Physiotherapeutic Approach for Osteochondroma of 4 And 5 Ribs-A Case Report

The most frequent benign bone tumor is osteochondroma, which account for 45 percent of all benign bone tumours. Although not a real neoplasm, osteochondroma (exostosis) is the most common lesion and is often classed as a tumour. The majority of them develop in the metaphyseal region of long bones like the femur and tibia. A 21-year-old female presented to the orthopedic OPD with complaints of pain and swelling over dorsal spine since 2 years with left upper limb radiculopathy since 1 month. Pain was insidious in onset which started 1 month back and it aggravated ever since. On inspection swelling present over paraspinal region of approximately 5cm in length and 4cm in width. On palpation swelling was not adherent to skin, immobile and firm in consistency. Osteochondroma represent the most common bone tumor accounting for 20 to 50% of all benign osseous tumors. In osteochondroma maintaining mobility is important for activities of daily living and to maintain the quality of life. Physiotherapy plays a significant role in maintaining the mobility and improving the quality of life.


INTRODUCTION
The most frequent benign bone tumor is osteochondroma, which account for 45 percent of all benign bone tumours [1]. Although not a real neoplasm, osteochondroma (exostosis) is the most common lesion and is often classed as a tumour [2]. The majority of them develop in the metaphyseal region of long bones like the femur and tibia [3]. Flat bones and the spine can also develop osteochondroma. A primary chest wall tumour called osteochondroma of the rib is a rare condition. Only 1.5 percent of all osteochondroma are costal osteochondroma. A rib deformity or enlargement with calcification of the cartilaginous cap is the most common appearance. Osteochondroma are most common in children and adolescents, with only a few cases in the elderly. The great majority of these tumours are nonhereditary and appear as a single lesion [4].
Hereditary multiple osteochondroma (HMOs), a condition that is inherited in an autosomal dominant way, account for about 15% of all osteochondroma. Malignant transformation of a single osteochondroma occurs in 1-2 percent of patients, while it occurs in 1 percent to 25 percent of patients with HMO syndrome [5].
Because osteochondroma is frequently asymptomatic, the only clinical symptom is a painless, slow-growing lump on the affected bone. Mechanical irritation of soft tissues, fracture, peripheral nerve or spinal cord compression, damage to blood vessels, internal injury or malignant transformation can all cause symptoms.
Osteochondroma are either pendiculated or sessile, with a significant diameter of 1 to 2 cm with a thin cartilaginous cap.
Osteochondroma occur solely in endochondral ossified bones and are thought to be caused by the lateral section of the growth plate being displaced, which subsequently spreads out from the surrounding joint diagonally to the long axis of the bone [6]. We report the case of a 21-year-old woman who complained of pain over dorsal spine and left upper limb radiculopathy due to osteochondroma of the fourth and fifth left ribs. The appropriate indication for surgery as well as the possible complications are discussed.

PATIENT INFORMATION
A 21-year-old female presented to the orthopedic OPD with complaints of pain and swelling over dorsal spine since 2 years with left upper limb radiculopathy since 1 month. Pain was insidious in onset which started 1 month back and it aggravated ever since. Pain is then associated with tingling and numbness in left upper limb. Swelling had increased gradually over two years with tenderness since past 4 months. The patient's BMI was 22.22. She was right-handed. There was no history of trauma. There was no history of sudden weight lost, fever or any other constitutional symptoms. Patient had taken analgesics for the complaints prescribed by private practitioners. Patient had no significant past history. There was no significant family history.

CLINICAL FINDINGS
After obtaining consent from the patient, she was examined. On inspection swelling present over paraspinal region of approximately 5cm in length and 4cm in width. On palpation swelling was not adherent to skin, immobile and firm in consistency. Tenderness was present over swelling. There was spasm of paraspinal muscle. HRCT Thorax showed irregular heterogenous bone density lesion in 4 th -5 th intercoastal space seen arising from neck of 4 th and 5 th rib. USG suggested calcified mass in paraspinal region. Fine needle aspiration cytology from swelling suggested chondrocytes admixed with fat cells and muscle fibres.

Phase 1 (0-4 Weeks)
The primary physiotherapy goal was to maintain mobility, reduce tingling and numbness.
To maintain the mobility of joint, active upper limb range of motion exercises were performed including shoulder flexion, extension, abduction, adduction initially the exercises were performed in gravity eliminated plan progressed to g=antigravity plan 10 repetitions were performed 3 times a day. Chest expansion exercises including thoracic expansion exercises were given in which the patient keeps his/her hand in a crossed way where right hand holds left shoulder and left hand holds right shoulder and the patient is asked to deep breath it is repeated 07 times in one set and 3 set per day. Transcutaneous electrical nerve stimulation for 7 minutes in sweep pattern.

Phase 2 (5 to 8 Weeks)
In second phase the goal is to maintain the mobility and increase the strength and cardiovascular endurance.
To increase the strength of upper limb resistance band exercises were given .Initially the exercises were started with yellow resistance band progressed to red resistance band exercises including shoulder flexion, extension, abduction, adduction were given. For cardiovascular endurance light aerobic exercises were given like spot marching, step ups were given. Cycling for 10 minutes with minimum resistance and walking for 10 minutes was given.

DISCUSSION
In this case we present a 21 year old female with osteochondroma of ribs. The primary goal of physiotherapy was to maintain the mobility and to increase the strength and cardiovascular endurance of the patient. The physiotherapy treatment plan included mobility exercises, strengthening exercises with resistance band and aerobic exercises for endurance [7].
Osteochondroma represent the most common bone tumor accounting for 20 to 50% of all benign osseous tumors. Complications associated with osteochondroma are common, including osseous deformities, fracture, and bursa formation with or without bursitis, vascular compromise, neurologic symptoms, and malignant transformation. Mobility is reduced because of the tumor and a role of physiotherapist comes there itself. In this case the osteochondroma is of ribs so, the lung functions are affected as well [8,9]. The goal includes maintaining the lung compliance Costal osteochondroma is a rare but important condition to recognize due to its complications, such as reduced range of movement, pain, cosmetic abnormalities and bursitis. Costal osteochondroma tend to grow into the chest cavity and such lesions are rarely exophytic [10].

CONCLUSIONS
Osteochondroma is a common bone tumor which leads to decreased mobility and complications like deformities fractures and many more. In osteochondroma maintaining mobility is important for activities of daily living and to maintain the quality of life. Physiotherapy plays a significant role in maintaining the mobility and improving the quality of life.

CONSENT
The procedure was explained to the patient in patient's language. Informed consent was obtained from the patient.