Case Study Dan Preece DPM PGY2 HPI 9 yo healthy male with dorsal right foot pain Duration of pain x 3 months Hx of multiple episodes of blunt trauma to right foot Mass noted with swelling ID: 254723
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Slide1
Bone Tumor Case Study
Dan Preece DPM PGY-2Slide2
HPI: 9
yo
healthy male with dorsal right foot pain. Duration
of pain x 3
months.
Hx
of multiple episodes of blunt trauma to right foot. Mass noted with swelling
dorsal right foot, pain 7/10, some night pain, CAM boot failed to resolve pain, dorsal
mass appears to enlarging
.
PE
:
painful palpable
mass over
Right
1st met base.
L and R feet asymmetric. No erythema, ulceration, rash. Remainder of exam is consistent with healthy 9
yo
male.Slide3
What would you do now?Slide4
Imaging:Slide5
Imaging:Slide6
What next?
What other imaging?
Differential?
Treatment options?Slide7
1st MRI, Jan 2011:
Findings
: diffuse edema within the proximal 1st metatarsal with diffuse periostitis. There
are
periosteal or subcortical cystic lesions which
are
felt to represent
superiosteal
hematoma or seroma given the
pt’s
hx
of repeated injury to this location. Short interval f/u is
recommended
as there are additional lesions
which could
have this appearance.
Repeat
imaging
recommended
in 3-6 months, with and w/o contrast.Slide8
Progress note:
Pain worsening, Right foot mass enlarging clinically. CAM walker failed to relieve pain.
No other changes to health status.
What are you going to do now?Slide9
2
nd
MRI 3 months later (April 2011):Slide10Slide11Slide12Slide13Slide14Slide15Slide16Slide17Slide18
2nd MRI Read:
T2 hyperintense expansile proximal met eccentric lesion abutting the dorsal growth plate of the 1
st
met. Regional periosteal thickening present. Prominent marrow edema and enhancement. Lesion measures 2 x 1.2 cm,
increased
from 1.6 x 1.7 cm.
Diff: chronic intraosseous abscess or unusual unicameral bone cyst w/ inflammatory changes (less likely). The expansion and peripheral location could be seen w/ aneurysmal bone cyst but single internal cavity is not typical of that
Dx
.
Surgical evaluation should be considered. Slide19
Next step?Slide20
Tx:
Debridement, curettage. Care taken to preserve growth plate.
Packed deficit with:
Osteosponge
(
Bacterin
)
Osteosponge
:
• 100% bone
• Osteoconductive
• Osteoinductive
• Elastic, sponge-like properties
• Radiolucent
• Complements orthopedic applicationsSlide21Slide22Slide23
Surgical Findings:
Op report
: appearance
of intraosseous ganglion cyst, gelatinous fluid aspirated, dorsal cortex
discovered fractured with aspects absent,
growth plate not
penetrated or affected by mass.
Path
: sent to Mayo
Clinic and
UoU
by
pathology
for
consultation:
Dx
:
benign
chondromyxoid
fibroma
.
Fluid
Cytology
: No malignant cells. Slide24
Post op:
30 days s/p
surgery, walking in boot, no pain
.
X-rays show incorporation of graft, no pathologic
fx
or recurrence of lesion.Slide25
Chrondomyxoid Fibroma
:
R
are
, benign, cartilage-forming tumor of the tubular long bones
.
Clinical
Features
—
usually
presents in the teens or 20s. Approximately one-quarter of cases occur in the proximal
tibia, distal
femur and calcaneus
next
most common sites.
Males affected 1.5
times as often as
females.
Symptoms
include
pain and swelling
.
Radiographic
Findings
—
eccentric
, intramedullary, lobulated or bubbly lesion in the metaphysis; it has a sclerotic
border.
It typically is lucent, with a rare chondral
matrix.
Differential
Diagnosis
—
Nonossifying
fibroma
, aneurysmal
bone
cyst,
chondroblastoma
,
osteomyelitis
, fibrous dysplasia.
Treatment
—
curettage
and bone
grafting.
Prognosis
—
generally
is good. There is a 20 percent risk of recurrence, which may require en bloc
resection.
Source: Up To Date