How is exostosis formed?
Exostosis occurs in approximately every tenth patient with a bone tumor. And among benign bone tumors, 35–45% of cases are due to exostosis. Therefore, it is the most common benign bone tumor.
Bone development
As is known, bone during its development in the prenatal period can come from two sources: connective tissue and cartilage. In the first option, most of the bones of the skull, the lower jaw and the collarbone are formed. The remaining bones of the skeleton are based on cartilaginous tissue, which is then replaced by bone tissue along almost its entire length.
Where does exostosis appear?
Osteochondroma develops in bones of cartilaginous origin. It is most often found on the epiphysis (end) of a long bone, such as the tibia or femur. Much less often it appears on flat bones - pelvic bones, scapula, ribs, etc.
A separate topic of discussion is the development of exostoses in the oral cavity: palatal, at the site of an extracted tooth, articular processes of the lower jaw, etc.
Reasons for the development of exostosis
The exact causes of tumor formation are currently unknown. Many researchers agree that multiple exostoses are a consequence of disorders of chondrogenesis, that is, the formation of cartilage tissue in the prenatal period. And isolated osteochondromas are true skeletal tumors.
Nevertheless, there is evidence of possible risk factors that, to one degree or another, can provoke the formation and growth of a tumor. These include:
- Various injuries of the periosteum and cartilage, for example, bruise.
- Infectious lesions (syphilis and other infections).
- Diseases of the endocrine system.
- Exposure to ionizing radiation.
- Heredity.
There are also other, less significant factors, the role of which in tumor formation has not yet been fully studied.
What is exostosis?
The article was prepared by pediatric orthopedic surgeon Mikhail Yurievich Stepanov
Exostosis is a benign osteochondral tumor-like growth that is located on the surface of the bone. Often this disease is inherited and most often it is secondary, as a complication of a particular disease.
As a rule, exostoses appear in teenage children; they can even develop in a small child, but, in most cases, the disease does not manifest itself in any way until the age of 7-8 years. However, during the period of intensive growth of the body (8-16 years), a sharp jump in this pathology occurs.
The danger of such an osteochondral growth is that it may not manifest itself at all for a long time, gradually growing to large sizes.
Diagnostics
Often exostosis is discovered completely by accident as a result of a simple examination. For a more detailed diagnosis, the doctor takes an x-ray. In some cases, a biopsy is performed with tissue collection.
Causes of exostosis
Of course, this disease does not appear just like that; it has its own reasons. As a rule, these are all kinds of injuries and microtraumas in childhood and adolescence, when there is increased tissue growth, fractures, strangulation, previous diseases (including infectious and viral), various pathologies of the periosteum and cartilage, strangulations, and various skeletal anomalies.
Symptoms
The disease is expressed in the appearance of a lump, which can be located throughout the body, located on any bone, but almost 50% of all exostoses are formed in the knee area (the lower part of the femur and the upper part of the fibula and tibia). Long tubular bones love such growths.
For the time being, the disease may not manifest itself in any way, but gradually it increases and can cause severe local pain and pain radiating to various segments.
Located next to large vessels and nerves, exostoses affect them, causing disturbances in the passage of nerve impulses and disruption of the blood supply to the extremities. In such cases, in addition to the pain that occurs when certain areas of the body are compressed, a person may experience numbness and sometimes dizziness.
If the growth is located near a joint, it causes limited movement. The appearance of such symptoms is very important and is an absolute indication for urgent treatment of the pathology. After all, if the disease is severe and grows quickly, there is a risk of its degeneration into a malignant tumor.
Types of exostoses
Exostoses can be of various shapes (resemble lines, balls, mushrooms, thorns) and sizes (from a few mm to the size of a large apple).
There are solitary growths, that is, single ones, located only in one place. Or maybe the so-called multiple exostotic chondrodysplasia, when tumors appear in several places at once (diagnosed in the knee, collarbone, hip and shoulder joints, ribs, shoulder blades, sometimes even in the oral cavity on the teeth).
One of the most serious forms of this disease is spinal exostosis, because in this case the tumor can affect the spinal cord and cause disturbances in its functioning.
Treatment
Exostoses are quite persistent formations, and they rarely resolve on their own, so there is only one treatment option - surgery.
As a rule, it is prescribed to persons who have reached the age of majority, until then the growths themselves can decrease in size.
