fracture osteochondroma
Post on 15-Jul-2015
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A RARE CASE OF FRACTURE
OSTEOCHONDROMA
A 14 year old , boy presented to our out patient department with pain in his right thigh following a fall from bench when pulled by a fellow classmate 2 days prior to the time of presentation.
On physical examination there was slight edema over the distal & medial aspect of right thigh & tenderness with palpation over a bony hard swelling.
Knee range of movements were painful and restricted
Neurovascular examination revealed no abnormality
X RAY WAS TAKEN
Direct radiography revealed fracture through the stalk of a pedunculated osteochondroma situated posteromedially.
When a detailed history was taken the patient revealed that he has noticed a swelling in medial aspect of lower right thigh about 4 years back , which did not show any s/o increase in size since then.
Patient also revealed that he used to have pain in the region of swelling upon prolong excertion.
What next????????????????
Leave i t o r exc i se the f rac tured f ragment??????????
We decided to excise the fractured fragment.
For excision anteromedial approach was adopted.
Fractured exostosis fragment extracted out extraperiosteally in Toto with intact cartilaginous cap
Specimen was then sent for histopathological examination
Recuperating period was uneventful & patient resumed his pre traumatic state in 2 weeks
POST OPERATIVE RADIOGRAPH
HISTOPATHOLOGY
Can give rise to 2 malignant conditions
1.Osteosarcoma---- extremely rare
2.Chondrosarcoma--- 1-2% of cases osteochonroma is most common precursor lesion
for secondary chondrosarcoma
Increase in ca rt i l ag inous cap th i ckness- s/o ma l ignancy
But in skeletally immature individual look for additional features
1. Recent increase in size2. Irregular mineralization3. Soft tissue bands4. Grossly irregular surface5. Cystic changes6. Loss of architecture of cartilage7. Myxoid changes8. Necrosis9. Inc cellularity10.Mitotic activity11.Atypia
WHO CLASSIFICATION
“Defined as a cartilage capped bony projection arising on externalSurface of bone containing a marrow cavity that is continuous with That of underlying bone.”
Mc benign tumor3% general population30% of all benign tumor10-15% of all bone tumors15% of osteochondroma occur in HEREDITARY MULTIPLE OSTEOCHONDRAMATOSIS
LOCATION(common)
BONE PERCENTAGE
Femur 34
Humerus 18
Tibia 15
Pelvis 8
Scapula 5
Ribs 3
UNCOMMON SITES (17%)• Metacarpals• Condylar process of the mandible• Base of the skull• Talus• Calcaneus • Spine • Distal end of the clavicle
TYPES
TYPE SESSILE PEDUNCULATED
Incidence Uncommon Common
Location Proximal humerus and scapula
Knee , hip and ankle
Appearance Flat plateau like stalk producing a broad based protuberance
• Elongated bony stalk merging with the host bone
• The hyaline cap is lobulated giving its appearance
SESSILE VARIANT
Solitary Osteochondroma Lateral radiograph of a sessile osteochondroma of the distal femur.
EPIDEMIOLOGY
Usually in adolescent/children rarely in infants/newbornsNo sex predilection (exception HMO)
CLINICAL FEATURES
Usually asymptomatic and an incidental finding
Significant symptoms occur as a result of complications
COMPLICATIONS COMPLICATION PERCENTAGE
Fracture 7
Deformity 23
Vascular injury 7
Neurological compromise 10
Adventitious bursae formation 27
Mechanical irritation 10
Malignancy ( Solitary / HME ) <1 , > 10
Fracture of osteochondroma
Well established yet uncommon
Most often a/w traumaReported incidence – 4 in 727- dahlin et al 5 in 70- theodorous
At most risk- proximal tibial > distal femur
Natural course1.Fracture union2.Regression / Resorption3.Non union
RADIOLOGICAL FEATURES
Plain radiograph
Stalk of a flat protuberance emerging from the surface of the boneOn occasions , it ends up as a hook like formation
Benign vs ma l ignant ????
CT very accurate for defining osteochondroma
Osteochondroma vs osteosarcoma
Reliability of ct in diagnosis of osteosarcoma
USGExamination of choice – suspecting vascular lesions
Accurate method for examining cartilaginous cap of osteochondroma
Only way to pin point bursitis
MRIMost precise imaging method for symptomatic causes of bone masses
Differentiate osteochondroma from other surface bony lesions.
Cartilaginous caps- T2WI- high T1WI-low
Perichondrium
High signal in T1WI-------
High signal in T2WI-------
False positive results in ?
Benign vs ma l ignant
Challenge but accurately diagnose
Osteosarcoma>2cm in adult>3cm in children
ChondrosarcomaLow T1 signal after IV contrast infusion- rare in benign lesions
MRI IS GOLD STANDARD FOR DIAGNOSIS OF MALIGNANT TRANSFORMATION
NUCLEAR MEDICINE
Examine the metabolic activity of tumor
Thallium 201 – used for malignant transformation
ANGIOGRAPHY
Vascular lesions
Neovascularization of cartilaginous cap
s.no Author Group Conclusion
1 Shapiro et al 22 pt with HME 2.7 surgery for deformity correction
2 Wirganowicz 285 cases of benign exostosis
Elective excision – 12.5% cases a/w complications
3 Canelle et al 408 cases of exostosis
Malignant transformation riskMultiple exostosis-13%Solitary-cannot be determine
4 Saglik et al 382 cases of oc Essential to reconstruct the mass as well as reconstruct the deformities
5 Bottner et al 86 symptomatic oc Post operatively93.4%- preoperative symptoms resolved4.7%- complications7%- minor compplications5.8%- local recurrence
s.no Author Group Conclusion
6 Vasseur & fabre 97 cases with vascular complications
66%-solitaryProphylactic resection if the tumor is present in the vicinity of the vessels
7 Garrison et al 75 cases of osteosarcoma having arisen from oc
1.Excision- 78% recurrence2. Resection- 15% recurrence3. Amputation
8 Pierz et al 43 cases of HME 27of 43 required about 1-5 surgeries to control their lesions
9 Shin et al 29 pts of HMO In young pts simple excision o tumor improve range of movements o forearm but it cannot control the progress o the disease
CONCLUSION
The treatment of choice for osteochondroma is surgical .
The tumor should be excised when symptoms or complications have presented.
A prophylactic resection is suggested only if the lesion lies next to a vessel.
An osteochondroma must be completely excised, without leakage of myxomatous tissue or part of the cartilaginous cap, especially when a
sarcomatous change is suspected.
In addition to resection, reconstructive techniques have to be undertaken.
Chemotherapy and radiotherapy are suggested in dedifferentiated tumors.
Thank you & have a cheerful evening
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