The patient arrived to radiology on August 5, 2012. The patient was a 10 year old hispanic male whom presented to the hospital with pain in his right ankle. Prior to coming into the radiology department he had fallen on a play structure at his school. Immediately after his fall he was brought to the hospital by his parents. As a result the patient was x-rayed on August 5, 2012. An ankle complete series was performed which consisted of an AP, Oblique, and Lateral view. However, due to his age comparison films were also taken of his left ankle which consisted of only an ap and lateral. According to the radiology report from the images obtained the patient was said to have a non-ossifying fibroma in his right distal tibia metaphysis region. The recommendation following his visit from the radiologists was for the patient to be seen again for a followup in six months. On March 1, 2013 the patient returned to the department for his 6 month followup. Since the patient was being seen for a followup on this visit instead of for trauma like his initial visit, only three images were obtained. An AP, Oblique, and Lateral view of only his right ankle. According to the radiology reports from this visit the patient still was said to have a non ossifying fibroma on his right lower leg/ankle. A non-ossifying fibroma is a benign, non-aggressive tumor. It is non cancerous and is mainly composed of fibrous tissue. (Boston Children's Hospital, 2011) Non-ossifying fibromas are composed histologically of whorled bundles of fibrous connective tissue and giant cells. More commonly non-ossifying fibromas are found in children and adolescents. (Kalish, S., Lebman, B., LaVoice, M., 2013) Generally, there are minimal to no symptoms associated with non-ossifying fibromas. (Boston Children's Hospital, 2011) In fact, the lesions associated with non-ossifying fibromas are more likely found accidentally on x-rays. The prevalence of occurrence in male versus female for non-ossifying fibromas are twice more often for males than in females. According to research, it has been estimated that 30-40 percent of people 20 years of age and younger have non-ossifying fibroma’s. However, although many people will have non-ossifying fibroma’s, studies show that few of these people will have any symptoms. Non-ossifying fibroma’s do not become cancerous and they do not metastasize. However, there is an approximate 8 percent of people with non-ossifying fibroma that will have more than one tumor. (2) Smaller non-ossifying fibromas generally are asymptomatic. These smaller lesions are usually found incidentally in children. On the other hand, larger lesions are uncommon. Nonetheless, the larger lesions can be associated with pathological fractures leading to pain and swelling. (Kalish, S., Lebman, B., LaVoice, M., 2013) There are several exams done in different imaging modalities to find non-ossifying fibromas. The diagnostic procedures for non-ossifying fibroma’s are used to determine the exact type of tumor present and whether or not the tumor has spread. X- rays are used to produce images of internal tissues, bones and organs onto film. (1) On an x-ray image, the tumor will appear dark with a thin surrounding white rim.(2) Another modality that is used is CT and MRI. These two modalities have the ability to capture a more detailed view of the body. (Boston Children's Hospital, 2011) In addition, a CT scan or MRI can show the exact size of the tumor. It can also show if there has been any change in the appearance over time. Furthermore, the images form these modalities can also show cortical integrity, or in other words how thin the strong outer portion of the bone is in the region of the non-ossifying fibroma, or pathologic fracture. Generally, a bone scan is sometimes more helpful and preferred than general x-ray because it allows the ability to see if there is more than one tumor. (2) Aside from imaging modalities used to diagnose non-ossifying fibromas physical exams can be done as well. Although this is very uncommon it is an alternative and is sometimes done. Generally the physical exam is done in combination with one of the three imaging modalities of choice; x-ray, CT, or MRI. If a physical exam is done it would also include a neurologic function tests to measure reflexes, muscle strength, eye and mouth movement, coordination and alertness. Treatment options for people with non-ossifying fibromas can vary. Typically these tumors resolve on their own. This occurs usually when skeletal maturity has occurred or when the bones stop growing. The tumor is only a problem if it causes a fracture while active. Yet, the good thing is once the tumor has resolved itself it rarely comes back. Thus, the primary reason to treat a non-ossifying fibroma is to avoid a fracture, especially in very athletic children. If a fracture exists or the tumor has weakened the bone, the doctor may make a decision to operate. For fractures, the operation is generally put off until the fracture heals. Sometimes the doctor might find it necessary to surgically place metal rods and pins to fix a broken bone. The two types of procedures to treat a non-ossifying fibroma are curettage and bone grafting. According to the medical dictionary curettage is the removal of tissue or growths from the interior of a body cavity by scrapping with a curette. (Merriam-Webster, 2011) Bone grafting is a surgical procedure by which new bone or replacement material is placed into spaces between or around broken bone or holes in bones to aid in healing. (Merriam-Webster, 2011) During this operation for non-ossifying fibromas, the cyst is scraped out of the bone with a special instrument called a curette. This instrument has a scoop, loop or ring at its tip. The remaining cavity is then packed with donor bone tissue (allograft), bone chips taken from another bone (autograft), or other materials. (Boston Children's Hospital, 2011) Generally, the bone graft can be held in place with pins, plates, or screws. In order to close the wound after surgery, stitches are used. Additionally, a splint or cast is usually used to prevent injury or movement while healing. (Vorvick, 2012) The most common risks associated with the curettage and bone graft procedure for non-ossifying fibromas include; reactions to medication, problems breathing (while in surgery), bleeding, infection, and pain at the site of injury or surgery. (Vorvick, 2012) Morbidity from non-ossifying fibromas are very uncommon. This may be due to the fact that they are benign, non-cancerous, non-aggressive tumors. The only complication that has been known to result from non-ossifying fibromas are fractures at the site of the tumor. However morbidity can occur as a result of the curettage and bone graft procedure associated with treatment of non-ossifying fibromas. Anytime a person goes under for surgery there is always a risk that death can result from other complications related to the process of surgery.
References:
American Academy of Orthopedic Surgeons (AAOS) May, 2011. Non- Ossifying Fibroma. Retrieved from; http://orthoinfo.aaos.org/topic.cfm?topic=A00603
Boston Children's Hospital (2011). Non-Ossifying Fibroma. Retrieved from; http://www.childrenshospital.org/az/Site1083/mainpageS1083P0.html
Kalish, S., Lebman, B., LaVoice, M. (2013) Non-Ossifying Fibroma Leading to Tibial Fracture. Chapter 47, Pg 242-244. Retrieved from; http://www.podiatryinstitute.com/pdfs/update_1995/1995_47.pdf
