Osteochondroma

General Information

Osteochondroma is an outgrowth of medullary and cortical bone

A portion of the cartilaginous growth plate grows outward instead of
longitudinally and forms the osteochondroma/exostosis (like a branch on a
tree)

It consists of bone covered with cartilaginous cap (exostosis)

May be secondary to a growth plate injury (Node of Ranvier injured)

Osteochondromas are benign, non-neoplastic conditions

Hamartomatous anomaly

It can occur as a solitary lesion or as multiple exostoses associated with a

hereditary condition known as Multiple Hereditary Exostoses (MHE)

Radiation exposure can also be a cause of multiple osteochondromas

Solitary Osteochondromas are the most common benign bone tumors and
constitute 35% of all benign bone tumors and 10% of all bone tumors
overall

There are 2 forms

Pedunculated (with a stalk)

Sessile (flat without a stalk)

Osteochondromas likely arise from displaced cartilage through periosteal

defect and grow at right angles to normal growth plate

Lesions have self-limited growth that ceases after skeletal maturity

Due to endochondral ossification, cartilage cap diminishes in thickness as

age increases

Osteochondroma -(most common benign neoplasm of bone that leads to biopsy)

Types:

Solitary Osetocartilaginous Exostosis

Hereditary Multiple Exostoses (HME)

Radiographic Subtypes:

Pedunculated
Sessile

Multiple Heredity Exostoses (MHE)

Clinical Data:

Male predominance (3:1)

Autosomal Dominant inheritance

There is variability in size and number of ostechondromas (variable

penetrance)

Any portion of the skeleton preformed in cartilage may be involved

Evident during childhood

MHE may be bilaterally symmetric

One side may predominate

There is a higher incidence of malignant transformation (10-20%) of

osteochondromas that

develop in MHE. Most commonly a secondary low grade chondrosarcoma

develops.

Clinical Presentation
Signs/Symptoms:

Hard swelling for many years

Symptoms dependent on location/size

May cause mechanical symptoms from compression of adjacent structures

such as tendons,

nerve or blood vessels

An overlying bursa may form and result in a bursitis

Rare vascular injuries and arterial aneurysms from adjacent

osteochondromas

Malignant Transformation: Solitary osteochondroma <1%

Prevalence:

Male>Female 1.8:1

Age:

Usually presents clinically by the third decade of life

Sites:

Appendicular skeleton: Femur (30%) Tibia (20%) Humerus (2-%) Hand and
Foot (10%)
Pelvis (5%) Scapula (4%)

Surface of metaphyseal portions of long tubular bones

Knee area 35% of cases

Radiographic Presentation
Plain X-rays:

Projects from bone with narrow (pedunculated) to broad (sessile) stalk

Corticomedullary continuity: Medullary bone continuous with that of
osteochondroma and cortex blends with that of osteochondroma

Calcification in cartilaginous cap ("Ring and Arc" and stippled

calcifications)

Lobular growth pattern

Long bones: arise from metaphysis, grows away from epiphysis toward
diaphysis,

May be associated with failure of tubulation in Multiple Hereditary

Exostosis

Flat bones: tend to be larger and sessile, variable appearance

Cartilage cap thickness is visualized best on MRI, not XR

Bursa may exist external to cartilage cap (seen on MRI)

Roll over the images for more information

Osteochondroma Vs. Secondary Chondrosarcoma

The cartilaginous cap deserves the most attention when differentiating a benign
osteochondroma from a secondary chondrosarcoma that arose from a pre-existing
osteochondroma
In adults, the cartilaginous cap regresses and becomes thin due to enchondral ossificastion of
the majority of the cap.
Malignant transformation is suggested by:

Cartilaginous cap thickness greater than 2cm

Cortical destruction

Backgrowth of the cartilaginous cap into the stalk or medullary canal

Lysis of calcifications in cap

Osteochondroma: Cartilage Cap

Radiographs

Chondroid Calcification in cap

Increasing destruction or change in appearance is worrisome for
malignancy

Ultrasound

Good for cap and bursae

Bone Scan

Increased uptake in the cap

MRI:

Best test for evaluating thickness of cap and surrounding bursa

Intermediate T1W Images

High Intensity T2W Images because of fluid content

The cap will appear as soft tissue with calcification

Can be difficult to distinguish from muscle

CT

Cap thickness

Benign < 1.5cm (0.1 - 3.0cm; Avg. 0.6 - 0.9 cm)

Malignant > 1.5 cm (1.5 - 12cm; Ave. 6cm)

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Pathology
Pathology:

Medullary and cortical continuity w/ underlying bone

Hyaline Cartilage Cap with lobular growth

Cartilage cap involutes after growth

Gross Pathology

The osteochondroma is completely covered in periosteum

Cut surface shows hyaline composition of cartilage cap

Cap

Younger patients thicker cap because of growth hormone

Smooth or knobby

2 mm to 1 cm thick

Beneath the cap, calcified cartilage which appear as white deposits are present
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Microscopic Pathology
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Treatment
Simple excision:

Cosmetic reasons
Impingement on tendons, nerves or blood vessels

Pain and limitation of motion

For multiple exostoses, corrective surgery may be necessary due to

secondary deformities

Prognosis

Recurrence after excision is rare

Rarely, osteochondromas may give rise to malignant chondrosarcoma
o

Solitary osteochondromas 1%-2%

Multiple osteochondromas 5%-25%

Most common sites to undergo malignant change

o

Scapula, pelvis, ribs, proximal femur

Multiple Heredity Exostoses (MHE)

Clinical Data:

Male predominance (3:1)

AD inheritance

Variability in size and number

Any portion of the skeleton preformed in cartilage may be involved

Present in childhood

May be bilaterally symmetric

One side may predominate

Increased incidence of malignant transformation (10-20%)

Radiographically characterized by multiple osteochondromas and

undertubulation of bones

(Erlenmeyer Flask Deformity)

Roll over the images for more information

Subungal Exostosis - Dupuytren Exostosis

Osteochondroma Variant
Females > Males (2:1)

Often painful and associated with trauma and infection

Fibrocartilage cap

Located away from physis

Dysplasia Episphysealis Hemimelica - Trevor Disease

Male predominance (3:1)

Very rare < 100 cases

Swelling, pain and deformity

Usually lower extremity, unilateral

65% multiple done involvement: talus, distal femur, tibia

Dysplasia Episphysealis Hemimelica - Trevor Disease

Ankle and knee most common

Medial joint 2X lateral

Lobular epiphyseal mass

Histologically identical to an osteochondroma

May produce deformity and secondary osteoarthritis