eMedicine Specialties > Radiology > Musculoskeletal
Osteochondroma and Osteochondromatosis: Imaging
Updated: Oct 19, 2009
Radiography
Findings
Plain radiograph of the cervical spine shows a solitary osteochondroma of the posterior elements of C6.
Radiographs of both hands of 36-year-old man show multiple osteochondromas involving the radii right distal fibula, metacarpals, and phalanges. Note the large osteochondroma involving the terminal phalanx of the right index finger.
Plain radiograph of the pelvis in a 41-year-old woman shows multiple osteochondromas affecting the left transverse process of L5, the iliac blades, the superior pubic rami, the ischial spines, and the femoral necks. Note the modeling deformity of the femoral necks and the narrowing of the pelvic inlet as a result of osteochondromas. Several reports have described osteochondromas interfering with normal vaginal birth in pregnancy and leading to a higher rate of Cesarean deliveries.
Solitary osteochondroma. Radiograph of 24-year-old woman who presented with a hard, palpable mass on the medial aspect of the upper calf. A bulbous, pedunculated osteochondroma arising from the medial side of the upper tibial diaphysis and pointing away from the metaphysis is noted. The patient reported no history of hereditary multiple exostoses.
Multiple osteochondromatosis. Radiograph of the pelvis in a 28-year-old woman known to have hereditary multiple exostoses who presented with a painful swelling of the left buttock. Note the multiple osteochondromas and fragmentation of the osteochondroma arising from the left anterior iliac crest (see Image 8 in Multimedia).
The plain radiographic appearances of an osteochondroma are those of a pedunculated or sessile bony excrescence with well-defined margins. In adults, the cartilage cap often contains flecks of calcification. Osteochondromas arising from the surface of a bone contain spongiosa and cortex that appear continuous with the parent bone; this is particularly obvious in long bones.
The most common site of origin for an osteochondroma is the metaphysis at bony sites of tendon and ligamentous attachments. Osteochondromas usually point away from its point of attachment toward the diaphysis. The metaphysis of the affected tubular bone may be widened. The long tubular bones are affected most frequently. In long bones, osteochondromas are typically located at the metaphysis. The sites of predilection include the distal femoral metaphysis, the proximal humeral metaphysis, the tibia, and the fibula.
The small bones of the hands and feet are affected in around 10% of patients. The innominate bone is involved in 5% of patients. The spine is less frequently involved (2%), but it can lead to cord compression. The scapula is affected in 1% of patients.
Osteochondromas arise less frequently from flat bones than from long bones. The spine, pelvis, ribs, and scapulae are the bones most commonly affected. A subungual osteochondroma is rare, but it is particularly prone to a painful bursa (not visible on plain radiographs) and fracture. An osteochondroma of the sesamoid bone of the hallux has been described, but it is extremely rare. Osteochondromas arising from the pelvis are commonly large and are typically associated with a soft-tissue mass that may grow outward or inward, displacing adjacent structures.
Radiologically differentiating a benign tumor from a sarcoma is problematic in the pelvis, particularly when the mass has a soft-tissue component. Planar tomography is still a cost-effective and useful procedure in depicting bone detail in complex skeletal areas. Typically, osteochondromas arising from the ribs are located at the costochondral junction, where they can cause a pneumothorax/hemothorax (rare) that may be evident on a plain radiograph.42,43 When the small bones of the hands and feet are affected, the appearances of the osteochondromas are identical to those found in the long bones.
Serial radiographs showing an enlarging osteochondroma with irregularity of its margin and accompanied by a soft-tissue mass should alert the clinician to sarcomatous transformation, particularly when the finding is accompanied by pain. Bone erosions and irregularity or scattered calcification are further clues that malignant transformation may have occurred.
Hereditary multiple exostoses (HME) is characterized by multiple osteochondromas that typically involve the proximal part of the humerus and the distal and proximal portions of the femur, tibia, and fibula. Often, there are associated defects of bone modeling and bony deformities — in particular, bilateral coxa valga and widening of the proximal femoral metaphysis. Bilateral, progressive changes in the forearm have been linked to the severity of the underlying disease.
Radial bowing may ensue as a result of disproportionate ulnar shortening with relative radial overgrowth. Radial-head subluxation or dislocation may be a sequel to the radial overgrowth, with a superficial resemblance to a Madelung anomaly, but the characteristic relative elongation or dorsal subluxation of the distal ulna seen in Madelung deformity is not present.
Plain radiographic findings of dysplasia epiphysealis hemimelica (DEH) include irregular ossification occurring to 1 side of the ossifying epiphysis or a carpal or tarsal bone. The adjacent metaphysis may be widened. With progression of disease, a lobulated bony mass protrudes from the epiphysis or the carpal or tarsal bone. Severe disease is associated with muscle wasting, growth disturbance, and joint deformities.
