أمراض و أورام العظام فى الانسان-لغة انجليزية- كتبته بنفسى-diseases of bones

[mohamed_ameer]

أمراض و أورام العظام فى الانسان-لغة انجليزية- كتبته بنفسى

-diseases of the bones in human

differential diagnosis of bone swellings

1- osteomyelitis :- a) acute :- the patient is usually a child complaining of severe pain and swelling in a limb. the onset is acute with high fever, rigor and severe constitutional disturbance.. examination reveals exquisite tenderness over the end of the bone with extensive cellulitis or subperiosteal abscess. marked leucocytosis is present and blood culture may be positive but X-ray examination is negative. the differential diagnosis is from acute rheumatic arthritis, acute suppurative arthritis, cellulitis and Ewing's sarcoma. of these, acute rheumatic arthritis, cellulitis and Ewing's sarcoma. of these, acute rheumatic arthritis is the commonest and most important.... it is differentiated by the history of fleeting affection of other joints, the characteristic acid sweats and the presence of maximum tenderness over the joint and not over the end of the bone.

b) chronic :- may follow acute osteomyelitis or septic compound fracture.... the patient presents with single or multiple sinuses and examination shows palpable thickening of the underlying bone... the sinuses are adherent to the bone and probing may reveal the presence of a loose sequestrum... recurrent acute exacerbations are common with fever, pain and discharge...x-ray examination shows thickening of the bone and the presence of a sequestrum or sequestra lying in the cavity enclosed by an involucrum.


2- sclerosing osteoperiostitis of Garre :- a chronic inflammatory condition of the bone which results in diffuse thickening and sclerosis with obliteration of the medullary cavity... there is deep aching pain in the limb, worse in bed because of the vasodilatation induced by warmth... the bone is diffusely thickened and tender and its surface is irregular... x-ray examination shows fusiform thickening of the bone which can be differentiated from sarcoma by the absence of bone destruction and swelling of the soft tissue shadow...in doubtful cases biopsy is essential..

3- brodie's abscess:- an encysted abscess in the metaphysis of a long bone, especially the two ends of the tibia, the lower end of the femur and the upper end of the humerus... the patient complains of intermittent aching pain in the affected bone with swelling of the neighbouring joint... the bone is thickened and tender and during an exacerbation, the soft tissues may be oedematous and the joint may contain a sympathetic effusion... radiography reveals a small clear cavity surrounded with a thin ring of sclerosis and the affected bones is often thickenend by deposit of subperiosteal new bone.


4) typhoid osteomyelitis arises usually from 6 to 8 weeks after the onset of the fever but may appear months or years later... the tibia , sternum and ribs are the commonest sites... there is pain, swelling and tenderness in the affected bone and subperiosteal abscess may be palpable... the temperature is raised and widal reaction is positive....x-ray examination shows destruction with little or no new-bone formation... aspiration yields a yellowish brown seropus from which a pure culture of the organism can be obtained.


5) tuberculosis of the bone occurs in three main forms, depending on the type of the bone affected :- a) in long bones it begins in the epiphysis or metaphysis (tuberculous osteitis) ;
b) in flat bones it starts in the deeper layers of the periosteum (tuberculous periostitis); c) in the small bones of the hands and feet it affects the diaphysis (tuberculous dactylitis)


the disease is indidious in onset and the patient may complain only of slight weakness or aching pain until cold abscess or tuberculous arthritis develops... examination reveals local tenderness and warmth, thickening of the bone, wasting of the muscles and pale swelling of the overlying soft tissues ( tumour album)....at a later stage,, the presence of a cold abscess or tuberculous sinus is pathognomonic....x-ray examination shows generalized decalcification and rarefaction with central destruction and blurring of the outline of the bone without any new bone formation.


6- syphilis :- in the tertiary stage, the bones may be involved by solitary gummata or diffuse gummatous periostitis. the disease occurs most often in the tibia and other subcutaneous bones: skull, calvicle, sternum and ulna.. characteristically,, the middle of the diaphysis of the bone is affected... the patient complains of severe boring pain particularly at night.... clinically the bone is thickened with alteration of its regular outline and loss of its sharp margin... if softening occurs , the skin breaks down to form a typical syphilitic ulcer... other signs of syphilis are usually present,, the W. R. is positive and x-ray examination shows marked thickening and sclerosis of the bone .

7- solitary bone cyst occurs most often in children and adolescents and usually affects the upper metaphysis of the humerus, femur or tibia.. it is associated with little pain and swelling and often attracts attention because of spontaneous fracture... radiography shows a clear void cavity expanding the bone without any new bone formation.


