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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)

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METABOLIC BONE DISEASES  Osteoporosis  Penurunan massa tulang  Tidak dapat memperbaiki maupun mempertahankan massa tulang  After menopause  estrogen deficiency  Causes : multiple .

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. Osteomalacia  Unmineralized bone matrix resulting from a diminished rate of mineralization  Congenital and acquired metabolic abnormalities  Penurunan serum calcium. phosphorus. dan keduanya.

 Bacterial stains are rarely helpful. or through to hematogenous route. etc. proteus. Infection of a prosthesis is a different process. pseudomonas.  Treatment is antibiotics and surgical drainage. Can resemble malignant bone tumor because of lytic and regenerative changes. usually neutrophilic. About 5% of acute cases develop into chronic osteomyelitis. Other microorganisme : klebsiella. In spine.  Can be acute.  May see bone necrosis of central region (sequestrum) and new bone forming around it (involucrum). Inflammation dominated by lymphocytes and plasma cells. subcute or chronic  Lytic lesion in metaphysis with periosteal reaction. . streptococcus.  Local or exogenous causes. the disc space is narrowed and the vertebral end plates are eroded.OSTEOMYELITIS  Bacterial osteomyelitis may be caused by a large variety of microorganisme  70 – 90% due to coagulase-positive staphylococci.

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. proleferasi sel epithelioid. 0.OSTEOMYELITIS TUBERKULOSA  Merupakan infeksi oleh Mycobacterium tuberculosis. terdiri dari serbukan limfosit.  Hematogenous infection  Dapat terjadi dimana saja. bacilli.3 .  Radiologi  joints. Ditemukan pembentukan tuberkel.4 microns. sel datia langhans dan nekrosis perkijuan. biasanya spine and hip pada anak-anak dan knee pada orang dewasa. destruction of subchondral bone.  Mikroskopis  Organisms. BTA (+) .

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BONE NECROSIS  Infarct  Aseptic (avascular) bone necrosis  Osteochodritis dissecans  Radiation necrosis .

 80% associated with alcohol abuse or steroid therapy.  MRI shows marrow edema early.ASEPTIC (AVASCULAR) BONE NECROSIS  Usually ages 30's . Complications include secondary osteoarthritis. If involving joint. Joint pain and osteoarthritis when near joint. Surrounding granulation tissue and sclerotic bone.40's. sarcoma. possibly subchondral radiolucent crescent sign. The terms avascular/aseptic necrosis are often used when the infarct involves the end of a long bone. followed by increased density. secondary infection. fracture.  Predominantly male.  Either medullary (in marrow).  Loss of nuclei in bone. Usually femoral or humeral head. . Necrosis of marrow fat and hematopoietic tissue may be easier to appreciate. Conventional x-ray shows no abnormalities for months. it leads to osteoarthritis. or subarticular bone. See also Osteochondritis dessicans.  If infarct underlies joint.

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 Most cases are probably related to trauma. totally or partially separated from original site. A loose body is formed when the detached fragment remains viable in the joint space (the bone dies but the cartilage survives) .OSTEOCHODRITIS DISSECANS  Usually young adults.  Most common site is the lateral aspect of medial femoral condyle.  Small area of bone necrosis adjacent to articular surface.  Specimen is a portion of bone with articular cartilage.

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1% for single lesions.PAGET’S DISEASE  90% > 55 tahun  Focal or diffuse. and Western Europe. Rare in ribs. pelvis.  Benign by itself. Australia. excessive osteoblast activity with poorly organized bone. Lumbosacral spine. thick trabeculae. One of the few lesions that can uniformly enlarge bone. skull. usually osteosarcoma. but carries a high risk of sarcoma. prominent. May be caused by slow virus (seen by electron microscopy) in osteoclasts. increased osteoclast and osteoblast activity with fibrous stroma. then radiodense due to coarse trabeculae. 10% for multiple lesions (accounts for 3% of osteosarcomas).  Resorptive phase (early). scalloped remodeling lines in a mosaic pattern. and long bones. Intermediate and late phase. . and numerous.  Radiolucent early.  Most common in England.

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There is prominent osteoclastic activity.Early changes. resulting in bone resorption. .

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A well-established case. . with thick. irregularly shaped bone trabeculae.

