8 Bone Tissue

Objectives
In this chapter we will study
• methods used to diagnose bone disorders;
• bone anatomy in relation to bone pathology;
• three noncancerous bone diseases—osteoporosis, osteomyelitis, and osteochondrosis; and
• four forms of bone cancer—osteosarcoma, chondrosarcoma, fibrosarcoma, and myeloma.

Diagnosing Bone Disorders Bone Anatomy in Relation to Bone Pathology

As living organs, bones are subject not only to fractures but also Bone has a unique composition; it is important to understand its
to several other diseases. The signs and symptoms of a disorder of anatomy in order to appreciate the signs and symptoms of bone
the bone tissue per se can be difficult to distinguish from those of diseases. Bone is a living tissue; it requires an adequate blood sup-
other skeletomuscular diseases, thus testing the diagnostic skill of a ply (vascularity) so as to provide oxygen and nutrients to the bone
physician. Some of the procedures described in this chapter of the cells immersed within the matrices of bone. Bone tissue has two
clinical manual also apply to chapters 9 and 10, which deal with the matrices: organic matrix and inorganic matrix. The organic ma-
skeleton as a whole and the joints, respectively. trix, synthesized by osteoblasts, includes type I collage and vari-
Pain is the most common symptom of a bone disorder, but ous protein-carbohydrate complexes, such as glycosaminoglycans,
patients often wait until other symptoms arise before seeking help. proteoglycans, and glycoproteins. The inorganic matrix is primar-
Such delay may allow the disease to reach a more advanced stage ily comprised of calcium molecules, along with some other ions,
or to involve additional tissues or body structures. Pain alone does such as phosphate and magnesium. Bone also contains some water.
little to help a clinician make the proper diagnosis. The physical The type I collagen in the organic matrix gives bone its toughness
examination must include careful observation of the patient’s gait (tensile strength); the calcium molecules in the inorganic matrix
and posture for clues as to which bones or joints are involved. Bone gives bone its hardness (compression strength) and the water gives
abnormalities can often be detected by palpation. In addition, vari- bone some degree of elasticity. Bone diseases due to defects in
ous tests can aid diagnosis, including the following: the type I collagen in the organic matrix, make bones lose tough-
ness and become more brittle, such as the condition Osteogenesis
• Imaging techniques such as X rays and CT and MRI scans
Imperfecta (Brittle bone disease). Bone conditions due to a defect
may reveal dislocations, tumors, and changes in bone size.
in the inorganic matrix cause bones to become soft, such as the
• Bone scans (densitometry) help detect bone cancers, infections, condition osteomalacia in adults and rickets in infants and chil-
necrosis, trauma, degenerative bone diseases, and metabolic dren. Disease conditions that cause a decrease in both the organic
disorders that affect the skeleton. To perform a bone scan, the and inorganic matrices cause bone to be extremely weak and able
patient is injected with a radioisotope that has an affinity for to easily fracture, such as osteoporosis and certain bone tumors.
bone. After allowing the radioisotope to accumulate in the bones,
the pattern of gamma-ray emission is monitored. Diseased bones
Common Bone Disorders
show a different pattern of emission than healthy bones.
A wide variety of disorders affect the bones, skeleton, and joints.
• Angiography is the process of making an X ray of the
Although these disorders can be difficult to separate, this chapter
blood vessels. The circulatory system must be injected with
covers some of the common ones that primarily affect bone tissue
a contrast medium, such as barium or iodine compounds, to
itself.
enhance the visibility of the vessels on an X ray. Although
this procedure is not limited to examination of the skeletal Osteoporosis
system, it is useful for evaluating the blood flow to the bones.
Osteoporosis is the most common disorder of the skeletal system.
• Hematologic tests can provide clues to bone disorders by In the United States alone, osteoporosis is estimated to cost billions
measuring the concentrations of enzymes and other chemicals of dollars per year, including treatment expenses and indirect costs
in the blood serum. For example, an elevated concentration such as lost work. Here we explore further aspects of this disease.
of alkaline phosphatase may indicate bone cancer or osteitis Osteoporosis is a metabolic disease in which the density of
deformans. Bone cancer, fractures, and long-term immobility bone is reduced, but the remaining bone has a normal proportion
can raise the serum calcium concentration. Bone tumors raise of minerals to organic content. The histology of the bone remains
the serum phosphate level. normal, but the amount of bone becomes inadequate to provide
• Biopsy is used to evaluate both the gross and microscopic mechanical support for the body. Thus, a person with osteoporo-
anatomy of a small sample of bone. sis becomes increasingly susceptible to fractures, especially of the

