By: Dr. Raad. J. AL-shaibany Benign bone tumour By: Dr. Raad. J. AL-shaibany

Fibrous dysplasia Clinical features: The proximal femur, tibia, humerus, ribs and cranio-facial bones. Young adult or adolecent Asymptomatic. pathological fracture. pain, limp, bony enlargement, or deformity . Occasionally the bone disorder is associated with café-au-lait patches on the skin and (in girls) precocious sexual development (Albright’s syndrome).

X-rays: Complication: Malignant transformation to fibrosarcoma . show radiolucent ‘cystic’ areas in the metaphysic or shaft; ‘ground-glass’appearance. ‘shepherd’s crook’ deformity of the proximal femur. Monomelic, poiyostotic Complication: Malignant transformation to fibrosarcoma . Treatment : Curettage +bone graft with or without bone cement, depending on its size. Deformities may need correction by osteotomies. Internal fixation..

Fibrous dysplasia

OSTEOID OSTEOMA Clinical features : Usually under 30 years of age and males predominate. Any bone except the skull may be affected, but mostly the femur or tibia. Persistent pain(night), Typically relieved by salicylates. Limping or muscle wasting and weakness; Spinal lesions may cause intense pain, muscle spasm and scoliosis. No risk of malignant transformation

x-ray: is a small radiolucent area, the so-called ‘nidus’. Lesions in the diaphysis or in the metaphysis. 99mTc-MDP scintigraphy ,CT DXD small Brodie’s abscess . Ewing’s sarcoma chronic periostitis   Treatment : The only effective treatment is complete removal or destruction of the nidus after localization of its site by x-ray and CT scan.

Osteoid osteoma

OSTEOBLASTOMA (GIANT OSTEOID OSTEOMA) Clinical features: Usually seen in young adults, more often in men occur in the spine and the flat bones; patients present with pain and local muscle spasm. X-ray: shows a well-demarcated osteolytic lesion which may contain small flecks of ossification Complications: 1. a typical aneurysmal bone .2.A low-grad osteosarcoma. 3.Recurrence after excision Treatment : Treatment consists of excision and bone Grafting  

Osteoblastoma

CHONDROMA (ENCHONDROMA) It is cartilaginous tumor in the metaphyses . Clinical features : . They are seen at any age (but mostly in young people) . Chondromas are usually asymptomatic . . Pathological fracture . Any bone preformed in cartilage (most commonly the tubular bones of hand andfeet). Lesions may be solitary or multiple .

X-ray: shows a well-defined, centrally placed radiolucent area at the junction of metaphysis and diaphysis ; with slight bone expansion and sometimes flecks of calcification which is apathognomonic feature. Complications There is a small but significant risk of malignant change – Signs of malignant transformation in patients over 30 years are: (1) the onset of pain; (2) enlargement of the lesion; and (3) cortical erosion. Treatment: .curettage with bone grafting the area; with a fairly high recurrence rate. .Chondromas in expendable sites are better removed en bloc

Chondroma

CHONDROBLASTOMA Clinical features: This benign cartilage tumour appear primarily in the epiphysis,. Clinical features: Patients are adolescent and young adult especially male. Usually of the proximal humerus, femur or tibia The presenting symptom is a constant ache in the joint; the tender spot is actually in the adjacent bone.

X-ray : . shows a rounded, well-demarcated radiolucent area in the epiphysis with no hint of central calcification, .sometimes the lesion may extends across the physeal line. .Occasionally the articular surface is breached.   Treatment: After the end of the growth period the lesion can be removed: 1 .By marginal excision wherever possible with or without joint reconstruction 2. (less satisfactorily) by curettage and alcohol or phenol cauterization and replaced with autogenous bone grafts.

CHondroblastoma

CHONDROMYXOID FIBROMA It is benign cartilaginous lesions, Clinical features: This is seen mainly in adolescents and young adults. It may occur in any bone but is more common in those of the lower limb. Patients seldom complain and the lesion is usually discovered by accident or after a pathological fracture. Malignant change has been recorded but this is extremely rare

X-ray: Very characteristic: there is a rounded or ovoid radiolucent area placed eccentrically in the metaphysis. The endosteal margin may be scalloped, but is almost always bounded by a dense zone of reactive bone extending tongue-like towards the diaphysis. Sometimes there is calcification . Treatment : .Thorough curettage followed by autogenous bone grafting.

