MUSKULOSKELETAL

Dosen Pengampu :
dr. Fairuz C.Quzwain, SpPA
NIP.132313010
ANATOMI DAN HISTOLOGI
Berdasarkan bentuknya tulang dibagi
menjdi : tulang panjang (mis. femur,
humerus), tulang pipih (mis. Pelvis), dan
tulang pendek ( mis, phalang).
Tulang panjang dibagi menjadi beberapa
regio : diaphysis, epiphysis, metaphysis.
Penumbuhan tulang berawal dari epiphyseal
plate, dimana dimulainya endochondral
ossification.
 Epiphyseal plate most common site of
occurrence of most primary bone tumors.
Histologi : tulang matur terdiri dari outer compact
layer ( cortex, cortical bone, compact bone) dan
central spongy region ( spongiosa, medulla,
cancelous bone)
METABOLIC BONE DISEASES
Osteoporosis
Penurunan massa tulang
Tidak dapat memperbaiki maupun
mempertahankan massa tulang
After menopause estrogen deficiency
Causes : multiple
 Osteomalacia
Unmineralized bone matrix resulting from a
diminished rate of mineralization
Congenital and acquired metabolic
abnormalities
Penurunan serum calcium, phosphorus, dan
keduanya.
OSTEOMYELITIS
Bacterial osteomyelitis may be caused by a large variety of
microorganisme
70 90% due to coagulase-positive staphylococci. Other microorganisme
: klebsiella, proteus, pseudomonas, streptococcus, etc.
Local or exogenous causes, or through to hematogenous route.
Can be acute, subcute or chronic
Lytic lesion in metaphysis with periosteal reaction. In spine, the disc
space is narrowed and the vertebral end plates are eroded. Can
resemble malignant bone tumor because of lytic and regenerative
changes.
May see bone necrosis of central region (sequestrum) and new bone
forming around it (involucrum). Inflammation dominated by
lymphocytes and plasma cells. Infection of a prosthesis is a different
process, usually neutrophilic.
Bacterial stains are rarely helpful.
Treatment is antibiotics and surgical drainage. About 5% of acute cases
develop into chronic osteomyelitis.
OSTEOMYELITIS TUBERKULOSA
Merupakan infeksi oleh Mycobacterium
tuberculosis.
Hematogenous infection
Dapat terjadi dimana saja, biasanya spine and hip
pada anak-anak dan knee pada orang dewasa.
Radiologi joints, destruction of subchondral
bone.
Mikroskopis Organisms, bacilli, 0.3 - 4 microns.
BTA (+) . Ditemukan pembentukan tuberkel,
terdiri dari serbukan limfosit, proleferasi sel
epithelioid, sel datia langhans dan nekrosis
perkijuan.
BONE NECROSIS
Infarct
Aseptic (avascular) bone necrosis
Osteochodritis dissecans
Radiation necrosis
ASEPTIC (AVASCULAR) BONE NECROSIS

Usually ages 30's - 40's.

Predominantly male.
Either medullary (in marrow), or subarticular bone. Usually
femoral or humeral head.
80% associated with alcohol abuse or steroid therapy. Joint pain
and osteoarthritis when near joint.
MRI shows marrow edema early. Conventional x-ray shows no
abnormalities for months, followed by increased density. If
involving joint, possibly subchondral radiolucent crescent sign.
Loss of nuclei in bone. Necrosis of marrow fat and hematopoietic
tissue may be easier to appreciate. Surrounding granulation tissue
and sclerotic bone. Complications include secondary osteoarthritis,
fracture, secondary infection, sarcoma. The terms
avascular/aseptic necrosis are often used when the infarct involves
the end of a long bone. See also Osteochondritis dessicans.
If infarct underlies joint, it leads to osteoarthritis.
OSTEOCHODRITIS DISSECANS

Usually young adults.

Most common site is the lateral aspect of
medial femoral condyle.
Most cases are probably related to trauma.
Small area of bone necrosis adjacent to
articular surface, totally or partially separated
from original site.