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wrist and hip. About half the people who suffer hip fractures as a body’s disease-fighting white blood cells and antibodies. Further-
result of osteoporosis never walk again. more, the bacteria may secrete toxins that promote bone necrosis,
Osteoporosis mainly involves a loss of spongy bone; compact and osteocytes are unable to significantly replace necrotic bone.
bone is relatively unaffected. Osteoporosis is caused by aging in Osteomyelitis is classified according to the route of bacterial in-
95% or more of patients, but it can also occur due to hormonal vasion. Exogenous osteomyelitis occurs when bacteria invade from
imbalances, immobilization (as when a limb is in a cast), bone tu- outside the body—for example, through open fractures, wounds, or
mors, lack of weight-bearing exercise, and prolonged space flight. surgical procedures such as joint replacement. Endogenous osteomy-
When osteoporosis affects only a particular part of the body, such elitis occurs when bacteria, most often Staphylococcus aureus, in-
as one limb, it is called regional osteoporosis. vade the bone from infected sites elsewhere in the body—especially
Postmenopausal white women are at the greatest risk for os- from ear, sinus, cutaneous, and dental infections. This is a common
teoporosis. Estrogen helps preserve bone mass by inhibiting the complication of sickle-cell disease and animal bites.
bone-dissolving action of osteoclasts, but after menopause the In children, the inflammation induced by either type of os-
ovaries are inactive and estrogen is no longer secreted. In the ab- teomyelitis causes the periosteum to move away from underlying
sence of this inhibitory stimulus, bone resorption by osteoclasts tissues. This “lifting” of the periosteum results in decreased blood
increases and exceeds the bone deposition by osteoblasts. Thus, flow and the subsequent necrosis and death of the infected area of
there is a net loss of bone mass. the bone. Osteoblasts surround the infected bone with new bone,
The clinical manifestations of osteoporosis depend on the but the openings in the newly synthesized bone allow pus to es-
bones involved. The first symptom is pain in the bones, often de- cape into the surrounding soft tissues. In adults, the periosteum
scribed as an aching back. This pain is short-lived, but is aggra- is firmly attached to the bone surface, so this does not occur.
vated by weight-bearing, even standing. The patient often does not Instead, the infection weakens the bone and makes it more sus-
seek medical attention because the pain usually subsides within ceptible to fracture.
a few weeks. Blood tests show relatively normal circulating con- Signs and symptoms of osteomyelitis vary depending on
centrations of calcium and phosphorus, but parathyroid hormone the infectious agent (type and source), duration (acute, subacute,
(PTH) concentrations are lower than normal. Chemical indicators chronic), site of infection, and age of the patient. Osteomyelitis is
of bone turnover are high, including urine levels of calcium and marked at first by relatively vague signs: low-grade fever, inflamed
certain collagen derivatives released by the degenerating bone. lymph nodes (lymphadenitis), and local pain and swelling. If the
The loss of bone density can be detected by X ray, but only after infection progresses, it causes high fever, nausea, pain, inflamma-
25% to 30% of the bone mass has already been lost. tion of the neighboring tissues, and muscle spasms. In chronic os-
Treatment of osteoporosis is aimed at preventing further bone teomyelitis, the long bones may develop large lesions, up to 4 cm in
loss and halting the progression of the disease. Dietary intakes of diameter, at their ends.
calcium and vitamin D are prescribed to increase the absorption of Osteomyelitis is diagnosed by means of radioisotopic bone
calcium. Patients are advised to limit their intake of caffeine, alco- scanning, CT, and MRI. Blood testing can also aid diagnosis
hol, nicotine, and carbonated beverages. Regular, moderate, weight- since the disease typically produces an elevated leukocyte count.
bearing exercise is recommended to slow the loss of bone and in Osteomyelitis is treated by means of drainage and antibiotics. It
some cases to stimulate bone formation. Hormone replacement may require drilling holes into the bone to allow for drainage and
(estrogen and progestin) is recommended to decrease osteoclast for antibiotics to reach the site of infection. In some instances, sur-
activity in postmenopausal women. Estrogen does not significantly gery is required to remove the exudate. If the infection occurs at
restore lost bone, but it slows the progression of the disease by in- the site of an artificial joint (prosthesis), the prosthesis may need
hibiting bone resorption. However, estrogen may increase the inci- to be removed in order to treat the surrounding bone.
dence of breast and uterine cancer for some women and is therefore
not always an option. Other treatments include calcitonin, given Osteochondrosis
by injection or in a nasal spray, as well as oral calcitriol and other
Osteochondrosis is a family of avascular bone diseases oc-
medications to minimize calcium loss. Paradoxically, intermittent
curring in children—that is, skeletal deformities resulting from
low doses of parathyroid hormone can increase bone mass.
disturbances in the blood supply to the ossification centers of
Although patients with osteoporosis should exercise, they must
growing bones. It is still uncertain why the ossification centers
also take precautions to avoid falling, which can result in fractures.
sometimes lack a normal blood supply. Tissues around the area of
As a preventive measure, weight-bearing exercise and proper nutri-
bone necrosis become inflamed, joints are weakened, and bones
tion are now being encouraged for young pre-menopausal females
may fracture at cartilaginous regions in and near the joints. The
in the hope that depositing a greater bone mass will protect them
synovial membranes become inflamed and trigger pain and mus-
from osteoporosis in later years.
cle spasms, often the first clinical signs of the disease. In the late
stages of the disease, new blood vessels grow into the affected
Osteomyelitis area and the bone is repaired. However, this restorative growth
Bone may become infected by viruses, bacteria, fungi, and para- is structurally abnormal and may cause discomfort, a limp, and
sites; bacterial infection of bone is called osteomyelitis. This is an altered joint function. Younger children are more likely than older
especially difficult and expensive disease to treat because when ones to realize a complete restoration of normal joint structure
bacteria invade the bone, they are relatively sheltered from the and function.

