Unusual Presentation of Non-Hemophilic Haemosiderotic Synovitis Mimicking Pigmented Villonodular Synovitis in the Left Shoulder, A Case Report

CSM 2014 Sports Physical Therapy Section Poster Presentations (Abstracts SPO1228–SPO1309, SPO6761)

Pigmented Villonodular Synovitis, although uncommon, can lead to significant joint destruction if not diagnosed and treated early. Concurrent polyarticular presentation in adults is exceedingly rare, appearing in less than 1% of cases. This case report presents a unique and rare occurrence of Pigmented Villonodular Synovitis involving both the ankle and shoulder joints simultaneously in an adult patient. The patient initially developed a diffuse form Pigmented Villonodular Synovitis in the left ankle, which was managed with total synovectomy at another tertiary hospital. Two months later, a separate localized form Pigmented Villonodular Synovitis was diagnosed in the left glenohumeral joint, necessitating arthroscopic marginal resection at our hospital. At the one-year follow-up, the magnetic resonance imaging of the left shoulder showed no signs of Pigmented Villonodular Synovitis recurrence, with full range of motion and no pain. However, the magnetic resonance imaging of the left ankle revealed a recurrence of the Pigmented Villonodular Synovitis, despite the range of motion remaining within normal limits. This case demonstrates the importance of considering multiarticular Pigmented Villonodular Synovitis when symptoms manifest in multiple joints. Early diagnosis and appropriate intervention are critical to prevent joint destruction and optimize patient outcomes.

A 16-year-old male with hypermobility spectrum disorder (HSD) and Raynaud's phenomenon (RP) was referred to a clinical exercise physiologist (CEP) by their pediatric rheumatologist. The patient presented with arthralgia in the left knee and shoulder. Specifically, the left knee presented discomfort during activities of daily living (ADL), and the left shoulder had a reduced range of motion resulting from pain. Finally, complaints of painful fingers were also significant due to increased RP flare-ups during winter. A posture analysis was conducted, indicating relatively poor posture. Range of motion and manual muscle testing were suboptimal in the shoulders, but optimal in the knees and hips. The Kendal test, patella compression test, and Clarke's sign were conducted due to knee pain. Functional tests included a pelvic bridge, squat, Neer's test, and wall push-up. Finally, the modified pediatric clinical test of sensory interaction in balance (mPCTSIB) was completed to determine the interaction between balance systems. Analysis of all the tests conducted above confirmed the diagnosis of HSD and also indicated scapula dyskinesia, supraspinatus impingement, and patellofemoral pain syndrome. Consequently, the CEP treatment focused on strengthening the foot, knee, and hip kinetic chain, as a 12-week home program, along with hand exercises as needed to aid in the pain and stiffness experienced during RP flare-ups. The physiotherapist treatment was more hands on in the use of myofascial release, electrotherapy, taping, and posture correction of the neck and shoulder over four in-house visits. Finally, a 6-month follow-up was conducted by the CEP, in which the patient showed improvement with a pain-free range of motion and the ability to optimally conduct ADLs.

Patient: Male, 73-year-oldFinal Diagnosis: Intramuscular myxomaSymptoms: Shoulder painMedication:—Clinical Procedure: —Specialty: General and Internal Medicine • Orthopedics and TraumatologyObjective:Rare diseaseBackground:Intramuscular myxomas are rare and benign soft-tissue tumors of uncertain differentiation. Predisposing or precipitating factors have not yet been reported. Activating mutation in GNAS (exons 8 and 9) is detected in >90% of sporadic cases. The role of chronic myopathy, tendinopathy, or trauma to muscles in the etiology of these neoplasms is not known. We report an unusual case of a deltoid mass found following longstanding rotator cuff tendinopathy and a recent fall, later confirmed to be an intramuscular myxoma on biopsy.Case Report:A 73-year-old man with a 5-year history of left shoulder pain and rotator cuff tear presented with intractable pain in his left shoulder after a recent fall at home. Physical examination was suggestive of a rotator cuff injury and magnetic resonance imaging (MRI) of the left shoulder revealed a 2.7×2.5×3.7cm T1 hypo- and T2 hyperin-tense oblong mass-like signal abnormality with heterogeneous, predominantly peripheral enhancement within the deltoid muscle concerning for a malignant mass. Surgical resection was carried out along with left reverse total shoulder replacement, and histopathology revealed findings consistent with an intramuscular myxoma.Conclusions:Intramuscular myxomas are rare, benign tumors. This case report presents one such myxoma incidentally found in a patient with longstanding rotator cuff tendinopathy and a recent fall. Although this co-occurrence is likely incidental, further research and case series review of similar presentations may influence postulations of the pathophysiology of myxomas.

