Left Proximal Humerus Research Articles

Fibrocartilaginous mesenchymoma, a unique osseous lesion: case report with review of the literature

Fibrocartilaginous mesenchymoma is a rare osseous tumor that primarily arises in the long bones of children and adolescents. This lesion can grow quickly and reach a considerable size, despite its benign nature. It has proved challenging to diagnose and can be mistaken for a spectrum of benign and malignant bone tumors. The histological presentation of unique epiphyseal plate-like cartilage with destruction of the surrounding cortical bone and exhibition of dense fibrous stroma are important indicators for the diagnosis of fibrocartilaginous mesenchymoma. An 11-year-old boy presented with a left proximal humerus mass thought to be an aneurysmal bone cyst. The patient was lost to follow-up and came back 3 years later with massive growth of the lesion. Owing to the aggressive nature of the tumor, a left forequarter amputation was performed. Histological examination demonstrated numerous islands of cartilage with an exuberant spindle cell component characteristic of FCM. No distant metastases or local recurrences were identified at 2 years post-amputation. Because of the rapid growth of this lesion, it should be considered in the differential diagnosis of bone lesions in children and young adults.

A Four-week-old Infant With an Intracardiac Mass

A Four-week-old Infant With an Intracardiac Mass

Osteosarcoma masked by osteomyelitis and cellulitis in a dog

This clinical report describes a 10-year-old female spayed German Shepherd dog cross that was presented with cellulitis of the left proximal forelimb and osteomyelitis of the left proximal humerus, and was ultimately diagnosed with metastatic osteosarcoma. The diagnosis of cellulitis and osteomyelitis was made using ultrasound, radiography, cytology and histopathology, all of which were consistent with cellulitis and osteomyelitis. Cultures were negative. The patient was treated using two surgical debridements and long-term broad-spectrum antibiotic drugs. Despite surgical and medical treatment, the dog's condition progressed. A lytic lesion of the left proximal humerus was identified radiographically. One hundred forty-one days after initial presentation, the dog was presented with a non-weight bearing lameness of the left forelimb. An amputation was scheduled. Preoperative computed tomography scan of the thorax revealed gross metastatic disease to the lungs. The patient was euthanatized and a post-mortem examination revealed osteosarcoma of the left proximal humerus with widespread metastasis. To our knowledge, this case is the first reported case of osteomyelitis masking osteosarcoma in a dog. It serves as a reminder to maintain a high index of suspicion when managing cases with a signalment, history and radiographic lesion that are consistent with a primary bone tumour.

CASE REPORT AND CLINICAL REVIEW: Acute lameness associated with osseous metastasis of a peri‐renal carcinoma in a horse

We present a case of aggressive metastatic carcinoma in a horse that was initially presented for shoulder lameness. Although radiography and scintigraphy were useful for localising a lesion in the proximal humerus, subsequent development of non-specific signs of systemic disease prompted further evaluation. Haematology and blood biochemistry, urinalysis and ultrasonography were all instrumental in identifying renal involvement. A diagnosis of a peri-renal mass causing secondary renal failure prompted euthanasia of the horse because of the poor prognosis. Antemortem findings were supported by necropsy, with secondary lesions also identified in the spleen, liver, 8th left rib and proximal humerus. Histological examination yielded a diagnosis of undifferentiated metastatic carcinoma.

Rhabdomyosarcoma in a Yellow-Headed Caracara (Milvago chimachima)

Rhabdomyosarcoma is a malignant tumor originating from rhabdomyoblasts that is rarely reported in domestic animals or in free-living and pet birds. This paper presents a case of rhabdomyosarcoma in a free-ranging yellow-headed caracara (Milvago chimachima), originating from the muscle region of proximal left humerus, with metastases in the left pectoral muscles, heart, lungs, and proventriculus. The cytology was suggestive of rhabdomyosarcoma because of malignant features and cytoplasmic cross-striations in cells. The histopathologic examination revealed neoplastic proliferation composed of spindle cells arranged in irregular sheets or bundles with marked cellular pleomorphism, moderate mitotic ratio, and multinucleated giant cells. Some neoplastic cells also presented evidence of scant cytoplasmic cross-striations visible at histologic sections stained by hematoxylin and eosin and phosphotungstic acid hematoxylin. Immunohistochemically, tumors cells were positive for desmin and negative for alpha-smooth muscle actin and S100 protein.

