Epiphyseal Lesions Research Articles

Management of limb length discrepancy after bone sarcoma resection about the knee in the skeletally immature.

Patients with bone sarcomas increasingly choose limb salvage. This can lead to issues with limb length discrepancy (LLD) for the skeletally immature. We synthesize management options into an algorithm and report our results. Patients with bone sarcomas involving any location from the femoral diaphysis to the tibial diaphysis 12 years or younger were reviewed. Our clinical pathway prescribed patients with metadiaphyseal lesions to intercalary allograft reconstruction, epiphyseal lesions and less than 5 cm expected LLD to osteoarticular allograft and patients with more than 5 cm expected LLD to extendable prosthesis. Twenty patients met inclusion criteria: 11 with osteoarticular allografts, 5 with extendable prostheses and 4 with intercalary allografts; median age 11.5 years; median follow-up 8.2 years; and final median LLD 1.6 cm. Five patients had contralateral epiphysiodesis, two patients underwent contralateral femoral shortening and a median of 6 (range 4-8) lengthenings were performed for extendable prostheses. Four patients had residual LLD over 3 cm. There were 13 revisions in 8 patients and 2 amputations. Limb-salvage in paediatric bone sarcoma of the knee can be managed with multiple techniques producing satisfactory results in regards to LLD. Careful pre-operative planning and shared decision making is a requisite given the high rate of secondary procedures for both LLD and reconstructive failures. Level of evidence: Level III Retrospective Comparative Study.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients.

To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature. We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected. Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

A Case Report of Recurrent Chondroblastoma in a 19 Year Old Male

Introduction: Chondroblastoma is a rare benign, epiphyseal bone tumor that typically affects the second decade of life and represents approximately 1% of all bone tumors. Radiologically it manifest as a lytic tomour lesion in the epiphysis of long bones. Case report: We present a case of 19 year-old male who presented with recurrent symptoms of pain and swelling in right shoulder associated with restricted shoulder mobility. Preoperative radiological imaging showed large lytic epiphyseal lesion arising from upper end of humerus interspersed with areas of calcification. MRI was done which reveal significant findings of chondroblastoma which guided in the planning of treatment. Conclusion: Chondroblastomas are typically benign, but rarely it can progress locally or metastatise. Recurrence is also noted even after surgical resection which may suggest inadequate curettage. Early diagnosis and aggressive primary management prevents further surgeries and recurrences.

К вопросу о комплексной лучевой диагностике воспалительных заболеваний костей у детей на ранней стадии процесса

Aim: to study the possibilities of diagnostic radiology methods for changes in metaphyses and epiphyses at an early stage of the inflammatory process in children aged 1 and older and adolescents. Patients and Methods: 76 emergency patients with a diagnosis of acute metaepiphysial hematogenous osteomyelitis were examined using standard radiography (SR), ultrasonography (US), magnetic resonance imaging (MRI) and computed tomography (CT). The age of the patients ranged from 1 to 18 years. All patients in the admission department underwent US and SR with a mandatory examination of the contralateral region. After analyzing the obtained data, additional examination algorithms were formed using MRI and CT. Results and Discussion: US of the targeted area was descriptive concerning the soft tissue pathological component: paraosseous soft tissues edema was determined in 75%, structural changes of the joint, in particular, synovitis — in 78.9%, joint effusion — in 57.9%. X-ray examination had a limited opportunity to detect destructive changes in bone tissue at the early stages of the pathological process (6.6%). At the same time, MRI revealed the maximum number of semiotic signs of acute hematogenous osteomyelitis, the most significant of which were: trabecular bone marrow edema (100%), periosteal changes (96.1%) and extraosseous changes (98.5%). CT was performed in 26 patients with multifocal disease, as well as in the late stage of the inflammatory process for preoperative planning. Bone destruction at an early stage occurred in 32.7% of patients, a change in the growth area — in 81.0 % of cases. Along with these semiotic signs, sequesters (55.3 %) and fistula tracts (31.3%) were visualized. Conclusion: the obtained results made it possible to systematize information on the diagnostic radiology efficacy for acute metaphyseal and epiphyseal lesions in the early stage of the inflammatory process in children aged 1 and older and adolescents. KEYWORDS: osteomyelitis, epiphysis, metaphysis, diagnostic radiology, pediatrics. FOR CITATION: Sholokhova N.A., Olkhova E.B. On the issue of complex diagnostic radiology of inflammatory bone diseases in children at an early stage. Russian Medical Inquiry. 2021;5(5):330–334 (in Russ.). DOI: 10.32364/2587-6821-2021-5-5-330-334.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