Chondromyxoid fibroma

SIMPLE BONE CYST Clinical features: .This lesion (also known as a solitary cyst or unicameral bone cyst) appears during childhood. .Typically in the metaphysis of one of the long bones and most commonly in the proximal humerus or femur. .It tends to heal spontaneously and it is seldom seen in adults. .The condition is usually discovered after a pathological fracture or as an incidental finding on x-ray.

X-ray : show a well-demarcated radiolucent area in the metaphysis, often extending up to the physeal plate; the cortex may be thinned and the bone expanded Treatment : Asymptomatic lesions in older children can be left alone but the patient should avoid injury which might cause a fracture. Active’ cysts (those in young children, usually abutting against the physeal plate and obviously enlarging in sequential x-rays) should be treated by aspiration of fluid and injection of 80–160 mg of methylprednisolone or autogenous bone marrow. If the cyst goes on enlarging, or if there is a pathological fracture, the cavity should be curetted and bone graft cleaned with or without internal fixation .  

Simple bone cyst

ANEURYSMAL BONE CYST Clinical features : . Aneurysmal bone cyst may be encountered at any age and in almost any bone, though more often in young adults and in the long-bone metaphyses. .Usually it arises spontaneously but it may appear after degeneration or hemorrhage in some other lesion like osteoblastoma or chondroblastoma . . Patients may complain of pain or palpable swelling . Malignant transformation does not occur.

X-rays : Show a well-defined radiolucent cyst, often trabeculated and eccentrically placed in the metaphysic and therefore may resemble a simple cyst or one of the other cyst-like lesions. Treatment: .The cyst should be carefully opened, thoroughly curetted and then packed with bone grafts. .Sometimes the graft is resorbed and the cyst recurs,necessitating a second or third operation. In these cases, packing with methylmethacrylate cement may be more effective.

Aneurysmal bone cyst

GIANT-CELL TUMOUR Repressenting 5 per cent of all primary bone tumours, is a lesion of uncertain origin. Clinical features: Appears in mature bone most commonly in the distal femur, proximal tibia, proximal humerus and distal radius, though other bones also may be affected. Pain at the end of a long bone; sometimes there is slight swelling. On examination there may be a palpable mass with warmth of the overlying tissue

X-ray : .A radiolucent area situated eccentrically at the end of a long bone and bounded by the subchondral bone plate which is so characteristic. Asoap-bubble appearance due to ridging of the surrounding bone. The cortex is thin and sometimes ballooned; aggressive lesions extend into the soft tissue. .CT scans and MRI are very important to reveal the extent of the tumour, both within the bone and beyond and to the joint.  

Treatment: 1. Well-confined, slow-growing lesions with benign histology can safely be treated by thorough curettage and ‘stripping’ of the cavity with burrs and gouges, followed by swabbing with hydrogen peroxide or by the application of liquid nitrogen; the cavity is then packed with bone chips. 2.More aggressive tumours, and recurrent lesions, should be treated by excision followed, if necessary, by bone grafting or prosthetic replacement. 3.Tumours in awkward sites (e.g. the spine) may be difficult to eradicate; supplementary radiotherapy is sometimes recommended.  

Giant cell tumour

Eosinophilic granuloma reticuloendothelial system (histiocytes and eosinophils) Clinical features: The patient is usually a child; there is seldom any complaint of pain and the condition is discovered incidentally or after apathological fracture. X-ray: shows a well-demarcated oval area of radiolucency within the bone; sometimes this is associated with marked reactive sclerosis. There may be multiple lesions and in the skull they have a characteristic punched-out appearance. Vertebral collapse may result in a flat wedge (vertebra plana) which is pathognomonic.

