orthopaedics

1. Dr Wazzan AL Juhani MD FRCSC
Dr. Majed Aalasbali

2. First Task
1- What is the age of the pt ?
 above 40 yr
 skeletal mature ( 20-40)
 Skeletal immature
2- Then Look at the X-ray Feature ?
 Benign looking Vs more aggressive feature
 Matrix
3- Location of the lesion .
• intra-articular
• epiphysis
• metaphysis
• diaphysis
 Then put in the spectrum .
 Benign Lesion
 Metz , vs primary bone tumor ( osteo sarcoma vs chondro, ewing )
 Metabolic Bone disease , e.g brown tumor, paget
 osteomyelitis ( local Tumor )

3. Benign Vs Malignant

5. Immature vs Mature

7. What to read in X-Ray
1. Site
2. Size
3. Matrix
4. Pattern/margins incl. zone of transition
5. Effect of the lesion on bone
6. Reaction of bone to the lesion
7. Soft tissue mass

8. site
• Which bone is affected (femur, radius,…)
• Where in the bone
 Diaphysis, metaphysis, epiphysis, or combination
 Central, eccentric, intracortical, surface

9. matrix
• Fibrous
• Cartilagenous
- stippled, arcs and rings
• Osseous
- cloud-like, dense

11. LESION EFFECT ON BONE
• Cortical thinning
 Lower grade, less aggressive
• Cortical expansion
 Low or high grade, tumor mimickers
• Cortical destruction
 High grade, aggressive

12. EFFECT BONE ON LESION
Periosteal reaction
 Absent
 Mild – one layer, 1-4 mm thick, adjacent to cortex
 Major - >5mm, multilayered or lamellated
“onion-skinning”, “hair-on-end”, “sunburst”

14. SOFT TISSUE MASS
Soft Tissue Mass
• Absent
• Present

15. Biopsy
 Fine Needle Aspiration (FNA)
 not typically used for sarcoma
 Core biopsy (Tru-cut)
 allow for tumor structural examination
 cytologic and stromal elements of the tumor
 frequently used for sarcoma
 Incisional biopsy
 small surgical incision carefully placed to access tumor without
contamination of critical structures
 Excisional biopsy
 small, superficial soft tissue masses

16. NOT FOR BIOPSY
 An asymptomatic (latent) or symptomatic bone lesion
(active) that appears entirely benign on imaging does
not need a biopsy
 A soft tissue lesion that appears entirely benign on
MRI (lipoma, hemangioma) does not need a biopsy
 When in doubt, it is safer to do a biopsy.

17. INDICATIONS FOR BIOPSY
1) Aggressive or malignant appearing bone or soft tissue
lesions
2) For soft tissue lesions - >5cm, deep to fascia or
overlying bone or neurovascular structures
3) Unclear diagnosis in symptomatic patient
4) Special situation - solitary bone lesion in a patient
with a history of carcinoma

18. BEFORE BIOPSY
 CBC, platelets, coagulation screen
 Cross-sectional imaging – depicts local anatomy, solid
areas of tumour
 Experienced musculoskeletal pathologist available

19. PRINCIPLES OF BIOPSY
SKIN
Avoid tenuous skin , Avoid transverse incision
DEEP
Through muscle , meticulous hemostasis , Avoid NV
SAMPLE
Ensure adequate diagnostic tissue , FROZEN –SECTION
CLOSURE
Tight muscle closure , drain at corner , compression dressing
Send for C/S

20.  For tumours without soft
tissue mass, plan biopsy
through area of maximal
cortical weakening based on
CT or MRI .
 For tumours or with soft
tissue mass, biopsy soft
tissue rather than creating
hole in bone .

21. A- bone forming Tumor
 Benign lesion
 Osteoma
 Enostosis
 osteod osteoma
 Osteoblastoma
 Malignant Tumor
 Osteosarcoma
 Soft tissue ( Extraskeletal ) osteosarcoma .

22. B- Cartilage ( chondrogenic Lesion)
 Benign lesion
 Enchondroma
 perisoteal chondroma
 osteochndroma
 chondroblastoma
 chondromyxoid fibroma
 Malignant Lesion
 chondrosarcoma


23. Fibrous lesion
 Benign Lesion
 Fibrous cortical defect
 fibrous dysplasia
 osteofibrous Dysplasia
 Malignant Tumor
 MFH

24. Tumor like lesion
 Benign lesion
 GCT
 Simple bone cyst
 ABC
 Interosseous lipoma
 Malignant Tumor
 Adamantinoma
 chordoma