IntroductionThe humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17–31%), kidney (13–15%) or lung (11–24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HypothesisWe hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients’ function. Materials and methodsBetween 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30–94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. ResultsSeven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. ConclusionsOur initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso–epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. Level of evidenceIV, retrospective study.

Solitary long-bone epiphyseal lesions in children: radiologic-pathological correlation and epidemiology.

Solitary epiphyseal lesions are rare and present with nonspecific imaging features. Knowledge regarding etiologies of pediatric epiphyseal lesions is limited to small studies. The purpose of this study was to determine the relative incidence of pathologies affecting the pediatric epiphysis based on biopsy-proven cases with imaging. We conducted a retrospective review of imaging studies including the terms "biopsy" or "resection" and entities known to affect the epiphysis and cross-referenced these with pathology reports, recording the relevant clinical data. Two radiologists performed comprehensive imaging review and recorded relevant features. Forty-nine children and adolescents met inclusion criteria. The long-bone epiphyseal lesion etiologies included chondroblastoma (n=22, 45%), nonspecific nonmalignant pathology (n=11, 22%), osteomyelitis (n=9, 18%), lymphoma (n=2, 4%) and 1 case of each of aneurysmal bone cyst, chondrosarcoma, enchondroma, hemangioendothelioma, and non-Langerhans cell histiocytosis. Median age was 13.1years old (range 1.5-18.6years). We performed comparative analysis of the two most common lesions in our series, chondroblastoma and osteomyelitis. Chondroblastoma was significantly more likely to be peripherally located (94% vs. 33%, P=0.002) and to demonstrate a discrete T1-weighted hypointense rim (94% vs. 33%, P=0.002); there were no significant differences in enhancement or intrinsic signal properties. Children with chondroblastoma were older (15.1years vs. 7.3years, P=0.001), and chondroblastoma lesions were significantly larger, with mean maximum lesion diameter of 25mm (interquartile range [IQR] 20-30) vs. 12mm (IQR 11-18) (P=0.001) and lesion volumes of 4.4mL (IQR 2.4-7.9) vs. 0.4mL (IQR 0.2-1.4) (P=0.01). This study reports the relative frequency of pathology of pediatric solitary epiphyseal lesions and describes several features that might assist in differentiating between chondroblastoma and osteomyelitis.

Radiological diagnosis of chronic recurrent multifocal osteomyelitis using whole-body MRI-based lesion distribution patterns

