Exostoses, or osteochondral growths of the tibia and fibula, are common findings during other musculoskeletal examinations. Most often they are asymptomatic, but in some cases they can lead to pain and reduce a person’s quality of life. They often form in childhood, although they are found more often in adults. Such neoplasms require dynamic monitoring, and in case of rapid growth and poor health, surgical removal.
What is exostosis of the tibia
The tibia and fibula are the long tubular bones of the lower leg. They connect at the knee and ankle joints, forming a single mechanical whole. The fibula is smaller than the tibia and is located on the outside of the lower leg. The tibia runs through the center of the lower leg and is the 2nd largest bone in the entire body. Its upper epiphysis (head) articulates with the femur, forming the knee joint, and its lower epiphysis with the talus tarsal bone forms the ankle joint.
On each of them a benign tumor can form - osteochondroma or osteochondral exostosis. It is the most common benign skeletal tumor. And the tibia is the second most frequently affected bone. In it, exostoses are found in 15-20% of cases of diagnosing osteochondromas. In most cases, the neoplasm grows from the compact bone surface of the metaphysis exophytically, that is, in an outward direction.
Metaphysis is a part of the tubular bone located between the epiphysis and the body of the bone. It is formed during the growth of the skeleton from cartilaginous cells formed in the epiphyseal plates (bone growth zones), which subsequently ossify. By the age of 18-25, the process of mitotic cell division normally stops, and bone growth in length stops.
Thus, exostosis is a bone growth zone that has separated from the epiphysis for one reason or another and continues to grow away from it. As a result, spherical, mushroom-shaped, comb-shaped or other shaped growths are formed, localized in the immediate vicinity of the bone joint of the knee or ankle joint. They have a narrow or thick stalk and a layer of cartilaginous tissue covering them on the outside. It is called a cartilaginous cap. Usually their growth stops along with the completion of the formation of the skeleton.
Osteochondromas of the tibia can reach large sizes and provoke joint deformation, disruption of their functioning and other complications.
What can hurt a joint?
There are no nerve endings in cartilage and menisci, so they cannot hurt. In fact, there is nothing in the joint that could hurt in the usual sense. The nerves do not approach the bones, but rather the periosteum - thin membranes covering the outside of the bone. Therefore, a person experiences pain when a bone is damaged. What happens if there is no fracture?
In the absence of a fracture, the source of pain may be the ligaments surrounding the knee joint and holding the menisci inside. In addition, the nerve endings approach the joint capsule, which can also cause pain.
Cartilage does not hurt: there are no nerve endings in them
When a mechanical injury occurs, the following occurs:
- the joint is injured, the ligaments swell;
- the body initiates the healing process - drives blood to the damaged area;
- the skin around the joint turns red, the joint swells;
- Synovial fluid stops circulating freely and puts pressure on the nerves in the joint capsule, which leads to increased pain.
After some time, the small ligaments heal, the swelling subsides, the fluid begins to circulate again - the pain disappears. This happens if only small ligaments are damaged, while the large ones and the meniscus remain intact. If the meniscus is damaged, the situation develops differently, since the person does not experience pain, but the structure continues to be damaged.
Over time, the meniscus is damaged even more, the cartilage around it also becomes deformed, finding itself in unfavorable conditions. Their surface gradually wears away, which leads to friction of the bones, irritation of the nerve endings in the periosteum and, as a result, pain. This is how arthrosis of the knee joint develops - a disease that is rarely diagnosed at an early stage.
When a person is prescribed treatment for arthrosis or osteoarthritis, the condition of his joints already leaves much to be desired. There is almost certainly not enough synovial fluid in the joint capsule, and in conditions of insufficient lubrication, the cartilage quickly dries out, cracks and wears out. The situation can be corrected with intra-articular injections of the synovial fluid substitute Noltrex.
Noltrex is like the missing brick in building a house
The drug is injected into the joint capsule and evenly distributed over the cartilaginous surfaces. Due to its high molecular weight, it does not penetrate inside, but lingers there, performing the function of a lubricant. Noltrex does not contain animal proteins, therefore it does not cause allergies and is not recognized by the body's immune cells. A few injections are enough to restore the physiological characteristics of the joint for a year, a year and a half, or even two, and therefore relieve a person from pain.
Features of development
Exostosis of the tibia goes through several stages in its development:
· formation of a painless and non-palpable cartilaginous growth in the area of the metaphysis of the tibia or fibula;
· systematic ossification of the neoplasm with preservation of the cartilaginous cap, its active increase in size;
· stopping the growth of the bone part while maintaining the possibility of increasing the size of the cartilage tissue.
