EXAMINATION OF A CASE OF TUMOUR (exostoses)

CHIEF COMPLAINTS :- 1) PAIN

2) SWELLING

3) INABILITY TO WALK

HISTORY/PRESENTING ILLNESS; - elaborate on PAIN- (pneumonic- SOCRATES)

SWELLING; –ONSET, SITE, DURATION, PROGESSION (pea nut to lump), presence of other swellings,
secondary changes, any impairment in function, associated symptoms like pain, fever,( OS-
osteosarcoma) difficulty in breathing, back pain(secondaries)

PAIN;-SOCRATES (which appears first, pain first (malignancy), swelling first (benign tumor), E ing’s
mimics osteomyelitis like picture.

ADL; - there will be hindrance in his daily activities, like cycling, running, walking etc.

NEGATIVE HISTORY; - Associated trauma (#pedicle of exostoses), fever (bursitis, OS), night cries/relieved
with aspirin (osteoid osteoma), limb length discrepancy (exostoses-shortening, cystic lesions
lengthening) Angular deformities (exostoses, fibrous dysplasia), similar swellings elsewhere (exostoses,
enchondroma, fibrous dysplasia.

GPE; - Screen for Anemia, Cachexia, Examine the thyroid, Lungs, Abdomen, Breast, Prostate for primary
lesions.

GAIT; - painless, or painful (osteosarcoma), assisted or unaided, short limb gait.

ATTITUDE AND DEFORMITY;-

Child in supine or sitting posture with hips in----- deg of flexion, knee in----deg flexion, ankle in ---deg of
plantar or dorsiflexion, look for angular deformities like Genu valgus and Varus(exostoses)

INSPECTION;-

Inspection should be done from all sides anteriorly, Posteriorly, medially and laterally and pick up
rele ant findings, if it’s a s elling des ri e as SIZE, SHAPE, SURFACE, EDGES, MARGINS, NUMBER, SKIN
OVER THE SWELLINGS, ENGORGED VEINS ,

Site- where is the lesion - Epiphyseal-osteoclastoma, chondroblastoma.

-Metaphyseal- Brodie abscess, osteoma, SBC, osteosarcoma.

- Diaphyseal- E ing’s, multiple myeloma, osteoid osteoma.

Size and shape--size of a peanut, or egg, oval, and comment on shape round, pedunculated.
Surface -smooth or lobulated –benign tumors, cystic lesions,

-irregular in shape, bosselated appearance, (malignancy)

Edges – ill defined (inflammatory, sessile exostoses, osteosarcoma, osteoclastoma

-Well defined – Exostoses,

Skin over the swelling and engorged veins ;– look for ulcers ,engorged veins if present describe .

PALPATION; -

TEMPARATURE- Feel for local rise in temperature (OS), Bursitis sec to impingement in exostoses.

TENDERNESS- seen in osteosarcoma (OS), Brodies abscess,

Confirm inspectory findings particularly (SIZE, SHAPE, SURFACE, EDGES, MARGINS, NUMBER, SKIN OVER
THE SWELLINGS, ENGORGED VEINS,) and add the below findings

Look for CONSISTENCY – bony hard- osteoid osteoma, eggshell crackling- (osteoclastoma), variable-
consistency (osteosarcoma).

PLANE OF SWELLING – Soft tissue tumors (moves in one or two planes), Bony swellings – fixed to the
underlying bone no movement in any plane.

PULSATIONS- Vascular tumors- osteoclastoma, telangectactic OS, hemangioma, thyroid, renal tumors,

PRESSURE SYMPTOMS- Look for distal paresis, oedema,

MOVEMENTS;-

ACTIVE AND PASSIVE; – Look for limitation of movements in a joint above and joint below (exostoses-
causing impingement, malignant tumors can limit movement)

Look for reactive synovitis and joint effusion of the nearby joints (OS)

MEASUREMENTS; –-

LINEAR MEASUREMENTS; -- look for any limb length discrepancy (exostoses- we see shortening, and in
cystic lesions like SBC, ABC lengthening due to stimulation of growth plate).

CIRCUMFERENTIAL MEASUREMENTS; – Look for quadriceps wasting, very important. Girth of limb in
osteosarcoma

EXAMINATION OF DISTAL NEUROVASCULAR STRUCTURES; - Look for nerve compression (exostoses)

and vascular involvement.
DIAGNOSIS; – ANATOMICAL; – tell its bony or a soft tissue tumor, and the site its arising from epi,
Meta or diaphysis, and the bone from where it arises like femur, tibia etc.

PATHOLOGICAL; - it’s a benign or a malignant tumor and give a differential diagnosis for
the same.

INVESTIGATION;-

LABORATORY; - HB,WBC, TCDC,

RADIOLOGICAL; - X-RAYS

SPECIAL INVESTIGATIONS; - CT SCAN /MRI SCAN,