8- osteoma :- several clinical varieties are encountered :

a) ivory osteoma arises from the membrane bones of the skull... it may grow from the outer table forming a hard rounded or lobulated sessile mass... it may occur in the orbit producing exophthalmos, in the auditory meatus causing deafness and vertigo or in the nose blocking the air sinuses.

b) cancellous osteoma arises from the epiphyseal cartilage of any bone but is commonest around the knee... the tumour appears in childhood or adolescence as perdunculated or mushroom-shaped swelling growing from the metaphysis but may be shifted towards the diaphysis with growth in length of the bone... the tumour is covered with a cap of epiphyseal cartilage with adventitious bursa on the top and continues to grow until the epiphysis of the parent bone unites... the osteoma often remains symptomless until it causes obvious disfigurement , pain from pressure on a neighbouring nerve, mechanical blocking of joint movement or interference with the action of neighbouring tendons or until it is complicated by adventitious bursitis or pathological fracrture of its pedicle


c) diaphyseal aclasis is a hereditary condition manifesting it self in later childhood and affecting males more often than females... it is characterized by three main features :- multiple exostoses, unmodelled metaphyses and swarfism... multiple cancellous osteomata are found in the region of the knee, shoulder and wrist but any bone formed in cartilage may be affected... the affected metaphyses are often cylindrical in shape and irregular in structure.. due to impaired growth of the affected bones, the patient is often dwarfed and deformities, such as genu valgum, manus varus or valgus may arise... the patient is usually unaware of the condition until complications occur.

d) subungual exostosis is an irregular bony outgrowth under the nail of the big toe... the nail becomes lifted up and deformed and the tumour projects as a granulating mass from under the side of the nail... it is differentiated from the granuloma of ingrowing toe nail by its bony hard consistency and fixity to the bone ....


e) osteoid osteoma is rare lesion which occurs in the cortex of long bones, particularly the tibia and femur, and in the cancellous tissue of the small bones of the foot... it affects both sexes between the ages of 10 and 25 years... pain is a marked feature and may interfere with sleep... examination may show slight thickening or localized tenderness but often no signs are detectable... x-ray examination reveals a small area of translucency surrounded by a zone of thickening and sclerosis and tomography may show the " nidus" as a denser shadow in the centre of the translucent area... the condition should be differentiated from Brodie's abscess and sclerosing osteomyelitis of Garre by the history , radiography, and if necessary, biopsy.


9) chondroma : a) enchondroma arises in the small bones of the hands and feet rarely in the long bones of the limbs... the tumours are usually multiple and may be generalized (dyschondroplasia or ollier's disease )... they usually appear in childhood giving rise to a fusiform enlargement of the bone and later to a large lobulated mass...x-ray examination shows a large obulated cavity expanding the bone with small specks of calcification producing a characteristic mottled or stippled appearance... sarcomatous change may occur in tumours of long bones in adults but hands and feet.


b) ecchondroma (osteochondroma) is a solitary tumour arising at the end of a long bone, particularly the femur and humerus, or from the surface of a flat bone such as the scapula, sternum, ribs and pelvic bones... it forms a hard painless lobulated swelling fixed to the bone... there is frequently excessive bone formation in the tumour and malignant change is not uncommon, particularly in the flat bones.


10 ) osteoclastoma usually occurs between the ages of 20 and 40 years and is commonest at the knee, shoulder, wrist and jaw... the tumour arises in the epiphysis and less often in the metaphysis, forming a painless rounded hard swelling close to the joint... the end of the bone may be so expanded that a drumstick appearance is produced and the bone cortex may be so thinned that it yields or breaks on pressure with characteristic egg shell crackling ... the tumour may expand the bone on all aspects or may grow eccentrically but overlying tissues are not involved... the movements of the neighbouring joint may be limited and a sympathetic effusion may be present ...x-ray examination shows abrupt expansion of the bone by a translucent cavity traversed by thin wide trabeculae producing a characteristic soap-bubble appearance and demarcated from the shaft by a thin bony septum known as the medullary plug or operculum... unlike sarcoma, there is no destruction , no new bone formaton and no swelling of the soft tissue shadow.



