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Osteochondroma of the Proximal Humerus with Frictional Bursitis and Secondary Synovial Osteochondromatosis

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Osteochondroma of the Proximal Humerus with Frictional Bursitis and Secondary Synovial Osteochondromatosis JBR–BTR, 2015, 98: 45-47. OSTEOCHONDROMA OF THE PROXIMAL HUMERUS WITH FRICTIONAL BURSITIS AND SECONDARY SYNOVIAL OSTEOCHONDROMATOSIS J. De Groote1,2, B. Geerts1,2, K. Mermuys1, K. Verstraete1,2 We report a case of multiple hereditary exostosis in a 33-year old patient with clinical symptoms of pain and impression of a growing mass of the left shoulder alerting potential risk of malignant transformation of an osteo- chondroma. Imaging studies illustrated perilesional bursitis surrounding an osteochondroma of the proximal humerus. Malignant transformation was excluded with MRI. Fragments of the osteochondroma were dislocated in the inflammatory synovial bursa illustrating a case of secondary synovial osteochondromatosis. Key-word: Osteochondroma. Case report A 33-year-old man was referred by his general practitioner to the de- partment of orthopaedic surgery with persisting pain and impression of a growing mass of the left shoul- der. The patient had a medical histo- ry of osteochondromas of the knee and pelvis in the context of Multiple Hereditary Exostosis (MHE). One le- sion has previously been resected because of high risk for malignant transformation. There was no recent history of trauma. Clinical inspection of the left shoulder girdle illustrated a soft tis- sue swelling medial from the proxi- mal humeral diaphysis. Clinical ex- amination showed a general painful shoulder mobility and minimal loss of range of motion with active endo- and exorotation. A B Conventional imaging of the left Fig. 1. — Conventional radiography of the left shoulder. A: AP view in neutral posi- shoulder showed a well defined tion: osteochondroma of the medial side of the proximal humerus. The lesion shows a bony lesion extending from the pattern of rings and arcs to confluent calcifications. An accessory bone fragment (ar- proximal humeral metaphysis to di- row) projecting over the axillary soft tissues associated with a surrounding soft tissue aphysis with a pattern of chondroid component. A smaller isolated loose fragment is located close to the inferomedial bor- matrix mineralisation suggesting an der of the primary lesion (arrowhead). B: AP view in exorotation: superposition of the osteochondroma. Accessory bone isolated bone fragment and the superomedial border of the osteochondroma (arrow). Small focal hyperdensities are located inferior to the lesion associated by a surround- fragments were located in the sur- ing soft tissue mass (arrowhead). rounding axillary soft tissues (Fig. 1). Further assessment of the lesion was done by MRI (fig. 2) Illustrating an osteochondroma surrounded by a thin walled fluid collection postero- medial. Cystic wall and surrounding soft tissue enhancement post con- The diagnosis was made of ‘exos- The patient was successfully treat- trast injection suggested the diagno- tosis bursata’: frictional bursitis ed with bursectomy and resection of sis of frictional bursitis. The bone secondary to an osteochondroma. the osteochondroma with relief of fragments illustrated on radiography Osteochondral fragments of differ- his discomforts. were situated in this bursa and ent shape and size became separat- showed a similar pattern of chon- ed from the primary osteochondral Discussion droid mineralisation suggesting lesion and migrated into the bursa these are primary originating from resulting in a secondary form of the osteochondroma. synovial osteochondro matosis. An osteochondroma is defined as a hyaline cartilage capped lesion of cortical and medullary bone arising on the external surface of a primary or parental bone. Continuity of le- From: 1. Department of Radiology, AZ Sint Jan, Brugge, 2. Department of Radiology, sional cortex and medullary canal UZ Gent, Ghent, Belgium. Address for correspondence: Dr J. De Groote, Department of Radiology, UZ Gent, De with the underlying bone is pathog- Pintelaan 185, 9000 Gent, Belgium. E-mail: [email protected] nomonic for osteochondromas (1). de groote-.indd 45 19/02/15 15:57 46 JBR–BTR, 2015, 98 (1) The lesion is usually located at the metaphysis of a long bone, most frequently in the distal femur but any bone developing from preformed cartilage may be involved (1). The hyaline cartilage is difficult to assess on conventional radiography but may be suggested by the identifi- cation of rings and arcs or flocculent calcifications as the result of chon- droid mineralisation (1, 3). MRI may also demonstrate corti- A ▲ cal and medullary continuity and is D considered the best imaging modal- ity to evaluate cartilage cap thick- ness and its surrounding soft tissues. The high water content of the hya- line cartilage cap creates an