures of the changed bone quite often are the first display of a disease. Along with bone changes development of branchy hemangiomas in cellulose and muscles is quite often observed (see. Maffuchchi syndrome ). On the roentgenogram changes not only structures, but also shapes of bones (fig. 16) come to light. In metafizarny sites of long tubular bones there are oval and fan-shaped centers of an enlightenment corresponding to not calciphied cartilaginous tissue.
The group of diseases, homogeneous on a pathogeny, is made cartilaginous a dysplasia of regions of growth (fizarny a dysplasia). Carry an ekzostozny chondrodysplasia, or youthful osteoarticular to them exostoses (see), being a malformation of a cartilage of a rostkovy zone which produces bone substance not strictly perpendicularly to a rostkovy zone, and aside that leads to formation of osteoarticular ledges (fig. 17). In process of growth To. they are removed from region of growth to a metaphysis and even a diaphysis. Exostoses grow in the basic towards the center of a bone, unlike the tumors growing randomly. Ossification of an exostosis goes from the basis to the periphery, with end of human height exostoses stop growth. The most frequent localization — rostkovy zones of an active epiphysis of long tubular bones in knee, humeral, radiocarpal joints.
Treats systemic lesions of a skeleton chondrodystrophia (see), at a cut enchondral growth of bones, and periosteal and endosteal ossification usual is broken. Clinically the disease is shown by dwarfism, disproportionate growth, shortening of extremities, hl. obr. proximal a whitefish cops, with a normal growth of a backbone. Tubular bones are thickened, bent, hilly, an epiphysis is deformed, expressed varus and valgus deformations of the lower extremities (fig. 18). Pathogenetic therapy of a disease does not exist, attempts to achieve lengthening of the lower extremities in the operational way become. Prevention of deformations at early age is necessary.
Local defeat of one region of growth is characteristic of fizarny displaziya of a post-natal origin. They are combined by a perversion of growth of one epiphyseal cartilage with ossification of a part or all region of growth of one K. K to them carry Blant's disease, a disease of Madelunga, dysplastic varus deformation of a neck of a hip. Blant's (fig. 19) disease, or the deforming osteochondrosis of a tibial bone — inborn varus deformation of a shin as a result of premature ossification of a medial part of a proximal epiphyseal cartilage of a tibial bone (see. Blanta disease ). A disease of Madelunga, or hron, an incomplete dislocation of a brush — the shift of a brush in the palmar direction with a deviation in the beam or elbow party. Deformation is caused by a dysplasia of a distal epiphyseal cartilage of a beam bone. Similar deformation can arise under the influence of acquired diseases — tumors, effects of a change, osteomyelitis, etc. Dysplastic varus deformation of a neck of a hip — disturbance of normal ossification of an epiphyseal cartilage of a neck of a hip. Under the influence of loading there can be an epiphysiolysis with varus deformation of a neck of a hip.
Operational treatment of deformations at fizarny displaziya consists in corrective osteotomies.
Epiphyseal a dysplasia are connected with a malformation of the fabrics making a basis of an epiphysis. Allocate two forms of epiphyseal displaziya: dysplasia of a joint cartilage and dysplasia of cartilaginous tissue of the epiphysis. The epiphyseal dysplasia, at a cut is noted the excess growth of a joint cartilage, carries the name multiple deforming joint a chondrodysplasia, or Volkov's diseases. In 1962 this disease was for the first time described as a dysplasia of a skeleton with growth in cavities of joints of cartilaginous tissue in a combination with secondary giantism of one or several extremities and other manifestations of insufficiency of a mesenchyma. The tutopodvizhnost of joints, their sharp increase in volume, lengthening of the affected extremity from 7 to 20 cm (fig. 20), growth of a cartilage in the form of rollers on the course of seams of a skull, vascular and a nevus pigmentosus on a trunk and extremities, a hyperkeratosis of skin is noted. On the roentgenogram the thickening of an epiphysis, uneven fringed contours of joint surfaces is visible. In a cavity of joints intra joint bodies of irregular shape decide on accurate and equal contours. Data of microscopic examination confirm growth in a cavity of a joint dystrophic of the changed cartilage soldered to a cover cartilage. Treatment operational: at considerable lengthening of the lower extremity cartilaginous masses deletes together with a patella, To. shins or hips resect throughout 8 — 10 cm. On fingers of brushes and feet excise cartilaginous growths.
Defect of ossification of a kernel of an epiphysis leads to the slowed-down, wrong, perverted its formation and is the cornerstone of many inborn general diseases from group of epiphyseal displaziya. The multiple epiphyseal dysplasia concerns to them (see. Ferbank disease ). The disease is shown at early children's age, but quite often comes to light at adults. Patients of low growth at the expense of the shortened lower extremities, at them are observed deformations and contractures of joints of top and bottom extremities (fig. 21). At rentgenol, a research find late emergence of kernels of ossification in large joints, their slowed down and maldevelopment. The Spondiloepifizarny dysplasia is shown by sharper deformations of a skeleton with indispensable changes in a backbone: bodies of vertebrae are flattened (a universal platyspondylia), in chest and lumbosacral departments vertebrae quite often get a wedge-shaped form.
Restriction of loads of joints, dignity. - hens. treatment of patients with epiphyseal displaziya can slow down process of destruction and prevent development of contractures. At severe forms operational treatment is shown: osteotomies (see), resections of joints, elimination of contractures by means of pivotally-distraktsionnykh devices of Volkov — Oganesyan.