To explore the distribution patterns and extent of chronic recurrent multifocal osteomyelitis (CRMO) using whole-body magnetic resonance imaging (WBMRI). Children with established diagnoses of CRMO, who had undergone WBMRI, had their images reviewed by three radiologists using a novel pictorial mapping system for determining lesion load and distribution patterns. Thirty-seven children (mean 12 years; range 2-18 years) had 317 lesions (8.6 lesions per patient [LPP]; range 2-27). Multifocal involvement was noted in 33 (89%) and unifocal in four (11%). The tibia was most frequently involved (68% of patients; 29% of lesions). Clavicular involvement was noted in 38% and spinal lesions in 19% of patients. Bilateral disease involved the fibulas (80%), tibias (68%), and foot phalanges (67%) most frequently. In 93% of bilateral disease, there was also symmetry. A "tibio-appendicular multi-focal pattern" (tibial but no clavicular involvement) was present in 54% whereas a "claviculo-spinal pauci-focal pattern" (clavicular lesions, no tibial involvement; few additional lesions mainly of the spine) was present in 24%. Only 14% had synchronous involvement of the clavicle and tibia. In the long bones, 65% of lesions were metaphyseal (distal metaphysis 42%) and 35% epiphyseal (173 peri-physeal lesions). Epiphyseal lesions were minimal in 60% whereas metaphyseal lesions were extensive in 75%. Sixty-six percent of tibial symmetric lesions and 100% of symmetric lesions of the radius, humerus, and ulna were of equal severity. CRMO lesions are often multifocal and can have typical long bone distal metaphyseal locations. Two main phenotypic patterns have emerged: multifocal predominantly tibial involvement or pauci-focal clavicular and spinal disease.

Symptomatic steroid induce multifocal diaphyseal bone infarcts treated with intra-medullary nailing

Introduction Non traumatic osteonecrosis is the ischaemic death of cellular elements within bone. Etiological factors implicated include long term corticiosteroid use, alcoholism, sickle cell disease, systemic lupus erythematosus, amongst others. Common sites of involvement include the proximal femur, knee, shoulder, ankle. Metaphyseal-diaphyseal lesions have been well described radiolographically, however are commonly considered asymptomatic. There is thus a paucity of literature describing techniques used for symptomatic diaphyseal or metaphyseal lesions not involving the epiphyseal region. Case description Our patient is a 40-year-old woman diagnosed with Arnold-Chiari malformation in 2005 who was then surgically treated with foramen magnum decompression. In 2010 she was treated with 4 months of Dexamethasone 2mg for chemical meningitis. She presented to the Orthopaedic outpatient clinic in 2012, 16 months after ceasing steroid medication, with a 6 month history of difficulty walking due to pain in bilateral groins and bilaterally along her shins, left worse than right. MRI of both hips demonstrated anterior serpiginous lesions within the femoral heads consisted with AVN (Ficat II). MRI of lower legs showed isolated bone infarct in the metaphyseal-dyaphyseal region of her tibias bilaterally. She had bilateral total hip arthroplasties with immediate relief of hip symptoms. Our patient underwent bilateral tibial intramedullary nailing using a Stryker T2 nail with a medial parapatellar approach. At both the 6 week and 5 month follow-up she had no further pain, was non tender to palpation and was very satisfied with result. Results and Conclusions We are unaware of any reports of the development of symptomatic diaphyseal osteonecrosis in patients receiving corticosteroids for the treatment of meningitis. Much of the literature regarding management of osteonecrosis is focused on the treatment of epiphyseal lesions in the femoral head and around the knee. Diaphyseal lesions have been well described radiologically but are often defined as asymptomatic and clinically insignificant. Our use of intramedullary nailing thus illustrates an effective surgical option for the treatment of symptomatic diaphyseal osteonecrosis. Take home message Osteonecrosis must be considered in all patients receiving high dose or long term steroids for any indication. Intramedullary nailing can be a successful method of treating symptomatic diaphyseal osteonecrosis of long bones.

Epithelioid hemangioma of bone: radiologic and magnetic resonance imaging characteristics with histopathological correlation

Epithelioid hemangioma is a rare vascular tumor that can occur in soft tissues or bone. The tumor is part of a spectrum of vascular tumors that also includes epithelioid hemangioendothelioma and angiosarcoma. When involving the bone, the tumor usually involves the metaphysis or diaphysis of the long tubular bones and most commonly occurs in adults. It has been rarely reported in pediatric patients, and in these reported patients, the tumor primarily involves the epiphysis. To review three cases of epithelioid hemangioma of bone occurring in pediatric patients involving the epiphysis and to explore the imaging features of this tumor. Retrospectively review three cases of epithelioid hemangioma occurring in skeletally immature patients. These tumors primarily involved the epiphyses or epiphyseal equivalent bones. One lesion was centered in the metaphysis but extended to the epiphysis. These are three cases presenting in an unusual location and at an unusual age. Epithelioid hemangioma, though rare, can occur in pediatric patients and appears to involve the epiphyses in these patients. This is in contrast to the usual age and location reported. Epithelioid hemangioma may be considered for an epiphyseal lesion in a skeletally immature patient.

