Fracture: not routinely biopsied unless there is non-union, delayed healing or is thought to be pathological. In the former there is little or no new bone formation and only loose fibrous tissue. Sometimes there may be evidence of accompanying infection. Pathological fracture is most often due to metastatic carcinoma or myeloma although occasionally a primary bone tumour such as malignant fibrous histiocytoma, dedifferentiated chondrosarcoma or a benign bone cyst may be the cause.
Osteomyelitis: in the acute stages this disease is not routinely biopsied but when a biopsy is submitted material will be routinely sent to microbiology for culture as well. Infection is most commonly due to Staph. aureus but increasingly, low-virulence organisms are being implicated as in drug addicts or the immuno-suppressed. Chronic osteomyelitis can result in marked bone deformity and usually is characterised by prominent bone formation with quite minimal inflammation. The pathologist should always be aware of tuberculosis, which is increasing in incidence.
Metabolic bone disease: osteoporosis is very effectively diagnosed using DEXA (dual energy X-ray absorptiometry) and is almost never routinely biopsied. Osteomalacia is most uncommon in the UK but may rarely be seen in renal failure or in patients taking long-term phenytoin therapy. Paget's disease is easily diagnosed using plain X-ray, serum alkaline phosphatase and urinary hydroxyproline so it is almost never biopsied.
Avascular necrosis: seen in some fractures (neck of femur, scaphoid, talus), chronic steroid therapy, alcohol abuse, sickle cell anaemia, Caisson disease (dysbarism).
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