A 14-year-old boy presented with right thigh pain after a fall. X-rays revealed a fracture through the stalk of a pedunculated osteochondroma in his right thigh. The fractured fragment was surgically excised. Histopathological examination found the excised fragment to be a cartilage capped bony projection, consistent with an osteochondroma. Osteochondromas are benign bone tumors that can rarely transform into cancers like osteosarcoma or chondrosarcoma. Surgical excision is usually recommended for symptomatic osteochondromas or those with complications like fractures.

1. A RARE CASE OF
FRACTURE
OSTEOCHONDROMA

2. A 14 year old , boy presented to our out patient department with
pain in his right thigh following a fall from bench when pulled by a
fellow classmate 2 days prior to the time of presentation.
On physical examination there was slight edema over the distal &
medial aspect of right thigh & tenderness with palpation over a bony
hard swelling.
Knee range of movements were painful and restricted
Neurovascular examination revealed no abnormality

4. X RAY WAS TAKEN
Direct radiography revealed fracture through the stalk of a
pedunculated osteochondroma situated posteromedially.

5. When a detailed history was taken the patient revealed that he has noticed a
swelling in medial aspect of lower right thigh about 4 years back , which did not
show any s/o increase in size since then.
Patient also revealed that he used to have pain in the region of swelling upon
prolong excertion.

6. W h a t n e x t ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
Leave it or excise the fractured
fragment??????????

7. We decided to excise the fractured fragment.
For excision anteromedial approach was adopted.
Fractured exostosis fragment extracted out extraperiosteally in Toto with intact
cartilaginous cap
Specimen was then sent for histopathological examination
Recuperating period was uneventful & patient resumed his pre traumatic state in 2
weeks

9. POST OPERATIVE RADIOGRAPH

10. HISTOPATHOLOGY

12. Can give rise to 2 malignant conditions
1.Osteosarcoma---- extremely rare
2.Chondrosarcoma--- 1-2% of cases
osteochonroma is most common precursor lesion
for secondary chondrosarcoma
Increase in cartilaginous cap thickness- s/o malignancy
But in skeletally immature individual look for additional features

13. 1. Recent increase in size
2. Irregular mineralization
3. Soft tissue bands
4. Grossly irregular surface
5. Cystic changes
6. Loss of architecture of cartilage
7. Myxoid changes
8. Necrosis
9. Inc cellularity
10.Mitotic activity
11.Atypia

14. WHO CLASSIFICATION
“Defined as a cartilage capped bony projection arising on external
Surface of bone containing a marrow cavity that is continuous with
That of underlying bone.”
Mc benign tumor
3% general population
30% of all benign tumor
10-15% of all bone tumors
15% of osteochondroma occur in HEREDITARY MULTIPLE
OSTEOCHONDRAMATOSIS

15. LOCATION
(common)
BONE PERCENTAGE
Femur 34
Humerus 18
Tibia 15
Pelvis 8
Scapula 5
Ribs 3

16. UNCOMMON SITES (17%)
• Metacarpals
• Condylar process of the mandible
• Base of the skull
• Talus
• Calcaneus
• Spine
• Distal end of the clavicle

17. TYPES
TYPE SESSILE PEDUNCULATED
Incidence Uncommon Common
Location Proximal humerus
and scapula
Knee , hip and ankle
Appearance Flat plateau like
stalk producing a
broad based
protuberance
• Elongated bony
stalk merging with
the host bone
• The hyaline cap is
lobulated giving its
appearance

18. SESSILE VARIANT
Solitary
Osteochondroma
Lateral radiograph of a
sessile
osteochondroma of the
distal femur.

19. EPIDEMIOLOGY
Usually in adolescent/children rarely in infants/newborns
No sex predilection (exception HMO)
CLINICAL FEATURES
Usually asymptomatic and an incidental finding
Significant symptoms occur as a result of complications

20. COMPLICATIONS
COMPLICATION PERCENTAGE
Fracture 7
Deformity 23
Vascular injury 7
Neurological compromise 10
Adventitious bursae formation 27
Mechanical irritation 10
Malignancy ( Solitary / HME ) <1 , > 10

21. Fracture of osteochondroma
Well established yet uncommon
Most often a/w trauma
Reported incidence – 4 in 727- dahlin et al
5 in 70- theodorous
At most risk- proximal tibial > distal femur
Natural course
1.Fracture union
2.Regression / Resorption
3.Non union

22. RADIOLOGICAL FEATURES
Plain radiograph
Stalk of a flat protuberance emerging from the surface of the bone
On occasions , it ends up as a hook like formation
Benign vs malignant ????

23. CT
 very accurate for defining osteochondroma
Osteochondroma vs osteosarcoma
Reliability of ct in diagnosis of osteosarcoma
USG
Examination of choice – suspecting vascular lesions
Accurate method for examining cartilaginous cap of osteochondroma
Only way to pin point bursitis

24. MRI
Most precise imaging method for symptomatic causes of bone masses
Differentiate osteochondroma from other surface bony lesions.
Cartilaginous caps- T2WI- high
T1WI-low
Perichondrium
High signal in T1WI-------
High signal in T2WI-------
False positive results in ?

26. Benign vs malignant
Challenge but accurately diagnose
Osteosarcoma
>2cm in adult
>3cm in children
Chondrosarcoma
Low T1 signal after IV contrast infusion- rare in benign lesions
MRI IS GOLD STANDARD FOR DIAGNOSIS OF MALIGNANT TRANSFORMATION

27. NUCLEAR MEDICINE
Examine the metabolic activity of tumor
Thallium 201 – used for malignant transformation
ANGIOGRAPHY
Vascular lesions
Neovascularization of cartilaginous cap

28. s.no Author Group Conclusion
1 Shapiro et al 22 pt with HME 2.7 surgery for deformity
correction
2 Wirganowicz 285 cases of
benign exostosis
Elective excision – 12.5% cases
a/w complications
3 Canelle et al 408 cases of
exostosis
Malignant transformation risk
Multiple exostosis-13%
Solitary-cannot be determine
4 Saglik et al 382 cases of oc Essential to reconstruct the mass
as well as reconstruct the
deformities
5 Bottner et al 86 symptomatic oc Post operatively
93.4%- preoperative symptoms
resolved
4.7%- complications
7%- minor compplications
5.8%- local recurrence

29. s.no Author Group Conclusion
6 Vasseur & fabre 97 cases with
vascular
complications
66%-solitary
Prophylactic resection if the
tumor is present in the vicinity
of the vessels
7 Garrison et al 75 cases of
osteosarcoma having
arisen from oc
1.Excision- 78% recurrence
2. Resection- 15% recurrence
3. Amputation
8 Pierz et al 43 cases of HME 27of 43 required about 1-5
surgeries to control their
lesions
9 Shin et al 29 pts of HMO In young pts simple excision o
tumor improve range of
movements o forearm but it
cannot control the progress o
the disease

30. CONCLUSION
 The treatment of choice for osteochondroma is surgical .
 The tumor should be excised when symptoms or complications have
presented.
 A prophylactic resection is suggested only if the lesion lies next to a
vessel.
 An osteochondroma must be completely excised, without leakage of
myxomatous tissue or part of the cartilaginous cap, especially when a
sarcomatous change is suspected.
 In addition to resection, reconstructive techniques have to be
undertaken.
 Chemotherapy and radiotherapy are suggested in dedifferentiated
tumors.

31. Thank you & have a cheerful evening