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Intraarticular osteoid osteoma of the distal humerus
Intraarticular osteoid distal humerus
osteoma
Nurettin
MD,
Heybell,
MD,
Osteoid osteoma is a exfraarticular portions osteoma of the elbow osteoma of the distal unusual radiographic SURG
7 997;6:3
and Muharrem
Babacan,
of the
/k~anbu/, Turkey
and painful tumor most commonly affecting the small, benign, of the long bones, especially the femur or tibia. Osteoid is uncommon. In this article a 7 9-year-old man with an osteoid humerus is presented to illustrate the diagnostic problems and features of an infraarf;cular osfeoid osfeoma. (J SHOULDER ELBOW
7 7-3.)
CASE REPORT A 19-year-old man reported a 3-year history of right elbow pain. He had a stiff elbow with swelling. He had been treated with periods of immobilization, manipulation under general anand nonsteroidal antiinflammatory esthesia, agents. The elbow pain was worse at night and was relieved by aspirin. Physical examination revealed diffuse tenderness of the elbow and marked atrophy of the muscles of the entire arm without any neurovascular deficit. The range of motion of the elbow was decreased with flexion from 25” to 40” and 70” of supination and pronation. Laboratory investigations including the sedimentation rate were normal. Radiographs showed no definite lesion. The suspected diagnosis of osteoid osteoma was confirmed by computed tomography, and the exact location of the nidus was identified (Figure 1). At operation a posterior approach without olecranon osteotomy was performed. The triceps was split longitudinally. An excisional biopsy under fluoroscopy with a Coombs Bone biopsy system (Biomet Ltd., Bridgend, South Glamorgen) was performed. A softened area at the olecranon fossa was excised and was presumed to be the nidus. Reddish brown tissue was obtained. Additional curettage was performed. After the procedure his symptoms were relieved.
From the Department of Orthopaedlcs And Traumatology, CerrahUnlverslty of Istanbul, Reprint repasa Faculty of Medrclne, quests Muharrem Babacan, MD, Cerrahpasa TIP Fakultesl, Ortopedl ve Travmatololl Ana BIIlm Dah, Cerrahpasa 34303, Istanbul, Turkey Copyright Board
0
1997
by Journal
of Shoulder
of Trustees
10X2746/97/$5
00 + 0
32/4/78511
and
Elbow
Surgery
Figure clficatlons
1
Preoperative In nldus
computed
tomography.
Noie
cal-
At follow-up 10 months later he had no complications with a full range of motion (Figures 2 and 3).
DISCUSSION Osteoid osteoma is a benign osteoblastic lesion characterized by a well-demarcated core (nidus) usually less than 1 cm in diameter and by a distinctive surrounding zone of reactive bone formation.5 It has become a well-established clinical and pathologic entity since it was first described by Jaffe6 in 1935. It most commonly affects the extraarticular portions of the long bones with 50% of the reported cases in the tibia or femur.2, 4 It occurs mainly in young adults and is twice as prevalent in men.2,4, lo Relief of pain by nonsteroidal antiinflammatory agents is characteristic of osteoid osteoma. The radiographic presentation provides the single most reliable diagnostic 311
312
Heybeli
and Babacan
J. Shoulder
Elbow
Surg.
May/June
Figure en-bloc
2 PostoperatIve resection
computed
tomography
showing
guide; the nidus appears as a relatively radiolucent focus. If the lesion develops in the cortex, the adiacent cortical bone becomes strikingly thickened by periosteal new bone formation, but when it arises in cancellous bone, sclerosis is seen5 Osteoid osteoma arising in an intraarticular or paraarticular site can present a diagnostic problem.8, “, l2 To our knowledge no more than 10 osteoid osteomas of the distal humerus have been reported in the English literature.‘, 3, 7, * They do not have the classical clinical and radiographic features seen in extraarticular locations. Atrophy of muscle, localized swelling, and tenderness are frequent findings. The lesion may be mistaken for tuberculous synovitis or rheumatoid arthritis.5 The pathogenesis of the synovitis seen in intraarticular osteoid osteoma is not clear. Lafforgue et al.7 reported a case of osteoid osteoma with elbow synovitis with the hypertrophic synovium resembling the histologic pattern seen in rheumatoid arthritis. lmmunohistochemistry showed a local immunologic activation induced by osteoid osteoma, but the mechanism remains hypothetical.7 On radiographic examination new bone formation may be slight or absent and the nidus invisible. Before computed tomography became widespread, these lesions could only be diagnosed by biopsy. 8 When osteoid osteoma is
Figure en-bloc
3 Postoperative resection In more
computed tomography distal section
1997
she jwlng
suspected, the sequential diagnostic workup should include: first, conventional radiography, second, isotopic scanning, and third, computed tomography. Isotopic scanning is the technique most often used to identify the lesions that cannot be seen on radiographs. However, when the lesion is intraarticular, isotopic activity may not be confined to a circumscribed area of increased uptake but distributes more diffusely because of the associated synovitis with its reactive hyperemia. 3 Computed tomography scanning is probably the best supplement to clinical and x-ray examination and is useful both for diagnosis and for exact localization of the lesions.9 In the young adult with persistent unexplained elbow pain and evidence of synovitis, osteoid osteoma should be considered in the differential diagnosis.