Malignant Melanoma of the Subcutaneous Tissues in an Umbrella Cockatoo (Cacatua alba)

A 24-year-old female umbrella cockatoo (Cacatua alba) was examined because of a subcutaneous swelling of the left shoulder. Radiographs of the left wing revealed boney proliferation of the left proximal humerus. At surgery, an unencapsulated infiltrative nonpigmented mass within the subcutaneous tissue and skeletal muscle was identified overlying the left humerus. The mass was surgically excised and submitted for histologic examination; however, the cockatoo died after excision. Histologically, the mass was composed of nests and sheets of pleomorphic neoplastic cells with a high mitotic index and extensive necrosis. Rare neoplastic cells contained fine brown cytoplasmic granules that stained black with Fontana-Masson, confirming the presence of melanin pigment. The histomorphologic diagnosis was consistent with an anaplastic malignant melanoma of subcutaneous tissues.

Reconstruction with Composite Cement-Autoclaved Autograft after a Near-Total Excision of the Humerus for Osteosarcoma: A Case Report

Osteosarcoma occurring in the humerus is often confined to the proximal part, in which case, reconstruction after excision is less daunting. When the tumour spreads down the medullary cavity distally, a total humeral replacement is often required. This is costly and beyond the means of the average patient in a developing country. An amputation is often the procedure of first resort. We report a 13-year-old boy with osteosarcoma originating from the left proximal humerus, with involvement of the marrow reaching down to the distal diaphyseal-metaphyseal junction, leaving only 6cm of the distal humerus intact after wide resection. Reconstruction of the defect was done with a composite cement-autoclaved autograft fixed to the remaining humerus with a plate. At 40 months of follow-up, the patient is well with normal function of the elbow, wrist and hand. Salvaging the limb despite near total involvement of the humerus by high grade osteosarcoma is possible using material available in the average orthopaedic operating room.

Secondary supratentorial primitive neuroectodermal tumor following treatment of childhood osteosarcoma

A 16-year-old Caucasian male was diagnosed with a primitive neuroectodermal tumor (PNET) 5 years following the diagnosis of nonmetastatic osteosarcoma of the left proximal humerus. The patient was initially treated with standard chemotherapy and limb salvage resection for osteosarcoma. Nine months after the completion of therapy, he developed lung metastases for which he underwent surgical resection and received additional chemotherapy. Almost 5 years after the osteosarcoma diagnosis, the patient was diagnosed with a supratentorial PNET, which represents the first known case reported in a patient with osteosarcoma.

A Primary Extragonadal Teratoma of the Proximal Humerus

A extragonadal malignant teratoma of the extremity is a rare pheonemenon. We describe a extremely rare case of malignant teratoma of the left proximal humerus in a 14-yr-old female. Radiologic evaluations, including magnetic resonance imaging, suggested a malignant bone tumor, but a pathological examination revealed an immature bony teratoma. Bone scintigraphy and positron emission tomography computed tomography scan showed increased uptake of proximal humerus but no other abnormal lesion.

Primary haemangiosarcoma in the proximal humerus of a Clydesdale gelding

SummaryAn 11‐year‐old Clydesdale gelding was presented for investigation of left forelimb lameness of 2 weeks' duration. The use of scintigraphic imaging helped to localise the source of lameness to the left proximal humerus. In this report, the clinical and diagnostic imaging features of a primary osseous haemangiosarcoma in a horse are described, along with the challenges of establishing a definitive diagnosis ante mortem. In addition, neoplasia of the appendicular skeleton should be considered a differential cause of lameness in the horse.

