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Presented by Edward McCarthy, M.D. and prepared by Jon Davison, M.D.
Case 3: A 20-year old man had pain in his ankle for 2 months.
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1. Question
Week 221: Case 3
A 20-year old man had pain in his ankle for 2 months. The pain was worse with activity. A radiograph demonstrated a fuzzy area of radiodensity in his distal tibia associated with a periosteal reaction.images/JMD_5-15-05_SPWC/Case_3/1.jpg
images/JMD_5-15-05_SPWC/Case_3/2.jpg
images/JMD_5-15-05_SPWC/Case_3/3.jpg
images/JMD_5-15-05_SPWC/Case_3/4.jpgCorrect
Answer: Stress fracture
Histology: none provided
Discussion: Histologically a stress fracture shows typical characteristics of a fracture callus with granulation tissue, new bone formation, and hyaline cartilage that is undergoing endochondrial ossification. Examination of multiple areas will show a zonal pattern. Stress fractures are frequently misdiagnosed as more ominous lesions. A key feature in the clinical history is that of pain on activity.
The lesion is not an osteosarcoma. Osteosarcomas have are very cellular and pleomorphic with abnormal mitotic figures. Although the callous of the stress fracture can be cellular and show mitoses, abnormal mitoses are never present.
The lesion is not an osteoid osteoma. Stress fractures may indeed be confused with osteoid osteomas if they have been chronic. The intense periosteal reaction can mimic that seen in osteoid osteoma. A CT scan is often necessary to find a nidus of osteoid osteoma. This case does not show discreet nidus with benign osteoblasts producing neoplastic osteoid.
Incorrect
Answer: Stress fracture
Histology: none provided
Discussion: Histologically a stress fracture shows typical characteristics of a fracture callus with granulation tissue, new bone formation, and hyaline cartilage that is undergoing endochondrial ossification. Examination of multiple areas will show a zonal pattern. Stress fractures are frequently misdiagnosed as more ominous lesions. A key feature in the clinical history is that of pain on activity.
The lesion is not an osteosarcoma. Osteosarcomas have are very cellular and pleomorphic with abnormal mitotic figures. Although the callous of the stress fracture can be cellular and show mitoses, abnormal mitoses are never present.
The lesion is not an osteoid osteoma. Stress fractures may indeed be confused with osteoid osteomas if they have been chronic. The intense periosteal reaction can mimic that seen in osteoid osteoma. A CT scan is often necessary to find a nidus of osteoid osteoma. This case does not show discreet nidus with benign osteoblasts producing neoplastic osteoid.