REFERENCES 1
Blerfeld mrnlmal
C Osteord osteoma parn NY Statej Med
2
Campanaccr Sprrnger-Verlag,
3
Cronemeyer Rl, Kirchmer NA, De Smet AA, Neff JR lntraatircular osteord osteoma of the humerus srmulatrng synovrtls of the elbow a case report J Bone Jornt Surg Am 198 1 A,63, 1 172-4
4
Greenspan
M
A,
artrcular 1981,81
Bone and soft 1990 355-75
Klein MJ
Radrology
trssue
and
communrcatron 1371-2 tumours
pathology
New
and York
of bone
1. Shoulder Elbow Volume 6, Number
Heybeli
Surg. 3
tumors In Phlladelph~a
Lewis WB
5
Huvos AG ders, 1990
Bone tumors 49-6 1
6
Jaffe Hl Osteold osteoma a benign composed of osieold and atypIcal bone 3 1 709-28
7
8
MM, edltor Musculoskeleial Saunders, 1992 1 3-72 2nd
ed
Phlladelphla
oncology WB
osteoblastlc Arch Surg
RC, Frelberger
RH Osteold
osteoma
problem 1 18590
report
of four cases
J Bonejolni
3 13
Surg Am
Saun-
9
osteoma 1992.17A
tumor 1935,
Otsuka NY, Hasilngs DE, Fornasler VL Osteold ihe elbow a reDort of SIX cases I Hand Sura” 458-61
0
PICCI P, Mlrra Bone iumours 48
JM, editor 1989 226.
1
Roberts P, Davies AM, Starkle CM, Grlmer Rj The nldus of an osteold osieoma mlmlcklng an OS supratrochleare dorsale Br j Radio1 1990,63 899-902
2
Sim FH, Dahlln nostlc problems
lafforgue P, Senbel E, Boucraui J, Horschowsky N, Golsteln MM, Chrestlan MA, et al Elbow synovltls related to an lntraarilcular osteold osteoma of the humerus, with bmmunologlcal and hlstochemlcal studies J Rheumatol 1992,19 633-6 Marcove
dlagnostlc 1966,48A
and Babacan
of the elbow-a
JM Osteold Philadelphia
osteoma lea and
In Mlrra Feblger,
of
DC, Beabout JW. Osteold osteoma dlagJ Bone Joint Surg Am 1975,57A 154-9
osteoma
Nurettin
MD,
Heybell,
MD,
Osteoid osteoma is a exfraarticular portions osteoma of the elbow osteoma of the distal unusual radiographic SURG
7 997;6:3
and Muharrem
Babacan,
of the
/k~anbu/, Turkey
and painful tumor most commonly affecting the small, benign, of the long bones, especially the femur or tibia. Osteoid is uncommon. In this article a 7 9-year-old man with an osteoid humerus is presented to illustrate the diagnostic problems and features of an infraarf;cular osfeoid osfeoma. (J SHOULDER ELBOW
7 7-3.)
CASE REPORT A 19-year-old man reported a 3-year history of right elbow pain. He had a stiff elbow with swelling. He had been treated with periods of immobilization, manipulation under general anand nonsteroidal antiinflammatory esthesia, agents. The elbow pain was worse at night and was relieved by aspirin. Physical examination revealed diffuse tenderness of the elbow and marked atrophy of the muscles of the entire arm without any neurovascular deficit. The range of motion of the elbow was decreased with flexion from 25” to 40” and 70” of supination and pronation. Laboratory investigations including the sedimentation rate were normal. Radiographs showed no definite lesion. The suspected diagnosis of osteoid osteoma was confirmed by computed tomography, and the exact location of the nidus was identified (Figure 1). At operation a posterior approach without olecranon osteotomy was performed. The triceps was split longitudinally. An excisional biopsy under fluoroscopy with a Coombs Bone biopsy system (Biomet Ltd., Bridgend, South Glamorgen) was performed. A softened area at the olecranon fossa was excised and was presumed to be the nidus. Reddish brown tissue was obtained. Additional curettage was performed. After the procedure his symptoms were relieved.
From the Department of Orthopaedlcs And Traumatology, CerrahUnlverslty of Istanbul, Reprint repasa Faculty of Medrclne, quests Muharrem Babacan, MD, Cerrahpasa TIP Fakultesl, Ortopedl ve Travmatololl Ana BIIlm Dah, Cerrahpasa 34303, Istanbul, Turkey Copyright Board
0
1997
by Journal
of Shoulder
of Trustees
10X2746/97/$5
00 + 0
32/4/78511
and
Elbow
Surgery
Figure clficatlons
1
Preoperative In nldus
computed
tomography.
Noie
cal-
At follow-up 10 months later he had no complications with a full range of motion (Figures 2 and 3).