 Charcot joint. myxoid cysts within trabecular bone (subchondral cyst). reparative changes (chondrocyte clones). sclerosis of subchondral bone. thickening of underlying bony trabeculae.OSTEOARTHRITIS  = Osteoarthrosis. Degenerative joint disease.  Early/mild changes occur on surface of cartilage. vertical clefts. Late/severe changes include erosion of cartilage.  Most commonly hip and knee. Loose bodies are pieces of broken off cartilage and bone. and subchondral cysts. older patients.  Increasing frequency with age.  X-ray reveals loss of cartilage. formation of bone spurs at joint edge. loss of chondrocyte nuclei. Gradual onset of joint pain and stiffness. possibly osteophytes. decreased basophilia. .

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Combined features of RA. ankles.  Affects women 3 . knee. splenomegaly and neutropenia known as Felty's syndrome. Frequently affected joints include elbows. spine and temporomandibular articulations. though can affect all ages.5 times more often than men. Often family history.RHEUMATOID ARTHRITIS (RA)  Affects about 1% of world's population.  Peak incidences occur in 30's and 50's. .  Typically slow and insiduous onset in more than half of patients. wrists.  Joints of feet and hands are nearly always affected. 10% have acute onset. 70% are HLA-DR4. hips.

causing erosion of joint cartilage). hyperemia. subchondral cysts and osteoporosis. Earliest changes occur in synovium. forming fibrous ankylosis and eventually bony ankylosis. resulting in fractures. pannus bridges apposing bones. proliferation of synovial lining cells and infiltration by plasma cells and lymphocytes (forming pannus.  Second phase. synovium and granulation tissue penetrate bone forming erosions. . Following cartilage destruction.

surrounded by histiocytic inflammatory reaction. composed of necrotic center with fibrin. often arranged in palisading fashion. Extraarticular manifestations include rheumatoid nodules. . Other pathologic findings include necrotizing arteritis and amyloidosis.

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chondromatosis. fibrous dysplasia dan osteofibrous dysplasia.  Pada umumnya keganasan pada tulang terjadi de novo.TUMORS  Klasifikasi tumor yang direferensikan banyak center adalah klasifikasi menurut WHO. antara lain paget’s disease.  Terdapat beberapa lesi jinak pada tulang yang dapat menjadi predisposisi menjadi keganasan. osteochondromatosis. .

 Lima parameter yang penting diketahui dalam keganasan tulang adalah : umur. area tulang ( epiphysis. Ro appearance. . jenis tulang. diaphysis. microscopic appearance. metaphysis ).

BONE-FORMING TUMORS .

 Biasanya terjadi pada umur 40 – 50 tahun dengan ratio laki-laki dan wanita adalah 2:1  Penderita dengan Gardner’s syndrome . padat dengan gambaran lamellarnya. OSTEOMA  Osteoma merupakan tumor jinak tulang. tumbuh hiperplastis. yang biasanya terjadi pada daerah tulang pipih misalnya tengkorak dan tulang wajah. . biasanya terjadi multipel osteoma dgn beberapa kelainan ( intestinal polyposis dan soft tissue tumors)  Secara mikroskopis tampak tulang matur.

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seldom larger than 1. more intense at night. 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 .OSTEOID OSTEOMA  Benign bone neoplasm  10 – 30 yrs  2:1 male-female ratio  Inntense pain  most prominent symptoms. relieved by NSAID  Every bone  Most are centered in the cortex (85%)  X-ray : radiolucent central nidus.5 cm.

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Foreign bodies 6. Pada usia tua. Paget’s disease 2.  Predisposing factor : 1. Trauma . Chemotherapy 4. Tumor ini lebih sering terjadi pada laki-laki dibandingkan wanita. Preexisting benign bone lesion 5.  Biasanya mengenai penderita usia muda yaitu 10 – 25 tahun. Osteosarcoma  Osteosarcoma atau osteogenic sarcoma merupakan tumor ganas primer tulang yang paling banyak terjadi. insidensi terbanyak terjadi pada usia lebih dari 40 tahun. Radiation exposure 3.

the tumor may : 1.  From its usual origin in the metaphysisof a long bone. Spread along the marrow cavity 2. Metastasize trough the bloodstream to distant sites. Arising de novo  Metaphyseal area of the long bones. particularly the lung . the upper end of the tibia. Elevate or perforate the periosteum 4. Invade the adjacent cortex 3. particularly the lower end of the femur. Extend into the joint space 7. Form satellite nodules independent from main tumor mass 8. Extend into the epiphysis 6. and the upper end of the humerus. Extend into the soft tissues 5.