Fibrous osteodysplasia (see) — a malformation To., connected with disturbance of normal ossification of a skeleton at a connective tissue stage of embryonic development. Embryonal osteoblastic fabric, filling marrowy space, interferes with education full To. also causes sharp deformations of a skeleton and shortening of extremities.
Imperfect bone formation, or inborn insufficiency and fragility of bones (see. Bone formation imperfect ) — the dysplastic damage of a skeleton connected with the wrong formation of a bone tissue. It is shown by frequent changes in the pre-natal and post-natal period, sometimes changes begin from 7 — 12 years.
Hyperostoses (see) call group of diseases of dysplastic character with patol, growth of a bone tissue of one or a row K. Overdevelopment of correctly created bone tissue is observed at an inborn system hyperostosis (see. Kamurati — Engelmanna a disease ), melocheostosis, osteopoikiloses (see), Mari's syndrome — Bambergera (see. Bambergera — Mari a periostosis ). Disturbance of development of bone and hemopoietic fabrics as a result of growth of the first in the marrowy channel leads to an osteomyelodisplasia (see. Osteomyelofibrosis ) and marble disease (see).
These hyperostoses are connected with development of sclerous processes in bones and are different types of dysplastic diseases, relatives by the nature: in all cases it is about a perversion of processes of bone formation. The increase in mass of bone structures leading to formation of dense, thick, massive bones is caused osteosclerosis (see). Thickenings To. in the form of focal outgrowths call osteophytes (see).
From the diseases of dysplastic character combined by the general name «bone eozinofilez» it is possible to allocate three forms: an eosinophilic granuloma of a bone with single one-bone defeat, a multiple form eosinophilic granuloma of a bone (see) and a bone xanthomatosis — a combination of multiple damage of a skeleton and hypothalamic area (see. Henda — Schueller — Krischena a disease ). This form is followed by defeat of a front share of a hypophysis and quite often general serious condition of the patient. The disease belongs to a dysplasia of reticuloendothelial system of the post-natal period. The centers of destruction of various size are localized in bones of a skeleton, causing pain, a swelling of the struck department of a bone, is frequent patol, changes. Most often process is localized in femurs, pelvic bones, bodies of vertebras and bones of a calvaria. At bone xanthomatosis (see) a frequent triad of symptoms — bone changes, not diabetes mellitus and pucheglazy — it is caused by development of the eosinophilic centers near a hypophysis and cherepnomozgovy nerves. Rentgenol, a picture in typical cases is characterized by the centers of depression with polycycling scalloped edges (fig. 22). At morfol, a research the basis of the center is made by reticular macrophages, histiocytes and eosinophils. Treatment consists in a scraping or a resection of the center of defeat. In rare instances of multiple damage of bones of a skull radiation therapy is possible. The forecast is in close connection with early diagnosis and correctly chosen method of treatment.
Tumors. Distinguish primary and secondary, i.e. metastatic, tumors. Primary tumors To. can consist of the different fabrics which are a part To. as body: bone, cartilaginous, reticular, fibrous, fatty, hemopoietic, vascular, nervous. Modern classifications of tumors To. are constructed, as a rule, on gistol, to the principle.
The international classification of primary tumors and opukholepodobny diseases To.
I. Osteogenic tumors. High-quality: osteoma, osteoid osteoma, osteoblastoma. Malignant: osteosarcoma (osteosarcoma), yukstakortikalny (parostalny) sarcoma.
II. Hryashcheobrazuyushchy tumors. High-quality: chondroma, osteochondroma (osteoarticular exostosis), Hondroblastoma, chondromyxoid fibroma. Malignant: chondrosarcoma, yukstakortikalny chondrosarcoma, mesenchymal chondrosarcoma.
III. Giant-cell tumor (osteoblastoclastoma).
IV. Tumors of marrow: Ewing's sarcoma, reticulosarcoma, lymphosarcoma, myeloma.
V. Vascular tumors. High-quality: hemangioma, lymphangioma, glomichesky tumor (glomangioma). Intermediate, or uncertain: gemangioendotelioma, Gemangioperitsitoma. Malignant: angiosarcoma.
VI. Other connective tissue tumors. High-quality: desmoidny fibroma, lipoma. Malignant: fibrosarcoma, liposarcoma, mesenchymoma, undifferentiated sarcoma.
VII. Other tumors: chordoma, adamantinoma of long tubular bones, neurilemoma (shvannoma, neurinoma), neurofibroma.
VIII. Not classified tumors.
IX. Opukholepodobny changes: A chondromatosis of bones, a solitary cyst (simple, or single-chamber, a cyst), an aneurysmal cyst, a yukstakortikalny cyst (intra bone ganglion), metafizarny cortical defect (not osteogene fibroma), an eosinophilic granuloma, a fibrous dysplasia, an ossifying miositis, a brown tumor at a hyper parathyroidism.
Tumors are usually localized in internal departments To., in long bones — in an epiphysis and a diaphysis, is more rare in a cortical layer or periostalno. Localization of a tumor can give it some features. E.g., osteoid osteoma (see) cortical a layer differs in the small sizes, but causes massive periosteal bone growths. At localization of a tumor in spongy substance K. formation of a narrow osteosclerotic rim around a tumor is characteristic, and the tumor can reach the big sizes — a huge osteoid osteoma, an osteoblastoma. In development of a number of tumors To. the age of patients matters: Hondroblastoma (see), chondromyxoid fibroma (see), osteoid osteoma, Ewing tumor (see), osteogene sarcoma (see) develop preferential at children's, teenage, youthful age, osteoblastoclastoma (see) — from 21 to 30 years. After 40 years metastatic tumors prevail.