Paget Disease of the Humerus Mimicking Metastatic Disease in a Patient With Metastatic Malignant Mesothelioma on Whole Body F-18 FDG PET/CT

A 71-year-old man with newly diagnosed malignant mesothelioma was referred for an F-18 FDG PET/CT study to evaluate the extent of disease. PET showed mild FDG uptake in the right chest, corresponding to a lobulated, mass-like right pleural effusion versus thickening involving the entire right pleural space, and some mediastinal involvement, on the accompanying CT scan. In addition, marked FDG uptake was seen in the proximal left humerus, suspicious for an osseous metastasis. The corresponding CT scan findings of cortical thickening and a "Swiss cheese" appearance were most consistent with Paget disease. The intense FDG uptake in an osseous lesion on FDG-PET in our case reminds us of the variable nature of FDG uptake in Paget disease, the possibility of false-positive findings on FDG-PET in patients with cancer, and the usefulness of the fusion techniques in the evaluation of skeletal lesions, with the potential for discriminating between benign Paget disease and other pathologic bone findings.

Pectoralis Injury In Water Skier

HISTORY: A 40 y/o right hand dominant male presented with left shoulder pain and anterior chest wall pain that began while water skiing. He was transferring to one ski when he fell to the left side and his left arm continued to go into the water and was forcefully abducted and externally rotated. He experienced intense abrupt pain at the lateral chest wall and medial humerus. He denied hearing a pop or having paresthesias. The pain prevented him from continuing to water ski. The following morning his left anterior chest wall and medial aspect of his left arm were markedly swollen and bruised. Over the next 2 days, he noticed weakness of his left shoulder with persistent pain and swelling. He iced this region and took Ibuprofen intermittently. PHYSICAL EXAMINATION: Shoulder exam revealed edema and ecchymosis that extended from the left sternum to the proximal medial humerus. Loss of anterior axillary fold and lateral shifting of the left pectoralis sternal head were noted. Maximal tenderness was palpated in the left proximal medial humerus and sternal attachment of the left pectoralis major muscle. There was decreased muscle strength (4/5) of shoulder adduction in abducted external rotation position. There was full active and passive range of motion of the left shoulder. Supine exam revealed palpable thickening of the left pectoralis muscle with a small divot noted. Normal sensation and pulse. DIFFERENTIAL DIAGNOSIS: Pectoralis major musculotendinous rupture Pectoralis major muscle strain Humeral shaft avulsion fracture TESTS AND RESULTS: Shoulder X-rays (2 views): Normal. Left Humerus X-rays (2 views): Normal. MRI: Rupture of left pectoralis major muscle tendon insertion from sternum. FINAL WORKING DIAGNOSIS: Left pectoralis major musculotendinous rupture TREATMENT AND OUTCOMES: Open left pectoralis major tendon repair. Left shoulder immobilizer for 2 weeks. Physical therapy to normalize range of motion and strength; focusing on shoulder internal rotation, adduction, and forward flexion for 3 months duration. At cessation of physical therapy, strength was 5/5 in internal rotation, forward flexion, and adduction. Good pectoralis contour was noted. Patient released to weightlifting at 50% of maximum and instructed to gradually work up to 100% at six months postoperative.

Right Lower Extremity Swelling

A 4-month-old male infant who was born at 24 weeks’ gestation with right lower extremity swelling. ### Prenatal and Birth Histories ### Medications The infant experienced hypercalcemia and hypophosphatemia for most of his hospital stay (Table). View this table: Table. Laboratory Values During Postnatal Hospital Stay On postnatal day 125, the infant had right lower extremity swelling. Skeletal survey showed fractures in the right distal femur, right and left proximal tibia (Fig. 1), left distal femoral epiphysis and proximal left humerus, left distal radius, right proximal humerus, right distal radius and ulna (Fig. 3 - seen later). Bilateral rib fractures also were present (Fig. 2). Associated findings included decreased bone density, minimal bowing of the lower extremities, metaphyseal widening, and significant soft-tissue swelling in the knees and shoulders. Figure 1. Portable left lower extremity radiograph demonstrates …

Poly-epiphyseal overgrowth: description of a previously unreported skeletal dysplasia

A skeletal dysplasia with previously unreported features is presented. Its evolution was characterized by growth abnormalities of bones without involvement of other organs. Advanced bone age, increased stature and irregular epiphyseal ossification with stippling of the main long bones were documented. Physeal overgrowth was massive in the left proximal humerus and femur. Furthermore, the hip joint appeared fused with an abundant mass of pathological calcific tissue extending from the femur to the ilium. Pathological epiphyses were characterized by anarchic cartilaginous proliferation with multiple ossification centres, while lamellar bone apposition and remodelling were normal. The observed bone changes were different from those in any previously reported syndrome, metabolic defect or bone dysplasia. However, they clearly indicated a defect of endochondral ossification with some resemblance to phenotypes observed in dysplasia epiphysealis hemimelica.