Specimen is a portion of bone with articular
cartilage. A loose body is formed when the
detached fragment remains viable in the joint
space (the bone dies but the cartilage survives)
PAGETS DISEASE
90% > 55 tahun
Focal or diffuse. Lumbosacral spine, pelvis, skull, and long
bones. Rare in ribs.
Most common in England, Australia, and Western Europe. May be
caused by slow virus (seen by electron microscopy) in
osteoclasts.
Radiolucent early, then radiodense due to coarse trabeculae.
One of the few lesions that can uniformly enlarge bone.
Resorptive phase (early), increased osteoclast and osteoblast
activity with fibrous stroma. Intermediate and late phase,
excessive osteoblast activity with poorly organized bone, thick
trabeculae, and numerous, prominent, scalloped remodeling
lines in a mosaic pattern.
Benign by itself, but carries a high risk of sarcoma, usually
osteosarcoma, 1% for single lesions, 10% for multiple lesions
(accounts for 3% of osteosarcomas).
Early changes. There is prominent osteoclastic
activity, resulting in bone resorption.
A well-established case, with thick, irregularly
shaped bone trabeculae.
OSTEOARTHRITIS
= Osteoarthrosis, Degenerative joint disease.
Increasing frequency with age.
Most commonly hip and knee.
Charcot joint, older patients. Gradual onset of joint pain and
stiffness.
X-ray reveals loss of cartilage, sclerosis of subchondral
bone, possibly osteophytes, and subchondral cysts.
Early/mild changes occur on surface of cartilage, decreased
basophilia, vertical clefts, loss of chondrocyte nuclei,
reparative changes (chondrocyte clones). Late/severe
changes include erosion of cartilage, myxoid cysts within
trabecular bone (subchondral cyst), thickening of underlying
bony trabeculae, formation of bone spurs at joint edge.
Loose bodies are pieces of broken off cartilage and bone.
RHEUMATOID ARTHRITIS (RA)
Affects about 1% of world's population.
Peak incidences occur in 30's and 50's, though can
affect all ages.
Affects women 3 - 5 times more often than men.
Joints of feet and hands are nearly always affected.
Frequently affected joints include elbows, knee,
wrists, ankles, hips, spine and temporomandibular
articulations.
Typically slow and insiduous onset in more than half
of patients. 10% have acute onset. Often family
history. 70% are HLA-DR4. Combined features of RA,
splenomegaly and neutropenia known as Felty's
syndrome.
 Earliest changes occur in synovium,
hyperemia, proliferation of synovial lining
cells and infiltration by plasma cells and
lymphocytes (forming pannus, causing erosion
of joint cartilage).
Second phase, synovium and granulation tissue
penetrate bone forming erosions, subchondral
cysts and osteoporosis, resulting in fractures.
Following cartilage destruction, pannus
bridges apposing bones, forming fibrous
ankylosis and eventually bony ankylosis.
 Extraarticular manifestations include
rheumatoid nodules, composed of necrotic
center with fibrin, surrounded by histiocytic
inflammatory reaction, often arranged in
palisading fashion. Other pathologic findings
include necrotizing arteritis and amyloidosis.
TUMORS
Klasifikasi tumor yang direferensikan banyak
center adalah klasifikasi menurut WHO.
Pada umumnya keganasan pada tulang
terjadi de novo.
Terdapat beberapa lesi jinak pada tulang
yang dapat menjadi predisposisi menjadi
keganasan, antara lain pagets disease,
chondromatosis, osteochondromatosis,
fibrous dysplasia dan osteofibrous dysplasia.
 Lima parameter yang penting diketahui
dalam keganasan tulang adalah : umur, jenis
tulang, area tulang ( epiphysis, diaphysis,
metaphysis ), Ro appearance, microscopic
appearance.
BONE-FORMING TUMORS
 OSTEOMA
Osteoma merupakan tumor jinak tulang, yang
biasanya terjadi pada daerah tulang pipih misalnya
tengkorak dan tulang wajah.
Biasanya terjadi pada umur 40 50 tahun dengan
ratio laki-laki dan wanita adalah 2:1
Penderita dengan Gardners syndrome , biasanya
terjadi multipel osteoma dgn beberapa kelainan
( intestinal polyposis dan soft tissue tumors)
Secara mikroskopis tampak tulang matur, padat
dengan gambaran lamellarnya, tumbuh hiperplastis.
