Materi Muskuloskeletal

Muhammad Ilyas

Coaching Ujian BPNRI

Oktober 2014
TUMOR TULANG
Faktor Usia
Location
in the
Skeleton
2 KEYS TO DIAGNOSIS
 Tissue Type & Grade of Tumor
 Tissue Type of Tumor
• Bone-forming/Osteogenic Lessions:
– Osteoma, osteoid osteoma, osteoblastoma
– Osteosarcoma*
• Cartilage-forming/Chondrogenic Lessions:
– chondroma (enchondroma)
– Chondrosarcoma
• Miscellaneous Lessions:
– Ewing’s sarcoma*
– Giant cell tumor of bone
 Tumor-like conditions of bone
• Bone cysts
– Simple bone cyst
– Aneurysmal bone cyst
• Fibrous-osseous lesions
– Fibrous dysplasia
• Eosinophilic granuloma (Langerhans histiocytosis)
• Osteochondroma - ?hamartoma
• Grade:
– Local
aggressiveness
(margins)
– Differentiation
(maturity of
matrix)
– Metabolic activity
– Size
 Klasifikasi Tumor
• Tumor Jinak:
– Osteoma, osteochondroma (exostosis),
enchondroma, chondroblastoma, chondromyxoid
fibroma,, osteoid osteoma.
– Aggressive: giant cell tumour ('osteoclastoma'),
osteoblastoma, chordoma, adamantinoma
• Tumor Ganas:
– Osteosarcoma, chondrosarcoma, fibrosarcoma,
malignant fibrous histiocytoma, Ewing's sarcoma.
Benign VS Malignant
 Radiographic Margin:
Geographic, Mouth eaten, Permeative
 Radiographic Margin

TYPE I TYPE II TYPE III

Geographic Moth-eaten Permeated
Periosteal Reaction
Tumor
Matrix
Tumor Matrix : osteoblastic; punctate, annular, and popcorn-like calcifications
within the radiolucent lesion : Enchondroma - Chondrosarcoma
Site of Lessions
 • Uniform/homogen,
oval long axis
OSTEOMA parallel to stress line,
irregular outline
• Well-differentiated
mature bone
• Medullary : Bone
island
• Periosteum :
• Skull: “Button
osteoma”
• Sinuses to long-
bone : “Ivory
exostosis”
 OSTEOMA

BONE ISLAND “BUTTON” OSTEOMA

 OSTEOID OSTEOMA
• Cortex/Periosteum >> Medullary
• Long Bones >> Flat Bones
• Any bone, but femur and tibia commonly
• Ro : Radiologically lesion consists of a small
(< 1.5 cm) central nidus with surrounding
bony sclerosis
 OSTEOID OSTEOMA

cortical periosteal medullary

 OSTEOBLASTOMA
• Children & young adult (10 – 30 years old)
• Any bone but commonly in spine, progresif
• Spine  bone forming neoplasm in posterior
elements (DD/ ABC & Osteoid osteoma)
• Out side spine  calcified central nidus with
surrounding radiolucent halo and reactive
sclerosis. (DD Osteoid osteoma)
OSTEOBLASTOMA

6 mths later
 OSTEOSARCOMA:
a malignant tumor which forms bone
• CHILDREN, YOUNG ADULTS BUT LONG
“TAIL”
• MOST FREQUENT 1º MALIGNANT BONE
TUMOR
• PAINFUL
• MEDULLARY > PERIOSTEAL > SOFT
TISSUE > CORTEX
• LONG BONES > SPINE
KLASIFIKASI OSTEOSARCOMA
Primary Osteosarcoma:
Conventional
low grade intramedullary
parosteal
Periosteal
high grade surface,
Telangectic
small cell
Secondary Osteosarcoma
Conventional Osteosarcoma
• High grade
• Common type of
Osteosarcoma
• Common
radiographic:
• Aggressive
lesion producing
osteoid matrix.
• Periosteal
reaction:
“codmans
triangle” or
“sunbrust” or
“hair on end”
appearence
Conventional Osteosarcoma
 Periosteal
Osteosarcoma
• Intemidate grade
• Arises from surface of
bone
• Commonly on femur and
tibia.
 Intramedullary Osteosarcoma
• Rare
• Low grade
 Parosteal
Osteosarcoma
• Low grade malignancy,
well differetiated
• Rare
• Arises on surface of bone
and invades medullary
cavity only at later stages.
• It has peculiar tendency to
occur as a lobulated mass
on the posterior aspect of
femur
Parosteal Osteosarcoma,
marrow invasion
 Telangectic Small cell
Osteosarcoma Osteosarcoma
• Lytic lesion • Rare
• High grade
• Resemble Ewing sarcoma
or Lymphoma
SECONDARY
SARCOMA
Initial 9 months later

