Morphological parameters of the acromion

The purpose of this study was to record the basic morphometric values of the acromion. Forty-four pairs of dried scapulas were reviewed. Acromial shape was evaluated in relation to sex, symmetry and presence of subacromial enthesophytes and classified according to Bigliani with the following results: type I (flat): 26.1%, type II (curved): 55.6% and type III (hooked): 18.1%. There was a greater percentage of type III in men (56.2% vs. 43.7%) and type I in women (56.5% vs. 43.4%). Acromial morphology was symmetric in 29 acromia (65.9%). Enthesophytes were most common in type III (75%). A rough inferior surface of the acromion was most frequently found in type III (81.2%). Nine other scapular osteological parameters were also measured. Many differences were noted between male and female scapulae. The great variety of morphological features is assumed to be related to rotator cuff pathology and other shoulder impairments.

Fine needle aspiration cytology of intraosseous ganglion: a case report

BACKGROUND

Intraosseous ganglia are histologically identical to their soft tissue counterparts. Fine needle aspiration cytology (FNAC) has been described for ganglia of soft tissue, but not for intraosseous ganglia.

CASE

A 59-year-old woman was incidentally found to have a circumscribed, lytic lesion in the right scapular bone on radiographic studies performed for chronic impingement syndrome. Cytologic examination of the aspirated material from the lesion was reported as nondiagnostic. Open curettage of the lesion with bone grafting was performed. Histologic examination showed an intraosseous ganglion. A review of the FNA smears revealed findings diagnostic of intraosseous ganglion.

CONCLUSION

The FNAC findings of intraosseous ganglia are similar to those of their soft tissue counterparts. The diagnostic finding is mucoid material with free-floating macrophages. A correct cytologic diagnosis of this entity would ensure proper individualized patient management.

Klippel-Feil syndrome and Sprengel deformity combined with an intraspinal course of the left subclavian artery and a bovine aortic arch variant

SUMMARY

We present a case of Klippel-Feil syndrome and Sprengel deformity with a bovine aortic arch and an aberrant course of the left subclavian artery in a 14-year-old boy. CT and MR imaging of the neck and upper thorax demonstrated a cervical osseous segmentation anomaly, a left common carotid artery originating from the innominate artery, and a left subclavian artery coursing through the intraspinal space at the C6 through T1 level. Possible embryonic mechanisms and clinical significance of this variant are reviewed.

Scapulohumeral osteochondrosis. A retrospective study of 32 horses

OBJECTIVES

To review the outcome of equine shoulder osteochondrosis (OC) with surgical or conservative treatment.

METHODS

Retrospective study of 32 horses, less than two years of age, with scapulohumeral joint (SHJ) OC. The lesion severity was graded based on measurements taken from lateromedial radiographs. Follow-up information was obtained from racing records or telephone conversations with owners. Successful outcome was defined as the ability of the horse to perform its intended use.

RESULTS

Sixteen of 32 horses were affected bilaterally (48 joints). Eleven of 16 horses with bilateral OC underwent arthroscopic surgery; five had bilateral arthroscopy, six had unilateral arthroscopy of the most severely affected joint. Eight of 16 horses with unilateral OC underwent arthroscopy. The overall outcome was 'poor'. Only 15.4% (4/26) of potential race horses started a race, whereas 67% (4/6) non-racehorses were 'sound' for the intended use. Statistical analysis evaluating the effect of breed on outcome showed a statistically significant difference. There were no significant interactions between outcome and gender, affected limb, unilateral versus bilateral involvement, treatment or severity of the radiographic lesion. However, radiographic lesion severity on the humerus and glenoid showed significant positive correlation.

CLINICAL SIGNIFICANCE

The overall poor prognosis for shoulder OC in young horses appears to be, in part, dependent on breed and intended use. There was not any difference in outcome between surgically and conservatively treated horses.

Subcutaneous ossifying lipoma: case report and review of the literature

BACKGROUND

Lipomas can undergo a variety of changes, one of which is ossification. Ossifying lipoma (OL), independent of bone tissue, is rare. No case has been reported with this heading in the dermatopathological literature.

CASE REPORT

A 73-year-old woman was referred for a subcutaneous mass on the left scapular region that had been present for more than 22 years.

RESULTS

The lesion was an OL measuring 8 cm and weighing 75 g. Only 25 cases of OL have been described in soft tissues. Including the present report, locations in order of frequency are the head and neck area (11 cases), the limbs (9 cases) and the trunk (6 cases). Average patient age is 50.9 years (range, 17-81 years). History is measured in years (mean, more than 6 years). Average tumor size is 7.1 cm (range, 0.8-20 cm). The adipose component is usually predominant and the mature bone tissue is irregular in distribution. Bone spicules are surrounded by fibrous tissue bands. Chondrous structures are found in 46.2% of tumors. No recurrences have been reported.