Local reaction to a tumor is expressed in a rassasyvaniye To. in the field of its arrangement, and in certain cases in formation of the fibrous or bone capsule around benign tumors. Rassasyvaniye occurs as a smooth, osteoklastichesky, alar resorption. Tumor cells do not take part in a rassasyvaniye. In some tumors, napr, in to a chondroma (see), to an angioma (see), the centers of calcification or a reactive osteogenesis are formed that can have diagnostic value. In a case patol, a change in the field of a tumor gistol, the picture is supplemented with a reactive osteogenesis like a bone callosity. The so-called excess bone callosity can be clinically taken for a malignant tumor (microscopically for a chondroma, a chondrosarcoma).
The exophytic growing tumors — high-quality an osteoma and osteosarcomas which always arise vnutrikostno enter into group of osteogenic tumors (in spongy or cortical substance).
Spongy osteoma (see) proceed from To. the wide basis (tabulyarny an osteoma) or narrower leg (an osteoma on a leg), are covered with the closing bone plate being direct continuation of a bast layer To., from a cut they proceed. On the roentgenogram the bone drawing with the wrong krupnopetlisty or close-meshed structure is well-marked. Compact an osteoma happen homogeneous dense structure and hl are located. obr. in okolonosovy bosoms.
Osteosarcomas radiological have three versions: osteolytic, osteoblastic and mixed.
Osteolytic sarcoma arises in the form of single irregular shape of the homogeneous and unstructured, indistinctly outlined center of destruction (fig. 23). On border of destruction the small zone of a reactive sclerosis (enostalny reaction), and along a diaphysis — an otsloyenny periostitis in the form of a so-called reactive visor or a triangle (periosteal reaction) usually is located.
Osteoblastic sarcoma at the central emergence (fig. 24) comes to light in the form of shapeless, poorly konturiruyemy centers of consolidation in spongy substance flat or tubular To. Further the tumoral bone tissue diffuzno fills a marrowy cavity and cortical substance burgeons, merging with it. Then tumoral masses goes beyond To. in soft tissues are also defined on their background in the form of homogeneous consolidation of the most various form.
At eccentric emergence the tumor can come from the limited site of this or that surface To. and to form sometimes very fancy hilly growths (fig. 25) having clearly the defined basis or in the form of the uneven and hilly coupling to cover To. from all directions. This version having a little longer current is allocated with a number of authors in a separate form under the name parostalny sarcoma (see) or malignant osteoma, since rentgenol. the picture it in some cases formally reminds an osteoma.
At the mixed osteosarcoma on the roentgenogram it is possible to find the tumoral osteogenesis giving sites of sharply expressed consolidation of bone structure (eburnation) and near them the centers of destruction; there can be sites of a tumoral osteogenesis in the tumoral masses burgeoning from To. in soft tissues (fig. 26). Both at osteoblastic, and at the mixed osteosarcoma there is a periosteal reaction, most often in the form of a periosteal visor, typical for all kinds of osteosarcomas.
Among hryashcheobrazuyushchy tumors To. distinguish intra bone (enchondromas) and extra bone (ecchondroma) tumors (see. Chondroma ). The enchondroma can blow up in a varying degree To., thinning cortical substance on the respective sites. The basic rentgenol, a symptom of enchondromas are changes of bone structure. It is possible to distinguish three types of enchondromas: I \with dominance of destruction To. (calcification of cartilaginous masses is absent); II \mixed, when destruction To. and calcification of cartilaginous tissue are combined in various options (fig. 27); III \with dominance of calcification or even ossification.
At an enchondroma of the I type in struck To. the roundish or oval site of an enlightenment caused by accumulation of not calciphied cartilage is found. At an enchondroma of the II type against the background of this enlightenment speckled shadows of limy inclusions are located. At an enchondroma of the III type of these speckled shadows there is a lot of that enlightenments (destruction) are almost not defined also To. it is represented as if stuffed with limy masses. Among them bone beams come to light. Periosteal stratifications, as a rule, are absent. Enchondromas have very big tendency to an ozlokachestvleniye and quite often pass into a chondrosarcoma.
A specific place is held by the intra bone cartilaginous tumor which is arising from elements of an epiphyseal rostkovy cartilage at children and teenagers and received the name hondroblastoma (see). It is a benign tumor, at a cut isolated cases of a malignancy are described. Enostalny and periosteal reactions are poorly expressed.
Extra bone cartilaginous tumors (peripheral a chondroma, an ecchondroma) meet at later age and in any department of a skeleton. Against the background of the increased and condensed soft tissues that is caused by accumulation ekzofitno of the growing not calciphied cartilage, are defined multiple, various sizes, generally small, the sites of calcification scattered on all tumor (fig. 28). Regarding cases along with calcification is available or even ossification prevails.
