Ortho Patho Meet on Aneurysmal Bone Cyst by Dr. Saumya Agarwal
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Transcript of Ortho Patho Meet on Aneurysmal Bone Cyst by Dr. Saumya Agarwal
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