Rupture de l’artère brachiale et paralysie radiale secondaire à une exostose proximale de l’humérus chez une enfant de 14 ans

Rupture of the brachial artery associated with radial nerve palsy in a context of exostosis of the proximal humerus has not been described to date in the literature. Our patient was a fourteen girl with a history of violent pain occurring suddenly with no prodrome or triggering factor. The pain was localized at the level of the proximal left humerus. Physical examination revealed the presence of a hematoma and complete motor radial nerve palsy. The diagnosis was not confirmed by computed tomography with contrast injection but was confirmed by magnetic resonance imaging which eliminated malignant transformation of the exostosis. After checking the neurovascular bundles and evacuating the hematoma, treatment consisted in resection of the exostosis and arterial repair with an autologous venous graft. We discuss the diagnostic and therapeutic challenges which present vascular complications due to exostosis.

Comparison Between Polyurethanes Containing Castor Oil (Soft Segment) and Cancellous Bone Autograft in the Treatment of Segmental Bone Defect Induced in Rabbits

The aim of this study is to compare polyurethanes containing castor oil (soft segment) in granular form compared to cancellous bone autograft applied to a segmental bone defect. Norfolk adult female rabbits - approximately 13 months of age with a mean body weight of 4.5 kg - are used. In both radial diaphyses, 1 cm osteoperiosteal segmental defects are created. The defect in the left radius is filled with the castor-oil-based polyurethane, and the right one, filled with cancellous bone autograft, collected from the left proximal humerus. The rabbits are euthanazed at 15, 30, 60, and 120 days postsurgery (5 animals/ period), for histological analyses. By radiographic analyses, at these time points, the bone regeneration is more evident and accelerated in the bone defects treated with the cancellous bone autograft. At 120 days postsurgery, the segmental bone defects treated with the cancellous bone autograft are totally reconstituted and remodeled, while the bone defects treated with polyurethane polymer have bone formation of 79%. Histological study shows that the polyurethane acts as a space filler, minimizing the local production of fibrous tissue. No granule degradation, resorption or any inflammatory reaction is detected. Thus, it is possible to conclude that the castor-oil-plant-based polyurethane - in the granule presentation - is biocompatible and osteointegrated, but does not show the same bone regeneration capacity as the cancellous bone autograft.

Multifocal osteomyelitis in a child: a rare manifestation of cat scratch disease

We present a case of a 9-year-old immunocompetent girl who presented with pain in her left elbow and a painful swelling at her left clavicle. She had no lymphadenopathy or fever. Four hot spots were seen at her left clavicle, proximal and distal left humerus and lumbo-sacral spine on a bone scan. A magnetic resonance imaging showed an inflammatory process with bone destruction at her clavicle. Serological testing and polymerase chain reaction performed on a bone biopsy identified a Bartonella henselae infection. She was treated with rifampin and trimethoprim-sulphamethoxazole. After a relapse half a year later, the patient recovered fully. Multifocal osteomyelitis is a rare manifestation of cat scratch disease in children.

The birds of the Djurab Pliocene faunas, Chad, Central Africa

The Pliocene sites of the Djurab region (Chad, Africa) have yielded 19 avian remains. They belong to seven different taxa: a cormorant, Phalacrocorax cf. carbo, a darter, Anhinga cf. melanogaster, a heron (Ardeidae), a Ciconiidae of the tribe Leptoptilini, the size of the extant African species of marabou stork or Saddlebill, an extinct marabou stork (or adjutant) of large size - Leptoptilos sp. B, an Anserinae (swan or goose), and a duck (Anatinae). These birds indicate freshwater environments, a slow river or a lake. Also represented in the landscape were open as well as forested areas, like gallery forest. The avifaunas are thus well congruent with other paleoenvironmental results obtained at these sites, particularly regarding the humid character of the region in the Pliocene, and generally of the climate for that period in a part of the Sahel which is now desertic.