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Bone Tumors the femur and pelvis. The tumor is composed of large masses of
Bones are comprised of multiple tissue types, each of which can hyaline cartilage and fibrous tissue. It erodes the bone, enlarges
give rise to a tumor. Bone tumors are classified as osteogenic, it, and often invades the joint cavity. The tumor can be surgically
chondrogenic, collagenic, or myelogenic, depending on whether excised, but often returns. Therefore, amputation is often the treat-
they involve overgrowth of osseous tissue, cartilage, collagenous ment of choice.
tissue, or bone marrow, respectively. Here we consider one example Fibrosarcoma is a solitary collagenous tumor seen most often
of each. A neoplasm is any tumor (new, abnormal, nonfunctional in the metaphysis of the femur or tibia. Its progression is from
tissue growth). Tumors may be benign or malignant (cancerous). the inside of the bone out—that is, it begins in the marrow cavity,
All the tumors presented in this chapter are malignant neoplasms. spreads to the compact bone, and eventually breaks through into
Osteogenic (bone-forming) tumors exhibit excessive growth the soft tissue around the bone. Fibrosarcoma often metastasizes to
of osseous tissue. The most common malignant osteogenic tumor is the lung. Radiotherapy is usually ineffective against fibrosarcoma;
osteosarcoma, which accounts for 38% of all bone tumors. Osteo- amputation or other radical surgery is generally necessary to save
sarcomas occur most frequently in adolescents and young adults, the patient.
and they most commonly affect the humerus, femur, or tibia; half Myeloma, responsible for about 27% of bone tumors, is the
of the cases involve the knee. The tumor is usually found in the malignant proliferation of certain immune cells called plasma
bone marrow, but it also has highly destructive effects on the sur- cells. About one out of six patients exhibit multiple myeloma, the
rounding bone. The growing tumor eventually breaks through the presence of more than one tumor. Myeloma is common in peo-
bone surface and lifts the periosteum from the bone. This triggers ple over 40 and is more common in males than in females and in
bizarre abnormal bone growth at the surface. The area becomes blacks than in whites. The progression of myeloma is opposite that
progressively painful and swollen. The tumor is treated primar- of fibrosarcoma—that is, it invades the bone from the outside in,
ily with surgery; chemotherapy and reconstructive techniques are eventually invading the marrow. It causes increasingly severe pain
helpful in reducing the need for amputation. that is often mistaken at first for arthritis or a herniated interverte-
Chondrogenic tumors produce excessive growths of car- bral disc. The prognosis is poor, and patients are generally treated
tilage or a cartilage-like substance called chondroid tissue. only to relieve discomfort. Radiotherapy and chemotherapy are not
Chondrosarcoma, the most common form (20% of bone tumors), very effective against myeloma.
usually occurs in people 50 to 70 years of age. It most often affects