OSTEOID OSTEOMA
Benign bone neoplasm
10 30 yrs
2:1 male-female ratio
Inntense pain most prominent symptoms, more intense
at night, relieved by NSAID
Every bone
Most are centered in the cortex (85%)
X-ray : radiolucent central nidus, seldom larger than 1,5
cm. This nidus is surrounded by a peripheral sclerotic
reaction
Microscopically : sharply delineated central nidus is
composed of more or less calcifiedosteoid lined by plump
osteoblasts and growing within highly vascularized
connective tissue
 Osteosarcoma
Osteosarcoma atau osteogenic sarcoma merupakan tumor ganas
primer tulang yang paling banyak terjadi.
Biasanya mengenai penderita usia muda yaitu 10 25 tahun.
Pada usia tua, insidensi terbanyak terjadi pada usia lebih dari 40
tahun. Tumor ini lebih sering terjadi pada laki-laki dibandingkan
wanita.
Predisposing factor :

1. Pagets disease
2. Radiation exposure
3. Chemotherapy
4. Preexisting benign bone lesion
5. Foreign bodies
6. Trauma
 Arising de novo
Metaphyseal area of the long bones, particularly the lower end
of the femur, the upper end of the tibia, and the upper end of
the humerus.
From its usual origin in the metaphysisof a long bone, the tumor
may :
1. Spread along the marrow cavity
2. Invade the adjacent cortex
3. Elevate or perforate the periosteum
4. Extend into the soft tissues
5. Extend into the epiphysis
6. Extend into the joint space
7. Form satellite nodules independent from main tumor mass
8. Metastasize trough the bloodstream to distant sites,
particularly the lung
 Molecular genetic features :
1. The most common cytogenetic
abnormalities detected in osteosarcoma
involve chromosomes 1,2,6, 12and 17.
2. Mutations of p53 have been found in about
20% of osteosarcoma
 The key feature for the diagnosis in the
detection of osteoid and/or bone (calcified
osteoid) produced directly by the tumor cells
without interposition of cartilage.
Osteoid is recognized by its eosinophilic-
staining quality, its glassy appearance,
irregular contour, surrounded by a rim of
osteoblast.
 Microscopic variants and special types :
1. Telengiectatic
2. Small cell
3. Fibrohistiocytic
4. Anaplastic
5. Well differentiated intramedullary
Other variant of osteosarcoma are defined on the basis of
t0pographic, clinical, or radiographic features, or
combination of them :
6. Parosteal osteosarcoma
7. Periosteal osteosarcoma
8. Osteosarcoma of the jaw
9. Osteosarcoma in pagets disease
 Pathologic diagnosis before instituting definitive
therapy : biopsy
Needle biopsy in experienced hands is
extremely reliable
Laboratory test are of no great value in the
diagnosis of osrteosarcoma. The only
abnormality detected with some frequency is
elevation of serum alkaline fosfatase
The therapy of osteosarcoma of the
extremities has usually consisted of amputation
or disarticulation, depending on the location of
the tumor.
CARTILAGE-FORMING TUMORS
CHONDROMA
A common benign cartilaginous tumor
Most frequently in the small bones of hands
and feet, particularly the proximal phalanges
About 30% chondromas are multiple.
Multiple enchondromas having predominantly
unilateral distribution olliers disease
The association of multiple endchondromas
with soft tissues hemangiomas Maffucis
syndrome
Microscopically are composed of mature
lobules of hyaline cartilage.
 Osteochondroma
Osteochondroma atau disebut osteochondromatosis bila terjadi
multipel, merupakan tumor jinak tulang yang paling banyak
terjadi.
Biasanya mengenai usia muda yaitu 10 30 tahun. Tumor ini
terjadi pada daerah metafise pada tulang panjang yaitu femur,
tibia, maupun humerus.
Secara radiologis tampak tulang dengan exostosis, sessile atau
dengan tangkai. Biasanya kurang dari 5 cm. Adanya kemungkinan
keganasan apabila cartilagenous cap lebih dari 3 cm, irregular
margins of cartilage cap, lucent zones pada lesi.