Chondrosarcoma (see) makes more than 11% of cases of malignant tumors To. Its preferential localization — proximal departments long tubular To., pelvic To., breast, edges. Its current can be long, and intervals between a recurrence can exceed 5 — 10 years. At a repeated recurrence their terms are progressively shortened. On degree of a maturity (zlokachestvennost) distinguish chondrosarcomas of high, average and low degree of a maturity. The forecast at a chondrosarcoma more favorable, than at an osteosarcoma and Ewing's tumor. The mesenchymal chondrosarcoma differs in a small differentiation of tumor cells and existence, sites of rather mature cartilage; she is multiple; the current is malignant, but can be long.
Osteoblastoclastoma (see) — the benign tumor, affects preferential metadiaphyseal departments of long tubular bones. It is clinicoradiologically subdivided into passive and cystous, active and cystous and lytic types; the lytic type is most inclined to a malignancy.
Rentgenol, a picture at Ewing's tumors (see. Ewing tumor ) develops of three components — the centers of destruction, enostalny reaction and periosteal stratifications. Small - focal destruction meets at defeat of metafizarny departments tubular, flat and spongy To.; lamellar destruction meets at defeat of a diaphysis; macrofocal destruction is observed rather seldom, hl. obr. at defeat flat K. Rentgenol, the picture of enostalny reaction is expressed variously: from a sclerous border on border of the centers of destruction before sharp diffusion consolidation of bone structure — eburnation of almost all affected bone. At Ewing's tumor it is possible to meet all existing forms of periosteal growths: a periostitis otsloyenny and layered, hilly and fringed, needle and even in the form of a visor.
The leader rentgenol, a symptom of miyelomatozny defeat is destruction of a bone tissue. Usually it is multiple damages of a skeleton of melkoochagovy or macrofocal character in the absence of enostalny and periosteal reaction. The long time a myelomatosis radiological can be shown by the single center that allowed even to allocate an independent form — a so-called solitary myeloma (see. Multiple myeloma ).
At vascular tumors — intra bone hemangiomas (see) a bone cylindrical or it is kolboobrazno blown up. Structure To. acquires the cellular porous drawing (fig. 29). Changes extend to all To. or take only a part it. Most often intra bone angiomas are localized in vertebras and edges. At the mixed form of a hemangioma also people around are surprised To. vessels. At the same time swelling can be observed To. and small - and the sredneyacheisty drawing; in other cases periosteal growths come to light as manifestation of reaction on is excessive the developed okolokostny vessels; in the third — can meet calcification and ossification in soft tissues (fig. 30). In the thickness of a myagkotkanny tumor multiple phleboliths (fig. 31) of different size, and also sites of ossification meet.
From tumors To. a connective tissue origin most often meets fibrosarcoma (see). Distinguish out of - and intra bone tumors. The extra bone tumor — a periosteal fibrosarcoma on the roentgenogram appears against the background of soft tissues in the form of more or less accurately outlined roundish, oval or krupnobugristy education adjoining K. Chasto against the background of this education accumulations of bone beams are visible various size of calcification, occasionally. Structure To. remains not changed. Only regional defects meet To. as a result of an atrophy from pressure slowly growing tumor. When growth of a tumor gains infiltriruyushchy character, it can burgeon not only in surrounding soft tissues, but also in To. (both in subject, and in next), forming then the regional centers of destruction (fig. 32).
Intra bone fibrous tumors meet much less often, generally on the lower extremities. They can have from the very beginning the expressed malignant character. Lokalizuyas in metaphyses (is more often in the field of a knee joint), they have rentgenol, the picture similar to a picture of an osteolytic osteosarcoma. Along with it there are intra bone fibrous tumors differing in a long-term high-quality current. On roentgenograms the tumor is presented in the form of the center of the enlightenment of a rounded or oval shape caused by accumulation of fibrous fabric inside To.; at this level K. it can be blown up. Periosteal stratifications are absent (fig. 33).
Destruction of a sacrum at to a chordoma (see) it is presented it is central the located center of the different sizes with the multiple bone partitions of this or that thickness or semi-partitions giving to a sacrum the coarse drawing. Sometimes quite considerable inflation of a sacrum (fig. 34) takes place.
Adamantinoma long tubular To. has morfol, looking alike to the world literature is described by maxillary K. V adamantinoma several tens of such tumors, is almost exclusive in tibial To. (fig. 35). The tumor is located in a marrowy cavity, reaches the big sizes, the cortical layer can burgeon. Microscopically it is not always similar to a typical adamantinoma, can have adenomatous character. Along with adenomatous sites there can be cavities with an epithelial-like vystilka like a multilayer flat epithelium (fig. 36). In other places vascular structures with transitions to epithelial-like can be expressed. Existing many years, adamantinomas can make big destructions To. or proceed zlokachestvenno with formation of metastasises in the remote bodies.
Distinguish the following metastatic tumors of K. Metastaziruyet in To. hl. obr. cancer of a lung, milk, prostatic, thyroid glands with formation of usually multiple nodes or diffusion growths (tsvetn. fig. 15). Metastasises of cancer can be osteolytic or osteosclerotic. Hypernephroid tumors quite often form single metastasises which removal can give good to lay down. effect. Also some benign tumors can metastasize To. without their structural malignancy, napr, an osteoblastoclastoma. In similar cases operational removal of metastatic nodes (including pulmonary) along with removal of primary center leads to treatment.
On rentgenol, a picture distinguish the following kinds of metastasises in To.: lytic, blastic and mixed.
