Osteochondroma

Kevin D. Plancher and Michael Bothwell

History and Clinical Presentation

A 14-year-old boy presents with a growth on the end of his index finger. He notes that it has slowly been getting larger. He has had the growth for 3 years, but recently became concerned following his mother's battle with cancer. It is not painful unless he hits it hard on something. The patient has no history of cancer.

Physical Examination

A cartilaginous growth is seen on the end of the index finger. The mass projects from the volar surface. There are no other growths on either of the patient's hand.

Diagnostic Studies

Radiographs reveal a peripheral bone projection or growth with flaring of the meta-physic of the bone (Fig. 89—1). There is also a communication of the cortical and cancellous bone, which may contain focal areas of calcification at the site of the osteo-chondroma. Covering the top of the tumor is a thin, sclerotic area of cartilaginous cells.

Histologically, the surface of the lesion reveals a thin smooth, translucent, bluish cartilaginous cap. The lesion may be pedunculated or sessile. When pedunculated the lesion projects away from its nearest joint (Fig. 89—2).

Differential Diagnosis

Inclusion cysts Giant cell tumors Chondrosarcoma

Diagnosis

Osteochondroma is the most common benign tumor of bone. It originates in the metaphysis of long bones and may have multiple foci. The tumor typically appears in the second decade and has a male predominance of 1.7 to 1.0. In the upper extremity it is commonly located in the proximal humerus as well as the distal radius and ulna (Fig. 89-3).

Figure 89—1. Osteochondroma seen on the distal volar aspect of the index finger with flaring of the metaphysis.

Osteochondroma Hand
Figure 89—2. An unusualparosteal osteochondroma seen in this Figure 89—3. A classic osteochondroma seen in the volar aspect of arthritic digit. Note the cleavage plane. the distal radius with growth projecting away from the nearest joint.

A solitary osteochondroma is a stage 1 tumor that is asymptomatic and needs to be followed in the office. The indications for surgical treatment consist of functional limitations, cosmetic reasons, or pain. Surgical treatment in children should be withheld due to the unknown growth potential of the tumor in a growth plate. If surgical treatment is needed, then great care should be taken to complete a meticulous excision. Malignant degeneration in solitary osteochondromas is rare. Multiple osteochondro-mas cause significant forearm deformities, including ulnar angulation of the distal radius articular surface, ulnar translation of the carpus, and dislocation of the radial head.

Aggressive intervention is recommended when any deformity is present. Malignant degeneration in multiple osteochondromas is 10 to 20% per patient.

Surgical Management

The mass should be removed surgically from the end of the finger. The bone is exposed by incising the periosteum, and a segment of bone is removed. The periosteum should not be elevated over the mass with an elevator. This may leave cartilaginous cells, which may lead to recurrence. The nail may also be removed if the mass is involved with the terminal tuft of the distal phalanx.

Complications

Complications following excision of an osteochondroma include fracture, bone deformity, vascular injury, pseudoaneurysm, nerve damage, bursa formation around the lesion, and malignant transformation.

Suggested Readings

Burgess RC, Cates H. Deformities of the forearm in patients who have multiple cartilaginous exostois. J Bone Join Surg [Am] 1993;75:13-18.

Gitelis S, McDonald D. Common benign tumors and usual treatment. In: Simon M, Springfield D, eds. Surgery for Bone and Soft-Tissue Tumors. Philadelphia: LippincottRaven; 1998:191-205.

Ostrowksi ML, Spjut HJ. Lesions of the bones of the hands and feet. Am J Surg Pathol 1997;21:676-690.

Wold L, McLeod R, Sim F, Unni KK. Atlas of Orthopedic Pathology. Philadelphia: WB Saunders; 1990.

Wood YE, Sauser D, Mudge D. The treatment of hereditary multiple exostosis of the upper extremity. J Hand Surg [Am] 1985;10:505-513.

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