Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Musculoskeletal
Neoplasms
Benign neoplasms
Malignant neoplasms
3 7. Osteoblastoma
2
4 8. Fibrous
dysplasia
7 9. Non ossifying
8 1 fibroma and
fibrocortical
11 defect
3
10. Neurofibroma
13 11. Eosinophilic
granuloma
12. Aneurysmal
9 bone cysts
10
13. Giant cell
6 tumours
14. Haemangioma
1
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Treatment: excision
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Treatment:
X-ray appearance of curettage and
a chondroblastoma bone graft
Musculoskeletal Neoplasms 279
tumour to look smaller on X-ray than it
actually is. Growth disturbances are common
at the epiphysis which may be broadened and
the limb shortened.
The osteochondroma has a classical
appearance on X-ray and, as it is often
multiple, other lesions should be looked for.
The tumours may press on tendons and liga-
ments, or may be prominent and therefore
liable to be knocked. In 1-3% of patients
the cartilaginous cap may undergo malignant
change to a chondrosarcoma.
If the lesion is symptomatic or malignant
change is suspected it should be excised in
its entirety rather than taking an isolated
biopsy which may not include the part of the
tumour undergoing malignant change.
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Treatment:
X-ray appearance hydrocortisone injection
of a bone cyst or excise and bone graft
Musculoskeletal Neoplasms 281
Osteoid osteoma
An osteoid osteoma is a cystic area in a
bone which may have a small nidus (similar
to that of a chronically infected Brodie’s
abscess) on X-ray and a hot area on isotope
scanning. The area is lined by fibrous tis-
sue and classically is most painful at night,
with the pain being relieved dramatically by
aspirin. If the area is larger than 2cm in
diameter it is usually called an
osteoblastoma. The treatment is curettage
of the lesion which usually results in a
dramatic cure.
Osteoblastoma
An osteoblastoma is a benign, congenital
lesion which is usually present in the
metaphysis of a long bone and is often
confused with an osteoid osteoma. One dif-
ferentiation is size and the osteoblastoma
is usually larger than 2cm in diameter, and
has a punched-out appearance with a clearly
demarcated margin. The treatment is curettage
and bone grafting if large.
Benign Soft Tissue Neoplasms
Fibrous tissue
Fibrous dysplasia
Fibrous dysplasia is a congenital defect and
may affect one bone (monostotic fibrous
dysplasia) or more than one (polyostotic
fibrous dysplasia). X-rays show an expan-
sion of the bone, cystic spaces and increased
trabeculae. The areas are usually ‘hot’ on
isotope bone scanning and occasionally
pathological fractures may occur.
If the areas are large, or pathological
fractures occur, they may require curettage,
bone grafting and occasionally internal
fixation.
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X-ray appearance of a
mid-tibial
Scoliosis pseudoarthrosis
Musculoskeletal Neoplasms 285
Vascular
Eosinophilic granuloma
This is a congenital, benign lesion of a
long bone or of the spine and is one of the
mucopolysaccharoidoses. It may cause a
complete collapse of a spine (vertebra pla-
na) or a fracture. It occasionally requires
curettage and bone grafting and possibly
internal stabilisation.
Aneurysmal bone cyst
An aneurysmal bone cyst is a benign bone
tumour of young adults, usually involving
the shaft of a long bone but may affect a
vertebra. There is often expansion of the
bone which is filled with blood. The bone is
weakened and may fracture.
The cyst should be curetted, if accessible,
and filled with bone graft if necessary. The
bone graft is taken from the ipsilateral
iliac crest. Fractures may need stabilisa-
tion with plates or nails. Inaccessible
tumours such as those involving the spine,
or recurrences after surgery, may need low
dosage radiotherapy.
‘Benign’ giant cell tumour
This may present in every gradation from a
circumscribed tumour at the epiphysis of a
long bone extending to the articular margin,
to a highly malignant tumour (described below)
extending into the soft tissues.
Benign tumours are best treated with
excision of non-essential bones or curettage
and grafting in essential bones. Liquid
nitrogen into the cavity before grafting will
diminish the likelihood of recurrence.