Ax T1 Cor T2 T1 postgado
 OSTEOSARCOMA:
Special anatomical situations
 OSTEOSARCOMA:

Osteoblastic Chondroblastic Telangiectatic

 CARTILAGE FORMING TUMOR
• LOW:
– NODULES
– MINERALIZATION THROUGHOUT
• HIGH
– UNCOMMON
– DEGENERATED vs. DEDIFFERENTIATED
• ALL:
– INVASIVE IN BONE, “PUSHING” IN SOFT
TISSUES
 CHONDROMA
• Usually solitary lesion
• Multiple lesions (enchondromatosis or Ollier`s
disease)
• Lack of normal enchondral ossification below
the growth plate
• A well defined radiolucent central lesion within
the metaphysis or diaphysis  slightly
expanded
• Calcification: stippled or flecks, “smoke ring or
popcorn” ossification
ENCHONDROMA
ENCHONDROMA
 OSTEOCHONDROMA
• Pertumbuhan keluar dari tulang berasal dari cortex
diafise tulang panjang  arah menjauhi sendi
• Tipe pedunculated (khas tonjolan tulang dari
cortex dengan gambaran dari trabekula lesi
masuk dalam medulla melalui defek dari cortex)
• Kalsifikasi dalam lesi
• Pada pelvis dan scapula  gambaran irreguler
dengan densitas tinggi  memberi gambaran
Bunga Kol
OSTEOCHONDROMA
OSTEOCHONDROMA
Points wrong”
Osteochondroma:
OSTEOCHONDROMA
Medullary
continuity
Cartilage cap

Soft tissue
mass
PERIOSTEAL CHONDROMA
 CHONDROBLASTOMA
• CHILDREN, YOUNG ADULTS
• LONG BONE EPIPHYSIS (humerus,
femur)>> FLAT BONES
• PAINFUL (prostaglandin)
• GROWTH USUALLY LIMITED
CHONDROBLASTOMA
 CHONDROMYXOID
FIBROMA

• Usually resembles non-

ossifying fibroma
• Not usually calcified
 CHONDROSARCOMA
• 3rd most common primary malignant bone tumor
• Older adults
• Long bones >> Flat bones
• Mostly low, intermediate grade
• Malignant cartilage with anaplastic chondrocytes
in spaces with focal enchondral ossification and
calcification
Chondrosarcoma
 CHONDROSARCOMA
SUBTYPES BASED ON LOCATION

• MEDULLARY (CENTRAL) most common

• INTRACORTICAL least common
• SURFACE (PERIPHERAL)
• SOFT TISSUE (rare)
 CHONDROSARCOMA
• SUBTYPES BASED UPON ETIOLOGY:
– Primary
– Secondary: DEGENERATION of chondroma
• SUBTYPES BASED UPON HISTOLOGY
– HYALINE
– MYXOID
– DEDIFFERENTIATED
– MESENCHYMAL (soft tissues)
– CLEAR CELL (epiphyseal, slow)
 CHONDROSARCOMA
borderline lesion

nodular growth
CHONDROSARCOMA
Longitudinal growth
CHONDROSARCOMA
Soft Tissue
 CHONDROSARCOMA

Mesenchymal surface lesion

CHONDROSARCOMA:
Dedifferentiation
CHONDROSARCOMA:
Dedifferentiation
 EWING’S TUMOR
• 4th most common primary malignancy
• 9% of primary malignancy of bone
• Age: most occur in 5 – 25 yrs; 80% < age 20
• Males > females
• Commonly metaphyses of long bones(often
extension to diaphyses) and flat bones of
shoulder and pelvic girdle.
• Neural origin same as PNET and ASKIN
tumor
 Ewing’s Tumor

X-ray : Destructive lesion in the

MRI :
diaphyses of longbone with and
“onion skin” periosteal reaction To evaluate full extent of lesion
EWING’S / PNET:
Permeated margins