At lytic metastasises tumoral process is presented by destruction of bone substance in the form of the single or multiple centers of the most various form and size which are located is central and eccentric both in flat, and in tubular To. These centers are usually accurately outlined and even at their large number almost do not merge with each other. Enostalny and periosteal reactions, as a rule, are absent.
At a blastic version destruction is absent also a metastatic node in To. it is presented by the center of consolidation. The centers of consolidation can be round, oval or most irregular shape. Periosteal reaction is absent. In the presence of the multiple sites of consolidation of irregular shape located closely to each other affected areas of a skeleton acquire very peculiar drawing reminding reorganization at Pedzhet's disease. Such pedzhetovsky drawing is characteristic of metastasises of cancer of some bodies, napr, a prostate. At the mixed kind of metastasises the combination of the centers of destruction to the centers of consolidation in the most various ratios takes place.
Tumors To. it is necessary to differentiate with nek-ry opukholepodobny changes: chondromatosis of bones (see), metafizarny cortical defect, eosinophilic granuloma (see), intra bone ganglion. Metafizarny fibrous defect (synonym; cortical fibrous defect, not osteogene fibroma, neossifitsiruyushchayasya fibroma) comes to light at children on roentgenograms in the form of the small center of destruction in cortical substance of long tubular bones, is more often in metaphyses (fig. 37). Proceeds asymptomatically or with small pains, can pass without treatment. Microscopically it is the centers of growth of fibrous fabric with not numerous colossal cells (fig. 38). The same structure has metafizarny cortical defect. But it extends to the marrowy canal and can reach the big size (fig. 39). An intra bone ganglion — the limited center of dystrophic sliming of fabric of interosseous spaces. In the central part it the cavity with mucous contents, around it fibrous fabric is usually formed.
Bone cyst (synonym: a juvenile, simple bone cyst) — a cavity in To., containing serous or bloody liquid; the hl develops at children of advanced age and at teenagers, a thicket at boys. obr. in long tubular To. (fig. 40). Beginning in metafizarny area, in process of growth To. it is displaced to a diaphysis. As a rule, the cyst of a solitarn, can proceed asymptomatically, being shown patol, a change. Current high-quality. In walls of cysts osteoblastoclastoma sites can meet. The cyst is more often than an odnokamern, but can consist of several cameras which are usually reported among themselves. Some forms of multichamber cysts allocate in an independent nozol, a form under the name of an aneurysmal cyst (see. Bone cyst ).
Diagnosis of tumors To. shall be complex, taking into account klinikolaboratorny, radiological and pathoanatomical data.
Rentgenol, symptoms of primary tumoral defeats To. are not numerous. It is destruction, deformation To., enostalny and periosteal reactions. All these symptoms are not specific to tumoral process and meet at many other diseases To. The correct recognition requires the careful analysis of all symptoms in comparison to data of the anamnesis, clinic, a lab. researches, biopsy and dynamic observation.
For gistol, studying of a tumor apply generally puncture or open biopsy. At suspicion of cartilaginous tumors and the open biopsy since sites, important for diagnosis, can be not in all places of a tumor is tumor Ewing more preferable. Apply also methods radio isotope diagnosis (see). More and more diagnosis of tumors enters practice tsitol, To. Apply an angiography to definition of nature of a tumor, and women have a test sex chromatin (see).
Treatment of tumors To. generally operational. At benign tumors the regional or segmented resection is most accepted. The scraping is applied less often owing to its not radicalism, especially in the absence of the capsule at a tumor. At malignant tumors usually apply amputation or an exarticulation of an extremity, sometimes a wide resection.
Radiation therapy of tumors To. it can be carried out as an independent type of treatment, and also in combination with a surgical oncotomy or with chemotherapy. The choice of this or that method depends from gistol, structures of a tumor and a stage of a disease.
By the standard and most effective method of treatment of osteosarcomas, hondro-and fibrosarcomas the combination of radiation therapy to operation is. At an osteosarcoma the main method of beam treatment is the remote gamma therapy, at a cut radiation is made from 2 — 4 fields (depending on extent and the volume of a tumor) in a total focal dose 7000 — 9000 is glad. New techniques of radiation of osteosarcomas and a hondrofibrosarok gained distribution: radiation in the conditions of the local hypoxia reached by an applying a tourniquet on the affected extremity in a total focal dose 7000 — 12 000 I am glad for 3 — 4 fractions with an interval between them in 10 days or in a total dose 10 000 — 12 000 I am glad at a single dose 2000 — 2500 is glad two times a week, and also longitudinal radiation of long tubular bones, at Krom the radiation of the betatron with energy of 25 Mev goes along an axis of a bone from two opposite fields. It is noted that at a combination of beam treatment to chemotherapy (adriamycin, a methotrexate, Vincristinum and Cyclophosphanum) the frequency of metastasises decreases more than twice.
At hondro-and a fibrosarcoma the combination of treatment to preirradiation is recommended. Technique of radiation at the same time same, as well as technique of radiation of osteosarcomas. Also preventive courses of chemotherapy after the end of beam or himioluchevy treatment during 1/2 — are recommended 2 years.
These acquired polyetiological diseases To. arise owing to disturbance of blood circulation in a bone tissue under the influence of toxic defeats (phosphoric, fluoric and other poisonings) or as a result of alimentary frustration, napr, osteomalacy (see), rickets (see), an urovsky disease of Kashin — Beck (see. Kashina — Beck a disease ), scurvy (see).