Cystic Lesions With Suspected Soft Tissue Infiltration

In April 2010, a 19-year-old soccer player presented with a 4-week history of pain after a tap against his right knee. Medical and family histories were unremarkable and no abnormalities were found on physical examination. A radiograph of the right knee showed osteolytic lesions in the distal femur and the head of the tibia. On magnetic resonance imaging, the epiphyseal lesions were visualized as cystic and nonsclerotic and extended to the articular surface of the distal femur and proximal tibia (Figure 1). Soft tissue extension was suspected from the tibia. Laboratory test results showed normal blood cell count, renal function, and concentration of C-reactive protein. Aneurysmatic bone cysts were suspected and a biopsy was performed. Histopathological examination detected spindle cell infiltrates with hemorrhages, fragmented trabecular bone, and numerous osteoclastic giant cells proliferating at a rate of 10% suggesting an aggressive giant cell lesion. Since it was still not determined whether the lesions were malignant, flourodeoxyglucose F 18positron emission tomography/computed tomographywasperformedand foundadditional lesions in the left distal femur and the leftmandible. Biopsyof themandible showed the same type of tissue as seen in the right femur and tibia. Quiz at jamasurgery.com A B

Fresh Osteochondral Allograft Transplantation for Treatment of Chondroblastoma of the Femoral Head: A Case Report.

In 1908, Erich Lexer reported the use of donor tissue from freshly amputated limbs for use in joint replacement1. Fresh allograft utilization increased in the 1970s, and fresh allografts have been successfully used in treating articular cartilage defects in the knee, ankle, hip, and shoulder2-9. Although frozen osteoarticular allografts are commonly used in limb salvage surgical procedures in musculoskeletal oncology, fresh allografts are rarely used. Chondroblastoma is a rare tumor that accounts for approximately 1% to 2% of all benign bone tumors10-14. Patients with chondroblastoma have pain and limitation of joint movement11-14. Imaging studies show lytic epiphyseal lesions with a sclerotic margin11,15. Treatment usually involves curettage and packing of the defect with bone graft11,12,14. We present a thirty-four-year-old man who underwent fresh osteochondral allografting after removal of a chondroblastoma that had caused articular cartilage and subchondral bone collapse in the weight-bearing portion of the femoral head. The patient was informed that data concerning the case would be presented for publication, and he provided consent. A thirty-four-year-old man presented with a two-year history of pain in the left side of the groin with walking, which was exacerbated with abduction and external rotation of the hip. Physical examination demonstrated full passive hip motion equivalent to the contralateral hip, with pain at the extremes of abduction and external rotation. The preoperative Harris hip score was 86. Radiographs showed a lytic epiphyseal lesion in the femoral head (Fig. 1). Magnetic resonance imaging (MRI) demonstrated edema surrounding the lesion, with irregularity of the overlying articular cartilage in the weight-bearing portion of the femoral head (Fig. 2). Fig. 1 Preoperative anteroposterior radiograph with a well-defined epiphyseal lesion with sclerotic margins, which are findings …

Epiphyseal lesion of the humerus in a child

Epiphyseal lesion of the humerus in a child

Epiphyseal lesion of the humerus in a child

A 13-year-old boy presented with a one-and-a-half-month history of right shoulder pain that was precipitated by a competitive wrestling episode during which he felt a “cracking” sensation. The patient did not seek immediate medical attention and was treated at home with a sling, ice, and ibuprofen. After incomplete pain relief radiographs were obtained (Fig. 1). Past medical history was unremarkable. Physical examination revealed a right upper extremity that had no muscular asymmetry, normal neurological and vascular function, and normal motor function with a full range of shoulder motion in all planes and axes. A magnetic resonance imaging (MRI) scan followed by open biopsy were performed (Figs. 2 and 3). What is the diagnosis?