CONCLUSIONS

OL is rare but has a characteristic gross, radiological and histological appearance. It has the same prognosis as simple lipoma. Excision is the treatment to be chosen.

Aneurysmal bone cyst of the paediatric shoulder girdle: a case series and literature review

Limited research has analysed paediatric shoulder girdle aneurysmal bone cyst management and outcomes. This study analysed locations affected, investigations, treatments and recurrence in children treated at the London Bone Tumour Unit between 1998 and 2004 and in English and French literature between 1956 and 2004. The proximal humerus and clavicle are most frequently affected whereas scapula involvement is rare. Radiographs, computed tomography and MRI are valuable. Sole curettage of clavicle and scapula lesions has low recurrence rates. Proximal humerus lesions recur most frequently. Curettage alone or with cementation are the most appealing treatments but are associated with significant recurrence.

Sprengel's deformity in Klippel-Feil syndrome

STUDY DESIGN

A retrospective study.

OBJECTIVES

To address the role of congenitally fused cervical segments, the degree of cervical scoliosis, and other risk factors on the presence of Sprengel's deformity (SD) in young patients with Klippel-Feil syndrome (KFS).

SUMMARY OF BACKGROUND DATA

Numerous abnormalities are associated with KFS, one of the most common being SD. It has been postulated that more severe forms of KFS may be more associated with extraspinal manifestations, such as SD.

METHODS

Thirty KFS patients from a single institution were reviewed. Cervical neutral lateral/dynamic/anteroposterior and thoracic anteroposterior plain radiographs were assessed. Radiographically, occipitalization (O-C1), number of congenitally fused segments (C1-T1), classification type (Types I-III), degree of cervical scoliosis, and the presence of SD was assessed. Clinical chart review entailed patient demographics and evidence of the clinical assessment of SD. The threshold for statistical significance was P < 0.05.

RESULTS

There were 11 males (36.7%) and 19 females (63.3%) with a mean age of 13.5 years (range, 2.7-26.3 years). Occipitalization was present in 10 (33.3%) individuals and C2-C3 was the most common level fused (70.0%). The mean number of congenitally fused segments was 3.3 (range, 1-6 levels). The mean degree of cervical scoliosis was 17.3 degrees (range, 0 degrees-67 degrees). There were 6 (20%) Type I, 15 Type II (50.0%), and 9 Type III (30%) patients. SD was noted in 5 (16.7%) of the patients. Four patients had unilateral, whereas 1 patient had bilateral SD. There was 4.0 and 3.1 mean number of congenitally fused segments in patients with or without SD, respectively. SD did not occur in Type I patients (single fused block). The presence of SD was found to be nonsignificant regarding sex type (P = 0.327), presence of occipitalization (P = 0.300), number of congenitally fused segments (P = 0.246), specific congenitally fused segments (P > 0.05), classification type (P > 0.05), and scoliosis (P = 0.702).

CONCLUSION

SD occurred in 16.7% of KFS patients. Sex type, number of congenitally fused segments, specific fused patterns, occipitalization, classification type, and the degree of cervical scoliosis did not seem to be significantly associated with the presence of SD in KFS patients in our series. Thorough examination for the presence and degree of SD in KFS is necessary, irrespective of the extent of cervical abnormalities. Alternatively, the treating physician should not dismiss a thorough cervical spine examination in patients with SD, evaluating factors that may predispose the KFS patient to an increased risk of neurologic injury.

Primary malignancies mistaken for pseudotumours in haemophilic patients

Pseudotumours are a rare complication of haemophilia. Surgery undertaken for pseudotumour on a lesion that is subsequently found to be malignant can be expected to adversely affect patient outcome. We present six case reports found from a literature search of patients with haemophilia who underwent surgery on what was a primary malignancy misdiagnosed as a pseudotumour and give a subsequent discussion.

An unusual presentation of whiplash injury: long thoracic and spinal accessory nerve injury

Whiplash injuries from motor vehicle accidents are very common. The usual presentation and course of this condition normally results in resolution of symptoms within a few weeks. Brachial plexus traction injuries without any bone or joint lesion of the cervical spine have been reported before. We report a case where a gentleman was involved in a rear end vehicle collision, sustained a whiplash injury and was later found to have a long thoracic nerve palsy and spinal accessory nerve palsy. Although isolated injuries of both nerves following a whiplash injury have been reported, combined injury of the two nerves following a whiplash injury is very uncommon and is being reported for the first time.

Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients

BACKGROUND

The treatment of type II superior labral anterior posterior (SLAP) lesions remains controversial. Many surgeons are reluctant to combine a SLAP repair with an acromioplasty for fear of postoperative shoulder stiffness and a poor clinical outcome.

HYPOTHESIS

A SLAP repair and an acromioplasty done concomitantly may yield acceptable outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We compared the clinical results of 50 patients who had either an isolated type II SLAP repair (SLAP group, 34 patients) or a combined type II SLAP repair and acromioplasty (combined group, 16 patients). Patients were excluded for full-thickness rotator cuff tears or instability. All patients were evaluated with the L'Insalata Functional Shoulder Rating Questionnaire, with the American Shoulder and Elbow Surgeons (ASES) questionnaire, and by subjective evaluation.

RESULTS

At an average of 3.4 years postoperatively, the L'Insalata and ASES scores were similar for the 2 groups: 87.1 and 85.8 for the SLAP group and 85.1 and 86.5 for the combined group, respectively (P > .05). Subjectively, only 65% of the patients in the SLAP group reported a "good" or "excellent" satisfaction with the surgery, compared with an 81% "good" or "excellent" satisfaction rating among the patients in the combined group. Seven patients (21%) in the SLAP group had postoperative clinical impingement, compared with no patients (0%) in the combined group (P < .03).

CONCLUSIONS

According to our data, these 2 procedures done concomitantly may yield acceptable outcomes. Our findings indicated that a combined type II SLAP repair and acromioplasty had no negative effect clinically and, furthermore, appeared to prevent residual clinical impingement.

Anaplastic large cell lymphoma of bone--is it a bad tumor?

A teenage boy presented with a CD30-positive anaplastic large cell lymphoma (ALCL) affecting his scapula and was successfully treated with chemotherapy. His clinical features and outcome were compared with other cases described in the literature. A further review of 11 ALCL cases with bony involvement treated in the UK since 1990, including two with primary bone disease, did not suggest an unfavorable treatment outcome. This finding will need to be confirmed by further study on a larger patient cohort with primary bone ALCL.

[Giant bursitis with rice bodies of the shoulder/neck region in a patient with rheumatoid arthritis without joint-connection]

Giant bursitis with rice bodies is an important clinical entity recognized in rheumatoid arthritis. Usually the bursitis is connected to a joint space. In this unusual case of a giant bursitis of the shoulder/neck region, no connection to a joint could be found. The bursitis lays directly on a rib. The clinical and radiological findings are presented and this special case is discussed in comparison to the literature.

Computer-assisted localization of osteoid osteoma: an initial experience

This article evaluates our initial experience with computer-assisted localization of osteoid osteoma. Nine patients with osteoid osteoma underwent minimally invasive computer-assisted surgery. Patients were followed prospectively for symptomatic relief and complications for an average of 31 months. Successful localization of osteoid osteoma occurred in 7 of 9 patients. Mean operative time was 88 minutes, and mean time to discharge was 1 day (range: same day to 2 days). No fractures, infections, or neurovascular complications occurred. Minimally invasive computer-assisted surgical excision of osteoid osteoma is a safe and feasible option for the surgical localization of osteoid osteoma. It is especially attractive for lesions located in poorly accessible anatomic sites.

Toxic osteoblastoma of the scapula

Osteoblastoma rarely occurs in the scapula, and toxic osteoblastoma is a very rare subtype of this bone-forming tumour. This report details the clinical, radiological and pathological features of a toxic osteoblastoma of the scapula; it is the first reported case to be diagnosed correctly pre-operatively and treated appropriately by excision.

MR Arthrography of the Glenohumeral Joint: Modified Posterior Approach without Imaging Guidance

Institutional review board approval and informed consent were obtained. The purpose of the study was to prospectively perform magnetic resonance (MR) arthrography of the glenohumeral joint by using modified posterior approach without ultrasonographic or fluoroscopic guidance. A solution containing 0.1 mL of gadolinium chelate, 15 mL of saline, and 5 mL of 2% lidocaine was subsequently injected into the glenohumeral joint in 147 patients (81 men, 66 women; age range, 20-79 years). A 21-gauge needle was advanced along a trajectory connecting a skin mark 3-4 cm below and 2 cm medially to the posterolateral margin of the acromion and the coracoid process, as assessed with palpation, proceeding in posteroanterior direction. The joint was successfully entered at first attempt in 125 (85%) patients, at second attempt in 19 (13%), and at third attempt in three (2%). Contrast material-enhanced images were evaluated for presence, site, and maximal extent of contrast material extravasation; route of diffusion of the extravasation; compromised or noncompromised diagnostic quality; and presence of gas bubbles. Extravasation occurred in seven patients: at the interval between the teres minor muscle and infraspinatus muscle in five and within the infraspinatus muscle belly in two; extravasation had diffused along the teres minor muscle and infraspinatus muscle in five (71%) and along the teres minor muscle in two (29%). The mean extension of extravasation was 15 mm. Image quality was not compromised, and no gas bubbles were detected. The procedure was successful in all patients, with no complications.