Essence of dystrophic defeat To. — osteochondropathy (see) — consists in local disturbance of blood circulation of a bone and emergence of sites of an aseptic necrosis in spongy K. Bolezn strikes an epiphysis and apophyses long tubular To. and some short To., bodies and apophyses of vertebrae. Diseases are known on surnames of the authors who described them (see. to Kalva disease , Köhler of a disease , Keniga disease , Kyummellya disease , Osgood — Shlattera a disease , Pertesa disease , Sheyermanna — Mau a disease ).
At osteodystrophies the attempt of the general treatment — removal of adenoma of epithelial body, prevention of avitaminosis, intoxication, a circulatory unefficiency of sites of a bone becomes.
Osteogene nefropatiya (see), renal osteodystrophies (see. Nephrogenic osteopathy ), Fankoni's syndrome (see. Fankoni nefronoftiz ) call a number of the general diseases at which into the forefront their connecting combination of the most struck systems acts pathogenetic: bone and renal. At hron, damage of kidneys for the second time and consistently system bone changes, on the wedge, a picture reminding rickets develop.
Endocrine osteodystrophies cause big changes in a bone skeleton, especially if defeat of thyroid, parathyroid glands or a hypophysis happened at early age. At recovery of normal function of a closed gland there occurs recovery of structure To.
Parathyroid osteodystrophy (see) is caused by a tumor of epithelial body. Typical changes of bones consist in the expressed general osteoporosis in combination with the cystous centers and patol, changes. The hypothyroidism leads to a growth disorder of a bone and dwarfism (see).
A peculiar disease state of a bone tissue is patol, reorganization To., edges develops at hron, overloads. In a basis patol, reorganizations lie disturbances biochemical, biophysical, processes, systems of regulation of exchange. There is activation, dissociation of basic processes of life activity To., including resorption and creation. The disturbances of content of mineral substances which are shown in insular deposits are possible; near them zones of a resorption, sites of a necrosis come to light. Fixing of mineral substances is broken. About zones of a necrosis the planes of a resorption filled with the necrotic mass, the remains of hemorrhages, particles of beams, bone glybka and so forth are possible; edges of the planes can be considerable mineralized. Here bone beams from ossiform fabric in different stages of formation, the so-called mosaic beams which are partially demineralized, the thinned old beams are noted. The periosteum is thickened, quite often mineralized.
Clinically patol, reorganization is the cornerstone of many painful states To., designated as a tired bone, a marching (mid-flight) change (see. Mid-flight foot ), a periostosis, Loozer's zones (see. Loozera of a zone ), reorganization at Pedzhet's disease (see. Pedzheta disease ), etc.
At patients with patol, reorganization complaints to pains, weakness, bystry fatigue of an extremity prevail, especially at loading. The zone of defeat is edematous, painful, soft tissues of a gipotrofirovana.
The diagnosis patol, reorganizations To. establish clinicoradiologically: overloads in the anamnesis, studying structural (technically correctly made, with existence of all details of bone structure) pictures. Submakrorentgeno a logical diagnostic method of reorganization To. consists in visual with increase twice the analysis of building blocks of a bone tissue according to the roentgenogram. At the same time there are visible elements of reorganization which skialogichesky sizes make from 0,1 to 1,5 — 2 mm. Basic elements of reorganization are conditionally presented in the figure 41.
The main morfol, substrates of reorganization are zones of a resorption of various form and localization and adjournment of mineral substances. The diagrammatic representation morfol, structures of reorganization in various departments To. it is presented in the figure 42.
Treatment patol, reorganizations depends on localization of process, depth and expressiveness of changes, existence of deformation of a bone and so forth; consider a degree of activity of processes of reorganization, feature funkts, loadings, etc. The main method of treatment is the immobilization in a plaster bandage. Duration of treatment depends on features of defeat. The immobilization is combined with fortifying therapy, physical therapy, to lay down. physical culture.
At operations on To. all types are applied anesthesia (see). The choice of quick access depends on character and localization patol, process. The most widespread operative measures on To. the following is. Trepanation (see) — the opening of a cavity which is either quick access, or independent operation. Make a sequestectomy or a necretomy for removal of sequesters. Osteotomy (see), osteoclasis (see) make at the expressed deformations To. at patients with effects of injuries, various dysplastic and dystrophic diseases. Subperiostal cross, ugloobrazny, fenestrated osteotomies are most often applied. A resection of an affected area To. (segmented or regional) it is shown at inflammatory, tumoral and dysplastic processes. The resection can be made podnadkostnichno or with removal of a periosteum. Substitution of defects To. after a resection it is carried out by means of bone allotransplants (see. Bone plastics ). After an expanded resection of joints function of an extremity can be recovered by endoprosthesis replacement of joints by metal or metalpolymeric endoprostheses. At extensive destructions apply resections of the joint ends of bones. Amputation (see) and exarticulation (see) make usually by force at heavy damages or for rescue of life at some malignant tumors.
Connection of fragments — osteosynthesis (see) carry out by means of metal plates, nails and so forth.
Broad use was found various compression distraktsionnye and pivotally-distraktsionnye by devices at reposition of bone fragments, correction of deformations, lengthening of the shortened extremities, postoperative rehabilitation for recovery of movements in joints (see. Distraktsionno-kompressionnye devices ).
Apply different types to anatomic recovery of an integrity of a bone, stimulation of regenerator processes and an osteogenesis bone plastics (see).