Case Study 8    The Bike Rider with a Broken Hip

Susan is a 55-year-old woman who regularly exercises by riding tumor. The only way to confirm either diagnosis is to conduct fur-
her bicycle around her neighborhood and on trails in a nearby park. ther tests.
One day while she is riding, a dog runs across her path, causing Susan consents to both a CT scan and bone densitometry.
her to fall. Susan lands heavily on her right side and feels a sharp These scans reveal no tumors but a loss of bone mass, specifically
pain in her hip as she tries to move. When she attempts to stand, spongy bone. The physician advises her to increase her dietary cal-
she cannot put any weight on her right leg. Some joggers help her cium intake to 1,500 mg/day, take vitamin D supplements, and de-
to a nearby bench and call for assistance. crease her intake of soft drinks, alcohol, caffeine, and nicotine. In
When the emergency medical technicians arrive, they immo- addition, the physician recommends steroid replacement therapy
bilize Susan’s leg and check for additional injuries. Upon initial to slow bone loss and other drugs to facilitate calcium absorption.
examination, it appears that Susan has some abrasions on her right He also encourages Susan to continue exercising once she recovers
side and a broken hip. The emergency team transports her to the from the fracture.
hospital. There, the emergency room physician notes that Susan’s The following day, surgery is performed to insert screws to
vital signs are stable and that, with the exception of her injuries, internally fix the position of the femur and allow proper healing.
she is in relatively good health. The surgery is successful, and after a period of observation, Susan
Suspecting a fracture of the femur, the physician orders a se- is released from the hospital. But approximately one week after
ries of X rays to determine the site and extent of the injury. Results the surgery, she begins to experience an increasing amount of pain
show a nondisplaced oblique fracture of the neck of the femur. In in her hip. The surgical area feels warm to the touch and is redder
reviewing her medical history, the physician notes that Susan is than the surrounding tissue. Because she has an appointment with
postmenopausal and not using steroid hormone (estrogen and pro- the surgeon the following day, Susan does not think she needs to
gestin) replacement therapy. But because she is physically active, visit the emergency room. But the next day at the surgeon’s office,
the physician believes the fracture may be pathological (caused it is noted that her temperature is elevated and her lymph nodes are
by a disease) and suggests further testing. When Susan asks why swollen. Blood drawn for evaluation shows an elevated concentra-
he suspects a problem, he tells her that, considering her age, the tion of lymphocytes. The surgeon orders a CT scan, which reveals
fracture could have resulted from either osteoporosis or a bone a subperiosteal abscess at the surgical site.

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 The surgeon immediately hospitalizes Susan and prescribes 5. Name the bone disease that develops a week after Susan’s
antibiotics to fight the infection. In addition, a tube is inserted in surgery. What are the signs and symptoms on which you base
the abscess to allow drainage. The surgeon tells Susan that if her your answer?
condition worsens, a second surgery may be necessary to replace 6. Based on the information given, what is the likely source of
the screws. However, he feels that at this time antibiotics and drain- Susan’s bone infection?
age will suffice. 7. John has chondrosarcoma of the tibia, and Marvin has
chondrosarcoma of the pelvis. Why would John’s prognosis
Based on this case study and other information in this chapter,
be better than Marvin’s?
answer the following questions.
8. Why would a bone tumor be a risk factor for a pathological
1. Why does the emergency room physician suspect osteoporo- fracture? How does a pathological fracture differ from a
sis or bone cancer? stress fracture?
2. What would the CT and densitometry scans reveal if Susan 9. Imaging techniques such as X ray, CT, and MRI are used to
had bone cancer rather than osteoporosis? diagnose many bone disorders. Why do these tools play such
3. What is the relevance of vitamin D to Susan’s prescribed an important role?
course of treatment? 10. Why are osteochondroses more prevalent in children than
4. Describe the type of fracture Susan presents with. in adults?

Activity
1. Investigate the rationale for the physician requesting Susan to 2. Investigate the most common cancers that metastasize to bone.
decrease her intake of soft drinks, drinking alcohol, and caf-
feine. Are some soft drinks worse than others in exacerbating
her clinical bone condition?

Selected Clinical Terms

chondrosarcoma A malignant neoplasm of cartilage or chon- osteomyelitis Bacterial infection of a bone.
droid tissue of the skeleton, invading and weakening the bone. osteoporosis A degenerative bone disease in which spongy
fibrosarcoma A malignant neoplasm that arises from deep bone is lost although the remaining bone is histologically
fibrous (collagenous) tissue and invades the bones and other normal; the bones become incapable of providing normal
adjacent tissues. mechanical support and increasingly susceptible to fractures.
myeloma Malignant proliferation of plasma cells with osteosarcoma A malignant neoplasm of the osseous tissue.
destructive invasion of the bone.
osteochondrosis Bone necrosis, deformity, and weakness
resulting from ischemia of the ossification centers.

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