Polyostotic Fibrous Dysplasia with Epiphyseal Involvement in Long Bones: A Case Report

Fibrous dysplasia (FD) is an uncommon, but well-known benign skeletal disorder. In cases affecting long bones, FD is commonly recognized to locate in the diaphyses or the metaphyses and to spare the epiphyses. In this paper, we present a rare case of polyostotic FD in a 13-year-old girl with unilateral multiple epiphyseal lesions arising in the femur, the tibia, and the fibula with the growth plates.

A systematic approach to magnetic resonance imaging evaluation of epiphyseal lesions

Magnetic Resonance Imaging (MRI) is the preferred modality of choice to image epiphyseal lesions. It provides excellent soft tissue resolution and extent of disease. A wide spectrum of tumor and tumor like lesions can involve the epiphysis. Early and accurate diagnosis as well as appropriate management of epiphyseal lesions is critical as these conditions may lead to disabling complications such as, limb length discrepancy, angular or joint surface deformities and secondary osteoarthritis. In this article, we discuss the role of conventional sequences, such as T1W, fluid sensitive T2W and intravenous (IV) Gadolinium enhanced sequences as well as the additional value of problem solving MRI sequences such as, chemical shift and diffusion weighted imaging. Based on the imaging findings on various MRI sequences and lesion characteristics, a systematic approach directed to the diagnoses of epiphyseal lesions is presented and discussed. MRI features of clinically and biopsy proven examples of the epiphyseal lesions, such as osteomyelitis, intra-osseous abscess, infiltrative malignancy, metastases, transient osteoporosis, subchondral insufficiency fracture, avascular necrosis, osteochondral fracture, osteochondritis dissecans, eosinophilic granuloma and geode are demonstrated. Using this systematic approach, the reader will be able to better characterize epiphyseal lesions with a potential to positively affect patient management.

Widespread Osteonecrosis in Children With Leukemia Revealed by Whole-body MRI

Confirmation of early long-bone epiphyseal osteonecrosis in pediatric patients with leukemia allows for medical and surgical intervention before articular surface collapse. MRI detects early osteonecrosis, but multiple focused MR images are required to capture all lesions. We determined whether whole-body MRI (WB-MRI) could (1) assist in diagnosing long-bone epiphyseal and other osteonecroses, (2) characterize articular surface involvement, and (3) detect preferential sites for osteonecrosis. We retrospectively reviewed prospectively collected data on all 11 pediatric patients newly diagnosed with leukemia who had musculoskeletal pain develop that persisted 4 weeks or more during leukemia treatment. All were screened for osteonecrosis by WB-MRI, which consisted of a one-time scan of the entire body. Osteonecrosis was defined as circumscribed lesions with a distinct rim of low signal intensity in the normally high-intensity marrow on T1-weighted images and high signal intensity in the normally low-intensity marrow on short-tau inversion recovery images. WB-MRI confirmed osteonecrosis in nine of 11 patients. All patients had multisite lesions; eight had long-bone epiphyseal lesions, which comprised 66 of 129 (51%) of all lesions. Osteonecrosis involving greater than 50% of the epiphyseal surface was present in 57% of distal femoral and proximal tibial lesions. All humeral and femoral head lesions involved more than 1/3 of the medial surface volume but were asymptomatic. No articular collapse was present. All osteonecrotic lesions were more common in the lower extremities. WB-MRI confirmed early epiphyseal osteonecrosis, with quantification of articular surface involvement. Lower limbs were preferentially affected, but asymptomatic humeral head osteonecrosis was present in five of nine patients. Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Epiphyseal Osteochondromas of the Upper Limb