Degree of Confidence
Plain radiography remains the primary modality for imaging osseous pathology. Experience with bone radiography extends over 100 years. The normal variants are well defined. The diagnosis of osteochondromas is straightforward, particularly at the common sites in long bones. Plain radiographs are particularly good for diagnosing complications related to osteochondromas, such as fractures, osseous deformity, and growth disturbances.
Plain radiography is inexpensive, effective, and universally available. With the advent of digital radiography, the radiation dose can be better regulated, and digital images have the advantage of better sensitivity, better image manipulation, and better storage. In addition, the images can be transmitted to distant facilities.
Osteochondromas arising from complex areas can be clarified by means of planar tomography.
False Positives/Negatives
The list of differential diagnoses for osteochondromas is extensive. Osteomas, osteophytes, enthesophytes, heterotopic ossification, and parosteal osteosarcomas can all mimic osteochondromas. The list of systemic disorders and developmental anomalies that are accompanied by osteochondromas or osteochondroma-like abnormalities is long, and these may cause confusion with solitary osteochondromas or with hereditary multiple exostoses (HME).
False-negative or false-positive diagnosis may occur with malignant transformation. However, problems may arise with resected tumors that appear radiologically aggressive, even with the histologic confirmation of malignancy.
Computed Tomography
Findings
Multiple osteochondromatosis. Nonenhanced, axial computed tomography (CT) scan through the pelvis (same patient as in Image 7 in Multimedia). Note the fragmentation of the osteochondroma and the considerable soft-tissue mass. Histology of the resected specimen revealed a low-grade chondrosarcoma.
CT scanning can provide excellent bone detail of osteochondromas developing in the spine, shoulder, or pelvis, despite the complex nature of these bones. CT myelography is useful in evaluating the size and extent of spinal osteochondromas in patients presenting with compressive myelopathy.
Degree of Confidence
CT scanning is an excellent modality for depicting bone detail in skeletal lesions and calcification within surrounding cartilage and soft tissue. One major disadvantage of CT scanning, however, is that it provides no information about the metabolic activity of bone lesions.
False Positives/Negatives
An increase in the size of osteochondromas due to bursitis is a known complication, and a false-positive diagnosis of malignant transformation has been reported with CT scanning and MRI. Therefore, ultrasonographic evaluation is always recommended for the evaluation of enlarging solitary osteochondromas.
Magnetic Resonance Imaging
Findings
MRI is useful for assessing the continuity of the parent bone with the cortical and medullary bone in an osteochondroma. Cartilage in the cap has high signal intensity on T2-weighted, spin-echo MRI scans. This characteristic allows measurement of the cap, which is an important consideration in malignant transformation. MRI also provides information about inflammation in reactive bursa formation, impingement syndromes, and arterial and venous compromise. This study is the method of choice for evaluating compression of the spinal cord, nerve roots, and peripheral nerves.50
De Beuckleer and associates showed that MRI improves accuracy in the diagnosis of low-grade chondrosarcomas.51 MRI scans contribute only to the diagnostic workup of cases in which malignant change is suspected, because osteochondromas have a characteristic appearance on plain radiographs.
With chondrosarcomas, the chondroid origin of tumors may be identified with the lobular high signal intensity. Short-tau inversion recovery (STIR) images show peritumoral, soft-tissue edema in 83% of chondrosarcomas. Muscle impingement should be considered in the differential diagnosis of pain in association with osteochondromatosis. On T2-weighted MRI scans, muscle impingement is depicted as increased signal intensity within the muscle.
Degree of Confidence
MRI is useful because it allows the depiction of the continuity of the parent bone with the cortical and medullary bone in an osteochondroma. This is an important prerequisite in differentiating osteochondromas from other surface bone lesions.
MRI allows the distinction of muscle impingement, which may be radiographically occult and can be clinically confused with other complications, such as a fracture, bursitis, or malignant degeneration. MRI also improves accuracy in diagnosing low-grade chondrosarcomas. MRI contributes only in cases in which a malignant transformation is suspected.
False Positives/Negatives
CT scanning and MRI have variable success in differentiating benign osteochondromas from malignant osteochondromas, and false-positive and false-negative studies may result. A false-positive diagnosis can occur with bursal inflammation.