11- osteogenic sarcoma occurs in childhood and adolescence and is practically unknown after the age of 40 except as a complication of paget's disease... the most common sites are the adjacent ends of the femur and tibia and the upper end of the humerus and the rarest are the distal ends of the bones of the forearm and leg and the small bones of the hands and feet... pain is always the first symptom and precedes the appearance of the swelling by weeks or months... the swelling is fusifirm and ensheathes one end of the bone merging gradually towards the shaft... the overlying skin is stretched, dusky , warm and the seat of dilated veins... the consistency is heterogeneous, varying from fleshy to bony hard... vascular tumours may show pulsation and bruit may be detected on auscultation... there may be some sympathetic effusion into the neighbouring joint but movement is free and painless... eventually , the surrounding soft tissues are invaded and pulmonary metastases develop...x-ray examination reveals a diffuse soft tissue shadow around the bone which is partially destroyed and rarefied... from the surface of the bone,, radiating spicules of new bone often project outwards at right angles to the shaft giving a characteristic sun-ray appearance and sometimes a wedge of new bone is present at the edge of the tumour (codnan's triangle).. in obscure cases,, arteriography may provide useful information.



12 parosteal fibrosarcoma is rare tumour which arises from the periosteum or muscular insertions... it forms a fairly well- circumscribed fixed mass which grows slowly and spreads around the bone like a sheath but rarely produces metastases...x-ray examination shows a soft tissue shadow with a shallow saucer-shaped depression in the cortex.


13- Ewing's sarcoma affects the diaphyses of long bones in children between 5 and 15 years of age.. a painful fusiform swelling appears in relation to the midshaft of the bone.. the overlying skin may be warm and congested and there may be enlargement of the regional lymph nodes, fever , malaise and leucocytosis so that an erroneous diagnosis of osteomyelitis may be made...in the later stages secondary deposits appear in other bones and anaemia and cachexia supervene but the tumour never fungates except after surgical exploration... x-ray examination shows central destruction and rarefaction with the deposition of subperiosteal bone in successive layers, producing a characteristic " onion peal" appearance....

the tumour is very radiosensitive and its rapid disappearance under radiotherapy is highly diagnostic.


14) multiple myeloma occurs between the ages of 40 and 60 years.. the disease is a primary malignant tumour of the bone marrow and so the bones most frequently affected the ribs, sternum, skull, vertebrae, pelvis and femora.. the onset is insidious with intermittent pain usually in the back, which gradually becomes persistent and severe...in the later stages, there may be multiple swellings, pathological fractures, deformities, severe girdle pains (spinal root compression), paraplegia (spinal cord involvement) and severe anaemia ( marrow destruction)...x-ray examination shows multiple out areas of destruction from the size of a pea to that of an orange ,Bence Jones' proteose can be demonstrated in the urine in approximately half the cases... when the urine is heated,, coagulation occurs at 55 C and disappears at 85 C but reappears again on cooling... examination of the blood shows marked secondary anaemia with a very high sedimentation rate and a marked increase in serum globulin... the sternal marrow is almost always affected and the diagnosis can be confirmed by sternal puncture




15) secondary deposits may arise from a primary growth in the thyroid, breast, bronchus, stomach, kidney, suprarenal prostate or testis. the bones most commonly affected area are the skull, sternum, ribs, vertebare, pelvis, femur and humerus. pain and pathological fracture are the usual symptoms but sometimes a swelling becomes palpable.. x-ray examination shows irregular destruction without any new bone formation unless a pathological fracture with callus formation has occured... in prostatic metastases, the serum acid phosphatase (normally 0.5- 2 units / 100 ml ) is elevated (over 5 units) and the affected bone may be thickened and sclerosed ( sclerosing metastases ).



16 ) osteitis fibrosa cystica ( von-Recklinghausen's disease) is due to parathyroid adenoma or hyperplasia... the disease occurs in young adults, particularly females. the patient complains of severe pains in the affected bones with malaise and lassitude, but sometimes the presenting symptom is a pathological fracture or a bony swelling, particularly in the jaw. unrinary symptoms, such as haematuria and renal colic, are common due to the formation of urinary calculi... the serum calcium is raised (over 11 mg /100 ml), the serum phosphorus is reduced ( below 3 mg/100 ml) and the alkaline phosphatase is elevated (above 13 K.A. units). x-ray examination shows diffuse decalcification with multiple cystic areas, pathological fracture or bending deformity.


17)osteitis deformans ( Paget's disease) affects chiefly the bones of the skull, spine, pelvis and lower limbs in the elderly subjects, particularly males. the first symptom is usually aching pain and tiredness in the legs. the bones become thickened and deformed leading to kyphosis and bowing of the legs with a gorilla like appearance or in appearance..... spontaneous fractures are common in the femur and tibia and cranial nerver palsies may result from narrowing of the foramina of the base of the skull... osteogenic sarcoma occurs in about 5% of cases...x-ray examination shows thickening and bending of the affected bones with a characteristic mottled or striated structure... the skull bones are markedly thickened with a very irregular knobbly
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