Common Fractures and Pathologies of Bone

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Metastatic bone disease is the result of the spreading of cancerous cells from one site within the body to the bones (Coleman, 2001). The cancer cells detach from the primary malignant tumour and disperse, attaching to a neighbouring tissue or organ. This results in the manifestation of cancerous cells within the microenvironment of the bone. Its supportive fertile conditions, the feeding vascular systems, provide a perfect space in which cancer can occupy and grow (Coughlin, Romero-Moreno, Mason, Nystrom, Boerckel, Niebur, Littlepage, 2017).

This document will further explore the probable causes of the two pathologies as well as providing the reader with symptoms, diagnostic techniques and available treatment options.

Metastatic bone disease, also known as secondary bone cancer, commonly derives from breast and prostate cancers (“Bone microenvironment and its role in bone metastasis”, 2019). It is formed by primary tumours spreading to the bones of the patient, consequently presenting some of the following symptoms: Hypercalcaemia (“High Calcium Levels or Hypercalcemia”, 2019); weakened bones; spinal cord compression (Secondary bone cancer, Diagnosis 2019); and pain in the area affected (Bone Metastases: When Cancer Spreads to the Bones – Health Encyclopedia – University of Rochester Medical Center, 2019). The prognosis of this disease is not positive, with most patients living for another six to forty-eight months after diagnosis. (“Metastatic Bone Disease: Practice Essentials, Background, Pathophysiology and Etiology”, 2019)

Bone resorption contributes to the formation of bone metastasis. Research has shown that tumours are able to replicate signalling which can therefore, trigger higher rates of bone resorption by osteoclasts situated within the host tissue. (“Bone microenvironment and its role in bone metastasis”, 2019). This indicates that the cancer cells can cause osteoclasts to break down bone unnecessarily and form osteolytic lesions, which provides the tumour with more space and essential resources for growth. This increase in bone resorption results in more bone being broken down, increasing the level of calcium in the bloodstream, consequently causing the symptom of Hypercalcaemia. Furthermore, the cancer cells can induce the counter response by stimulating osteoblasts to form osteoblastic lesions through the over production of bone. (“Bone Metastases: When Cancer Spreads to the Bones – Health Encyclopedia – University of Rochester Medical Center”, 2019).

The raised levels of calcium in the blood can be used as a diagnostic indicator. Blood tests can be used to determine the calcium concentration compared to expected levels. (“Secondary bone cancer | Diagnosis”, 2019) Another invasive diagnostic method is a Biopsy. (“Bone Metastases: When Cancer Spreads to the Bones – Health Encyclopedia – University of Rochester Medical Center”, 2019) This requires a sample of the possible secondary bone cancer to be extracted and examined under microscope. (“Diagnosis”, 2019)

The use of conventional imaging for diagnosis is limited due to the fact that it is only able to determine whether the bone lesion is osteoblastic or osteolytic late into the onset of the cancer. Therefore, whilst X-rays can be used, it should be understood that they cannot show the early signs within the soft tissue or the beginning of bone destruction. (Heindel et al., 2014)

As opposed to X-rays, CT does have the capability of showing the soft tissue and bone lesions in detail whilst also detecting the probability of fractures. However, CT is not the most reliable source for a diagnostic result as it cannot review tumours present in bone marrow. (Heindel et al., 2014)

MRI can also be used to diagnose metastatic bone disease.  As well as being a safer option for patients due to its non-ionising properties, (Heindel et al., 2014) it can also recognise metastases in their early stages, such as those in the bone marrow. MRI can be more accurate when it is merged with a PET scanner to form a hybrid. PET/MRI is an upcoming procedure for the diagnosis of metastatic bone disease as it enables the viewer to see lesions in detail, observing whether the lesion absorbs the radiotracer and is malignant. (O’Sullivan, 2015)

A form of treatment for metastatic bone cancer are bisphosphates. These can be administered via drip or tablet form and are designed to decrease calcium concentration within the bloodstream, as well as strengthening the weakened bones and normalising the osteoclast production. (“Bisphosphonates | Secondary bone cancer”, 2019). Other treatment options include radiation therapy and surgery to strengthen or replace the damaged bones. (“Metastatic Bone Disease: Practice Essentials, Background, Pathophysiology and Etiology”, 2019)