286 A Simple Guide to Orthopaedics
Benign Neoplasms
Eosinophilic granuloma
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X-ray appearance of
Treatment: curettage
a circumscribed
and bone graft
giant cell tumour
Musculoskeletal Neoplasms 287
Malignant
Neoplasms
Classification
Primary Neoplasms
Cartilage
Chondrosarcoma
Bone
Cortex
Osteogenic sarcoma
Periosteal and parosteal osteogenic
sarcoma
Paget’s osteogenic sarcoma
Medulla
“Malignant giant cell tumour”
Ewings sarcoma
Multiple myeloma
Soft tissue
Fibrosarcoma and malignant fibrohistiocy-
toma
Rhabdomyosarcoma
Synoviosarcoma
Basal squamous cell carcinoma and malignant
melonoma
Lipoma
Angiosarcoma
Secondary Neoplasms
288 A Simple Guide to Orthopaedics
Malignant Neoplasms
Common sites of occurrence
1. Chondrosarcoma
2. Osteogenic sarcoma
5
9 10 3. Giant cell tumour
5 4. Ewing’s sarcoma
1 3
5. Multiple myeloma
7
6. Malignant
6 8 fibrohistiocytoma
1
7. Rhabdomyosarcoma
4
2 8. Synoviosarcoma
3 9. Liposarcoma
2 10. Angiosarcoma
6
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Chondrosarcoma;
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Treatment: complete
secondary to diaphyseal excision
aclasis
Osteogenic Sarcoma
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Osteogenic Sarcoma
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Treatment
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Excision Chemotherapy or
radiotherapy
Musculoskeletal Neoplasms 299
Myeloma
(Solitary and multiple myeloma)
This is a tumour of the bone marrow in adults
with considerable numbers of plasma cells
present on biopsy. It may be solitary but
most cases are multiple with deposits in the
skull, vertebrae and other bones.
The diagnosis is made on a general systemic
upset accompanied by multiple tender areas
and sometimes pathological fractures. There
may also be severe back pain due to spinal
secondaries and sometimes paraplegia.
Radiological diagnosis depends on the
presence of classic ‘punched-out’ areas in
bone plus a bone marrow biopsy or tumour
showing the characteristic plasma cells. The
serum proteins usually show a reversed
albumin/globulin ratio on electrophoresis.
The urine in 40% of cases shows Bence–Jones
protein (proteins which cause cloudiness on
heating that disappear on boiling).
The treatment is chemotherapy and
radiotherapy if necessary. Pathological
fractures will usually require internal
stabilisation but the bone may be extremely
vascular and bleed profusely.
X-ray appearance
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Treatment
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Synoviosarcoma Rhabdomyosarcoma
of biceps brachii
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Angiosarcoma Neurofibrosarcoma
Skull
Ribs Humerus
Spine
Pelvis
Femur
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Instrument for
trephine biopsy
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Bone scan
Musculoskeletal Neoplasms 309
A trephine biopsy can usually be carried
out with a needle, but is better done with a
2 or 3 mm bone trephine under image
intensifier control. Occasionally an open
biopsy is indicated.
Treatment should aim at stabilisation
before a fracture has occurred, with early
mobilisation of the patient. The appropriate
general treatment is usually local radio-
therapy, plus hormones, such as tamoxifen
for breast secondaries and chemotherapy for
multiple myeloma, renal and other
secondaries.
Stabilisation of the spine, lower humerus,
radius, ulna, lower femur and tibia before a
fracture has occurred, is usually by the use
of a brace or skelecast. Metastases to the
pelvis require radiotherapy and those to the
acetabulum require skin traction and non-
weightbearing mobil-isation on crutches.
Potential and actual fractures of the shaft
of the humerus and femur are best treated
with prophylactic and therapeutic internal
fixation, together with methyl methacrylate
cement to give extra stability if necessary.
This must always be followed by radiotherapy
to the area as well as hormones and chemo-
therapy if indicated.
Secondary deposits with vertebral collapse
should normally be treated with a brace and
radiotherapy. If there is associated
paraplegia this should be treated as a sur-
gical emergency with decompression and sta-
bilisation.
In summary, the management of potential
and actual pathological fractures aims to
stabilise the fracture by the simplest method,
enabling the patient to be mobile and return
home or to a nursing home as soon as possible
after the appropriate radiotherapy and chem-
otherapy.
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