Often the tendency to form osteochondroma is inherited. In this case, the appearance of both single (solitary) exostoses and multiple bone lesions is possible. But the possibility of their acquisition during life as a result of trauma and microtrauma, inflammatory processes, compression of the leg, including when the cast is applied too tightly, etc., cannot be excluded.
Osteochondral exostosis of the tibia can become malignant. This is more often observed with multiple lesions, but it is also possible with solitary osteochondromas, although it is observed in less than 1% of cases.
Bone damage
Fracture options
The fibula can break:
spiral;- obliquely;
- transverse;
- splintered;
- fragmentary.
As a rule, such injuries are accompanied by subluxations and dislocations of the foot. Sometimes there is a rupture of the distal syndesmosis between both bones, shortening the bone.
How to identify a fibula fracture
With this type of injury, the picture is typical. A person faces:
with sharp pain during movement;- with swelling or hematoma in the damaged area;
- with a discrepancy in leg length, which is visible to the naked eye, in addition, the leg can be turned to the side;
- with noticeable bone displacement.
In this case, the factors predisposing to injury are the following:
- — deficiency of vitamin D, calcium;
- - elderly age;
- - bone fragility in early childhood;
- — pathologies affecting the condition of bones;
- - a strong blow.
Childhood fractures
Children under the age of three often break their fibula. This happens for several reasons, and one of them is a fall from a height. Such fractures are rarely open.
Symptoms are a painful response to touch, trouble lifting the leg, swelling of the soft tissues.
At this age, x-rays are not always a good solution, so bone scanning is more often used for diagnosis. If the fracture is confirmed, then therapy begins. A short bandage with plaster is applied to the leg until the leg recovers.
Complete rehabilitation usually occurs faster than in cases with adult patients. The reason is accelerated metabolism.
Sports related fractures
Athletes often encounter fractures that are closed and are called stress fractures.
Such injuries to the fibula heal quickly, since they are small cracks with a long period of nucleation.
The site of injury is painful and there is swelling. Recovery takes place without surgical intervention; it is enough to use plaster for two months.
Compound fractures
In severe cases of injury, surgery to fix the ankle may be required.
For this purpose, a frame apparatus or fastening of bones with pins is used.
If the fracture is aggravated by a developed infection, it comes to amputation of the damaged part of the leg. The photos are scary.
During the recovery period of the fibula, it is recommended to engage in therapeutic and preventive gymnastics.
Osteochondroma of the lower (distal) tibia
In a healthy ankle joint, the distal anterior portion of the tibia is round in shape. The neck of the talus, in contact with it, has a groove. When the joint is excessively extended, the anterior edge of the tibia receives microtrauma due to friction against the groove, which can cause the formation of osteochondral exostosis in this area. Moreover, the growth can form both on the anterior lower border of the tibia and in the groove of the talus itself.
Much less often, osteochondromas are observed in the distal part of the fibula, i.e., in the ankle or ankle area. They are usually the result of a direct blow or sprain to the ankle.
When the ankle joint is affected and the exostosis reaches a large size, it can become visible to the naked eye and look like a dense lump. You may also experience:
Pain with strong ankle extension;
· swelling of soft tissues;
· pain on palpation, increasing with hyperextension of the foot;
· limited mobility, which is especially acute for athletes, as their ability to run decreases.
Exostosis of the tibia can provoke the development of inflammatory processes in the ankle joint. In this case, the first symptoms may be manifestations of tenosynovitis and synovitis, i.e. inflammation of the tendons, ligaments and synovial membrane. This is manifested by pain in the ankle, aggravated by movement, a local increase in temperature, and swelling of the soft tissues.
Cartilage, joint capsule, synovial fluid...
In the place where the bones are connected to each other, their heads are covered with cartilage , which protects them from friction and impact. Inside the joint there are two menisci , shaped like crescents. They are needed as additional protection of cartilage and bones from mechanical stress.
Cartilage and menisci are located in the so-called joint capsule , inside which synovial fluid . Similar to oil, it lubricates all surfaces of the joint and prevents friction. This is true if there is enough synovial fluid and its viscosity is normal.
In front of the joint is the patella , or kneecap . It is held in place by ligaments and tendons, and covered inside with cartilage. The patella is a kind of shield that protects the internal components of the knee joint from damage.
This is what the knee joint looks like from the inside
How is the knee joint structured? Visual demonstration with detailed explanations:
Osteochondroma of the proximal (upper) tibia
The formation of exostosis of the tibia in the area of the proximal epiphysis can lead to severe deformation of the bone articulation. More often it is a solitary neoplasm. When it reaches a large size, it is easily detected with the naked eye. In the knee area, you can feel a dense but painless formation with a smooth or rough surface.