Glenoid osteolysis after arthroscopic labrum repair with a bioabsorbable suture anchor

Bioabsorbable suture anchors are commonly used for arthroscopic repair of rotator cuff and labrum lesions. They provide soft-tissue attachment to bone. They have been introduced to avoid complications such as artefacts on MRI scans, commonly seen with metal anchors. However, bioabsorbable implants may lead to other problems such as local osteolysis, cyst formation, soft tissue inflammation and release of implant fragments into the joint space. The author describes the case of a professional female volleyball player, who presented osteolysis of the superior pole of the glenoid after arthroscopic repair of a SLAP lesion with a PLLA suture anchor. This is the first reported case of glenoid osteolysis after arthroscopic insertion of a bioabsorbable suture anchor. The author feels that the cause of osteolysis was a biological response to mechanical stress.

Winged scapula as the presenting symptom of Chiari I malformation and syringomyelia

CASE REPORT

We report a 19-year-old girl with a 4-month history of an inability to fully elevate her upper extremity past the horizontal position. Physical examination revealed a winged scapula. MRI was demonstrative of a Chiari I malformation with a small cervical syrinx eccentrically placed to the same side as the dysfunctional extremity.

DISCUSSION

We believe this to be the first report of dysfunction of the long thoracic nerve via a hindbrain hernia-induced syrinx with a resultant winged scapula. We would hypothesize that enough anterior horn motor neurons and their axons destined for the long thoracic nerve were injured by the syringomyelia to result in isolated deinnervation of the serratus anterior muscle.

CONCLUSION

The clinician may wish to include syringomyelia in the differential diagnosis of a winged scapula.

Cytopathologic findings in “POEMS” syndrome associated with Castleman disease

A 34-year-old man with a history of a scorpion bite followed by increasing polyneuropathy and IgG lambda monoclonal gammopathy was referred for fine-needle aspiration of a lytic bone lesion and an enlarged axillary lymph node. The findings in the bone lesion were consistent with a plasmacytoma. The FNA of the lymph node showed a peculiar capillary proliferation in a background of polymorphous mature lymphocytes. Flow cytometric analysis showed a mixed lymphoid population. The lymph node was originally signed out descriptively, but review of the case showed features consistent with Castleman disease. After the pathologic findings and clinical features were discussed with the clinical team, the diagnosis of POEMS syndrome was established. Subsequent surgical excision of the lymph node was diagnosed as hyaline vascular-variant Castleman disease.

Infraclavicular brachial plexopathy secondary to coracoid osteoid osteoma

Coracoid osteoid osteomas are rare. This case report presents two patients with coracoid osteoid osteomas who developed neurologic sequelae of the infraclavicular brachial plexus (namely, musculocutaneous neuropathy in one patient with an anterior lesion, and suprascapular neuropathy in the other patient with a more posterior lesion). The neuropathy was due to soft tissue edema, which surrounded the bony lesion and was apparent on MRI. Surgical resection of the bony lesion in both cases produced excellent outcomes at long-term follow-up.

Proposal for classification of the suprascapular notch: A study on 423 dried scapulas

The present study proposes a simple and reproducible method to classify the morphology of the suprascapular notch (SSN), on the basis of specific geometrical parameters that clearly distinguish one type from another. Four hundred twenty-three dried scapulas from the Department of Anatomy in the University of Cologne, Germany, were examined. Five types of SSN were observed: type I, without a discrete notch, 35 (8.3%); type II, a notch that was longest in its transverse diameter, 177 (41.85%); type III, a notch that was longest in its vertical diameter, 177 (41.85%); type IV, a bony foramen, 31 (7.3%); type V, a notch and a bony foramen, 3 (0.7%). For the vertical diameter, we took the maximal diameter of the notch perpendicular to the imaginary line that joins the two superior corners of the notch. For the transverse diameter, we took the diameter perpendicular to the midpoint of the vertical diameter. This classification based on the vertical and the transverse diameters of the SSN suggested a clear distinction of the notch types. This simple classification included all the anatomical variations of the SSN. Using this method, the clinician will be able to define easily and quickly the notch type on a plain radiograph, and perhaps be able to correlate suprascapular nerve entrapment with a specific type of SSN.