Introduction:Septic arthritis comprises pathological invasion of the joint space followed by inflammation. Predisposing risk factors include prior rheumatic joint disease, people at the extremes of age, such as young children and elderly people who have joint prostheses. Although generally bacterial, the etiology can also be viral or fungal. Staphylococcus and streptococcus are common bacteria that cause an acute septic arthritis. However, streptococcus has been emerged as the second most frequent causative agent for septic arthritis. According to a few case reports, septic arthritis of the joint may be found to be associated with necrotising fasciitis.Case Report:A 10-year-old male child presented with a history of pain and swelling in the left arm and left shoulder from 3 to 4 days. His mother gave a history of a fall while playing 6 days back. Swelling was grossly increased on day 2 with erythema and induration over the whole of the left arm and shoulder. X-ray image showed soft-tissue swelling of the left arm. On Ultrasonography, a hypoechoic collection noted in the anterior compartment of the entire left arm just above the elbow joint.Conclusion:This case highlights the importance of thorough assessment in primary care, which led to the high index of suspicion of septic arthritis and necrotising soft-tissue infection and timely management of the patient

Phakomatosis pigmentovascularis type Ⅲa mainly manifested by zosteriform nevus spilus: A case report with dermoscopic features

Primary extraskeletal Ewing sarcoma (EES) is a rare small round cell malignancy that accounts for less than 1% of all sarcomas. It is found most commonly in the trunk and lower limbs and very rarely in the pleura and can be easily misdiagnosed in clinical practice. This study presents the case of an 11-year-old boy who presented to our hospital with no apparent cause of left shoulder pain for 6 months. On physical examination, tenderness was noted in the left chest wall and shoulder joint, which had a limited range of motion. Computed tomography (CT) and magnetic resonance imaging (MRI) of the chest revealed an irregular soft tissue mass in the upper left thorax, with a wide base attached to the adjacent pleura and bone destruction of the adjacent left first rib. The patient’s bone scan showed a dense focus of increased radiotracer accumulation in the left first rib. A subsequent CT-guided aspiration biopsy of the left pleural mass with histomorphology and immunohistochemical phenotyping led to a diagnosis of extraskeletal Ewing sarcoma. To inhibit tumor growth, alternating systemic chemotherapy cycles of vincristine, doxorubicin, and cyclophosphamide (VDC) and isocyclophosphamide and etoposide (IE) were administered at 3-week intervals. After completing three VDC and two IE cycles, the child’s condition was well and the pain in the left shoulder joint was relieved. However, a repeat MRI of the chest showed that the mass did not shrink.

We present a case of left suprascapular nerve palsy in a 39- year-old female secondary to compression from a large ganglion cyst. She presented with a two month history of left posterior shoulder pain which affected her work and disturbed her sleep. Clinical examination revealed a positive O'Brien's test. Supraspinatus and infraspinatus strength was mildly weakened. A magnetic resonance imaging (MRI) scan of the left shoulder revealed a superior labral anterior to posterior (SLAP) lesion with a large supraglenoid labral cyst extending posteriorly to the spinoglenoid notch, resulting in compression of the suprascapular nerve. Arthroscopy revealed the SLAP lesion with a haemorrhagic labral cyst at the posterosuperior aspect. Arthroscopic decompression of the cyst and SLAP repair with two suture anchors was performed. At 22 months postoperative follow-up, the patient's left shoulder remained asymptomatic with full range of motion and full strength. SLAP lesion; Supraglenoid Labral Cyst; Suprascapular Nerve Compression.