In some cases, the tumor does not cause a person any discomfort, so he can live with it all his life, periodically seeing a doctor.
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Manifestations of osteochondroma
In most cases, the disease is asymptomatic. Most often, a small tumor is an incidental finding during an X-ray examination. In case of significant growth, osteochondroma can cause pain in the affected area. In this regard, the patient is forced to consult a doctor.
The second important symptom is the appearance of a visible tumor with a significant size. Detection of a formation is also a reason to seek medical help.
Below we will look at some of the most common types of exostoses and their characteristic manifestations.
Exostosis of long bones
Long tubular bones are the most common location of osteochondroma. Usually occurs in children.
The most commonly affected bones are the femur, tibia, or humerus. As a rule, the tumor does not show itself for a long time. As osteochondroma grows, pain appears in its projection. The appearance of pain is associated with compression of nearby muscles, ligaments, nerve bundles and other structures by the growing tumor.
If the tumor size is significant, the patient himself can feel the “bump” above the tumor. The formation is usually painless on palpation.
In advanced cases, tumor growth leads to limb deformation.
Exostosis of the foot bones
Damage to the bones of the foot occurs in approximately 10–12% of cases of all osteochondromas. Most often the tumor is located on the forefoot or midfoot. Much less often, exostosis appears on the heel bone. Regardless of the location of the bone tumor, the main manifestations of the disease will be pain in the affected area and discomfort when walking.
When the forefoot is affected, the terminal phalanges of the toes are involved in the pathological process. Subungual exostoses are also common.
When exostosis forms on the metatarsal bone, it can shorten. In this case, the foot takes on an unusual shape and becomes deformed. As a result of shortening of the metatarsal bone, the corresponding toe visually appears shorter than the others.
Heel bone lesion
The severity of the manifestations of the disease depends on the shape and location of the exostosis. Bone growths on the heel bone can have different shapes - linear, mushroom-shaped, spherical, etc.
This growth is sometimes mistakenly called a “heel spur.” However, the origin of bone growth is secondary. First, a long-term injury to the ligaments and tendons of the foot occurs, and then ossification processes begin and a bone “growth” appears.
Primary exostosis is usually hereditary. At the same time, exostoses are often detected in other bone structures, including on the adjacent heel bone.
Manifestations of such localization of exostosis can include pain of varying intensity, discomfort when walking, and swelling. Sometimes a disturbance in the sensitivity of the foot may occur when the neurovascular bundles are compressed by bone growth.
Exostoses of vertebral bodies
Such growths on the vertebral body most often appear with osteochondrosis. They arise when the bone structures of the vertebral bodies rub against each other. Therefore, such exostosis is formed only by bone substance without a cartilaginous component.
Bone exostosis of the vertebral body is otherwise called osteophyte. They are usually multiple and located at the edges of the vertebral bodies.
Marginal osteophytes of the vertebral bodies most often lead to disruption of their normal mobility. Exostoses of the vertebral bodies are manifested by pain, crunching during movements and stiffness in the affected part of the spine. Also, these bony growths of the vertebral bodies can compress important vessels and nerves passing next to them. In this case, characteristic neurological symptoms appear.
Exostoses in the oral cavity
Bone growths in the oral cavity can have different locations. Accordingly, the possible reasons for their origin are also different. The most common localizations of exostoses in the oral cavity are:
- Palatal.
- On the external and internal surfaces of the lower jaw.
- On the walls of the alveolar processes - anatomical formations of the lower and upper jaws that bear teeth.
- On the articular surfaces of the lower jaw.
All exostoses of the oral cavity usually grow slowly and do not cause inconvenience to the patient for a long time. However, as it grows, formation pressure occurs on the bones and teeth, as well as injury to the oral mucosa. This is accompanied by pain, sometimes quite intense.
In almost all cases, oral exostosis is a smooth, hard protrusion under the gum. The mucous membrane of the gums is usually not changed. If the formation is large, it can stretch and have a relatively paler color.
The cause of the appearance of exostoses on the walls of the alveolar processes is most often a complex tooth extraction. In this case, damage and displacement of bone tissue and its improper fusion occur.
When the growth is located in the area of the articular process of the lower jaw, in addition to pain, asymmetry of the chin of the jaw may be observed - its displacement to the healthy side. This is accompanied by limited mouth opening and dental malocclusion.