Subperiosteal
spread
 ROUND CELL TUMOR:
RAPID GROWTH AFTER PATHOLOGICAL FRACTURE

2 months later
 Giant Cell Tumor
5% of bone neoplasms
Age: 20 to 40 yrs | Female>Male
Location: distal femur> proximal tibia > distal radius
Benign but pulmonary metastasis can occur
• Radiographic features :
– occurs only with a closed growth plate
– abuts articular surface: 84-99% come within 1 cm of the
articular surface 
– well defined with non-sclerotic margin
• Lesions: expansile, osteolytic, radiolucent without sclerotic
margins  without a periosteal reaction  eccentrically
MRI useful for determining extent of disease.
Giant cell tumor – x rays
Giant cell tumor – MRI
Dark in T1
weighted image
and Bright in
T2 weighted
images
 Simple bone cyst
• Solitary or unicameral bone cyst
• Expansion of bone & thinning of the bone
cortex through endosteal erosion.
• Pathological fracture.
• Extensive bone destruction resemble a
neoplasm
Simple bone cyst
Simple bone cyst
 Aneurysmal bone cyst
• < 20 years old
• Locally destructive blood filled reactive lesions of bone
• Proximal humerus, distal femur, proximal tibia and spine
• Radiographically:1
– Marked expansion of the involved bone, cystic bone
destruction and periosteal new bone formation 
expansile lytic lesion that elevates periosteum
– The lesion rapidly destroys the original bone cortex and is
contained only by a thin rim of periosteal new bone [egg
shell]
– During curettage there may be a considerable bleeding
from the fleshy lining membrane [welling or pouring of
blood]
Aneurysmal bone cyst
Aneurysmal bone cyst
Aneurysmal bone cyst
PENY. DISPLASIA TULANG
 Fibrous dysplasia
• Developmental anomaly
• Replacement of normal bone and
marrow by fibrous tissue and small,
woven spicules of bone.
• Radiographic appearance is lucent
area with lucent area having a
granular, ground-glass
appearance
• ground-glass matrix
• may be completely lucent (cystic) or
sclerotic
• well circumscribed lesions
• no periosteal reaction
Fibrous dysplasia
KELAINAN METABOLIK
 Rickets
• Rickets is a disorder involving softening and
weakening of the bones (of children).
• It is caused by lack of vitamin D, calcium or
phosphate in your diet.

• What could we do to prevent getting

rickets?
 Rickets
1. Kelainan tulang akibat defisiensi vit D,kerusakan ginjal, kerusakan
absorbsi mineral (usus)
2. Rontgen
1. Pembesaran chondrocostal junction (rachitis rosary)
2. Cupping metafise (tarikan otot-otot & ligamentum)
3. Bowing tulang2 panjang
4. Kadang2 Greenstick fraktur
5. Kalsifikasi subperiosteal
6. Tepi ala ossis ilii (irreguler)
7. Dens metaphysial line yang normal menghilang (irreguler +
frayed)
8. Kepala: Fontanella + sutura ( masih terbuka)
9. Osteoporosis
X-ray of a 20 month old boy with rickets

• Notice the
bow shape
of the legs.
 Rickets rosary :
pelebaran dan costa
depan akibat swelling
dari costochondral
junction
 Terjadi
deformitas pada
tibia dan fibula
yang
menyebabkan
bowing
( genu varum)
Genu Varum
 Normal
• 3.

Tampak pelebaran dari

lempeng epifisis dengan
cupping pada metafisis
 Tampak
pelebaran dari
metafisis dengan
cupping pada
epifisis
 Scurvy
1. Akibat defisiensi Vit C terjadi kegagalan pembentukan jaringan
Intraseluler termasuk tulang, kartilago & endotel
2. Pembentukan tulang terhambat, sedangkan reabsorbsi tetap
terjadi (osteoporosis)
3. Osteoporosis
4. Wimberger’s sign  epiphisis mengecil dgn tepi yg sklerotik
5. The white line of Fraenkel  garis yg tdk teratur cenderung
sklerotik
6. Trummefeld zone  pita transversal radiolusent pada
metaphysis
7. Pelkan’s sign  bayangan spur pada ujung-ujung tulang
ekstremitas
8. Elevasi periosteal  perdarahan subperiosteal
 Pelkan’s spur
Wimberger’s sign

White line of fraenkel

Trummerfeld zone
Trummefeld zone
Pelkan’s spur
Wimberger’s sign

White line of Fraenkel

Advance scurvy:
garis fraktur yg
menebal,zona provisional
kalsifikasi yg
rapuh,spur.epiphysis dan
zona provisional kalsifikasi
melebar ke kiri
 MRI
Potongan coronal T2-weighted

Potongan axial T2-weighted

FRAKTUR
Fraktur radius bagian distal
a.Fraktur Colles
fr.radius bagian distal (sampai 1 mm dibagian
distal) dengan angulasi ke posterior, dislokasi ke
posterior dan deviasi fragmen distal ke radial
b. Fraktur Smith
Fr.radius bagian distal dengan angulasi atau
dislokasi fragmen distal ke volar
Fr.Colles
Fraktur radius dan ulna
a. Fr.Monteggia

fr.ulna bagian proximal dengan dislokasi kaput

radii
b. Fr.Galeazzi
fr.radius bagian distal dengan dislokasi ulna
bagian distal
Fr. Monteggia
Fr. Galeazzi
Fr. Galeazzi Fr. Monteggia