Treatment: The condition usually heals spontaneously and is therefore rarely seen in adults. Occasionally, however, a solitary lesion may herald the onset of one of the generalized disorders like Hand–Schüller–Christian disease or Letterer–Siwe disease. Operation is usually done to obtain a biopsy; if the lesion is easily accessible it may be completely excised or curetted; if not, radiotherapy is effective

Eosinophilic granuloma

HAEMANGIOMA Clinical features: Osseous haemangiomas consist of vascular channels (capillary, venous or cavernous) Clinical features: Usually seen in middle-aged patients, the spine being the commonest site. They are usually symptomless and discovered accidentally when the back is x-rayed for some other reason.The patient may present with backache. Rarely the presenting feature may be a pathological fracture

x-ray : Coarse vertical trabeculation (theso-called ‘corduroy appearance’) in the vertebral body. Other sites include the skull and pelvis where the appearance occasionally suggests malignancy, but there is no associated cortical or medullary destruction. Treatment : Excision of such tumor associated with very severe bleeding,and embolization with or without surgery is best treatment choice.

Haemangioma

OSTEOSARCOMA Types: classic (intramedullary) form PAROSTEAL OSTEOSARCOMA PERIOSTEAL OSTEOSARCOMA PAGET’S SARCOMA Talengectatic type Secondary osteosarcomas Highly malignant tumour

Clinical features: predominantly in children and adolescents,. It may affect any bone but most commonly involves the long-bone metaphyses, especially around the knee and at the proximal end of the humerus. Pain is usually the first symptom; it is constant, worse at night and gradually increases in severity. lump. Pathological fracture is rare. local tenderness. In later cases there is a palpable mass and the overlying tissues may appear swollen and inflamed The ESR is usually raised Increase in serum alkaline phosphatase.  

X-rays: The x-ray appearances are variable: Hazy osteolytic areas may alternate with unusually dense osteoblastic areas. The endosteal margin is poorly defined. Often the cortex is breached and the tumour extends into the adjacent tissues; when this happens, streaks of new bone appear, radiating outwards from the cortex – the so-called ‘sunburst’ effect. Where the tumour emerges from the cortex, reactive new bone forms at the angles of periosteal elevation (Codman’s triangle).While both the sunburst appearance and Codman’s triangle are typical of osteosarcoma, they may occasionally be seen in other rapidly growing tumours.

Diagnosis and staging: In most cases the diagnosis can be made with confidence on the x-ray appearances. Conditions to beexcluded are . post-traumatic swellings, . Infection, . Stress fracture . Aggressive ‘cystic’ lesions . Other imaging studies are essential for staging purposes like 1.Radioisotope scans may show up skip lesions,but a negative scan does not exclude them. 2. CT andMRI reliably show the extent of the tumour. 3. Chest xrays , but pulmonary CT is a much more sensitive detector of lung metastases. About 10 per cent of patients have pulmonary metastases.

Treatment: it is still important to eradicate the primary lesion completely. Chemotherapy befor and after surgery. Amputation or wide resection. Pulmonary metastases,

Variant of osteosarcoma 1.paraosteal-osteosarcoma 2.periosteal-osteosarcoma 3.paget osteosarcoma

Osteosarcoma

Paraosteal osteosarcoma

Osteosarcoma Staging

Osteosarcoma treatment

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X-rays: show radiolucent ‘cystic’ areas in the metaphysic or shaft; because they contain fibrous tissue with diffuse spots of immature bone, the lucent patches typically have a slightly hazy or ‘ground-glass’appearance. The weightbearing bones may be bent, and one of the classic features is the ‘shepherd’s crook’ deformity of the proximal femur.

Fibrous dysplasia

Definition It is a pyramid shaped space between the upper part of the arm and the side of the chest Important Nerves, Blood and Lymph vessels travel through it from root of the neck to the upper limb

Apex Upper end of axilla or APEX is directed into the root of neck Bounded in front by the clavicle Behind by upper border of scapula Medially by outer border of the 1st rib

Base Lower end or Base is bounded in front by the anterior axillary fold formed by pectoralis major muscle Behind by posterior axillary fold formed by the tendons of latissimus dorsi and teres major muscles Medially by the chest wall

Walls of The Axilla Anterior wall: By the pectoralis major, Subclavius and pectoralis minor muscles Posterior wall: By the subscapularis, Latissimus dorsi and teres major muscles