Grodno Regional Children's Clinical Hospital
Details Published May 28, 2021
Exostosis
Exostosis - (osteochondroma, cartilaginous exostosis, osteochondral exostosis, bone spur) is a bone or osteochondral benign growth on the surface of the bone, covered throughout with periosteum and can be covered with a cartilaginous “cap”.
The reasons for the development of exostosis are different. There is a familial hereditary nature. The occurrence of exostosis is possible after injury (if the periosteum is damaged), an inflammatory process, hypothermia, radiation, and as a result of certain diseases (rheumatism, gout, syphilis, diabetes mellitus, osteomyelitis). The most common localization is the rib, clavicle, metadiaphyses of long tubular bones. Osteochondromas can be located
in the skull. There are single and multiple (osteochondromatosis) exostoses. There are various shapes (linear, spherical, flask-shaped, beak-shaped, spiky) and sizes (can reach 5 cm or even more).
Clinic
The growth of exostosis is slow. Intensive growth is more often observed during the period of physiological growth of the skeleton (8-18 years). With the rapid dynamics of exostosis, one should think about its malignant degeneration. Most often, slowly growing exostoses are asymptomatic and detected accidentally. They are detected during an X-ray examination when a compaction appears, palpable under the skin or visible during examination. Exostosis can only manifest itself as an aesthetic defect or put pressure on neighboring organs and neurovascular bundles. There may be varying degrees of pain (from mild to severe), depending on the size and location of the formation. There may be different lengths of the arms or legs (if the knee or shoulder joint is affected), lower height compared to the average age values (if the hip is affected), pain during physical activity (if the tumor is located under the tendon), sensory disturbances or cramps (if the hip is affected). nerve endings), blurred vision or drooping eyelid (with exostosis in the paranasal sinuses), epilepsy (when located on the inner surface of the skull).
Diagnostics
X-ray, MRI/CT studies allow us to judge the number of exostoses, shape, size, position and structure. On photographs and scans, exostosis is a formation of a bone structure, with clear contours, connected to the medullary canal by a wide/narrow base, with a continuous cortical layer (at the base of the exostosis there is no underlying cortical layer), a painful synovial bursa may form above the cartilaginous capsule. Damage to soft tissues and a cartilaginous “cap” (the thickness of which should not exceed 10 mm in an adult; 10-20 mm is an intermediate lesion; the formation is considered tumorous if it exceeds 20 mm; in children, the “cap” can normally reach 2 cm per period growth) can only be detected by magnetic resonance imaging.
Differential diagnosis
Differential radiodiagnosis is carried out with ecchondroma, secondary chondrosarcoma, subperiosteal hematoma, subungual exostosis (Dupuytren's subungual exostosis), Tourret's exostosis; hemimelic epiphyseal dysplasia (Trevor's disease), abnormal paraosteal osteochondromatous proliferation (Nora's disease), juxtacortical chondroma, parosteal osteosarcoma.
Treatment
Treatment of exostoses is only surgical. Performed for compression of a large nerve/vessels, pain syndrome, malignancy and for aesthetic reasons. For small formations, laser burning is possible.
Prognosis and complications
Osteochondroma can recur 1-26 months after removal of the primary formation (with incomplete removal of the cartilaginous “cap”). A serious complication is malignant degeneration (the structure most often corresponds to chondrosarcoma, chondromyxosarcoma and spindle cell sarcoma). Thrombosis of the popliteal vein and the development of a false aneurysm of the popliteal artery may occur. Sometimes bone fractures are complications of exostoses.
MRI doctor Yaroshchuk I.G.
Features of the course of osteochondromas in children
As mentioned above, this disease most often occurs in children and adolescents. This is due to periods of active growth of skeletal bones in childhood and adolescence. The first growth peak occurs at the age of 4–6 years, and the second during adolescence. It should be noted that osteochondromas under the age of one year, as a rule, do not occur.
Typically, osteochondromas stop growing during the period when skeletal growth ends. If the tumor continues to grow in adulthood, its malignancy (malignant degeneration) should be suspected.
