Post on 14-Dec-2014
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Dr. Sidharth yadav Orthopaedic dept.
Diagnosis of cystic lesions in skeletal system is based on radiologic analysis.
Radiologic analysis of bone lesion that are lytic 7 question has to be asked :-
Where is the lesion? How large is the lesion ? What’s the lesion doing to bone ? What is bone doing in response ? What kind of matrix ? Is the cortex eroded or intact ? Is there any soft tissue extension ?
Solitary bone cyst Aneurysmal bone
cyst Fibrous dysplasia Chondroma Chondromyxoid
fibroma chondroblastoma
Brown tumour hyperparathyroidism
Hydatid cyst Intraosseous
Ganglion Epidermoid cyst Giant cell tumour Fibrous cortical
defect
Is a common lesion of unknown cause & pathologyAge :- most commonly in 5-15 yrs rarely after 20 yrsSex :- male predominant (2:1)Location :- long tubular bones particularly
humreus & femur -metaphysael region is the preferred site.
2 types :-
Active cystic lesion :- develops under 10yrs age -adjacent to the epiphyseal plate.
Benign latent cyst :- develops after 20 yrs age
- seprated from epiphysis
Physical findings :- - Usually asymptomatic.-Cyst lying adjacent to growth plate can lead to growth disturbances.
X ray findings :- centrally located,lytic lesion.-Expansion of the bone.-Well marginated outline.-Thinning of the cortex( scalloping).- Fallen fragment sign- Periosteal surface is smooth.-loculated appearance is due to presence of ridges over inner surface of cyst.
Pathology :- Gross :- - Bone displays an area of fusiform expansion.- Underlying bone is egg-shell thin.- Cavity contain yellow fluid.- Thin layer of connective tissue lines the cavity that gives the pseudoloculated apperance on x-rays.
Microscopic :- - Connective tissue composed of fibroblast contaning multinucleated giant cells , foam cell.- Cortical wall consist of lossely trabeculated osseous tissue & many thin walled vessels.
Diagnosis :- -Is establisehed by aspiration , injection of radio-opaque substance & direct operative exposure.
Treatment :-Curettage Aspiration Steroid injection
Solitary expansile Blood filled reactive lesion of bone .Locally destructive.Age :- usually in 1st ,2nd & 3rd decade of life .
Sex :- slight female predominance.
Location :- any bone may be involved. -Most common is proximal humreus ,distal femur,proximal tibia & spine.
Types :-
Primary :- apperas de novo following intraosseous A-V fistula.Secondary :- results of cystic changes in GCT ,OSTEOBLASTOMA etc.
Clinical feature :--Pt complain of mild to moderate pain.-Swelling -Limitation of joint movements.-Neurological deficit or radicular pain.-Rapid growth may occur which clinically presents as a malignancy.
X ray findings :-Affected bone is expanded, cystic & ballooned outward.Ecentricaly placed.Cortex is breached.Surrounded by a faint outline representing new periosteal bone.
PATHOLOGY :-
GROSS :--Large mass is attached by a broad base to the shaft of long bone .-Growing outwards & displacing the soft tissue.-Thin shell of bone enclosing the blood filled spaces.-Bony shell is easily penetrable with a liver like friable mass interposed with gritty bone particles is encountered.
Microscopic :--Bone & marrow are replaced by the large pool of blood enclosed in fibro osseous septae.-Connective tissue bordering the vascular space contain multinucleated giant cells, new bone formation & calcium deposits.
Other investigation:-Bone scan :- shows diffuse or peripheral tracer uptake with decreased uptake in center.
Ct scan :- helpful in delineating the cyst in complex area ex. Spine ,pelvis .
MRI :- shows multi loculated cavities & fluid level.
Treatment :--Currettage & bone grafting.-Marginal resction Is indicated in expendable bone-Low dose radiation has been used effectively ,associated with rapid ossification.
•Benign lesions of hyaline cartilage.
•It can arise with in a bone ( ENCHONDROMA)
or on the surface of abone ( PERIOSTEAL /JUXTACORTICAL CHONDROMA).
•Usually presents as a solitary lesion but multiple lesion can also be present (enchondromatosis/OLLIER’S disease).
•Tumour may be accompanied by a vascular lesion (MAFFUCCI’S SYND.)
Age :- usually all age group are affected .More commonly young individiual in 2nd -4th decade.
Sex :- equally (M:F=1:1)
Location:- any bone can be affected but commonly phalanges of hand & feet.-solitary enchondromas involve humreus , tibia & femur.
Clinical findings :-
-Swelling-Tenderness -Pain
Pathology :- Gross :--Tumour is surrounded by a fibrous capsule.-The neoplastic tissue is composed of bluish white translucent cartilage- Areas of calcification.
Microscopically :--Tumour shows stages of cartilage formation.-Mesenchymal tissue is seen at periphery.-Most mature cartilage is seen at center.
X RAYS FINDINGS :-
-small loculated area with well defined margins.-Cortex is thinned & expanded.-Interlesional calcification :- calcification is irregular Stippled ,punctate or popcorn.-no reactive bone formation
CT scan :- Evaluate endosteal erosion to rule out chondrosarcoma.
Treatment of solitary enchondroma consisit of oberservation with serial radiographs.
