Pathological Fracture of Calcaneum: A Case Report

What to Learn from this Article?

Careful history and the examination will lead to proper investigation and from there to proper diagnosis and treatment.


Case Report | Volume 6 | Issue 4 | JOCR September-October 2016 | Page 92-95 | K Salauddin Arif, S Anoop, Sandeep Ravindran. DOI: 10.13107/jocr.2250-0685.588


Authors: K Salauddin Arif[1], S Anoop[1], Sandeep Ravindran[1]

[1]Department of Orthopaedics, Yenepoya Medical College Hospital, Deralakatte, Mangalore, Karnataka, India.

Address of Correspondence
Dr. S Anoop,
Department of Orthopaedics, University Road, Deralakatte, Mangalore – 575 018, Karnataka, India.
E-mail: anoopsuresh88@gmail.com


Abstract

Introduction:

Aneurysmal bone cysts are blood filled fibrous tumour like cysts that expand the bone giving it a blown out appearance. It is usually seen in the second decade. Aneurysmal bone cysts were first described by Jaffe and Litchensen in 1942. The exact aetiology is unknown. One of the most widely accepted idea was that aneurysmal bone cyst was a consequence of increased venous pressure and subsequent dilatation and rupture of local vascular network. However, studies by Panoutsakopoulus et al and Olivia et al uncovered the clonal neoplastic nature of aneurysmal bone cysts. Here we report a case of aneurysmal bone cyst of calcaneum which is one the rarest site.
Case Report: A 25 year old male presented with a history of trivial fall from a ladder and landing on right heel. He complained of pain and swelling. On examination, he had swelling over the medial aspect of right heel. Skin over the swelling was stretched and it was soft in consistency and tender. Curettage and bone grafting was done. Patient was pain free and was bearing weight fully on the operated limb, 12 weeks post operatively.
Conclusion: Aneurysmal Bone Cyst of calcaneum although seen rarely, should be considered as one of the differential diagnosis in the cystic lesions in calcaneum. Curettage and bone grafting has stood the test of time as standard treatment.
Keywords: Aneurysmal bone cyst; bone grafting; benign bone lesions; calcaneus; curettage.


Introduction

Aneurysmal bone cyst is an osteolytic bone neoplasm characterized by several sponge-like bloods or serum filled, generally non-endothelized spaces of various diameters [1]. It is rarely seen in bones of feet. Controversy exists regarding optional treatment. Regardless of techniques reported the recurrent rates ranges from 5% to greater than 40% [2-8]. At present curettage and bone grafting or insertion of Polymethyl methacrylate are the principal techniques, [2-9] but in the past radiation has been used [10]. In several other trials, sclerosing substances, bone substitutes and other agents seemed to be less effective than conventional curettage. Primary etiology probably is arteriovenous fistula within the bone [11].

Case Presentation
A 25 year old male presented with a history of trivial fall from a ladder (5 feet) and landing on right heel. He complained of pain and swelling. On examination, he had swelling over the medial aspect of right heel (Fig.1). Skin over the swelling was stretched and it was soft in consistency and tender. No relevant past history and family history in view of bone cyst and malignancy. No evidence of any risk factors.
Radiograph of right ankle revealed an eccentric, expansile, cystic lesion of the calcaneum with thin septae traversing the cystic cavity giving it a blown out or soap bubble appearance. There was a cortical breach suggesting fracture (Fig 2). In our case we avoided CT/MRI due to the expense and we proceeded with biopsy and histopathological examinations, which is more informative.fig-1-2
Patient underwent two staged procedure,first for biopsy followed by second procedure after confirmation by histopathological examination.
Under strict aseptic precautions, biopsy was done under anaesthesia. The specimen was sent for histopathological examination and it was diagnosed by Pathologist as Aneurysmal Bone Cyst.
A differential diagnosis of aneurysmal bone cyst or giant cell tumour with pathological fracture was made. Under spinal anaesthesia and strict aseptic precautions, the lesion was curetted and the cavity was filled with iliac bone grafts (Fig 3, 4). fig-3-4-5The curetted specimen was sent again for histopathological examination and the diagnosis was confirmed (Fig 5). The wound was closed, dressed and below knee posterior plaster slab was applied.
Post-operatively a non weight bearing crutch walking was allowed for 6 weeks followed by partial weight bearing for further 4 weeks. Follow up was done on 3rd and 6th month of post op (Fig 6, 7). Patient returned to his activities at the end of 6 months and we are still continuing the follow up, because the recurrence usually happens within 1 year.fig-6-7

Discussion
An aneurysmal bone cyst of calcaneum is a rare entity. Females are affected more often than males in the ratio of 1.04:1 [12]. The frequency of occurrence of aneurysmal bone cyst in various bones is as follows: [13, 14]
• Long bones: 50-60%, typically of the metaphysis
• Lower limb: 40%
• Tibia and fibula: 24%.
• Femur: 13%.
• Upper limb: 20%
• Spine and sacrum: 20-30%
• Foot 3%

Aneurysmal Bone Cyst of calcaneum comprises only about 1.6 % of the total aneurysmal bone cysts reported over the body [15].The various cystic lesions that can affect calcaneum include non neoplastic cysts, benign or malignant neoplastic lesions ranging from simple bone cyst, aneurysmal bone cyst, chondroblastoma, giant cell tumour, and osteosarcoma especially telangiectatic variety.Although often primary, up to a third of ABCs are secondary to an underlying lesion (e.g chondroblastoma, fibrousdysplasia, giant cell tumour , osteosarcoma)[16].Although radiographs are commonly employed to diagnose Aneurysmal Bone Cysts, CT scans and MRI has a role in diagnosis. CT helps in diagnosing whether it’s a primary or secondary.If it is a secondary aneurysmal bone cyst then CT scan will help us to identify the primary pathology. MRI might show the fluid levels because of blood. When biopsy is performed, the entire sample must be sent for histopathological examination because the primary diagnosis might be missed if we send limited samples, especially in case of secondary aneurysmal bone cyst. Other modalities of treatment employed are liquid nitrogen, phenol instillation [1] and filling the defect with bone graft or poly methyl methacrylate cement (PMMA). Advantages of bone grafting is readily available in the host;it is more biological compared to poly methyl methacrylate cement ;complications like infection which possibly could have occurred while using poly methyl methacrylate cement can be avoided. Here we treated with curettage and bone grafting because of the readily availability and its biological. Surgical curettage is sufficient to treat most ABCs of the feet, including the calcaneum. [17]
Recurrence usually happens within 1st year after surgery and almost all episodes occur within 2 years. Therefore a patient of aneurysmal bone cyst needs to be observed for at least this period of time to exclude any recurrence.

Conclusion

Aneurysmal Bone Cyst of calcaneum although seen rarely, should be considered as one of the differential diagnosis in the cystic lesions in calcaneum. Curettage and bone grafting has stood the test of time as standard treatment.

Clinical Message

Any patient presenting with unilateral heel pain should be subjected to at least radiological examination during their first visit, instead of labelling them as plantar fasciitis. The cause for heel pain could be a benign lesion or a malignant lesion as mentioned above. Management protocol varies from lesion to lesion. Further, early diagnosis can lead to early treatment and hence subsequent complications of late treatment can be avoided especially in aggressive bone tumors.

References

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How to Cite This Article: Arif KS, Anoop S, Ravindran S. Pathological Fracture of Calcaneum: A Case Report. Journal of Orthopaedic Case Reports 2016 Sep-Oct;6(4): 92-95. Available from:http://www.jocr.co.in/wp/2016/10/10/2250-0685-588-fulltext/

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