DISCUSSION Osteoid osteoma is a benign osteoblastic lesion characterized by a well-demarcated core (nidus) usually less than 1 cm in diameter and by a distinctive surrounding zone of reactive bone formation.5 It has become a well-established clinical and pathologic entity since it was first described by Jaffe6 in 1935. It most commonly affects the extraarticular portions of the long bones with 50% of the reported cases in the tibia or femur.2, 4 It occurs mainly in young adults and is twice as prevalent in men.2,4, lo Relief of pain by nonsteroidal antiinflammatory agents is characteristic of osteoid osteoma. The radiographic presentation provides the single most reliable diagnostic 311
312
Heybeli
and Babacan
J. Shoulder
Elbow
Surg.
May/June
Figure en-bloc
2 PostoperatIve resection
computed
tomography
showing
guide; the nidus appears as a relatively radiolucent focus. If the lesion develops in the cortex, the adiacent cortical bone becomes strikingly thickened by periosteal new bone formation, but when it arises in cancellous bone, sclerosis is seen5 Osteoid osteoma arising in an intraarticular or paraarticular site can present a diagnostic problem.8, “, l2 To our knowledge no more than 10 osteoid osteomas of the distal humerus have been reported in the English literature.‘, 3, 7, * They do not have the classical clinical and radiographic features seen in extraarticular locations. Atrophy of muscle, localized swelling, and tenderness are frequent findings. The lesion may be mistaken for tuberculous synovitis or rheumatoid arthritis.5 The pathogenesis of the synovitis seen in intraarticular osteoid osteoma is not clear. Lafforgue et al.7 reported a case of osteoid osteoma with elbow synovitis with the hypertrophic synovium resembling the histologic pattern seen in rheumatoid arthritis. lmmunohistochemistry showed a local immunologic activation induced by osteoid osteoma, but the mechanism remains hypothetical.7 On radiographic examination new bone formation may be slight or absent and the nidus invisible. Before computed tomography became widespread, these lesions could only be diagnosed by biopsy. 8 When osteoid osteoma is
Figure en-bloc
3 Postoperative resection In more
computed tomography distal section
1997
she jwlng
suspected, the sequential diagnostic workup should include: first, conventional radiography, second, isotopic scanning, and third, computed tomography. Isotopic scanning is the technique most often used to identify the lesions that cannot be seen on radiographs. However, when the lesion is intraarticular, isotopic activity may not be confined to a circumscribed area of increased uptake but distributes more diffusely because of the associated synovitis with its reactive hyperemia. 3 Computed tomography scanning is probably the best supplement to clinical and x-ray examination and is useful both for diagnosis and for exact localization of the lesions.9 In the young adult with persistent unexplained elbow pain and evidence of synovitis, osteoid osteoma should be considered in the differential diagnosis.
REFERENCES 1
Blerfeld mrnlmal
C Osteord osteoma parn NY Statej Med
2
Campanaccr Sprrnger-Verlag,
3
Cronemeyer Rl, Kirchmer NA, De Smet AA, Neff JR lntraatircular osteord osteoma of the humerus srmulatrng synovrtls of the elbow a case report J Bone Jornt Surg Am 198 1 A,63, 1 172-4
4
Greenspan
M
A,
artrcular 1981,81
Bone and soft 1990 355-75
Klein MJ
Radrology
trssue
and
communrcatron 1371-2 tumours
pathology
New
and York
of bone
1. Shoulder Elbow Volume 6, Number
Heybeli
Surg. 3
tumors In Phlladelph~a
Lewis WB
5
Huvos AG ders, 1990
Bone tumors 49-6 1
6
Jaffe Hl Osteold osteoma a benign composed of osieold and atypIcal bone 3 1 709-28
7
8
MM, edltor Musculoskeleial Saunders, 1992 1 3-72 2nd
ed
Phlladelphla
oncology WB
osteoblastlc Arch Surg
RC, Frelberger
RH Osteold
osteoma
problem 1 18590
report
of four cases
J Bonejolni
3 13
Surg Am
Saun-
9
osteoma 1992.17A
tumor 1935,
Otsuka NY, Hasilngs DE, Fornasler VL Osteold ihe elbow a reDort of SIX cases I Hand Sura” 458-61
0
PICCI P, Mlrra Bone iumours 48
JM, editor 1989 226.
1
Roberts P, Davies AM, Starkle CM, Grlmer Rj The nldus of an osteold osieoma mlmlcklng an OS supratrochleare dorsale Br j Radio1 1990,63 899-902
2
Sim FH, Dahlln nostlc problems
lafforgue P, Senbel E, Boucraui J, Horschowsky N, Golsteln MM, Chrestlan MA, et al Elbow synovltls related to an lntraarilcular osteold osteoma of the humerus, with bmmunologlcal and hlstochemlcal studies J Rheumatol 1992,19 633-6 Marcove
dlagnostlc 1966,48A
and Babacan
of the elbow-a
JM Osteold Philadelphia
osteoma lea and
In Mlrra Feblger,
of
DC, Beabout JW. Osteold osteoma dlagJ Bone Joint Surg Am 1975,57A 154-9