Osteoarthritis, abbreviated to OA, is a degenerative disease which results in the corrosion of cartilage tissue found at synovial bone joints. (“Hip Osteoarthritis (Degenerative Arthritis of the Hip)”, 2019) (Bloomfield JA, 1982) There are two types of OA; primary and secondary. Primary OA is referred to as idiopathic due to the aetiology being unknown (McCance, Huether, 2002) and is most commonly thought to be age-linked (William C. Shiel Jr., 2019)Secondary OA occurs due to breakdown of cartilage from a scenario such as trauma or joint overuse (McCance, Huether, 2002). The hip consists of a ball and socket joint, made up of the head of femur and acetabulum of the pelvis (Tortora & Derrickson, 2011). This type of joint allows flexible movement and is aided by articular cartilage surrounding the joint to prevent friction. The deterioration of this articular cartilage can cause many symptoms, including, stiffness of the joint (“Symptoms”, 2019), swelling (McCance, Huether, 2002), reduced movement (“Symptoms”, 2019) and pain in the back, hip or thigh (Andrew Cole, 2019)These symptoms will progressively worsen as osteoarthritis is not reversible. (Ltd, 2019)

There are several risk factors associated with Osteoarthritis. Previous hip injuries and obesity are examples that can contribute and encourage the formation of Osteoarthritis (“Osteoarthritis”, 2019).

The behaviour of chondrocytes contributes to the development of osteoarthritis of the hip joint. Chondrocytes are cells that synthesise cartilage matrix. An unknown stimulus causes these chondrocytes to release cytokines (Loeser, 2006) which are usually summoned due to an infection. These cytokines stimulate the chondrocytes to produce enzymes that break down the cartilage matrix (McCance, Huether, 2002), ultimately damaging the articular cartilage of the hip joint. This exposes the hip joint to further damage, e.g. cyst formation (“Osteoarthritis – Pathophysiology – Clinical Features – TeachMeSurgery”, 2019). The formation of cysts on the subchondral bone is another theory for the causation of OA; the fluid filled sacs can become over-pressurised, forcing them into the synovial cavity and consequently, eroding the articular cartilage further by cartilage fibrillation (McCance, Huether, 2002). The deterioration in the structure of the cartilage in the hip joint can form osteophytes, also referred to as spurs. The body produces osteophytes to reduce the friction between the head of femur and acetabulum. This however, results in a smaller joint space, therefore, encouraging more erosion.

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Osteophytes are useful when diagnosing a patient due to a lipping effect (Bloomfield JA, 1982) surrounding the hip joint, which can be seen with an x-ray. These spurs are a normal production with old age, however, osteoarthritis may cause an increase in their quantity (Andrew Cole, 2019). An x-ray may also be a good diagnostic tool as it would be able to show a reduction in joint space and loss of articular cartilage between the femur and acetabulum. (Bloomfield JA, 1982)

Whilst conventional imaging is the most cost-effective modality for diagnosing OA, it only suggests a reduction in joint space. MRI however, allows the articular cartilage to be directly imaged and therefore, provides a more accurate diagnosis. There are many variations on specifically imaging cartilage. One technique is Diffusion Weighted Imaging which focusses on the water molecules found in the articular cartilage. As Osteoarthritis progresses there is a change in the biochemical composition of the articular cartilage due to the decrease in glycosaminoglycans which consequently increases the water content of the cartilage (Chilla, Tan, Xu, Poh, 2015 June). Inferring that when the bone matrix breaks down, there is a larger allowance for water movement which can be monitored by comparing diffusion rates with other tissues.

Whilst a blood test would not be able to directly suggest osteoarthritis, it does have the advantage of ruling out other possible pathologies such as infection. (“Lab Tests for Hip Problems”, 2019)

Osteoarthritis causes severe joint pain; painkillers are used as a treatment method. If painkillers are not an option, NSAIDs can be prescribed (“Treatment”, 2019). These are drugs that decrease the inflammation of the hip joint and reduce pain. Furthermore, there several opportunities regarding surgical options. These include, arthrodesis, osteotomy and arthroplasty (Bull, 1985). However, surgical methods are rare and only carried out if the hip joint is badly destroyed. (“Treatment”, 2019)

To conclude, whilst Osteoarthritis of the hip joint and Metastatic bone disease are both pathologies of the bone, they are very different. Osteoarthritis is formed from the reduction of the joint space, resulting in the symptoms of pain, stiffness and reduced movement of the hip joint. Whereas, Metastatic bone disease is a derivative of primary cancer and can cause hypercalcemia, weakened bones and spinal cord compression.

Research revealed that MRI was the most appropriate diagnostic method for both pathologies. Its capability of showing soft tissue and bone in detail provides a more accurate diagnosis. Whilst blood tests were found to assist in the conclusion of diagnosis they are not able to provide a full diagnostic answer for OA or Metastatic bone disease.


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