In the postoperative period along with problems of prevention of various complications the main attention is paid to the earliest recovery of social full value and working ability of patients (see. Postoperative period , Rehabilitation ).
Bones and bone remains in the medicolegal relation
To. remain a long time after death and at the same time possess a large number of the signs valuable for identifications of the personality (see) and for the answer to other questions interesting the investigation.
Need court. - medical examinations arises at detection of skeletirovanny corpses, separate bones and their fragments. First of all identify the personality of the individual. Identification of the personality on bone remains begins with the solution of a question whether the found bones are parts of one or several skeletons and whether the bone remains directed to examination belong to a skeleton of the person or an animal. Then define a sex, age, growth and race of the person, to-rogo treated a skeleton K. Neobkhodimo to find on To. all features allowing to individualize the identity of the dead. The signs connected with a profession and a way of life, traces of the former damages and diseases, etc. concern to them.
Sometimes court. - to the medical expert raise only one or several questions, but, despite it, it is necessary to resolve all listed issues in the given sequence.
At court. - a medical research K. apply anatomo-morphological, microscopic, radiographic, spectrographic, biochemical, mathematical techniques. After acquaintance with the sent documents and objects of examination they are examined, photographed, cleared of soft tissues or pollution, if necessary separate fragments stick together, and strongly destroyed To. fix.
The research is begun with grouping separate To. according to their arrangement in a skeleton. If is revealed much To., bones of a skull, humeral are grouped, e.g., separately To. and To. forearms (fig. 43).
For the solution of a question of accessory To. to a skeleton of the person or an animal first of all apply comparative and anatomic and X-ray anatomic methods of a research. At impossibility to resolve an issue by these methods apply serological, comparative and microscopic or spectrographic methods.
For sex determination, age, growth and race on To. first of all careful visual examination, i.e. an osteoskopiya, and measurement is necessary — kraniometriya (see) and an osteometriya according to requirements anthropometries (see). Then follows radiographic, and if necessary microscopic, spectrographic, biochemical, researches. Apply domestic five-point tables, diagnostic coefficients and other mathematical methods to sex determination. For age determination are especially valuable To. skulls, teeth, long To. and backbone. At the same time quite often use microradiological and microscopic methods. Determination of race is almost possible only on a skull.
Determination of growth does not make great difficulties in the presence of a full skeleton. There are domestic tables for determination of growth on humeral, femoral To. (Y.-V. Y. Naynis), To. shins (A. K. Garmus), femoral and tibial To. (G.F. Debets). As a rule, the best results are yielded by tables for the corresponding races and nationalities.
At identification of the personality after careful studying of all private signs comparison of the obtained data with katamnestichesky data is desirable (case histories, roentgenograms, photograms, etc.). In the presence of a skull and the intravital photo their photocombination, and on a skull — waxed reconstruction of the person according to M. M. Gerasimov is possible.
The issue of prescription of death is resolved only when conditions of burial of a corpse and the place of detection of K. Primenyaetsya visual examination, direct microscopy and other methods are known.
The cause of death can be established on To. only in rare instances, napr when there are intravital injuries of a skull obviously not compatible to human life.
Table 1. AVERAGE CONCENTRATION AND the AVERAGE RELATIONS of CONCENTRATION of CALCIUM, PHOSPHORUS, SODIUM IN NORMAL AND PATHOLOGICAL TISSUES of the SKELETON of the PERSON (&vnbsp; mg / &гnbsp; dry fabric), according to V. V. Proshin (1973)
Table 2. CHEMICAL COMPOSITION of the BONE TISSUE is NORMAL ALSO AT RICKETS (as a percentage)
Table 3. DIFFERENTIAL DIAGNOSTIC CHARACTERS of SOME INFLAMMATORY DISEASES of KOSTYA
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Radio isotope diagnosis and radiation therapy — Gabuniya R. I. and Bizet r V. A. Radio isotope diagnosis of tumors of bones, Vopr, onkol., t. 17, No. 4, page 36, 1971, bibliogr.; Zubovsky G. A., Glazer Yu. Ya. and and-lyazutdinov I. A. Effektivnost of a skennirovaniye with use of Sr85 and Sr87m at tumors of bones, Medical radio-gramophones., t. 16, No. 5, page 3, 1971, bibliogr.; Kalashnikov B. M., V. E. Hare ipro-sh and V. V N. Neutron and activation analysis of mineral composition of bones, in the same place, t. 20, No. 7, page 82, 1975, bibliogr.; To N y sh I. T. Radiation therapy of an osteosarcoma at a local hypoxia, in the same place, t. 20, No. 12, page 28, 1975, bibliogr.; Kozlova A. V. Radiation therapy of malignant tumors, page 284, M., 1971, bibliogr.; Likhtarev I. A., Krasnoshchekovag. Item and Kind skok A. I. The chamber analysis and studying of metabolism of Sr-85 and at imperfect bone formation, Medical radio-gramophones., t. 17, No. 1, page 70, 1972; In vivo neutron activation analysis, Proceedings of a panel on in vivo neutron activation analysis organized by the International Atomic Energy Agency, Vienna, 1973, bibliogr.; Jani L., H u-nigH. R. u. Sartorius J. Therapie maligner Knochentumoren, Orthopadie, Bd 5, S. 152, 1976, Bibliogr.; Medical radioisotope scintigraphy, International Atomic Energy Agency, v. 2, p. 325 a. o., Vienna, 1969; Oeser H. u. a. Atlas der Szintigraphie, B., 1970.
