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 Chondroma
 Parosteal Osteosarcoma
 Myosistis ossificans

10. INVESTIGATIONS
 HB 13.7 gm%
 T.C 55OO CELLS /CUMM
 P.C 2.3 LAKHS
 ESR 10mm /1st 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: Osteochondroma 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 Delto-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. Histopathology
 MICROSCOPY:
Sections show cartilage with mature bone trabecule
having bone marrow elements.
IMPRESSION: Histological features are
consistent with Osteochondroma.

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. Pathogenesis
 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.

30. 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.

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

32.  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

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

34. 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.