Ultrasonography
Findings
Ultrasonography can be applied to analyze the cartilaginous cap of an osteochondroma. The cap appears as a hypoechoic layer covering a hyperechoic underlying bone. Malghem and associates compared ultrasonographic measurements of cap thickness with measurement performed on pathologic specimens in 22 resected exostoses and 2 exostotic chondrosarcomas.52 The ultrasonographic measurements proved accurate, with a mean measurement error of less than 2 mm for cartilaginous caps thinner than 2 cm.
Ultrasonography is also valuable in the diagnosis of bursitis and other complications associated with osteochondromas, such as arterial or venous thrombosis, as well as aneurysm and pseudoaneurysm formation.
Degree of Confidence
The detection rate and measurement accuracy of ultrasonography in the search for and evaluation of cartilaginous caps are comparable to those of MRI and are higher than those of CT. The high sensitivity and specificity of ultrasonography in peripheral vascular pathology is well established.
False Positives/Negatives
Ultrasonography remains operator dependent and can be labor intensive. Ultrasonograms cannot depict the cartilage cap when it is inwardly orientated; however, this is relatively uncommon. False-positive and false-negative results can occur, particularly in cases of deep vein thrombosis in the lower calf.
Nuclear Imaging
Findings
Osteochondroma with malignant degeneration. Plain radiograph of the pelvis in a 68-year-old woman who presented with a painful lump over the left greater trochanter. Note the sclerotic exostosis arising from the left greater trochanter. Technetium-99m (99mTc) diphosphonate scintigram (left) shows intense activity in the region of the left greater trochanter. At surgery (right), the lesion was diagnosed as a low-grade chondrosarcoma superimposed on an osteochondroma.
Scintigraphy with bone-seeking isotopes is an effective method of imaging osteochondromas that are metabolically active. Thallium-201 (201 Tl) scintigraphy is useful in differentiating malignant transformation from benign osteochondroma in hereditary multiple exostoses (HME).
Aoki and associates showed that fluorodeoxyglucose positron emission tomography (FDG-PET) could be an objective and quantitative adjunct in the differential diagnosis and grading of chondrosarcomas.47
Degree of Confidence
A normal isotopic bone scan virtually excludes the diagnosis of malignant transformation of an osteochondroma.
False Positives/Negatives
A positive isotopic bone scan does not allow differentiation of the endochondral ossification occurring in a benign osteochondroma from the hyperemia and osteoblastic reaction occurring in a chondrosarcoma. Negative findings of201 Tl scintigraphy may not exclude the possibility of chondrosarcomas, and the utility of this method may be limited.
In their article about the role of radionuclide scintigraphy, Hendel and associates concluded that single, standing, planar bone scintigraphy has no value in distinguishing benign osteochondromas from malignant chondrosarcomas.53
Angiography
Findings
Vascular complications can occur as a result of osteochondromas, particularly when a bone lesion occurs around the knee. In this situation, arteriography is considered essential in planning surgical treatment. Effective diagnostic imaging is a key to the early operative removal of sarcomas. Angiography has also been used to assess malignant transformation; angiograms may depict neovascularity and the true extent of disease.
Degree of Confidence
Angiography remains the criterion standard in depicting vascular pathology and is an essential part of vascular intervention.
False Positives/Negatives
False-negative angiograms are possible in true aneurysms and in false ones, because a laminated thrombus may lie along the wall and partially fill the aneurysm. In such cases, an ultrasonogram may prove invaluable.
More on Osteochondroma and Osteochondromatosis |
| Overview: Osteochondroma and Osteochondromatosis |
 Imaging: Osteochondroma and Osteochondromatosis |
| Follow-up: Osteochondroma and Osteochondromatosis |
| Multimedia: Osteochondroma and Osteochondromatosis |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics
Dysplasia Epiphysealis Hemimelica
Solitary Osteochondroma
Bone Metastases
Clinical guidelines
ACR Appropriateness Criteria® chronic hip pain
Taljanovic M, Daffner RH, Weissman BN, Bennett DL, Bleba JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic hip pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 8 p. [78 references]
Clinical trials
The Health Related Quality of Life in Patients With Hereditary Multiple Exostoses
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Keywords
osteochondroma, osteochondromatosis, hereditary multiple exostoses, HME, multiple osteocartilaginous exostoses, diaphyseal achalasia, diaphysial achalasia, multiple hereditary osteochondromata, multiple congenital osteochondromata, diaphyseal aclasis, diaphysial aclasis, chondral osteogenic dysplasia of direction, chondral osteoma, deforming chondrodysplasia, dyschondroplasia exostosing disease, exostotic dysplasia, multiple osteomatoses osteogenic disease, familial bony spurs, metaphyseal spurs, multiple epiphyseal dysplasia, dysplasia epiphysealis hemimelica, Trevor disease, Trevor's disease