25. Intra-articular Tumor
 PVNS
 Synovial chondromatosis
 lipoma Arborescnes
 Synovial Hmeangioma

26. Above 40 yr
 DDX ( think of Metz)
 Metz
 MM
 lymphoma
 May be some thing else
( Sarcoma)
 Infection vs Brown
Tumor

27. Big Five osteophilic
 Breast
 prostate
 Lung
 Kidney
 Thyroid
 Then think of GI , Melanoma

28. Metz
 some clue to DDX
 Most common is Breast + prostate
 Most common with Acral mets
 Lung
 Kidney
 cortical Mets : Lung , Kidney
 Most common to Bone + soft tissue
 Lung ,Kidney

29. Mets
 Most common site
 thoracolumbar spine
 sacrum
 PF
 pelvis
 ribs ,sternum
 PH

30. Approach
 Known Hx of cancer ?
 No Metastatic Work Up + Biopsy
 f/u MSK biopsy Principle .
 Yes solitary Lesion
 Metastatic Work up + Biopsy .
 Yes Multi focal Bone or Visceral Metz .
 Biopsy if not Proven before
 proven Metz treat accordingly .

31. Metz workup
 HX + E
 Breast , prostate & thyroid exam
 abdomen for organomegaly
 Lab ( Blood work) ,urine anaylsis
 Cbc anemia ,thrombo - Ca ,Ph ,ALP
 ESR CRP infection ,MM - serum /urine EP
 INR , ptt coagulopathy - PSA
 Liver enzyme , - TSH

32.  systemic work up
 Bone scan
 skeletal survey
 CT chest ,abdomen ,pelvis
 Bone marrow aspirate . Eg MM ,Lymphoma ,Ewing
sarcoma ( by the medical oncolgist)
 Local
 full length x-ray
 CT VS MRI

33. Goal of treatment
 Pain relief .
 Immediate mobilization .
 Immediate Rigid fixation
 durable fixation
 protect the entire Bone when feasible
 Radio therapy
 Reduce need for subsequent surgery .
 improve post-op Function
 Bisphosphonate

34. Case

36. Case 2

38. Brown Tumor
 pt looking well /bone scan
 Ca , ph , ALP
 PTH high
 Radiograph - osteopeina
 shoulder - sub periosteal ,sub chondral , Bone
 Hand resorpation
 spine sof tissue and chondral calcification
 skull

39.  Multiple lesion

40.  subperiosteal resorpation
Mainly Radial aspect of the middle
Phalanx

41.  Soft tissue calcification
 subperiosteal
resorpation
Mainly Radial aspect of the
middle Phalanx

42.  Tunneling of cortices

43. Rugger jersey spine

44. Salt and Pepper Skull

45. Resorpation of the clavicle

46. Less than 40
 more Of Benign Lesion
 Skeletal Immature ( Location )
 UBC osteoid osteoma / osteoblastoma
 ABC
 non ossifying fibroma
 EG
 Osteomyelitis
 Fibrous dysplasia
 Skeletal Mature
 GCT
 Enchndroma
 infection
 ABC

47. Classification of Benign Bone
Tumours
 Benign latent
(enchondroma)
 Benign active (Fibrous
dysplasia)
 Benign aggressive
(GCT)

48. Presentation
 Incidental finding
 Mass- Painless or Painful
 Pain without mass
 Pathological Fracture

51. Surface

52. Surface

53. Surface

54. Surface

56. Epiphyseal

57. Epiphyseal

58. Apophyseal

59. Epiphyseal lesions
 Chondroblastoma
 Clear cell chondrosarcoma
 Osteomyelitis (occasionally)

60. Epiphyseal-Metaphyseal

61. Epiphyseal-Metaphyseal

63. Epiphyseal-Metaphyseal
 Benign aggressive lesions
 GCT
 ABC
 osteoblastoma

64. Metaphyseal

65. Metaphyseal

66. Metaphyseal

73. Metaphyseal lesions
 Enchondroma
 UBC
 NOF/fibrous cortical defect
 Chondromyxoid fibroma
 Osteosarcoma
 Chondrosarcoma

74. Diaphyseal

75. Diaphyseal

76. Diaphyseal

77. Diaphyseal

78. Diaphyseal lesions
 Osteoid osteoma
 Fibrous dysplasia
 Osteofibrous dysplasia
 Adamantinoma
 Ewing’s sarcoma

79. Treatment
 Observe /asymptomatic
 Radio frequency ablation
 curettage and Bone graft /cement
 extensive Curettage
 Resection and replace

80. Case

81. Case


82. curettage and Bone graft /cement

84. extensive Curettage

87. Resection and replace

88.  And always remember
infection

89. Sarcoma treatment
 Bone sarcoma
 Chemo + wide margin + chemo
 Except : low grade sarcoma
 E.g paraosteal OS
 Chondrosarcoma
 Soft tissue sarcoma
Radiotherapy + wide margin