DOI: 10.5958/j.2319-5886.2.2.

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International Journal of Medical Research & Health Sciences

www.ijmrhs.com
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Volume 2 Issue 2 April-June

Coden: IJMRHS
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Copyright @2013

ISSN: 2319-5886

Received: 5 Mar 2013 Case report

Revised:24 Mar 2013

Accepted: 26th Mar 2013

OSTEOCHONDROMA ON DORSAL SURFACE OF THE SCAPULA IN 11 YEARS OLD CHILD- A CASE REPORT Yadkikar SV1, Yadkikar VS 2 Assistant Prof, 2Prof. & Unit Head, Department of Orthopaedics, Rural Medical College, Pravara institute of Medical Science (DU), Loni, Maharashtra, India
ABSTRACT
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Osteochondroma is the most common benign neoplasm of skeleton with an incidence of 30-40% amongst benign bone tumor. Its usually seen in the second decade of life common sites of occurrence are distal end of femur, proximal tibia but scapula is an unusual sight to occur with an overall incidence of 3-4 % worldwide. Common presenting complaints are swelling, pain, pseudo winging. Many times it may be presented as painless lump. As per radiological image there are two types-Sessile and pedunculated. Plain X-Ray in AP and Lateral View are Diagnostic for this lesion. On X-Ray it appears to be growth arising from parent bone. Investigation like CT scan is helpful in delineating lesions on either surface of scapula. Grossly it appears as an irregular grayish white mass with a cartilaginous cap which is characteristic of the lesion. Complete Excision is the treatment of choice. However recurrence and malignant transformation are not unknown. Usually following a complete excision there is a full functional recovery. Uncommon site of occurrence and peculiar symptoms of the patient stimulated us to write this case report. Keywords: Osteochondroma of scapula, Benign bone tumour
INTRODUCTION

Osteochondroma is common benign bone 1-4 tumor , with an overall incidence of about 3040 %4. The cartilage cap covering tumor is characteristic feature4. It is said that it arises because of a congenital defect in perichondrium4. Its frequently seen in the first two decades of life4. Common sites of occurrence are around the distal end of femur, proximal tibia, proximal humerus4, but scapula is an uncommon sight to occur1, 2,4. Many articles are available stating presence of osteochondroma on Ventral surface of scapula associated with pulmonary

complications1. Dorsal surface of scapula is a rare sight. Many times lesion are asymptomatic but patient may present with complaints like pain , pseduowinging4. Pain could be due to irritation of overlying soft tissues, bursitis of overlying swelling, fracture through the stalk of lesion, malignant transformation3, 4. Plane X-ray of chest in PA & Lateral Scapular view is often diagnostic2. However, the diagnosis of lesions on locations like ventral surface of scapula, Ilium, spine- CT Scan & MRI Scan are helpful for 2,3,4. Histopathology confirms the diagnosis2,3,4. Complete excision is treatment of choice1,2,4.
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But recurrence & malignant transformation can occur4. In this 11 year old female patient unusual site of occurrence (dorsal surface of scapula) & peculiar symptoms of inability to sleep only in supine position stimulated us to write this case report Case report 11 years old female child presented with chief complaints of swelling on the left side of the upper back and inability to sleep only in supine position due to pain since 1 year. It was gradually progressive & was not associated with any history of trauma, fever, weight loss or history of similar complaints in the past. On examination of the left scapular region: It was single, well defined, Oval swelling on the dorsal surface of left scapula away from the midline & away from the lateral border of scapula, measuring approximately 3cmx 2cm, it was located near centre of scapular blade, overlying skin was normal, no dilated veins were seen on the surface of swelling, there was no local rise of temperature, it was non tender, firm to hard in consistency with well defined margins. It was attached to underlying structures (scapula) and not to the overlying soft tissues and skin. It was non mobile, non translucent. It was not associated with restriction of left shoulder movements. There was no sensory or motor

deficit in left upper limb. There was no evidence of any other swelling in the body. Chest X-Ray in PA and Scapular lateral views were taken which showed a Well defined lobulated sessile swelling arising from dorsal surface of the left scapula. The swelling was very well visualized on lateral scapular view. Both corticocancellous portions of swelling were well blended with the corticocancellous host bone. There was no evidence of any pathological fracture. As our patient was very poor socioeconomic status, therefore CT scan or MRI of the left scapula could not be done. Provisional Diagnosis of Exostosis and osteochondroma was made. After which Patient was subjected to excisional biopsy under general anesthesia. The patient was given right lateral position. Curvilinear incision was given over the swelling and it was exposed by soft tissue dissection of overlying muscle and fascia. It was excised in toto. On Physical examination the swelling was of grayish white in color, irregular in shape and firm to hard in consistency. The dimensions of the swelling were 4x2x1 cm and it weighed 20 gm. Cut surface was grayish white in color and it was having a cartilaginous cap. Histopathology confirmed the diagnosis of osteochondroma. Postoperative period was uneventful and was not associated with restriction of left shoulder movement. During the follow up of 1 year there was no evidence of recurrence.

