Clinical Topics Conference: Chapter 26, Bones and Joints

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  1. 68 year-old woman with backache
  2. 55 year-old woman pain in the ankle and low grade fever for four years
  3. 13 year-old male first with pain in left thigh
  4. 60 year-old female with pain in the hips
  5. 55 year old male with rheumatoid arthritis and a bleeding ulcer

Clinical vignette 1

The patient was a 68 year old woman, with a chief complaint of backache. She was well until April, 1972, when she had sudden onset of severe back pain while lifting a heavy object, and was found to have a collapsed vertebra. After 2 weeks, the pain subsided. In October, 1987 she again had middle-back pain and x-ray showed two collapsed vertebra. Since then there were multiple compression fractures. Height had decreased from 5' 5" to less than 5'. She did not drink milk until her back problems began. Menopause was at age 50 years

Laboratory (normal values in parenthesis)

Ca 9.4 mg/dL (8.5-10.5)
P3.3 mEq/L (3.6-5.5)
PTH 50 pg/ml (10-50 pg/ml)
Alk Phos 94 mU/ml (30-110)
24 hour urine Ca 52 mg (<250)
Intestinal calcium absorption normal

Discussion topics

  1. List risk factors associated with osteoporosis.

  2. Does osteoporosis result from insufficient calcification of bone matrix?

  3. Is bone resportion increased in osteoporosis?

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    Clinical vignette 2

    The patient was a 55 year old woman with a chief complaint of pain in the ankle and low grade fever for four years. Four years prior to admission the patient had had an abscess removed from her leg. At that time, there was evidence of osteomyelitis in the underlying tibia which was fractured and went on to non-union. Four years after the original accident, amputation became necessary because of persistent local staphylococcal infection refractory to antibiotic therapy.

    Discussion topics

    1. What segment of the population is at greatest risk for the development of osteomyelitis?

    2. Which bacteria are most often causative in osteomyelitis?

    3. Why does osteomyelitis remain a clinical problem in the antibiotic era?

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    Clinical vignette 3

    A 13 year old white male first noted pain in the upper left leg after vigorous exercise, however, there was no history of prior trauma to the site. X-ray and MRI revealed a radiodense invasive process within the left upper tibial metaphysis, penetrating the cortex and causing an elevation of the periosteum.The patient had complained of low grade pain and tenderness below the left knee for 4 months.

    Following chemotherapy a segmental resection and reconstruction of the upper tibia was performed.

    LAB Tc99 bone scan revealed increased uptake in the area of the tumor.

    Discussion topics

    1. List risk factors associated with osteosarcoma.

    2. What is a typical route of metastasis for osteosarcoma?

    3. Why is the serum alkaline phosphatase often elevated in osteosarcoma?

    4. Define Codman triangle.

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    Clinical vignette 4

    This 60 year old Caucasian female had complained of pain in the hips for many years. She was admitted for hip replacement surgery. Fusiform enlargement of the distal phalanges was also noted bilaterally. At the time of admission, x-rays of the hips showed narrowing of joint spaces and osteophyte formation bilaterally.

    LAB: erythrocyte sedimentation rate - normal; serum rheumatoid factor - negative.

    Discussion topics

    1. Which joints are most frequently affected in osteoarthritis?

    2. What is the pathogenesis of Hebreden nodes and in what type of patients are they most frequently seen?

    3. Define eburnation.

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    Clinical vignette 5


    This 55 year old Caucasian male had rheumatoid arthritis for a number of years, with severe deformity and limitation of motion of the hands and wrists. He had been taking cortisone and other corticosteroids for an unspecified period of time. He died during surgery from severe bleeding and perforation of a gastric ulcer. At the time of death there was pronounced arthritic deformity of nearly all joints, except those of the vertebral column and knees.

    PE: Mild intermittent fever and ulnar deviation of fingers with subluxations of metacarpophalangeal joints bilaterally.

    LAB: Erythrocyte sedimentation rate - 40 mm/hour. Rheumatoid factor, latex agglutination titer - 80.

    Discussion topics

    1. Which joints are most frequently affected by rheumatoid arthritis?

    2. What is the likely cause of a bleeding and perforated gastric ulcer in this case?

    3. What is rheumatoid factor (RF) and how is it correlated with the clinical status of individual rheumatoid patients?

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