Osteochondroma

osteochondroma, exostosis

1. Bony swelling for evaluation Dr giridhar boyapati p.g . Dept. of orthopaedics

2. A 19 year old male presented with chief complaints of swelling over the right shoulder since 5 years. Swelling is insidious in onset and gradually progressive in nature and attained the present size . No sudden increase in size. Not associated with pain or discharging sinuses .

3. No history of trauma or fever. No history of any other swellings in the body. No history of chronic cough , significant weight loss . No other co-morbid conditions, otherwise a healthy individual. No past history of similar swellings. No relevant family history.

4. On General examination No significant pallor, cyanosis, icterus , oedema, regional lymphadenopathy noted. No signs of infection or any chronic disease. CVS : S1 S2 + CNS : No focal neurological deficit RS : NVBS, no added sounds P/A : soft, no organomegaly .

5. ON Local Examination .

6. ON INSPECTION A 4 X 4 cm size swelling over the antero - lateral aspect of Left proximal arm. Surface is Smooth , ovoid in shape, Skin over the swelling is normal . No significant muscle wasting. No scars, dilated veins, discharging sinuses

7. ON PALPATION No local raise of temperature. No bony tenderness. Well defined margins. Swelling is hard in consistency and fixed to the humerus. Not reducible or compressible . No fixity to the overlying skin.

8. No pulsations. No bruit on auscultation. Movements of the shoulder joint normal . No distal neurovascular deficit.

9. DEFFERENTIAL Diagnosis Exostosis / Osteochondroma Periosteal C hondroma Parosteal Osteosarcoma Myosistis ossificans

10. INVESTIGATIONS HB 13.7 gm % T.C 55OO CELLS /CUMM P.C 2.3 LAKHS ESR 10mm /1 st hr BT 2:30 CT 4:30 RBS 87mg% Na 142 meq /l K 4.3 meq /l B.UREA 31mg% S.CREATININE 0.7mg%

11. X-rays

12. X-ray report Exophytic lesion noted in lateral cortex of left humerus at meta- diaphysial junction away from the shoulder joint. Cortex and medulla of the lesion is continuous with that of the host bone. Asymmetric widening of meta- diaphysial juntion . Evidence of cartilage cap noted. Impression : O steochondroma of left proximal humerus.

13. MRI

14. MRI

15. MRI report Focal bony projection in metaphysical region of left proximal humerus laterally and anteriorly. Irregular cartilaginous cap covering the lesion. Maximum thickness of the cartilage cap is 5mm. No obvious bursal formation or vascular compression noted. IMPRESSION : Osteochondroma of left proximal humerus. Cartilage cap thickness is within normal limits.

16. Patient was advised EXCISION of the lesion 1. To rule out malignancy. 2. To prevent complications. 3. To confirm the diagnosis.

17. SURGICAL APPROACH 1.Using D elto -pectoral approach a curved incision is made over the left proximal arm and plane is created between Deltoid and Pectoralis major muscles. 2. Lesion is exposed on anterolateral aspect of humerus.

18. EXCISION 1.Multiple drill holes are made at the base of stalk of the lesion. 2. Drill holes are connected using osteotome and lesion is excised en-bloc.

19. Excised material sent for histopathology.

20. POST OPERATIVE PERIOD No wound related complications. Movements of the shoulder joint normal .

21. POST OPERATIVE XRAY

22. Histopathology

23. H istopathology MICROSCOPY: Sections show cartilage with mature bone trabecule having bone marrow elements . IMPRESSION: Histological features are consistent with O steochondroma .

24. CENSUS Total of 15 cases of exostosis were operated in the past 3 years. All cases are solitary exostosis. Male 10/ Female 5. Age group ranging from 8 – 21 years. Exostosis of Distal Femur: 8 cases Proximal Humerus : 6 cases Distal Tibia : 1 case.

25. Post operative period is un- eventfull . No recurrence . No neurovascular complications . Range of movements of adjacent joints is normal.

26. Exostosis Is a developmental anomaly of bone that result in formation of an exophytic outgrowth. Most common bone tumor . 30-50% of benign bone tumors . 10-15 % of all bone tumors. AGE : First two decades of life. Sex : male : female 1.5 to 1.

27. location Metaphysis of long bones. Most common sites Distal femur Proximal tibia Proximal Humerus Also seen in flat bones like ilium, scapula, clavicle.

28. P athogenesis Herniation of a fragment of epiphyseal growth plate through the periosteal bone cuff. Misdirected growth of portion of physical plate. Development of eccentric cartilage capped bony prominence.

29. Clinical features Mostly asymptomatic presenting as painless lump. Pain may be due to -pressure on surrounding structures. -bursitis -fracture of bony stalk -malignant change. mechanical block to joint movements.

30. Radiographic features. Occur in metaphysis or in the diaphysis. Never found in the epiphysis. Directed away from the growing end of long bones. C ortex and medulla of the tumor is continuous with that of the host bone. Exostosis is either pedunculated or sessile.

31. Ultrasound - to determine thickness of cartilage cap -extent of the bursa MRI STRUCTURE AND THICKNESS OF CARTILAGE CAP MALIGNENT CHANGE CORD COMPRESSION IN SPINAL LESIONS

32. TREATMENT INDICATIONS FOR EXCISION OF THE LESION Pressure symptoms Mechanical block Fracture of the pedicle Bursitis Malignancy Cosmetic ( commonest reason for excision)

33. Sarcomatous change Chondrosarcoma Malignant transformation in solitary exostosis < 1% multiple exostosis 5% flat bones 10% Malignant change: rapid increase in size pain local raise of temperature.