OSTEOCHONDROMA

UNICAMERAL BONE CYST

ANEURYSMAL BONE CYST

DR. ANWAR
 OSTEOCHONDROMAS

SOLIDARY MULTIPLE

SESSILE

PEDEUNCULATED
 SOLITARY OSTEOCHONDROMA
• The most common benign bone tumor.
• Risk factors:
• RADIATION
• TRAUMA
• The hallmark of the lesions is a hemartamatous lesion
often in the form of a bony stalk covered by cartillage
cap

• In contrast to true neoplasms, the growth of the lesion

is usually parallels to that of the patient skeletal
grwoth, and ceases when at skeletl skeletal maturity.
 EPIDEMOILOGY
• INCIDENCE:
• the most common benign bone tumor
• SEX :
• 1.5 times more common in male than female
• AGE:
• 50 % cases in second deccade of life

• Site:
• occur on the surface of the bone and often at sites of tendon insertion
• Common locations:
• Distal femur, proximal tibia, proximal femur, proximal humerus
PLAIN RADIOGRAPHS
 Histology
• Cut surface shows bluish transparent and smooth
cartilage cap

• Similar to a normal physis with surface is covered by

thin perichondrium

• Underlying trabecular bone

• The chondrocytes are arranged in a linear pattern

without nuclear atypia.

• Normal-appearing bone marrow in the lesion

 Presentation
• Most lesions are asymptomatic

• Usually present with painless mass which continue to

grow until skeletal maturity

• Some time it may cause vascular and neurological

symptoms due to pressure effect, but less common in
solitary lesoins
 Treatmnt
• NONOPERATIVE
• observation
• asymptomatic or minimally symptomatic cases
• OPERATIVE
– Try to delay surgery until skeletal maturity
– Marginal resection at base of stalk
• symptomatic lesions
• lesion may cause inflammation to surrounding tissue
• lesion may be cosmetically displeasing
MULTIPLE HERIDETIARY EXOSTOSIS (MHE)
• Caused by mutations in EXT1, EXT2, and EXT3 genes
(tumor suppressor genes)
• Inherited as an autosomal dominant disorder
• Often first discovered at a younger age than solitary
form
• The abnormaly broad and blunt metaphyses leads
to growth abnormality and deformities
 PRESENTATION
• Usually painless mass
• Some may cause
mechanical symptoms
due to pressure effect
– False aneurysms of major
lower extremity vessels
– Neuropathies caused
 PRESENTATION

• Lower limb deformities

– Femoral shortening and
limb-length discrepancy
– Coxa valga
– Short fibula leading to valgus
defromity of knee and ankle
• Upper extremity
– ulnar shortening
– radial bowing and radial
head dislocation
 Treatment
• Case specific depending upon degree of deformities
or functional disturbances
• Excision of exostoses to relieve the prsseure symptoms or
resrticted rom
• Corrective procedures: lengthening or corrective osteotomy of
the tibia, ulna and radius
• Excision or open reduction of the dislocated head of the radius.
• Combined approach of above
 Differential diagnosis
• Subungual Exostosis:
– arise from the dorsal aspect of the distal
phalanx of big toe.
– Most of the time history of trauma or infection
– Like osteochondromas, subungual exostosis is a
surface lesion. But there is no medullary
continuity.
• Bizarre Parosteal Osteochondromatous
proliferation (BPOP): ( Nora Lesion)
• arises from the bone cortex
• lacks medullary continuity and cartillage cap
• Supracondylar Spur:
• projects towards the elbow joint
 Malignancy
• Risk of malignant transformation is rare:
– <1% with solitary osteochondroma
– ~5-10% with MHE
• Most common: Secondary chondrosarcoma

• Features associated with sarcomatous transformation

• Growth after skeletal maturity
• Cortical destruction
• New onset pain after puberty
• Soft tissue mass
• Cartilage cap of thickness greater than 1.5 cm
BONE CYSTS
UBC ABC
 UNICAMERAL BONE CYST (UBC)
• Also called simple bone cyst
• It is an intramedullary unilocular cystic lesion
filled with serous fliud , and lined by a
membrane of variable thickness.
 Epidemiology
• Sex:
• Slighly greater incidence in males than
females
• Age:
• 80 % cases in fist 2 decades
• Site
• Proximal humerus (50 %),
• Proximal femur (25 %)
• Proximal tibia, calcaneum and distal radius
 Etiology
• The exact pathogenesis of these cystic lesions
is unclear.
• The most widely accepted theory is that a
focal defect in interstitial fluid drainage
ccauses increased local pressure, which leads
to focal bone necrosis and accumulation of
fluid.
 INSIDE THE CYST
• Usually filled with a clear yellow, serous fluid
which contains prostaglandins, oxygen-free
radicals, interleukins, cytokines all of which
may contribute to bone resorption.
• Pathologic fracture may cause bleeding into
the cyst
 PRESENTATION
• The majority are asymptomatic.

• Most of the time discovered only after pathological fracture

or incidentally on radiological examination for other reasons.

• A few patients may experience mild pain or limitation of

motion
 Radiographic Features

• Well outlined centrally and symmetrically located

lucent lesion expanding and thinning the cortices.
• Not wider than the epiphyseal plate.
• It usually abuts but rarely crosses the growth
plate.
• Epiphyseal involvement is uncommon.
• The lesion originally arises in metaphysis and
extends progressively into the diaphysis.
• Pathological fracture
typically shows “fallen
leaf” sign
 CLASSIFICATION

ACTIVACTIVE INACTIVE/ LATENT ATENT

 Treatment( pre fracture)
• OBSERVATION WITH SERIAL RADIOGRAOHS
• Small asymptomatic lesions in the upper extremities
• Aspiration of the csyt with injection of
• methylprednisolone acetate
• bone marrow injection
• demineralized bone matrix
– Active cysts in the proximal humerus
– Lesion at the risk of pathologcal fracture
– Lesion of the lower extrmity

• Curettage and bone grafting +/- internal fixation

• larger lesion at risk of pathological fracture specially in ower limb
• Non responding to steroid inj
 Minimally invasive technique
• The procedure is done under GA

• Under image guidance Two 18-gauge spinal needle/ Jamshedi needle

• Aspirate through one needle. The diagnosis of a unicameral bone cyst is confirmed
through the efflux of straw-colored cyst fluid.