Extraskeletal mesenchymal chondrosarcoma: Case report

This is a case report of an extraskeletal mesenchymal chondrosarcoma (ESMC) that originally occurred in the retroperitoneum of a 24-year-old female and later metastasized to the left proximal humerus. Mesenchymal chondrosarcomas are very rare in comparison to conventional chondrosarcomas and even more so when arising from an extraskeletal location. In this report, we discuss the major characteristics of ESMC and offer a review of the current knowledge regarding this rare disease entity.

Musculoskeletal case of the day. Pseudoaneurysm of the left superficial femoral artery.

About 6 months before presentation, this 62-year-old man noticed diffuse swelling and progressive loss of motion of the left shoulder and upper arm. About 4 months before presentation, he identified a nontender lump in the left shoulder. Physical examination revealed a large firm mass that extended into the root of the neck, medially to the chest wall, and inferiorly to the supracondylar region of the left elbow. Circulation, sensation, and function in the left hand were normal. Twenty years earlier, he had undergone biopsy for a left shoulder mass, which was diagnosed as an osteochondroma. The patient’s history did not reveal whether the mass had been completely surgically excised. Radiologic examination of the left humerus and shoulder (Fig. 1A) revealed a massive, amorphous, irregularly calcified, and ossified mass replacing and infiltrating the shoulder and arm as well as encircling the humerus. An anterior mTc methylene diphosphonate (MDP) scintigram (Fig. 1 B) showed markedly increased tracer accumulation in the mass in the left upper extremity. Intramedullary invasion, cortical destruction, and infiltration of adjacent structures by the juxtacortical humeral mass were shown by CT (Fig. 1 C). The extent of the tumor was delineated by MA examination. The Ti -weighted coronal MR images (Fig. i D) showed intermediate-signal tumor replacing the marrow of the left proximal humerus, enveloping the humerus, and infiltrating adjacent structures. The superior, medial, and inferior extent of the tumor was readily identified as bright signal infiltrating adjacent tissues on the T2-weighted MR coronal images (Fig. i E). Histologic examination revealed a parosteal osteosarcoma. Parosteal osteosarcoma is a rare, slow-growing, malignant, bone-forming neoplasm that arises from the surface of long bones. It has a better prognosis than conventional central osteosarcomas and other surface (juxtacortical) osteosarcomas [i -3]. Patients are generally affected in the second to fifth decades of life. They usually have gradual onset of pain, swelling, and a palpable mass [1 , 4]. The indolent behavior of the tumor delays diagnosis. As illustrated in this case, the tumor may attain enormous size before the patient seeks clinical evaluation [i , 4]. In addition, radiologic and histologic misdiagnosis as benign osteochondroma [2] may result in inadequate surgical excision of the tumor-a distinct possibility in this patient. The lesion most often arises from the metaphysis of a tubular bone, occasionally from the epiphysis, and rarely from the diaphysis [1 , 4]. The most common location is the posterior aspect of the distal femur, followed by the proximal humerus, the tibia, fibula, and ulna [i , 4]. This malignant neoplasm grows circumferentially along the cortex of the involved bone, eventually enveloping the bone shaft. Cortical destruction and neoplastic invasion of the medullary cavity are uncommon except in cases of prior treatment or a long history of growth, as illustrated in this case [3-5]. On radiographs, early parosteal osteosarcomas are radiodense, lobulated, or oval masses with a broad base of attachment to the external cortex. A thin, radiolucent cleavage plane between the tumor and underlying bone is characteristic but not a constant finding [i , 3-5]. Progressive growth of the tumor may obliterate this plane. This tumor ossifies from the base of the lesion to its periphery in contradistinction to myositis ossificans, which initially ossifies from the periphery [1 , 2, 4]. The differential diagnosis of a less advanced case of parosteal osteosarcoma includes osteochondroma, myositis ossificans, central osteosarcoma, extraosseous osteosarcoma, ossifying or calcifying hematoma, and exuberant callus [4, 5]. CT and MR studies assist in delineating the extent of the process and in preoperative planning [4, 5]. Margaret A. Stull Mark Glass-Royal