Originally described as osteochondromatous lesions arising from the tarsal bones, osteochondromas arising from the epiphysis or carpal/tarsal bones are less common than those arising from the metaphysis. Histologically, all osteochondromas are indistinguishable regardless of the location from which they arise. Few case reports and case series exist describing these lesions in the upper limb. We review 7 cases of osteochondromas arising from epiphyses and ossicles in the upper limb treated at 3 institutions. Patients were followed for an average of 5.7 years. The average patient age at the presentation was 7.8 years. We identified 25 lesions: 5 distal radial epiphyseal, 3 distal radial metaphyseal, 4 scaphoid, 4 lunate, 4 trapezial, 2 accessory ossicles adjacent to the trapezium, 2 trapezoid, and 1 metacarpal lesion. Three patients presented with pain, 5 with decreased motion, and 3 with angular deformity. In 1 case, the lesion presented as an incidental finding. Four patients underwent a total of 7 procedures: 2 open biopsies, 2 distal radial epiphyseal lesion excisions, 2 revisions, and 1 excision of all lesions with a scaphoid osteotomy. Intra-articular and transosseous lesions are more likely to result in angular deformities and loss of motion at the joints, whereas juxtaphyseal and transphyseal lesions are more likely to result in growth disturbances and angular deformities at the physis. Case series, level IV.

Treatment of proximal humeral dysplasia epiphysealis hemimelica with custom hemiarthroplasty: a case report

Dysplasia epiphysealis hemimelica is a rare disorder involving alterations in the growth of the epiphyses. It is more frequently encountered in the lower extremity, and shoulder girdle involvement is less common.1,2 Diagnosis is usually made by radiographically identifying epiphyseal lesions of varying size that alter joint size and shape. Often, these lesions progress to limit joint motion and can lead to pain. Presented here is a patient in whom epiphysiodesis failed and who underwent shoulder hemiarthroplasty after humeral head collapse.

Primary epiphyseal localization of primitive neuroectodermal tumor in a child

Primary epiphyseal lesions in children are rare and usually benign, with chondroblastoma being the most typical for this location and age. Very occasionally, malignant bone tumors may occur primary within long bones epiphyses during growth; few reports are given on such single cases in orthopedic and radiological scientific literature. This paper presents a case report on a malignant primitive neuroectodermal tumor affecting primary distal femoral epiphysis in a child, having a benign-looking lytic appearance. Short literature review and discussion on possible differential diagnosis of such lesion is also included.

Fibrous dysplasia around the elbow

First named by Lichtenstein in 1938, fibrous dysplasia is a noninherited, skeletal developmental abnormality that commonly presents in adolescents and young adults. Normal marrow and cancellous bone are replaced and weakened by immature woven bone and a dense fibrotic stroma containing a disorganized matrix of bony trabecular spicules. Fibrous dysplasia accounts approximately for 5% to 7% of benign bone tumors. It may be monostotic, accounting for 70% to 80% of cases, or polyostotic. Fibrous dysplasia frequently occurs in the ribs, femur, tibia, skull, pelvis, spine and shoulder. Within the long bones, the lesions are predominately diaphyseal, with an epiphyseal lesion rarely occurring. Radiographically, they are classically described by their ‘‘ground glass’’ appearance because they are well circumscribed, radiolucent lesions with a hazy quality to them. These lesions compromise the structural integrity of the involved bone and may lead to a bowing deformity in weight-bearing bones, hence the ‘‘shepherds crook’’ deformity describing coxa vara in the femur. Surgical treatment of fibrous dysplasia is palliative, the main goals being to limit pain and deformity and prevent pathologic fracture. Fractures through a lesion often heal without difficulty but are susceptible to repeat fracture because of the dysplastic nature of the bony callus that forms. Indications for surgery include nonunion, progressive deformity, or persistent pain. Surgical options include curettage and bone grafting (either cortical or cancellous), open reduction and internal fixation (ORIF), and vascularized bone grafts.