interme- diate to low signal on T1-weighted sequences and a high signal on T2- weighted sequences. Mineralised portions in the cartilage cap remain low in signal on all MR pulse se- quences (2). Thickness of the hyaline cartilage cap is the most important imaging E finding considering the risk of malig- Fig. 2. — MRI of the left shoulder. nant transformation to a secondary A: Axial T1 shows low intensity soft tis- chondrosarcoma. Cartilage cap sue component surrounding the osteo- thickness of more than 15 mm in a B chondroma with an isolated bone frag- skeletal mature patient should be ment (arrow) located in this soft tissue considered with great suspicion (1). component. B,C: coronal STIR demon- Other signs of malignant transfor- strates hyper-intense synovial fluid col- mation include growth of a previ- lection (horizontal arrow) surrounding ously unchanged osteochondroma the osteochondroma and extending pos- in a skeletal mature patient, irregular terior of the proximal humerus, contain- ing an isolated bone fragment (arrow- lesion surface, focal interior radiolu- head). D: on axial STIR, the posterobasal cencies, erosion or destruction of ad- facet of the lesion is peripherally sur- jacent bone and surrounding soft tis- rounded by a hyper-intense rim (arrow- sue mass formation containing head) representing the residual hyaline irregular calcifications (1, 2, 4-6). cartilage rim surrounded by a hypo-in- Osteochondromas usually are as- tense perichondrium. The cartilage rim ymptomatic but may show compli- has a maximal thickness of 4 mm. Central cations varying from cosmetic defor- ▲ hypo-intensities represent calcific chon- mity, fracture, vascular or neurogenic droid mineralisation of hyaline cartilage, compression, bursa formation and low in intensity on all MR pulse sequenc- es (arrow). E: axial T1 TSE + Gd shows malignant transformation (1). contrast enhancement of the thin lined Anatomically an inconsistent bur- wall of the fluid collection representing a sa is located in the axilla in between C synovial bursa and surrounding soft tis- the inferior angle of the scapula and sues anterolateral of the cranial segment the superior fibers of the latissimus of the latissimus dorsi muscle (arrow). dorsi muscle, more posterosuperior- ly a bursa is located between the ser- ratus anterior and the subscapularis muscle (5). Bursa neoformation be- tween an osteochondroma and the Osteochondromas are the most secondary enchondral ossification perilesional soft tissues has been de- common benign bone tumors (20- (maturation). Osteochondromas scribed as “exostosis bursata”, a re- 50%) or bone tumors in general (10- usually show a growth pattern sult of mechanical impingement 15%) (1, 2). The majority are solitary, similar to a normal physeal plate un- upon the adjacent muscles and ten- non hereditary (85%) but lesions can til skeletal maturity (2). Imaging dons (1, 4). Bursae are lined by also be multifocal in the context of characteristics of an individual os- synovium and may become symp- HME, a disorder inherited in an auto- teochondroma in HME is identical to tomatic due to inflammation, infec- somal dominant manner (1, 2). solitary lesions. tion or haemorrhage. Clinically, bursa Development of an osteochondro- An osteochondroma has the typi- formation may present as a painful ma results from separation and cal radiographic appearance of a le- growing perilesional mass, simulat- dislocation of an epiphyseal growth sion consisting of cortical and med- ing malignant transformation (1). plate fragment with persistent ullary bone continuous with the In rare cases chondral or fibrin growth of the cartilage fragment and underlying parental bone. fragments may be dislocated from de groote-.indd 46 19/02/15 15:57 OSTEOCHONDROMA OF THE PROXIMAL HUMERUS — DE GROOTE et al 47 the osteochondroma into the bursa frictional bursitis, clinically present- and Pathological Features. In Vivo, resulting in chondro-metaplasia in ing with symptoms of pain and a 2008, 22: 633-646. the synovial lining and secondary growing mass, mimicking malignant 3. Murphey M.D., et al.: From the formation of multiple chondroid transformation. We illustrated a case Archives of the AFIP: Imaging of bodies as in primary synovial osteo- of exostosis brusata with fragments Synovial Chondromatosis with Radiologic-Pathologic Correlation. chondromatosis (1, 4). of the primary osteochondroma dis- RadioGraphics, 2007, 27: 1465-1488. Secondary synovial osteochondro- located in the surrounding bursa as 4. Peh W.C.G., et al.: Osteochondroma matosis is a more common finding the result of friction with secondary and secondary synovial osteochon- in which several osteochondral bod- synovial osteochondromatosis. dromatosis. Skeletal Radiology, 1999, ies of different shapes and sizes are 28: 169-174. seen in a synovial fluid collection (3). References 5. Shackcloth M.J., Page R.D.: Scapular osteochondroma
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