Mikroskopis tampak cartilage cap ( jarang lebih dari 1 cm) yang
diliputi oleh jarinagn fibrosa. Dibawah cartilage cap, terdapat
endochondral ossification zone yang berhubungan dengan bony
pedicle. Pedicle menyambung dengan medulla tulang.
 Chondrosarcoma
Chondrosarcoma merupakan tumor ganas
tulang rawan.
Biasanya terjadi pada usia 30 60 tahun.
Predileksi tumor ini adalah tulang pelvis,
costa, femur, humerus dan vertebrae.
Dibagi menjadi 2 kategori mayor yaitu :
conventional chondrosarcoma dan
chondrosarcoma variants
Conventional chondrosarcoma : central,
peripheral, juxtacortical
 Microscopically : show remarkably wide
range of differentitation, the common
denominator being the production of
cartilaginous matrix and the lack of direct
bone formation by the tumor cell. This range
in differentiation is the basis for the grading
of these tumor into well, moderately, and
poorly differentiated.
 Chondrosarcoma variants :
1. Clear cell chondrosarcoma
2. Dedifferentiated chondrosarcoma
3. Mesenchymal chondrosarcoma
 Giant Cell Tumor of the Bone
Giant Cell Tumor atau disingkat dengan GCT pada
tulang, b iasanya terjadi pada usia 20 40 tahun. Tumor
ini paling sering terjadi pada wanita. Biasanya terjadi
pada tulang panjang, dan dapat mengenai metafisis
ataupun epifisis.
Radiologis ditemukan lesi osteolitik dengan batas tegas,
dan memberikan gambaran soap bubble
Secara mikroskopis tampak massa tumor terdapat
banyak osteoclast-type giant cells dengan jumlah inti
yang banyak (20-30). Ditemukan pula sel bentuk spindel
yang plump (gemuk ) dengan inti mempunyai karateristik
yang sama dengan inti pada giant cell, mitosis normal
dan tidak ditemukan pleomorphism. Dapat ditemukan
daerah yang nekrotik maupun perdarahan.
RHABDOMYOSARCOMA
Rhabdomyosarcoma merupakan tumor ganas yang
berasal dari sel otot lurik. Tumor ini dapat terjadi
pada anak-anak maupun usia tua. Pada anak-anak
biasanya mempunyai predileksi terutama di kepala,
sedangkan usia tua biasanya di ekstremitas. Terdapat
3 kategori mayor rhabdomyosarcoma yaitu
pleomorphic, embryonal, dan alveolar
rhabdomyosarcoma.
Secara mikroskopis diagnosis rhabdomyosarcoma
adalah ditemukan adanya sel rhabdomyoblast, yaitu
sel dengan sitoplasma yang eosinofil dan dengan inti
yang pleomorifk, hiperkromatis dan banyak
ditemukan mitosis. Dapat ditemukan pula sel limfosit,
sel plasma dan sel eosinofil
 Fibrosarcoma
Fibrosarcoma adalah tumor ganas jaringan
lunak yang berasal dari sel fibroblas. Tumor
ini paling banyak mengenai usia 30 50
tahun dengan lokasi tersering adalah
ekstremitas bawah. Gambaran mikroskopis
fibrosarcoma secara khas ditemukan sel-sel
spindel yang tumbuh hiperplastis dan
membentuk susunan fasikulus yang
memberikan gambaran khas herringbone
appearance.
 Radiologis ditemukan gambaran yang khas yaitu
sun burst appearance, periosteal reaction dan
codmans triangle.
Secara mikroskopis pada tumor ini harus
ditemukan adanya pembentukan osteoid ganas,
yaitu dengan gambaran eosinofilik, glassy
appearance, irregular countours, dan dikelilingi
oleh osteoblast. Gambaran lain adalah seperti
gambaran keganasan pada umumnya yaitu sel
dengan inti yang pleomorfik, hiperkromatis
dengan mitosis yang banyak dan adanya struktur
microtrabeculae yaitu massa berwarna basofil dan
menyerupai hifa jamur.