Publications in the media
Chondroma is a tumor of childhood and adolescence. The short tubular bones of the hand and foot are most often involved. Chondromas should be treated as potentially malignant tumors. Chondromas are divided into enchondromas and ecchondromas • Enchondroma is a tumor located inside the bone. In the center of the swollen single lesion there is a homogeneous clearing of irregular round or oval shape with clear contours. Against its homogeneous background, isolated shadows of foci of cartilage calcification are detected •
Echondroma is a tumor that originates from the bone and grows towards the soft tissue. Against the background of soft tissue compaction, areas of calcification of various sizes and intensity are identified. The boundaries of the tumor and its base are difficult to detect • Clinical picture. The phalanges of the fingers and toes, metatarsal, tarsal and metacarpal bones are most often affected, and less commonly the femur and humerus. Characterized by gradually developing swelling, when located close to the joint - arthralgia, synovitis. Enchondroma can transform into chondrosarcoma: in this case, tumor growth accelerates, pain appears, areas of tumor calcification and isotope accumulation appear on scintigraphy. To clarify the diagnosis, a tumor biopsy is indicated • Treatment of chondromas is only surgical - excochleation of the tumor, bone resection with bone grafting. If malignancy is suspected, segmental resection of the affected bone is performed.
Chondroblastoma is a rare tumor, accounting for 1–1.8% of primary bone tumors (10% of all skeletal tumors). Occurs mainly in childhood and adolescence. Favorite location is long tubular bones. Affects the epiphyses and metaphyses (proximal and distal femur, proximal tibia and humerus), less commonly, the pelvic bones and scapula • Clinical picture. Pain prevails, there is slight swelling, sometimes limited movement in the joint and muscle wasting • Diagnosis. Radiologically, a heterogeneous focus of destruction of a round or oval shape is determined. Differential diagnosis of chondroblastoma is carried out with solitary enchondroma and lytic form of osteoblastoclastoma • Treatment of chondroblastoma is surgical (curettage), however, given the possibility of malignancy, bone resection is recommended.
Chondromyxoid fibroma is a painless benign tumor. Its metaphyseal eccentric location in a long bone with thinning and swelling of the cortex resembles chondroblastoma. Most often occurs before the age of 30 • Clinical manifestations are minimal; remains asymptomatic for a long time; detected accidentally on radiographs in the form of a focus of destruction, sometimes surrounded by a sclerotic rim. Against the background of the focus of destruction, a trabecular pattern and petrification are visible • Treatment is surgical (excochleation of the tumor followed by replacement of the bone defect with a graft).
Osteochondroma - common • Localization: mainly in long tubular bones (medial surface of the proximal metaphysis of the humerus, distal metaphysis of the femur, proximal metaphysis of the tibia) • X-ray examination. The tumor is presented in the form of an additional shadow, connected to the bone by a stalk, or less often by a wide base. The contours are lumpy and uneven. With large tumor sizes, pronounced deformation of adjacent bones is detected • Differential diagnosis - with single and multiple osteochondral exostoses. Osteochondroma can become malignant • Treatment is surgical. Osteoblastoclastoma (giant cell tumor) occurs at a young age (in persons under 30 years of age), affects both the epiphysis and metaphysis of long tubular bones • Pathomorphology: along with mononuclear oval cells such as osteoblasts, multinucleated large giant cells such as osteoclasts are found • Forms: lytic, active -cystic and passive-cystic • Clinical picture: pain in the affected area, sometimes skin hyperemia, bone deformation, pathological fractures are possible • X-ray examination. The tumor has the appearance of an oval lesion of clearing. An important radiological sign of all forms of osteoblastoclastoma, distinguishing it from tuberculous bone lesions, is the absence of osteoporosis • Differential diagnosis: examines the exclusion of dysplasia (chondroma, chondroblastoma, fibrous dysplasia, etc.) • Treatment of osteoblastoclastoma is surgical. Gentle bone resection with tumor removal and simultaneous bone grafting (auto-, homografts or replacement with methyl methacryl) is the method of choice. If the spine is affected by a tumor, radiation therapy is used.