If the lesion apperas to be radiographically stable & asymptomatic then no further investigation is required.
If the lesion appers to be unstable , growing then extended curettage is done.
-Least common cartilage tumour.
-Not known to metastasize.
-2% of all benign tumour.
-Seen in patients <30yrs specially in 2nd
& 3rd decade
-Tumour is more common in male (M:F=2:1).
-Observed in long tubular bones specially in lower extermity.
Clinical features:--Pain near the joint without h/o trauma-Occasionally swelling-Pathological fractures ( rare)-May presents with soft tissue swelling.
Radiographic findings :--Translucent mass located eccentrically.-Fusiform expansion in small bones.-Cortex is expanded & thinned.-Margin’s are scalloped & sclerosis +.-Periosteal reaction is uncommon.
Pathology :-Gross :--Cut surface reveals solid tumour mass containing small cavities with mucoid tissue.-Calcified areas are unusual.-Surface is sharply demarcated ,lobulated & surrounded by thin scalloped border of dense bone.
Microscopic :--Composed of lobulated areas of stellate cells with indistinct cytoplasmic borders.-At the periphery ,the appearance is more cellular & collagenous.
-local excision & filling the cavity with autogenous bone.
-Curettage is not sufficient as tumour may recure especially childrens.
-Wide en- bloc excision gives high rate of cure.
-If tumour recure even after en bloc excision then studies has to be done to rule out the malignant transformation.
-Non inherited, sporadic developmental anomaly.-Replacement of bony tissue with fibrous tissue.Age :- begins in childhood(<10 yrs).Sex :- M:F=1:1Location :- base of the skull & long bones.
Clinical features:--Pain -Limp-Deformity-Asymmetry of face-Endocrine disorder- Limb length discrepancy.
Pathology :-
Gross :--Bone is irregular in shape & bent.-Grey tough fibrous tissue that cut with a gritty resistance “SANDPAPER”
Micro :- -composed of dense,mature collagenous tissue.-fibroblast are oriented in linear /whorl pattern.
Radiological findings :--intramedullay & predominantly diaphyseal.-central or ecentric in location.-Ground glass appearance.-lesion is well defined with sclerotic margins-Cortex thinning & expansion is seen.-Pathological fractures .-Bowing of bones.-HARRISON’S GROOVE.
- Conservative management includes bracing & modification of activities.
Surgical management :--Pathological fracture usually heals but develops deformity.
-Fracture of long bone should be treated preferably with I.M nails along with bone grafts.
Large lesion which jeopardize the integrity of bone should be treated with currettage & bone grafting
-Benign well circumscribed fibrous growth with in a small area of long bone.-A/k/a nonossifying fibroma,fibroxanthoma-Localised form of fibrous dysplasia.
Age :- <30yrsLocation :- metaphysis of long bone.
-usually lower limb.Sex :-M:F=1:1
Clinical feature :- -usually asymptomatic -occasionally presents with pathological fracture.
Pathology :-Gross :- thin cortex enclose soft /tough rubbery gray –yellow or reddish brown tissue.
Microscopic :-Spindle shaped cell distributed in a whorled pattern.Fibroblastic proliferation with high cellularity.Giant & foam cells are present.
X ray findings :--well defined lobulated lesion.-Ecentrically placed.-Cortex thinning & expansion -Multilocular appearance or ridges in bony wall.-No periosteal reaction.
Treatment :-Excision & curettage
-Hyperparathyroidism results in disorder of bone & mineral metabolism.-Diffuse & focal lesion may arise in multiple bones.-These lesion are K/as brown tumours due to the presence of haemorrhage in the lesion.
Location :- Any bone can be affected.Mainly diaphysis of long bone.
Clinical features :- StonesBones Groans
Radiological features :-Salt & pepper skullMultiple osteolytic lesions
Laboratory findings :-↑ed levels of PTHHyper calcemia↑ed serum phosphate & urate.
TREATMENT :- treatment of the primary cause will cause the healing of lesion.
-Lesion of uncertain pathogenesis.Age :- can occur at any age.-Most commonly seen in 20-60yrs age .
Location :- subchondral region of tubular bone ,acetabulam & carpel bones.-Simultaneous occurrence of peri osseous ganglion cyst .-This led to the theory of adjacent soft tissue ganglion extension in bone.
Clinical feature :-are usually clinically silent.-Chronic pain -Swelling if associated with soft tissue ganglion.-Usually solitary
Radiogaphic findings :--Well demarcated ,sharply circumscribed osteolytic lesion.-Sclerotic margin is evident.-In para articular location gas may be evident.
Treatment :-- Local excision of overlying soft tissue & curettage of involved bone.- Recurrence is rare.
-Uncommon.-Due to the intraosseous implantation of epidermoid tissue .-M >FAge :- usually in 2nd ,3rd & 4th decade of life.Location :- skull & phalanges of hand are commonly affected.
Clinically :--Pain & swelling
Microscopically :--They resemble epidermal cyst of skin.
-Cysts are filled with keratinous material & lined by squamous epithelium.
RADIOGRAPHIC :-Well defined osteolytic lesion with sclerotic margins .
CT & MRI are rarely required.
Treatment :- Excision