2.6. Mutations of p53 have been found in about 20% of osteosarcoma . The most common cytogenetic abnormalities detected in osteosarcoma involve chromosomes 1. 12and 17. Molecular genetic features : 1. 2.

its glassy appearance. . irregular contour. surrounded by a rim of osteoblast.  Osteoid is recognized by its eosinophilic- staining quality. 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.

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Telengiectatic 2. or combination of them : 6. clinical. Periosteal osteosarcoma 8. Well differentiated intramedullary Other variant of osteosarcoma are defined on the basis of t0pographic. Microscopic variants and special types : 1. Parosteal osteosarcoma 7. Osteosarcoma of the jaw 9. Anaplastic 5. or radiographic features. Osteosarcoma in paget’s disease . Fibrohistiocytic 4. Small cell 3.

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. 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. 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.

CARTILAGE-FORMING TUMORS .

 Multiple enchondromas having predominantly unilateral distribution  ollier’s disease  The association of multiple endchondromas with soft tissues hemangiomas  Maffuci’s syndrome  Microscopically are composed of mature lobules of hyaline cartilage.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.

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sessile atau dengan tangkai. maupun humerus.  Mikroskopis tampak cartilage cap ( jarang lebih dari 1 cm) yang diliputi oleh jarinagn fibrosa. Dibawah cartilage cap. Osteochondroma  Osteochondroma atau disebut osteochondromatosis bila terjadi multipel.  Biasanya mengenai usia muda yaitu 10 – 30 tahun. lucent zones pada lesi. terdapat endochondral ossification zone yang berhubungan dengan bony pedicle. Tumor ini terjadi pada daerah metafise pada tulang panjang yaitu femur. Adanya kemungkinan keganasan apabila cartilagenous cap lebih dari 3 cm. merupakan tumor jinak tulang yang paling banyak terjadi. irregular margins of cartilage cap.  Secara radiologis tampak tulang dengan exostosis. . tibia. Pedicle menyambung dengan medulla tulang. Biasanya kurang dari 5 cm.

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.

Dedifferentiated chondrosarcoma 3. Clear cell chondrosarcoma 2. Chondrosarcoma variants : 1. Mesenchymal chondrosarcoma .

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dan dapat mengenai metafisis ataupun epifisis. Tumor ini paling sering terjadi pada wanita. Dapat ditemukan daerah yang nekrotik maupun perdarahan. 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.  Radiologis ditemukan lesi osteolitik dengan batas tegas. b iasanya terjadi pada usia 20 – 40 tahun. . Giant Cell Tumor of the Bone  Giant Cell Tumor atau disingkat dengan GCT pada tulang. Biasanya terjadi pada tulang panjang.

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dan alveolar rhabdomyosarcoma. Terdapat 3 kategori mayor rhabdomyosarcoma yaitu pleomorphic. embryonal.RHABDOMYOSARCOMA  Rhabdomyosarcoma merupakan tumor ganas yang berasal dari sel otot lurik. Pada anak-anak biasanya mempunyai predileksi terutama di kepala. hiperkromatis dan banyak ditemukan mitosis. sedangkan usia tua biasanya di ekstremitas. yaitu sel dengan sitoplasma yang eosinofil dan dengan inti yang pleomorifk. sel plasma dan sel eosinofil .  Secara mikroskopis diagnosis rhabdomyosarcoma adalah ditemukan adanya sel rhabdomyoblast. Tumor ini dapat terjadi pada anak-anak maupun usia tua. Dapat ditemukan pula sel limfosit.

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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.

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. dan dikelilingi oleh osteoblast. hiperkromatis dengan mitosis yang banyak dan adanya struktur microtrabeculae yaitu massa berwarna basofil dan menyerupai hifa jamur. yaitu dengan gambaran eosinofilik. periosteal reaction dan codman’s triangle. glassy appearance.  Secara mikroskopis pada tumor ini harus ditemukan adanya pembentukan osteoid ganas. Radiologis ditemukan gambaran yang khas yaitu sun burst appearance. irregular countours. Gambaran lain adalah seperti gambaran keganasan pada umumnya yaitu sel dengan inti yang pleomorfik.