Fig. 1&2 Preoperative clinical pictures

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Fig.3:Intra operative procedures

Fig.4: Depicting dimensions of the excised mass

Fig.5: Histopathology (400 X High power) DISCUSSION

Fig.6:Post operative final range of motion left shoulder

Osteochondroma is one of the most common benign bone tumor2-4. It is postulated that it is a developmental anomaly of bone resulting in formation of exophytic outgrowth from surface of bone4. This tumor has a peculiar cartilaginous cap on its surface4. It has about 30-40% incidence2,4. It is frequently seen in first & second decades of life4 with common sites of occurrence are distal end of femur, proximal tibia, proximal humerus4. However scapula, Ilium, ends of the clavicle, carpal &tarsal bones are rare sites of occurrence4. Frequently osteochondromas are asymptomatic but patient may present with cosmetic complaints2,4. However there maybe complaint of pain due to mechanical irritation of surrounding muscles & soft tissues, bursitis around lesion, fracture

through the stalk of lesion or malignant transformation2-5 Overall incidence of scapular osteochondroma is around 4% 2-4. Patient usually have cosmetic complaints but may also complain of pain & psuedowinging2. Peculiar symptom of pain only on lying down in the supine position as in this case might be the presenting complaint. There are numerous articles about osteochondromas on ventral surface of scapula associated with pulmonary complications3. However osteochondromas on dorsal surface doesnt have any pulmonary complications. They are usually solitary 4. Standard AP & Lateral scapular views are the investigations of choice4. On X rays they present as an irregular mass protruding from the surface of host bone4. It could be sessile or pedunculated5. Corticocancellous bone of tumor
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is continuous with corticocancellous bone of In locations like scapula, host2,4. osteochondromas usually arise near the cartilaginous border of bone4. For lesions of the spine, ventral surface of scapula CT Scan&MRI are better investigation modalities1,4. There is a better evaluation of cartilage cap thickness (2mm or more) on MRI SCAN4. When thickness of cartilage cap increases more than 2mm its a probable indicator of malignant transformation4. Lesions could be differentially diagnosed as chondrosarcoma, myositis osscificans1,4. Histopathology confirms the diagnosis, which shows areas of endochondral ossification on the basal surface of hyaline cartilage4. Grossly it presents as an irregular bony mass with grayish cartilage cap normally measuring 1-3mm in thickness4 Growth of the tumor halts after the period of skeletal maturity4, so for asymptomatic lesions, no treatment is required4. But for symptomatic lesion complete excision is the treatment of choice1-4. However recurrence & malignant transformation of the lesion cannot be overruled4
CONCLUSION

Scapula is one of the rare site of occurrence for osteochondroma. For complaints of swelling over the scapula associated with difficulty in lying down only in supine position , osteochondroma can be considered as one of differential diagnosis.
REFERENCES

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orthopaedic Surgery. 2009; 14(1): DOI 10. 5580 /2930 3. Marcia F, Blacksin And Joseph B Neoplasm Of Scapula. American Journal Of Roentgenology.2000, 174 (6): 1729-35 4. Current concepts in bone & soft tissue tumors, Textbook of Orthopaedic Oncology by Dr Ajay Puri & Agarwal MG. 2nd ed , Publisher Paras medical books Pvt.Ltd. Hyderabad ,Chapter 7. Benign bone Lesion. Pg no72-77 5. Kyoji O, Kel T, Ryuji S, Naoto H. Large bursa formation associated with osteochondroma of scapula: A case report & review of the literature. Japanese journal of clinical oncology 1999;29(7); 356-360 6. Pongkripetch M, Sirikilchayanonta V. Analysis of bone tumours in Ramathibodi Hospital Thailand during 1977-1986: Study of 652 cases.J Med Assoc Thai 1989; 72: 621-28. 7. Tomo H, Ito Y, Aono M, Takaoka K.Chest wall deformity associated with osteochondroma of the scapula: a Case report and review of the literature.J Shoulder Elbow Surg.2005;14(1): 103-106 8. Samilson RL, Morris JM, Thompson RW. Tumours of scapula.Clin Orthop. 1968;58: 105-15 9. Christmas OD,Goldernberg RR.Untreated Solitary Osteochondroma.Report of two cases. J bone Joint Surg Am.1968;50(3): 50812 10. Essadki B, Moujtahid M, Lamine A, Fikry, Essadki O, Zryouil B. Solitary ost eochondroma of limbs:Clinical review of 76 cases and pathogenic hypothesis. Acta Orthop Belg. 2000;66: 146-53.

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