Also, an osteochondral growth can form on the posterolateral surface of the tibia and spread to the fibula or vice versa. In both cases, as the exostosis grows, it deforms the thinner fibula, increasing the risk of fracture, bending of the limb, and decreased function. Also, this location of the tumor creates the prerequisites for compression of the nerve passing between the bones and the development of corresponding sensory and motor disorders. Therefore, exostosis of the fibula or osteochondroma of the tibia pressing on it is indicated to be removed.
Treatment of shin fractures.
Treatment of tibia fractures in most cases is surgical, since it is often not possible to achieve adequate comparison of bone fragments and avoid secondary deformation in the cast. In addition, long periods of immobilization (12 weeks or more) lead to the formation of contractures in adjacent joints and severe muscle atrophy, which significantly complicates subsequent rehabilitation.
Surgical treatment of tibia fractures most often proceeds according to one of the following scenarios: closed reduction, osteosynthesis with a locking pin, open reduction, osteosynthesis with a plate and screws, as well as treatment of open fractures with external fixation devices. It is possible to use several techniques simultaneously in combination or to sequentially move from one technique to another.
Exostosis in a child
Most often, exostoses begin to form in childhood due to displacement of the epiphyseal plates, disorders of intrauterine development and genetic predisposition. Until 6-8 years of age, they usually do not appear in any way and grow slowly. But during the period of intensive growth, which occurs between 8 and 16 years, they also begin to actively increase in size. At this time, the first symptoms may already appear.
Additionally, the risk of accelerating the growth rate of formation is increased by hormonal fluctuations in the body that occur during puberty.
An osteochondral growth on the tibia, like exostosis of the fibula in a child, is rarely diagnosed. Typically, osteochondroma formed in childhood is detected in adulthood, since the disease is often asymptomatic.
Although it is possible that its symptoms may also appear during puberty. In this case, a dense formation in the form of a lump may be felt in the upper or lower part of the bone.
If osteochondral exostosis of the tibia in a child grows at a rapid pace, puts pressure on the fibula, provokes deformation of the knee joint, valgus deformity of the limb, or compresses blood vessels and nerve trunks, it is indicated to remove it. In such situations, it is important not to hesitate, since even with a minimal risk of transformation into a malignant tumor, osteochondroma can cause shortening and curvature of the lower leg.
Possible symptoms
In most cases, osteochondroma does not manifest itself, but is discovered in the tibia or fibula by chance during an x-ray when a fracture is suspected. However, in some cases it can be felt, although it remains painless. The formation of a lump on the leg causes concern and forces patients to consult an orthopedist.
In other cases, exostosis may not be visible externally, but provoke compression of the neurovascular bundle passing near it. This will already be manifested by the corresponding disorders:
pain in the affected area;
· pains shooting along the nerve;
· swelling of the lower limb;
· decreased tone of the lower leg muscles;
· limited mobility;
· feeling of numbness.
In such cases, you should immediately make an appointment with an orthopedic traumatologist.
Consequences after treatment
After traditional or surgical intervention, the following may appear:
- dysfunction in the ankle;
- constant swelling at the site of injury;
- deforming arthrosis;
- osteochondrosis;
- dependence on natural conditions.
Take care of your feet! When you ride a bicycle, roller skates, or skate, use shin guards, knee pads, etc.
The strength of bones depends on the amount of calcium in the body. A healthy lifestyle and caution can protect against many injuries.
In situations with a fracture of the fibula, a person should not fall into despair and urgently receive qualified medical care. After an injury, try to protect your legs from re-injury throughout your life.
Diagnostics
Bone exostosis of the tibia, like the fibula, is clearly visible on x-ray. Therefore, when an orthopedist detects a palpable dense formation in the area of the knee or ankle joint, it is a reason to take an x-ray in two projections. Exostosis is displayed on photographs as a formation with clear boundaries, often in the form of cauliflower due to the appearance of foci of calcification in the cartilaginous capsule. At the same time, the line of the joint space remains normal, which makes it possible to differentiate osteochondroma from osteophyte.
But cartilage tissue is not radiopaque. Since it is in this area that malignant cells can arise, CT and MRI are additionally prescribed to obtain complete information about the nature of the neoplasm. Magnetic resonance imaging is especially informative, showing not only the exact dimensions of the cartilage cap, but also the degree of involvement of the neurovascular bundle in the pathological process. It also provides comprehensive data for planning treatment tactics, although due to the high cost of the examination, it is not always carried out.
Posterior ankle fracture.
Most often occurs in combination with a fracture of the lateral malleolus or as part of a trimalleolar fracture. Surgical treatment is indicated when more than 25% of the area of the supporting plateau of the tibia is involved, and displacement is more than 2 mm. Most often, fixation with screws is used; if the displacement can be eliminated closed, the screws are installed from front to back; if open reduction is performed from the paraachilles approach, then the screws are installed from the back to the front; it is also possible to use an anti-slip plate installed proximally.