Osteoid osteoma . Some authors consider osteoid osteoma as a chronic focal necrotic non-purulent osteomyelitis, others classify osteoid osteoma as a tumor • Frequency. Osteoid osteoma is detected in young people (11–20 years), men are affected 2 times more often. Typically, osteoid osteoma is a solitary tumor localized in any part of the skeleton (usually in long tubular bones). The first place in terms of frequency of lesions is the femur, then the tibia and humerus • Clinical picture. The pain, especially at night, is localized, aggravated by pressing on the area. The skin is unchanged. If the tumor is localized on the lower extremities, lameness occurs. X-rays reveal an oval-shaped area of bone tissue destruction with clear contours. Around the lesion there is a zone of osteosclerosis due to periosteal and, to a lesser extent, endosteal changes. To clarify the nature of the lesion and more clearly identify the lesion, CT is indicated. Differential diagnosis for osteoid osteoma is carried out with Brodie's bone abscess • Treatment is surgical . After radical removal, as a rule, osteoid osteoma does not recur.
Osteoma is one of the most morphologically mature benign skeletal tumors, originating from osteoblasts. Diagnosed more often in childhood, sometimes it is an accidental x-ray finding • Types: compact and spongy. Spongy osteoma is most often localized in tubular bones. Compact osteoma can be localized in the bones of the calvarium and paranasal sinuses. X-ray diagnosis of osteomas is not difficult. Compact osteoma gives a homogeneous, structureless, intense shadow. Spongy osteoma of the tubular bone moves away from the joint as it grows; a thinned cortical layer can be traced throughout. The tumor has a trabecular structure. Tumor growth is exophytic • Treatment is removal of the tumor with a portion of healthy bone tissue and periosteum.
Hemangioma is a congenital anomaly in which the proliferation of endothelial cells leads to the formation of tumor-like aggregates; of the bones, the spine is most often affected: in the body of 1–2 vertebrae, proliferation of capillaries or cavernous cavities with partial destruction is detected • Clinical picture : minor pain, aggravated by pressure on the spinous process, movement, prolonged sitting or walking • X-ray examination : striation of bone tissue, in late stages - sclerosis of the vertebral body and compression • Treatment - unloading of the spine: wearing a rigid corset, radiation therapy, for compression of the spinal cord - laminectomy.
ICD-10 • D16 Benign neoplasm of bones and articular cartilage
Diagnostics
Diagnosing osteochondroma if it is significant in size is usually not difficult. Most often, patients themselves feel a “bump” and come to the doctor with this complaint.
To clarify the diagnosis, as well as in cases where osteochondromas are located in hard-to-reach places, X-ray examination is used. In the most complex cases, computer diagnostics (CT) and magnetic nuclear tomography (MRI) are used.
Treatment of osteochondromas
According to statistics, some osteochondromas (from 2 to 10%) can degenerate into a malignant tumor. Therefore, they are all subject to treatment.
However, according to some scientists, small asymptomatic osteochondromas in childhood can disappear on their own without treatment. In this case, regular medical supervision is necessary.
Surgical
Considering the above, the only correct method of treating osteochondromas is surgical - removal of the bone tumor.
The scope of the operation usually consists of removing the tumor and the part of the bone from which the tumor originates (marginal resection). In the vast majority of cases, this is enough for a complete recovery.
Traditional medicine
Quite often, especially on the Internet, you can find recommendations for treating osteochondromas with folk remedies, physiotherapy and other methods. Before starting any such treatment, you should discuss it with your doctor.
Among folk remedies, compresses are widely used on the affected area. The most common composition is a mixture of badger or bear fat, mummy and tincture of golden mustache or cinquefoil:
- To do this, you need to take one spoonful of tincture and fat, as well as a mummy tablet, which must first be crushed. Mix everything, apply to the exostosis, cover with a napkin on top. Cover the compress with foil and secure with an adhesive plaster or bandage.
- An infusion of elderberry flowers and hawthorn fruits is taken internally. You should take three tablespoons of raw materials (or a pre-prepared mixture), pour three glasses of boiling water and leave until completely cool. It is recommended to take 1/3 cup two to three times a day.
It must be borne in mind that traditional medicine does not help to completely cure exostosis. However, the only radical treatment option is surgery.
Treatment of exostoses in dentistry
Exostoses of the oral cavity often cause discomfort to the patient and are also a significant obstacle to dental prosthetics. Small formations are sometimes not removed if they do not cause discomfort.
Indications for removal of oral exostoses:
- Significant size and rapid growth of formations.
- Pain due to the pressure of the bony protrusion on adjacent teeth.
- Various cosmetic defects.
- In preparation for dental prosthetics.
Removal of exostoses in the oral cavity is usually performed under local anesthesia. Complications, as a rule, do not arise.