ORTHO PATHO MEET

PRESENTER : Dr. SAUMYA

AGARWAL

Junior resident Dept of Orthopaedics J.N.Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum

NAME : XYZ

AGE : 13 Yrs

SEX : FEMALE I.P NO. : 659161

ADDRESS : RESIDENT OF BELGAUM

OCCUPATION : STUDENT

CHIEF COMPLAINTS

Patient complaints of pain in right thigh since 2 months

Swelling in right thigh since 2 months

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 2 months back when she started complaining of pain in right thigh due to injury with a bench.

Pain was insidious in onset, gradually progressive, aggravated on working and relieved on rest

and later it was present at rest and during night.

Swelling was insidious in onset and was initially peanut size and now progressed to present size (06×08cm)

Swelling is associated with pain which is dull aching in nature and intermittent.

No history of :1) Fever2) Significant Loss of body weight3) Steroid intake4) Seizures 5) Other joint pain

PAST HISTORY

No history of similar complaints in the past.

Not a Known case of Diabetes Mellitus, Hypertension

and Ischemic heart disease.

Not a known case of Tuberculosis, hyperthyroidism

and other chronic illness.

FAMILY HISTORY Nothing significant

PERSONAL HISTORY

Diet : Mixed

Appetite : Not decreased

Sleep : Disturbed

Bowel & Bladder : Normal and regular

GENERAL EXAMINATION

Patient is conscious, cooperative and well oriented to time , place and person .

Moderately built Afebrile Pulse – 76 /min Blood pressure - 116/80 mmHg Respiratory rate – 20 / min No pallor / cyanosis / edema / icterus / clubbing /

lymphadenopathy

SYSTEMIC EXAMINATION

CVS : S1 S2 heard, No murmurs

RS : Air entry equal on both sides

PA : Soft, Non tender, no organomegaly,

Bowel . sounds heard

CNS : No focal neurological deficit

LOCAL EXAMINATION

Gait – Antalgic gait

Attitude – Patient is in supine position with

both patella facing upward and outward and

foot facing outwards.

INSPECTION – Left thigh – normal

Right thigh – A solitary swelling over medial aspect approximately 6*8 cm with smooth surface and ill defined margins

There are dilated veins over swelling

Skin over the swelling appears normal

No any sinus / scar / discharge / inflammatory changes

No evidence of shortening of both lower limbs

PALPATION – All the inspectory findings were confirmed local rise of temperature present Tenderness – present over the right thigh a solitary swelling over medial aspect of thigh

measuring 06*08 cm with ill defined edge hard in consistency, not mobile

Range of movement of right hip restricted terminally Range of movement of right knee restricted

terminally No muscle wasting Toe movements – present Distal pulses – felt on both sides No neurological deficit

INVESTIGATIONS Hb – 11.4 gm% TLC – 8920/ cumm RBC - 4,50000 / cumm ESR – 14 Platelet count – 2,53000/ cumm PCV - 36.3 Blood Group – B +

S. Creatinine – 0.9

Blood Urea – 19

S. Sodium – 138 meq/l

S. Potassium – 4.8 meq/l

S. Calcium - 9.8

S. Alkaline phosphatase – 600

X-RAY PELVIS AP VIEW SHOWING RIGHT FEMUR

X-RAY RIGHT FEMUR- LATERAL VIEW

X-RAY FINDINGS

An expansile osteolytic lesion seen in diaphysis of femur with thin sclerotic rim.

DIFFERENTIAL DIAGNOSIS

1) Unicameral bone cyst2) Aneurysmal bone cyst3) Telengiectatic osteosarcoma

PATHOLOGY

Aneurysmal bone cysts (ABC) 

are benign expansile tumour-like bone lesions of uncertain aetiology, composed of numerous blood filled channels, and mostly diagnosed

in children and adolescents

EPIDEMIOLOGY

Aneurysmal bone cysts are primarily seen in children and adolescents, with 80% occurring in

the patients less than 20 years of age  with female preponderence

PATHOLOGY

ABCs consist of blood-filled spaces of variable size that are separated by connective tissue containing trabeculae of bone or osteoid tissue and osteoclast giant cells.

They are not lined by endothelium.

FNAC is usually non-diagnostic and is dominated by fresh blood

PRIMARY Peculiar lesion of the bone characterized

by the presence of multilocular cystic tissue filled with blood.

Benign, locally destructive, prone for recurrence.

No underlying condition can be identified radio graphically/ microscopically.

GROSS Spongy, multilocular cystic

lesion filled with blood ( size varies from 1 mm- several cms.).

Small amount of spongy red brown soft tissue or thin membranous septa.

Borders- Irregular, lobulated, sharply demarcated.

MICROSCOPY

• Vascular spaces.• osteoclast like giant cells. • Intervening stroma is

cellular, no malignant osteoid.

• Solid areas-spindle cell proli

• Mitosis.• Chondroid areas-benign.• Degen. calcifying

fibromyxoid tissue.

SECONDARY

Aneurysmal bone cysts that are superimposed on a pre existing condition.

M/C - < 20 years. In contrast to primary, M/C seen in weight bearing

bones.

MICROSCOPY

Similar to primary aneurysmal bone cyst along with residual foci with microscopic features of an underlying condition.

CLINICAL PRESENTATION

Patients may present with pain, which may be of insidious onset or abrupt due to pathological fracture, with a palpable lump or with restricted movement.

LOCATION They are typically eccentrically located in

the metaphysis of long bones, adjacent to an unfused growth plate.

Although they have been described in most bones, the most common locations are 

long bones: 50-60%, typically of the metaphysislower limb: 40%

tibia and fibula: 24%, especially proximal tibia

femur: 13%, especially proximallyupper limb: 20%

spine and sacrum: 20-30%especially posterior elements, with extension into vertebral body in 40% of cases 

craniofacial: jaw, basi-sphenoid, and paranasal sinuses

RADIOGRAPHIC FINDINGS Radiographs demonstrate sharply

defined, expansile osteolytic lesions, with thin sclerotic margins.

CT will demonstrate these findings to a greater degree, and is also better at assessing cortical breach and extension into soft tissues.

BONE SCAN Doughnut sign: increased uptake

peripherally with a photopenic centre.

TREATMENT AND PROGNOSIS Traditionally these lesions have been treated

operatively (curettage and bone grafting) with a recurrence rate of ~20% (range 11-31%)

Percutaneous treatment with fibrosing agents has also been performed, either in isolation as a precursor to surgical excision