Walls of The Axilla Medial wall: By the upper 4 or 5 ribs and intercostal spaces covered by serratus anterior muscle Lateral wall: By the coracobrachialis and biceps muscles in the bicipital groove of humerus

Base The Base of axilla is formed by the skin stretching between the anterior and posterior walls

Clavipectoral Fascia It is a strong sheet of connective tissue Split above to enclose the subclavius muscle and is attached to the clavicle Below it splits to enclose the pectoralis minor muscle Then continues downward as the suspensory ligament of the axilla Then joins the fascial floor of armpit

Contents of Axilla Axillary artery and its branches Axillary vein and its tributaries Lymph vessels and lymph nodes Important nerve plexus the “Brachial Plexus” which innervates the upper limb

Axillary Artery Is a continuation of subclavian artery Begins at the lateral border of the 1st rib Ends at the lower border of teres major It continues as the brachial artery Closely related to brachial plexus cords Enclosed with them in the axillary sheath Axillary sheath is continuous with the prevertebral fascia Pectoralis minor divides it into 3 parts

1st Part of Axillary Artery Extends from the lateral border of the 1st rib to the upper border of pectoralis minor

Relation Anterior: Pectoralis major, covering fascia, skin, cephalic vein Posterior: Long thoracic nerve Lateral: Three cords of brachial plexus Medial: Axillary vein

2nd Part of Axillary Artery Lies behind the pectoralis minor muscle

Relation Anterior: Pectoralis minor and major, covering fascia and skin Posterior: Posterior cord of brachial plexus Lateral: Lateral cord of brachial plexus Medial: medial cord of brachial plexus and axillary vein

3rd Part of Axillary Artery Extends from lower border of pectoralis minor to the lower border of teres major

Relation Anterior: Pectoralis major, medial root of the median nerve Posterior: subscapularis, latissimus dorsi and teres major Lateral: Coracobrachialis, biceps, humerus Medial: Ulnar nerve, axillary vein, medial cutaneous nerve of the arm

Branches Branches of axillary artery supply the thoracic wall and the shoulder region 1st Part: Highest thoracic artery 2nd Part: Thoracoacromial and lateral thoracic arteries 3rd Part: Subscapular artery, anterior and posterior circumflex humeral arteries

Pectoralis Major Origin: Medial half of clavicle, sternum, upper 6 costal cartilages Insertion: Lateral lip of bicipital groove of the humerus NS: Medial and Lateral pectoral Nerve from medial and lateral pectoral cords of brachial plexus Action: Adducts the arm and rotates it medially, some fibers also cause flexion of arm

Subclavius Origin: From the first costal cartilage Insertion: Fibers move upward and laterally into the inferior surface of clavicle NS: Nerve to the subclavius from upper trunk of brachial plexus Action: Depresses the clavicle and steadies the bone

Pectoralis Minor Origin: From 3rd, 4th and 5th ribs Insertion: Coracoid Process NS: Medial pectoral nerve, a branch of the medial cord of brachial plexus Action: Pulls the shoulder downward and forward. Elevates the ribs of origin

Subscapularis Origin: Subscapular fossa on the anterior surface of scapula Insertion: On the lesser tuberosity of the humerus NS: Upper and Lower subscapular nerves Action: Medially rotates the arm and stabilizes the shoulder joint

Latissimus Dorsi Origin: Posterior part of the iliac crest, lumbar fascia and spines of lower 6 thoracic vertebrae, lower 3 ribs Insertion: Floor of the bicipital groove of humerus with teres major NS: Thoracodorsal nerve from posterior cord of brachial plexus Action: Extends, adducts and medially rotates the arm

Teres Major Origin: lower third of the lateral border of scapula Insertion: Medial lip of bicipital groove of humerus NS: Lower subscapular nerve from posterior cord of brachial plexus Action: Adducts and medially rotates the arm

Serratus Anterior Origin: From Outer surface of upper 8 ribs Insertion: Medial border of scapula in the region of inferior angle NS: Long thoracic nerve Action: Draws the scapula forward, rotates it