ORTHO-PATHO MEET

1. ORTHO-PATHO MEET
PRESENTER:
DR. MURUGESH M KURANI
Dept. of Orthopaedics, J N
Medical College, BELAGAVI.

2. CLINICAL HISTORY
• Name: xyz
• Age: 53 years.
• Sex: Female.
• Occupation: Housewife.

3. CHIEF COMPLAINTS
C/O swelling in the right ring finger since 3
months
C/O pain in the swelling since 3 months

4. HISTORY OF PRESENTING ILLNESS
Patient was apparently alright 3 months back,
later she noticed a small swelling in the right ring
finger which was associated with mild
intermittent pain. Swelling gradually progressed
to attain present size of around 1.5x1 cm.
Since last 15days pain increased in severity and is
continuous in nature.
Pain is more during night time.

5. Pain increases on movements and relieves
upon rest
No h/o trauma/ fall
No h/o fever/ weight loss/ decreased appetite
No h/o intake of any medication

6. PAST HISTORY:
• No history of similar complaints in the past.
• No h/o -ASTHAMA/TB / brucellosis
• No h/o DM/HTN
FAMILY HISTORY:
No h/o similar complaints in the family

7. PERSONAL HISTORY
• Diet : vegeterian
• Appetite : Adequate
• Sleep : decreased because of pain
• Bowel & Bladder : Normal and regular
• No h/o of smoking /tobacco/alcohol intake

8. GENERAL PHYSICAL EXAMINATION
An elderly female patient , moderately built & nourished,
conscious and co-operative & well oriented to time, place &
person.
VITALS:
• PR: 82/min
• BP: 134/86 mm of Hg in supine
• RR: 19 /min
• Temp- afebrile 98*F

9. Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Edema: absent

10. SYSTEMIC EXAMINATION
CVS: S1 S2 + ,no murmur
RS : B/L Normal vascular breath sounds present
B/L Air entry equal.
PA : Soft, Non tender,
Bowel sounds present, no organomegaly.
CNS: No focal neurological deficit.

11. LOCAL EXAMINATION
INSPECTION:
Localised ovoid swelling of
around 1.5X1 cm over middle
phalynx of right ring finger on
volar aspect. (parallel to long
axis of bone)
Skin over the swelling is
stretched.
No scar/ sinus/ redness.
No visible pulsations/ dilated
veins.

12. PALPATION
local rise of temperature.
Tenderness present over swelling.
Size: 1.5x1 cm, hard, fixed to underlying bone.
No distal neuro-vascular deficit.

13. MOVEMENTS:
Flexion at PIP joint terminally restricted.

14. INVESTIGATIONS:
Hb : 11.4g%
WBC : 6800 cells/cumm, N62, L 30, E 06, M 02
PLATELET COUNT : 3.05L/cumm
RBS : 116 mg%
UREA : 29mg%
CREATININE: 1.1 mg%
HIV, HBsAg, HCV : NON REACTIVE

15. X RAY OF RIGHT HAND
Sharply marginated,
lobulated,eccentrically
located lucent defect
in metaphysio-
epiphysial region of
middle phalynx of ring
finger.

16. MRI OF RIGHT HAND
IMPRESSION:
Well defined signal
abnormality along
palmar aspect of ring
finger in the region of
middle phalynx s/o
GCT of tendon
sheath d/d ganglion
cyst.

17. DIFFERENTIAL DIAGNOSIS
GANGLION CYST
GCT OF TENDON SHEATH
ENCHONDROMA
PERIOSTEAL CHONDROMA
SIMPLE BONE CYST
ANEURYSMAL BONE CYST
CHONDROBLASTOMA
CHONDROMYXOID FIBROMA
CHONDROSARCOMA

18. GCT TENDON SHEATH
A giant cell tumor of tendon sheath consists of
multinucleated giant cells, inflammatory cells, histiocytes,
and fibroblasts.
It develops in or near synovial joints, bursae, and tendon
sheaths and may represent a reactive inflammatory
process or a benign neoplasm.
AGE- It most frequently develops in people between 30 and 50
years of age.
SITE- It commonly appears in the hand and less commonly in
the foot, ankle, and knee.
Physical examination reveals a firm, small, lobulated mass
fixed to the underlying tissues or tendon sheaths.
Occasionally it can erode bone. This tumor may grow
slowly and recur following surgical excision.

