Examination of Swelling

DR SANTOSH MISHRA
Assistant Professor
Department Of Orthopaedics
Gandhi Medical College, Bhopal
 History

•Swelling- site, duration, mode of onset, progression,

solitary/multiple, painful/painless

•Pain- onset, duration, radiation, character, aggravating

factor , relieving factor, diurnal variation

•H/O trauma

•Associated symptoms- loss of appetite , fever , weight loss

 Inspection
1. Site
2. Shape- oval/spherical/globular/ irregular
3. Size- vertical and horizontal dimension
4. Surface- smooth/irregular
5. Number- single/multiple
6. Edge - well defined/ill defined
7. Extent
8. Skin-scar mark, ulcer, tense/shiny, redness, dilated veins,
pigmentation
9. Visible pulsation
 Palpation
1. Local temperature- back of hand
2. Tenderness
3. Size
4. Shape
5. Surface (smooth/irregular)
6. Margin( well defined / ill defined )
7. Extent
8. Consistency- uniform/ variable
9. Fixity to the bone
10. Lymphadenopathy
Benign tumor Malignant tumor
Insidious in onset, gradual in Acute in onset, rapid in
progression progression
• Skin is not stretched or shiny present
• No dilated veins
• No discoloration of skin
• No inflammation , ulcer
formation, loss of skin
appendages

Local temp-not raised raised

Surface-smooth irregular
Margins-well defined ill defined
Consistency- uniform variable
Lymphadenopathy-absent present
• Movement –joint above and below swelling

• Distal neuro-vascular status

Differential diagnosis of bony swelling
Investigations
X ray
1. Which bone is affected?
2. Which part of bone is affected?
3. What is the type of lesion: is it osteolytic, osteoblastic or
mixed?
4. Is there a periosteal reaction?
5. Is there soft tissue involvement?
6. What is the nature of the matrix: is it osteoid, chondroid or
fibroid?
7. Is the lesion solitary or are there multiple lesions?
What is the type of bone lesion?

Osteosclerotic
Osteolytic lesion
lesion
Zone of transition
Narrow zone of Wide zone of
transition-benign transition
tumor
 Fibrous dysplasia, Enchondroma, Non ossifying fibroma and
Periosteal reaction SBC are common bone lesions with no periosteal reaction
Solid periosteal reaction

Osteoid
osteoma
Onion skin periosteal
reaction
Codman’s triangle
Sunray
appearance
Pattern of cortical destruction
Geographical type Moth eaten Permeative type
• MRI- Intraosseous and soft tissue extension of tumor
Tumor proximity with neurovascular structure

• CT scan-Type of bone destruction, calcification/ossification

• Bone scan- distant metastasis

• Chest CT- lung metastasis

• ESR- elevated in infection; metastatic carcinoma; and small “blue
cell” tumors, such as Ewing sarcoma, lymphoma, leukemia, and
histiocytosis

• Hypercalcemia may be present with metastatic disease, multiple

myeloma

• Alkaline phosphatase - elevated in metabolic bone disease,

metastatic disease, osteosarcoma, Ewing sarcoma, or lymphoma.
Biopsy –gold standard
Management
• Curettage- benign tumor
Higher local recurrence
Resection

• Intralesional-surgical dissection within

the tumor

• Marginal resection-removal of tumor

with its psudocapsule

• Wide resection- entire tumor &

surrounded a cuff of
normal tissue

• Radical resection- entire compartment

removed
Adjuvant treatment
• Radiotherapy-multiple myeloma, lymphoma, and Ewing sarcoma,

• Chemotherapy –osteosarcoma
chemotherapy is not useful for cartilaginous lesions

• Adjuvant chemotherapy -chemotherapy administered postoperatively to treat

presumed micro-metastases.

• Neoadjuvant chemotherapy - chemotherapy administered

before surgical resection of the primary tumor
RESECTION AND RECONSTRUCTION

• Mega prosthesis
 X rays

Osteoid osteoma
osteochondroma
Enchondroma
GCT Simple bone cyst ABC
osteosarcoma
Ewing sarcoma
THANK YOU
Matrix
• Calcifications or mineralization within a bone lesion may be an
important clue in the differential diagnosis.
Chondroid matrix-
calcification Ring & arcs,
popcorn, focal stippled
or flocculent
Osteoid matrix
•  trabecular ossification
pattern -benign bone-forming
lesions

• cloud-like or ill-defined
amorphous pattern –
osteosarcomas.