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Orthopaedic Surgery - Hemangioma

Basics

Hemangioma is a benign vascular lesion that may arise within bone or soft tissue.

In orthopaedic practice, these lesions may involve the axial or appendicular skeleton as well as the surrounding soft tissues.

Many lesions historically labeled hemangiomas, particularly in soft tissue, are now more precisely categorized according to modern vascular-anomaly terminology, but the term remains widely used in musculoskeletal literature.

Age

Hemangiomas can occur at any age, although osseous lesions are most commonly diagnosed during the middle decades of life.

Epidemiology

Hemangiomas are relatively uncommon as symptomatic orthopaedic lesions.

No major difference in prevalence between males and females has been consistently demonstrated.

Risk Factors

No specific environmental or acquired risk factors are known.

Genetics

There is no established hereditary pattern for the typical musculoskeletal hemangioma.

Etiology

The exact cause is unknown.

These lesions are considered benign and nonmetastatic.

Some pathologists regard certain vascular lesions of this type as hamartomatous malformations rather than true neoplasms.

Diagnosis

Signs and Symptoms

Clinical presentation depends on whether the lesion involves bone or soft tissue.

Osseous Hemangioma

A bone lesion may present with a slowly progressive, poorly localized ache or localized swelling.

Many lesions are asymptomatic and found incidentally.

Occasionally, weakening of the involved bone may lead to a pathologic fracture.

Vertebral Hemangioma

Vertebral hemangiomas are commonly incidental findings.

More aggressive lesions can rarely produce vertebral expansion, collapse, epidural extension, pain, or neurologic compromise.

Soft-Tissue Hemangioma

Soft-tissue vascular lesions often present with intermittent swelling, fullness, or a soft mass.

Pain may be absent or mild.

Symptoms and size may fluctuate depending on limb position and venous filling.

Physical Examination

Soft-tissue lesions may feel soft, compressible, fluctuant, or springy on palpation.

Examination is often most informative when the affected limb is placed in a dependent position.

Positional Enlargement

Because the lesion contains vascular channels that fill with blood, it may enlarge when the extremity is dependent and partially collapse with elevation or compression.

After palpation, the lesion may refill gradually.

Laboratory Tests

There are no specific serum laboratory studies that establish the diagnosis of a hemangioma.

Laboratory tests are obtained only when another diagnosis is being considered.

Imaging

Soft-Tissue Lesions

Plain radiographs may be normal or may show indirect evidence of a vascular lesion.

Some lesions produce erosion or remodeling of adjacent bone.

Phleboliths

Rounded calcified thrombi, known as phleboliths, may be visible within soft-tissue vascular lesions.

They are seen in a substantial minority of cases and strongly support a venous vascular lesion when present.

MRI

MRI is the preferred modality for defining the extent and internal characteristics of a soft-tissue vascular lesion.

Gadolinium-enhanced imaging is particularly useful.

MRI Appearance

Typical findings may include serpiginous vascular channels with contrast enhancement.

Lesions may contain substantial fat, producing high signal on T1-weighted images.

Blood-filled vascular spaces and slow-flow components may also produce high signal on fluid-sensitive or T2-weighted sequences.

Osseous Hemangioma

Bone hemangiomas may be solitary or multiple.

They are often expansile and trabeculated and generally produce little or no aggressive periosteal reaction.

Vertebral Radiographic Appearance

A classic vertebral hemangioma demonstrates thickened vertical trabeculae.

On radiographs this produces a “corduroy” or vertically striated appearance.

CT Appearance

Axial CT may show thickened trabeculae seen end-on, creating the characteristic “polka-dot” appearance.

Other Radiographic Patterns

The imaging appearance can vary considerably.

Lesions may appear:

Trabeculated, expansile, “soap-bubble,” osteopenic, or predominantly lytic.

The absence of an aggressive periosteal response and the presence of characteristic internal trabeculation can help suggest the diagnosis.

Pathological Findings

Grossly, these lesions may appear markedly vascular and bloody.

Residual or thickened trabecular bone often passes through the lesion.

Microscopy

Histologic examination typically shows numerous thin-walled vascular channels containing red blood cells.

Depending on the lesion type, channels may be capillary-sized or larger.

Lymphatic channels may also be prominent in some vascular malformations.

Differential Diagnosis

Important considerations include:

Multiple myeloma, infection, simple or aneurysmal bone cyst, primary malignant bone tumor, and metastatic disease.

Other vascular tumors or malformations may also need to be distinguished histologically and radiographically.

Treatment

General Principles

Most asymptomatic osseous hemangiomas do not require treatment.

Management is determined by symptoms, location, structural risk, neurologic involvement, and diagnostic certainty.

Soft-Tissue Lesions

Soft-tissue vascular lesions may recur after surgical excision, particularly when they are diffuse or infiltrative.

For this reason, surgery is avoided when an effective less invasive treatment is available.

Compression

Compression garments or dressings may reduce swelling and discomfort in selected superficial or low-flow lesions.

Sclerotherapy

Image-guided sclerotherapy is commonly used for appropriate symptomatic venous malformations.

Agents vary by lesion characteristics and specialist preference.

Historically, alcohol has been used as a powerful sclerosant, although treatment requires experienced interventional specialists because significant complications are possible.

Osseous Lesions

Hemangiomas of bone rarely require surgical treatment when they are asymptomatic and structurally stable.

Observation is usually appropriate.

Physical Therapy

Physical therapy has no direct role in treating the vascular lesion itself.

It may occasionally be used for rehabilitation when weakness or functional limitation results from associated surgery or fracture.

Surgery

Surgery should generally be reserved for selected situations, such as:

Diagnostic uncertainty requiring biopsy, pathologic fracture, structural compromise, progressive neurologic deficit, severe refractory symptoms, or failure of other treatments.

Biopsy

Biopsy of a suspected vascular lesion requires careful planning because these tumors may bleed significantly.

The imaging appearance should be reviewed thoroughly before biopsy, and the procedure should be coordinated with an experienced musculoskeletal tumor team when diagnosis is uncertain.

Follow-Up

Prognosis

The overall prognosis is excellent because typical hemangiomas are benign and lack metastatic potential.

Recurrence

Local recurrence may occur, particularly in incompletely treated soft-tissue lesions.

Recurrence does not imply malignant transformation.

Complications

Pathologic Fracture

An osseous lesion that substantially weakens bone may rarely produce a pathologic fracture.

Neurologic Compromise

Aggressive vertebral lesions can occasionally cause spinal canal compromise and neurologic deficits.

Bleeding

Because these lesions are vascular, operative or biopsy procedures may be complicated by substantial hemorrhage.

Patient Monitoring

Most stable bone lesions require only observation unless symptoms, fracture risk, or structural changes develop.

Soft-tissue lesions may be followed with serial clinical examinations and MRI, particularly when symptoms or size are changing.

Follow-up intervals such as every 3–6 months initially may be appropriate for symptomatic or recently treated lesions, with longer intervals once stability is established.