BACKGROUND Pigmented villonodular synovitis is a rare clinical entity, with 2-3% of all PVNS cases affecting the shoulder. Diagnosis is challenging and can elude clinicians for years, with definitive treatment involving arthroscopic or open synovectomy. CASE REPORT A 50-year-old woman presented with left shoulder pain persisting for 2 years. She was initially conservatively treated by a rheumatologist, with corticosteroid schemes intra-articularly injected and per os, but no improvement of her symptoms was noted. Two years later, she was referred to the Orthopedics Department of our hospital with constant pain in her left shoulder, refractory to the conservative measures. Physical examination revealed tenderness of her shoulder on palpation and limited range of motion. The diagnosis of PVNS was established by preoperative magnetic resonance arthrography (MRA) and confirmed by biopsy from intra-operative tissue sampling. Arthroscopic debridement and synovectomy were performed, yielding good surgical results, and she now reports pain relief, improved function, and no recurrence of symptoms at 1-year follow-up. CONCLUSIONS The diagnosis of PVNS can be elusive for years. MRI and clinical suspicion along with tissue biopsy can set the diagnosis. Shoulder PVNS follows a similar natural history as knee PVNS, with conservative treatment failing and arthroscopic excision providing definite relief. We report a rare case of shoulder PVNS, underscoring the importance of considering PVNS in cases of shoulder pain refractory to conservative treatment.

Background. Painful shoulder syndrome is a common condition in society. Most patients experience pain and reduced mobility of the affected limb, which can have an impact on the quality of life. This report presents a case of a patient with pain and reduced range of motion in the left shoulder. Aim of the study. The study aim was to evaluate the efficacy of dry needling in the treatment of painful shoulder syndrome, based on functional measures of pain, disability and range of motion. Case report. A 42-year old patient reported pain in her left shoulder. A series of 6 dry needling sessions were performed, twice a week, for a period of 3 weeks. Prior to, and immediately after, the therapy a subjective pain assessment using the VAS pain rating scale and an assessment of the degree of disability using the Modified Laitinen Pain Questionnaire were performed. The range of motion within the shoulder girdle was also measured with a goniometer. Conclusion. Following the dry needling therapy, a reduction in pain and improved shoulder girdle mobility was observed.

Snapping scapula: Formation of an erosive, subscapular bursal cyst after partial scapulectomy

A middle-aged woman presented to our hospital with a chief complaint of a mass on the left shoulder for 1 year. The initial lump was small with no pain or tenderness, and the patient had not sought medical attention for numbness in the left shoulder. Clinical examination showed a mass on the left shoulder measuring 11 × 8 × 3 cm approximately with no apparent skin damage or ecchymosis. No limitations in left shoulder joint movements were observed, and the patient exhibited normal movement of the left elbow joint, wrist joint, and metacarpophalangeal joint. Moreover, the left radial artery was palpable.

Bilateral anterior shoulder dislocation is a relatively rare condition. In a patient presenting with bilateral shoulder pain, a posteroanterior radiograph of the shoulders easily reveals the diagnosis. A 76-year-old woman presented to our emergency room with complaints of bilateral shoulder pain. She had fallen forward with both elbows hitting the ground and also hit her right shoulder. A posteroanterior radiograph revealed a right anterior shoulder dislocation with no remarkable changes noted on the left shoulder. The right shoulder dislocation was resolved, and she was sent home. Six hours later, she was brought back to our emergency room with left shoulder pain. A repeat posteroanterior radiograph of the left shoulder revealed left shoulder dislocation. Bilateral anterior shoulder dislocation occurring after 6 hours is an extremely rare condition. We report this case with a review of the literature.

Palmar Fasciitis and Polyarthritis Syndrome in Patients with Ovarian Cancer—A Case Report and Review of the Literature

BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.