• Saline push via the 2nd needle

• 80 to 200 mg of methylprednisolone (Depo-Medrol) is used, depending on the weight

and age of the patient and the size of the lesion

• Steriod inj can be repeated after 2 months in case of recurrence

• PATHOLOGICAL FRACTURE
• upper extremity
• Can be treated conservatively because the fracture may
initiate cyst “healing.”
• Lower extremity
• should be treated with curettage, bone grafting, and internal
fixation.
• Flexible intramedullary nailing has been used in the femur
and humerus and provides early stability
 DDs

• ABC
– eccentric and more expansile than
UBC
• FIBROUS DYSPLASIA
– Also intramedullary lesion like UBC
– The upper or lower limit frequently
shows a triangular shaped image.
– The lesion has a ground glass
– Shepherd’s crook deformity
 ANURYSMAL BONE CYST
• An intramedullary lytic lesion of
metaphysis lined by membranes of
different thickness like UBC but it is:
• Eccentric
• Rapid growing
• Expansible
• Multiloculated
• Blood-filled
 Variants
• PRIMARY SECONDARY ABC (30 % )
• Arise in various benign and
ABC(70%) malignant conditions.
• When ABC arises “de • Most commonly in:
novo” in bone – – Giant cell tumor
– Chondroblastoma
• Without any pre – Fibrous dysplasia
existing lesion – Chondromyxoid fibroma
– NOF
 Epidemiology
• Age:
• 75% of patients are < 20 yrs.
• Sex:
• Male/female ratio is equal.
• Anatomic location
• 60% in long bones
– proximal humerus, distal femur, proximal tibia

• 15% in spine (posterior part of vertebrea)

• Metatarsal and calcaneus are the common
locations in the foot
• May be found in posterior elements of pelvis
 Etiology
• Although the pathogenesis is uncertain, it is likely that
aneurysmal bone cysts result from local circulatory
disturbance leading to increased venous pressure and
production of local hemorrhage.

• In 70% of primary ABCs there is an nderlying

chromosomal rearrangements involving the USP6 gene
(ubiquitin-specific protease)
 Presentation
• Mild-to-moderate pain and swelling that has
been present for weeks to months.
• May present with pathologic fracture
• Spinal lesions are similar to any space-occupying
lesion and may result in motor weakness,
sensory disturbance, and loss of bowel or
bladder control
 Radiographical features
• Metaphyseal, Expansile, Eccentric
• Lytic lesion with bony septae…bubbly
appearance
• Classic cases have thin rim of
periosteal new bone surrounding
lesion
• The lesion involves the cortex and
destroys it, bulging out into soft
tissues.
 CAPANNA CLASSIFICATION
• Type I lesions
– centrally located and well contained without expansion
• Type II lesions
– have marked expansion and cortical thinning
• Type III
– eccentric and metaphyseal and typically involve only one
cortex.
• Type IV
– lesions are the least common
– Develop subperiosteally, expanding away from the bone.
• Type V
– Occur periosteally and expand peripherally, ultimately
penetrating cortical bone.
 CT SCAN

• Particularly helpful in delineating

the cyst in areas of complex
anatomy, such as the spine or
pelvis

• CT scan highlights the calcified rim

at the periphery.
• CT may show internal septation
and multiple fluid-fluid levels –but
this sign more clear on mri
 MRI
• Confirm the entirely cystic
nature with the internal
septation
• Hematocrit effect
– Multiple fluid-fluid levels
 Histopathology
• Well-defined multiloculated
cystic lesions filled with
blood.
• The walls lack a true
endothelial lining. It is lined
bya layer of compressed
fibroblasts and histiocytes
 Tratment
NONOPERATIVE
• ABC with acute fracture
• Once healed, treat as an ABC without fracture
unless the fracture has led to spontaneous
healing of the ABC
 Operative
• Aggressive curettage (+/- adjuvant) and bone
grafting
• For symptomatic ABC without acute fracture
• Possible adjuvants
• phenol
• liquid nitrogen
• Selective Angioembiloization:
– To minimize the risk of bleeding for for lesion in pelvis and spine
– Can be used as definitive treatment of locations where curettage
would be extremely difficult.
• Radiatiotherapy
– Can induce rapid ossification; however, it is not used routinely
because of the potential for malignant transformation
• Marginal resection
– May be indicated for lesions in expendable bones like Fibula and ribs
• Denosumab
– When surgery would be associated with unacceptable morbidty.
 SCLEROTHERAPY

• It is feasible option in sites where surgical therapy is impossible or hazardous such as

pelvic, sacral or vertebral ABCs

• Has a similar rate of recurrence but better functional outcomes and fewer complications
like growth arrest and joint distruction than curretage.

• Commonly used sclerosing agents

–Polidocanol (polyglycol ether)
–Ethibloc (alcohol based)
• But associated with pulmonary embolism and cutaneous fistula formation
• HEALING RATE
– 93% compared with 84% in the curettage
 dds
• UBC
• Paraosteal osteosarcoma
• Giant cell tumor
Thank You
Thora sa proud hai
baki thek hai