Pathology — Andrianov V. L., etc. Inborn deformations of upper extremities, MJ5 1972, bibliogr.; Bogoyavlensky I. F. Fractures of bones of a wrist, L., 1972, bibliogr.; Vinogradova T. P. Tumors of bones, M., 1973, bibliogr.; In about l to about in M. V. Diseases of bones at children, M., 1974, bibliogr.; M. V. wolves and D e d about in and V. D. Children's orthopedics, M., 1972; M. V. and Nefedyev's Wolves of H. H. Inborn fragility of bones, M., 1972; In about l to about in M. V. of L. I isamoylov. Fibrous osteodysplasia, M., 1973, bibliogr.; Gratsiansky V. P. To a question of loozerovsky zones of reorganization and periostites from an overstrain, Surgery, No. 3, page 71, 1937; Kaplan A. V. Injury of bones and joints, M., 1979; Kvashnina V. I. Differential diagnosis of metafizar-ny cortical defects of tubular bones, Tashkent, 1971, bibliogr.; Kosinskaya N. S. Degenerative and dystrophic defeats of the bone and joint device, L., 1961, bibliogr.; it, Disturbances of development of the bone and joint device, L., 1966, bibliogr.; it, Fibrous dystrophies and dysplasia of bones, L., 1973; Meerson E. M., Yu to and N and G. P. and Nechvolodov of O. L. Klinik, diagnosis and genetic aspects of studying of a gipokhondroplaziya, Ortop, and travmat., No. 9, page 40, 1977; The Multivolume guide to orthopedics and traumatology, under the editorship of N. P. Novachenko, t. 2, page 516, M., 1968, bibliogr.; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1 — 2, M., 1964; Samoylova L. I. inefedyeva of H. H. A multiple epiphyseal dysplasia at children and teenagers, Ortop, and travmat., No. z, page 54, 1968; With and t of e of N to about M. I. K to a question of so-called «zones of reorganization» in bones (Umbauzonen), in the same place, No. 3, page 1, 1928; Tageri. L. and Dyachenko V. A. Radiodiagnosis of diseases of a backbone, M., 1971, bibliogr.; Trapeznikov H. N and Grigo-r about in and T. M. Primary tumors of pelvic bones, M., 1978, bibliogr.; Bone-certain aspects of neoplasia, ed. by of Page H. G. Price a. F. G. M. Ross, L., 1973; D o m i-n o k G. W. u. K n o with h H. G. Knochen-geschwiilste und geschwiilstahnliche Kno-chenerkrankungen, Jena, 1977, Bibliogr.; Edeiken J. a, H o d e s P. J. Roentgen diagnosis of diseases of bone, v. 1 — 2, Baltimore, 1973; Fairbank T. Dysplasia epiphisealis multiplex, Brit. J. Surg., v.34, p. 225, 1947; Forrester D. M. a. N e s s o n J. W. The radiology of joint diseases, Philadelphia, 1973; Greenfield G. B. Radiology of bone diseases, Philadelphia — Toronto, 1969; J o w s e at J. Metabolic diseases of bone, Philadelphia, 1977; Lichtenstein L. Bone tumors, St Louis, 1977, bibliogr.; Maroteaux P. Les maladies osseuses constitutioninneles, La maladie de Morquio, Rev. Rhum., t. 32, p. 42, 1965; Rubin Ph. Dynamic classification of bone dysplasias, Chicago, 1964; Simon G. Principles of bone X-ray diagnosis, L., 1973; Singer F. R. Paget’s disease of bone, N. Y., 1977, bibliogr.; S p j u t H. J. a. o. Tumors of bone and cartilage, Atlas of tumors pathology, Washington, 1970.
Bones and bone remains in the medicolegal relation — Alekseev of V. P. Osteometriya, M., 1966; Drills S. A. and Reznikov of B. D. Rentgenologiya in forensic medicine, Saratov, 1975, bibliogr.; Gerasimov M. M. Recovery of the person on a skull, M., 1955; Good-natured person V. I. Forensic medical examination of a skeletirovanny corpse, Kiev, 1960, bibliogr.; Laboratory and special methods of a research in forensic medicine, under the editorship of V. I. Pashkova and V. V. Tomilin, page 375, M., 1975; Naynis Y.-V. Y. Identification of the personality on proximal bones of extremities, Vilnius, 1972, bibliogr.; Pashkova V. I. Sketches of medicolegal osteology, M., 1963, bibliogr.; Rubezhanskiya. T. Definition on bone remains of prescription of burial of a corpse, M., 1978; Identifikation, hrsg. v. H. Hunger u. D. Leopold, Lpz., 1978, Bibliogr.; Krogman W. M of The human skeleton in forensic medicine, Springfield, 1962.
M. V. Volkov, L. I. Samoylova; I. F. Bogoyavlensky (reorganization of a bone), T. P. Vinogradova (PMC., stalemate. An., embr.), E. A. Vorobyova (An.), G. A. Zedgenidze (I am glad.), B. S. Kasavina, V. P. Torbenko (biochemical), I. G. Lagunova, L. D. Lindenbraten, S. A. Sviridov (rents.), Yu. E. Lukoyanov, B. A. Nikityuk (physical.), I. V. I. Naynis (court.).