19. GANGLION CYST
Ganglion cysts are unilocular or multilocular collections of translucent
fluid or gelatinous myxoid tissue surrounded by fibrous tissue.
AGE- They can occur in patients of any age and are located in a superficial
location adjacent to synovial joints or tendon sheaths.
SITE - They are commonly found near the wrist, hand, and knee.
Occasionally those that develop near the knee grow to a large size and
dissect through the surrounding soft tissues.
Enlargement of the limb or swelling caused by these unusual ganglia may
suggest the presence of a neoplasm. Although aspiration can remove the
fluid from a ganglion cyst, surgical resection is currently the most
predictable method of eradicating symptomatic lesions.

21. ENCHONDROMA
An enchondroma is a benign hyaline cartilage
lesion located in the medullary cavity of
otherwise normal bones.
It frequently occurs in the bones of the
hands and feet but may appear in any
bone including the femur, tibia, and
humerus.
It is generally considered an asymptomatic,
indolent lesion.
Plain radiographs reveal a central, well-
circumscribed lucent region that may be
mineralized. Enchondromas resemble
bone infarcts. Further imaging studies are
not necessary, but enchondromas normally
show increased activity on a bone scan.

22. During skeletal growth the lesions may slowly enlarge.
Following completion of normal growth, they cease to
enlarge and the cartilage component calcifies to give a
stippled radiographic appearance.
In extremely rare cases, a chondrosarcoma can develop
from an enchondroma. Because enchondromas are usually
asymptomatic and do not enlarge after skeletal maturity, a
lesion that causes pain or enlarges in an adult strongly
suggests the possibility of malignant transformation.
Enchondromas generally do not require surgical treatment.

23. PERIOSTEAL CHONDROMA
A periosteal chondroma is a rare, subperiosteal lesion consisting of
hyaline cartilage.
It forms between the cortical bone and overlying periosteum, often
creating an indentation in the bone surface and a smooth bulge of
periosteum-covered cartilage that projects into the soft tissues.
AGE- Most patients are young or middle-aged adults.
Presumably periosteal chondromas develop from proliferation of
cartilage-forming periosteal cells.
SITE- They occur most frequently in the proximal humeral metaphysis,
phalanges, metacarpals, and metatarsals.

24. They usually present as a solitary, painful mass or as an
incidental radiographic finding.
Radiographs show a scalloped depression in the bone
cortex and may show the faint image of a soft tissue mass
containing speckled regions of calcification.
Periosteal chondromas can slowly enlarge, but they have
not been shown to be aggressive.
For symptomatic or enlarging lesions, surgical resection
provides definitive local control.

25. SIMPLE BONE CYST
Simple, or unicameral, bone cysts consist of fluid-filled
cavities within bone lined by a thin layer of fibrous tissue.
Age- They occur most commonly in children less than 15
years of age.
Site- Approximately 50% occur in the proximal humeral
metaphysis. Other common sites include the proximal
femur and iliac wing.
They may cause slight expansion of bone and thinning of
the cortex. As a result patients often present with a
pathologic fracture through the cyst.

26. Radiographically, simple bone cysts are centrally
located, lucent lesions of the metaphysis. As new bone
in skeletally immature patients grows away from the
cyst, the lesion may eventually reside in the diaphysis.
The current recommended treatment of simple cysts
includes observation with restriction of activity and
steroid injections. Intralesional curettage and bone
grafting is generally reserved for large cysts at high risk
for fracture in the proximal femur.

27. ANEURYSMAL BONE CYST(ABC)
Aneurysmal bone cysts (ABCs) consist of blood-filled cavities lined by
fibrous septae that include giant cells and areas of osteoid but no true
endothelial cells.
AGE- Approximately 85% of patients with ABCs present before age 20.
The most common symptoms are pain, swelling, and tenderness on
palpation of the involved bone.
SITE- ABCs commonly involve the metaphysis of long bones, posterior
elements of the vertebrae, pelvis, or scapula, but they can occur
throughout the skeleton.
ABCs can grow rapidly and frequently cause pathologic fractures. When
located in the spine, they can cause neurologic compromise.

28. Plain radiographs show a lytic lesion causing marked
expansion of the involved bone and occasional
periosteal new bone formation. An MRI scan often
reveals fluid-fluid levels.
They may stop expanding and begin to ossify after
reaching a certain size or they may regress
spontaneously.
Standard treatment is a confirmatory biopsy followed
by intralesional curettage and bone grafting.

