Endgames Picture Quiz

Joint pain in hereditary multiple exostoses

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h656 (Published 11 February 2015) Cite this as: BMJ 2015;350:h656
  1. David J Bruce, core surgical trainee1,
  2. Duncan Whitwell, consultant orthopaedic surgeon2,
  3. Hemant Pandit, senior clinical lecturer2
  1. 1John Radcliffe Hospital, Oxford, OX3 9DU, UK
  2. 2Nuffield Orthopaedic Centre, Oxford, UK
  1. Correspondence to: D Bruce davebruce{at}doctors.org.uk

A 72 year old man who had never undergone joint surgery was referred to an orthopaedic clinic because of pain and stiffness in his right hip, which had been gradually worsening for many years. He was known to have hereditary multiple exostoses but was otherwise well. He had not noticed any recent new bony lumps. Pelvic radiography was performed (fig 1).

Fig 1 Anterioposterior pelvic radiograph of the patient

Questions

  • 1. What abnormalities does the radiograph show?

  • 2. What other disease process might be a concern?

  • 3. What other imaging would be useful for your assessment?

  • 4. What are the management options in this patient?

Answers

1. What abnormalities does the radiograph show?

Short answer

Bilateral osteoarthritis (right worse than left) and polyostotic multiple bone exostoses, with extensive surrounding mineralisation into the soft tissues.

Long answer

The radiograph (fig 2) shows bilateral osteoarthritis (right worse than left) and polyostotic multiple bone exostoses, with extensive surrounding mineralisation into the soft tissues.

Fig 2 Anterioposterior pelvic radiograph showing bilateral osteoarthritis (right worse than left) and polyostotic multiple bone exostoses (arrows), with extensive surrounding mineralisation into the soft tissues (asterisk)

Osteochondromas are the most common bone tumour, comprising up to half of benign bone growths. They are composed of cortical and medullary bone in continuity with that of the underlying bone, with a hyaline cartilage cap. The long bones of the lower limb are most commonly affected, although lesions can be seen in the upper limbs, scapular bone, pelvis, spine, and head.1 2 The nature of osteochondromas is unclear, and many clinicians treat them as if they were tumours. However, recent studies suggest that they consist of a non-clonal mixture of cells and are not true cancers.3 The lesions arise by separation of a fragment of the epiphyseal growth plate that herniates through the periosteal bone cuff surrounding the growth plate …

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