I. Bone and Joint Diseases: Clinical Principles

  • There are some key take home points to note of when approaching Bone and Joint diseases.
  • These are mostly clinical in nature, and require one to rely on the principles of thorough history taking and physical examination
  • Age
    • Neoplasms of the bone – children and adults get different bone tumours
    • Older age group patient tend to get conditions such as osteocarthritis and osteoporosis
  • Gender
    • Certain inflammatory conditions, particular Rheumatoid arthritis or Systemic lupus erythematosus, tend to occur with greater frequency in females   
    • Osteoporosis tends to occur more frequently in postmenopausal women

This applies to BOTH bone and joint diseases

  • Single or multiple site involvement
    • Bones – Multiple bony lesions may raise the consideration for metastatic disease
    • Joints – Some arthropathies are mono-articular whilst others are pauci- or polyarticular
  • General size / structure of bone/joints
    • Long bones (limb bones) vs Axial skeleton (spine, pelvis)
    • Small bones or joints (eg. hands and feet)
  • For bony neoplasms, specific location within long bones is important
    • Diaphysis (Ewing sarcoma); Metaphysis (osteosarcoma); Epiphysis (giant cell tumour)
  • Autoimmune conditions such as Systemic lupus erythematosus can result in joint disease
  • History of known malignancy eg. prostate or breast carcinoma should always raise the suspicion of metastases in patients with discrete bony lesions
  • This applies to both bone and joint diseases
  • Modalities include plain X rays and CT scans
  • Imaging essentially shows the Gross pathology, but in black and white
  • This is a useful test in joint diseases
    • Fluid can be sent to several labs for examination
      • Microbiology – Gram stain, ZN stain, culture
      • Pathology – for cytology examination and examination for crystals under the microscope
        • Gout – Negatively birefringent needle shaped crystals 
        • Pseudogout – Weakly positively birefringent rhomboid shaped crystals 

 

How do diseases of the MSK system manifest clinically?

Here are some main clinical manifestations of bone and joint disease (please note that this is not a detailed comprehensive list –  for that you can refer to clinical texts):

1. Bones 

  • Pain (night pain is worrying, eg. for neoplasm, or tuberculosis)
  • Swelling
  • Pathologic fracture – occurs in underlying abnormal bone, which can be due to infectious (eg. chronic osteomyelitis), metabolic (eg. osteoporosis) or neoplastic disease
  • Sinuses (associated with osteomyelitis)
  • Deformity (can be associated with metabolic conditions)

2. Joints

  • Pain, loss of function
  • Swelling
    • Clinically, septic arthritis and crystal arthropathies can sometimes be difficult to distinguish from each other, and require examination of joint fluid aspirate – see point 5 above 
  • Loss of function
  • Stiffness
  • Abnormal range of motion / locking (this may occur in traumatic conditions eg. ligamentous or meniscal injury in the knee, which will be covered during the clinical posting)

 3. Symptoms related to soft tissue structures close to bone/joints:

  • Nerve compression – eg. osteophytes in cervical spine arthritis can lead to nerve compression
  • Tendons, insertions – eg. pain from tendinitis
  • Joint capsule / tendon / tendon sheath Eg. Nodule – genglion

4. Systemic symptoms: Fever, weight loss

  • Other clinical manifestations of underlying systemic disease – eg. in patients with hyperuricaemia, disseminated infection, hyperparathyroidism 

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Copyright © 2015 by Department of Pathology, National University of Singapore