29. CHONDROBLASTOMA
A chondroblastoma is a benign cartilage tumor
consisting of regions or “islands” of densely
packed polyhedral cells called chondroblasts
admixed with fibrous tissue and chondrocytes
forming a cartilage matrix.
Site- epiphysis of long bones in patients with
open physes. They occur most commonly in the
proximal humerus, distal femur, proximal tibia,
and proximal femur.

30. Radiographs typically show an eccentric,
epiphyseal lucency with punctate calcifications. A
sclerotic rim surrounds the lucent area.
The lesions rarely involve more than half of the
epiphysis and only occasionally extend into the
metaphysis.
Intralesional curettage and bone grafting is
indicated for a chondroblastoma.

31. TREATMENT
Excision and curettage done under regional
block.

32. HISTOPATHOLOGY REPORT
GROSS EXAMINATION:
Single, grey white, firm tissue,
measuring 1.2x0.8x0.7cm. Cut section
shows grey white appearance.
MICROSCOPIC EXAMINATION:
Mass lined by lobules of chondrocytes
surrounded by fibroblasts along with
central areas of ossification. No
evidence of malignancy in the sections
studied.
IMPRESSION:
CHONDROMYXOID FIBROMA- MIDDLE
PHALYNX OF RIGHT RING FINGER.

33. CHONDROMYXOID FIBROMA
Rare, slow growing, benign cartilagenous tumor <1%, malignant degeneration is rare.
Charecterised by GRM1 gene fusion or promoter swapping.
Associated with a translocation at t(1;5)
Described in 1943 by Jaffe and Lichtenstein, who differentiated the histologic
findings from chondrosarcoma, before 1943 it is considered a giant cell varient.
Site: metaphysis of long bones – distal femur, proximal tibia (60%)
flat bones – ileum, ribs, skull bone
hand bones.
Age – ranges from 3-70 years, 60% are late adolescents and young adults.
Sex – M>F

34. X - RAY- Sharply marginated,
lobulated,eccentrically located
lucent defect in the
metaphysis, may extend into
epiphysis.
Macroscopy: sharp
circumscribed, often lobulated,
firm, gray white or blue gray.
Microscopy: pseudolobular
architecture, spindle shaped or
stellate cells, abondant myxoid
stroma to chondroid stroma.

35. TREATMENT:
Intralesional curettage or resection. Resulting bony defect has to filled
using iliac bone graft and screw fixation. Recurrence rate 25%.
Wide en block excision may lower the recurrence, but add unnecessary
morbidity.
Local adjunct treatment agents, such as phenol, methylmethacrylate
and liquid nitrogen have not been shown to decrease the
recurrence rate.
Radiotherapy may be used in tumors that are considered unresectable.

36. CHONDROSARCOMA
A chondrosarcoma is a malignant tumor, may develop from an
enchondroma or osteochondroma but occurs more commonly in bones
with no known preceding cartilage lesion.
AGE- Chondrosarcomas occur in adults and the elderly.
SITE- most commonly in the pelvis, scapula, humerus, femur, and tibia.
Patients with multiple hereditary exostoses, Ollier's disease and Maffucci's
syndrome have a higher risk for malignant transformation of a
cartilaginous lesion.
Chondrosarcomas vary considerably in their behavior: some enlarge
rapidly, aggressively invade normal tissue, metastasize, and cause death,
but most are low grade tumors that enlarge slowly, cause little damage to
adjacent tissues, and metastasize only after many years.

37. Plain radiographs reveal bone destruction
as well as mineralization within the
tumor.
HISTOPATHO: Chondrosarcoma of low
grade may mimic Chondromyxoid
fibroma except for the lack of a
myxoid element.
Low grade chondrosarcoma: few
mitotic figures with a bland histologic
appearance, enlarged chondrocytes
with plump multinucleated lacunae.
High grade chondrosarcoma:
hypercellular stroma consisting of
charecteristic “blue balls” of a
cartilage lesion which permeate the
bone trabeculae.

38. Wide surgical excision is necessary and offers
the best possibility of cure, as radiation and
chemotherapy have not proven to be effective
methods of treatment for chondrosarcoma.
Locally recurrent disease is common and may
be difficult to treat.

39. THANK YOU