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shoulder, humerus, upper arm

A 10 year old boy with pain in the left clavicle

Case Identification
Case ID Number: 
20100422LC
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 10 year old male had pain in the left shoulder for six months. An initial radiograph was interpreted as showing a non-displaced fracture. A slight fever was noticed which diminished after treatment with antibiotics.

Radiological findings:: 
The initial radiograph was interpreted as showing a non-displaced fracture. After the symptoms continued, a new radiograph was performed, which showed marked changes in the left clavicle.
Laboratory results:: 
On admission the patient's temperature ws 37.5°C. His WBC was 8.5 (4.5 - 9.5) with a normal differential. His electrolytes and liver function tests were normal, and the alkaline phosphatase was 738 (up to 740). The erythrocyte sedimentation rate was 52 (up to 15) and the protein C was 0.72 (up to 0.5). On examination his clavicle was enlarged and slightly tender. There were no neurovascular or cutaneous abnormalities. The motion of the left upper extremity was unimpaired.
Differential Diagnosis: 
Construct a differential diagnosis that has at least three entities; including a benign tumor, a malignant tumor, and a non-tumorous condition.
Image Reference: 

A 10 year old girl who fell during soccer

Case Identification
Case ID Number: 
20090727GF
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

An ten year old girl presented to her primary care physician with pain after a fall in a soccer game. The initial radiograph is shown at left as the main image.

Radiological findings:: 
Two weeks later she was seen in the orthopedic oncology clinic. New radiographs were taken, shown at left. A followup was arranged for four weeks later. The third radiograph is shown at left.

A 25 year old pilot with arm pain

Case Identification
Case ID Number: 
20111227PA
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This healthy male was treated for an expansile lesion of the left humeral diaphysis at age 13. At age 25, pain recurred, and xrays show a large new lesion with weakening of the bone.

Radiological findings:: 
Xrays from the three episodes of treatment are shown, with the most recent xrays shown last. In 1999 at age 12-13 there was an expansile lesion with an incomplete pathological fracture, and bright signal on MRI. Hydroxyapatite cement was used to fill the lesion. In 2006 xrays showed the HA graft material was still present, there was no expansion of the bone or weakening, but an MRI showed persistant mild signal change. In 2011 when the pain recurred, xrays showed a large new expansile lesion in the humerus. The new lesion is proximal to the the HA cement which was placed in 1999. There is no periosteal reaction. The bone is slightly expanded, and the cortex thinned but not violated.
Laboratory results:: 
The lesion was sampled at surgery, and based on findings of benign tissue, it was curetted and packed with PMMA cement. At surgery, there was slightly turbid, yellow fluid under mild pressure in the lesion, which was send for cytology. Curettings revealed significant amounts of tan cellular material, but also revealed a thin membrane with a shiny, synovial appearance covering portions of the lesion cavity.
Differential Diagnosis: 
The original pathological material from 1999 was described as "fibroproliferative lesion" but no definite diagnosis was given. Is this an NOF? Is it a recurrent UBC with fibrous proliferation? Or something else?
Further Work Up Needed:: 
The lesion was sampled, and based on findings of benign tissue, it was curetted and packed with PMMA cement. At surgery, there was slightly turbid, yellow fluid under mild pressure in the lesion, which was send for cytology. Curettings revealed significant amounts of tan cellular material, but also revealed a thin membrane with a shiny, synovial appearance covering portions of the lesion cavity. Pathology is pending
Pathology results:: 
See images
Special Features of this Case:: 
This lesion does not fit any classic diagnosis. UBC does not typically occur in the diaphysis, or contain large amounts of tissue, and NOF does not fit the xray appearance, behavior, or the fact that the lesion was fluid filled. FD can undergo cystic change, but usually demonstrates bone formation. None of these lesions typically regrow dramatically as this lesion seems to have done, in a young adult 12 or 13 years after initial treatment.

A 52 year old man with aching pain in the shoulder for 6 weeks.

Case Identification
Case ID Number: 
20091106AB
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 52 year old man had a six week history of aching pain in the shoulder at rest and with activities. On exam, there was pain and tenderness over the proximal humerus and the anterolateral arm, as well as pain with abduction and limitation of motion of the shoulder.

The lesion has a latent appearance and there is no sign of progressive growth. This coupled with the central, metaphyseal location, as well as the dense matrix calcification showing "rings and arcs" (see inset images) identify this lesion as an enchondroma.

Radiological findings:: 
The bone scan shows mild uptake in the lesion, which is expected since the natural tendency of cartilage in an enchondroma is to become replaced by bone over time. This leads to variable uptake on bone scans that should not be interpreted as malignant growth. The enchondroma should be followed with intermittent radiographs for one to two years to insure there is no progressive change. Definite growth in an enchondroma after skeletal maturity (as distinct from progressive ossification without size change) is a sign of neoplastic activity and requires a full work - up. Rotator cuff / subacromial bursa pathology might also cause the symptoms observed.
Special Features of this Case:: 
To resolve the issue of the patient's pain, remember that all of the symptoms can be explained on the basis of rotator cuff tendonitis or subacromial bursitis (call it whatever you prefer). To identify the origin of the pain, this patient had a diagnostic injection of marcaine placed into the subacromial bursa. His pain was completely (and temporarily) resolved. This simple but valuable diagnostic manouver helped pinpoint the origin of the patient's pain and eliminated the "red herring" of the enchondroma. The clinician can reassure the patient about the lesion and focus the treatment on the rotator cuff pathology.
Image Reference: 
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