Rev. bras. ortop. vol.52 número2

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

report

Osteoid

osteoma

of

the

distal

clavicle

夽

Bernardo

Barcellos

Terra

∗

_,

_Leandro

_Marano

_Rodrigues,

_David

_Victoria

_Hoffmann

_Padua,

Tannous

Jorge

Sassine,

José

Maria

Cavatte,

Anderson

De

Nadai

SantaCasadeMisericórdiadeVitória,DepartamentodeOrtopediaeTraumatologia,Vitória,ES,Brazil

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t

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Articlehistory:

Received23November2015

Accepted29March2016

Availableonline17February2017

Keywords:

Clavicle

Osteoidosteoma

Shoulder

a

b

s

t

r

a

c

t

Theosteoid osteomais a bonetumor thataccounts for10%ofbenigntumors. Itwas

describedin1935byJaffe,asatumorthataffectstheyoungadultpopulation,witha

pre-dominanceofmales.Thisstudyaimstopresentacaseoflatediagnosisofapatientwith

osteoidosteomaofthedistalclavicleregion.Femalepatient,44yearsold,non-professional

volleyballplayer, reportedpainintheanterior andsuperiorregionoftheshoulder

gir-dle,specificallyinthe acromioclavicular joint,whichworsenedatnight andhadbeen

treatedforninemonthsastendinitisoftherotatorcuffandacromioclavicularjoint

arthri-tis.Afterconfirmingthediagnosis,thepatientunderwentopensurgerywithresectionof

thedistalclavicle.Attwoyearsoffollow-up,thepatientpresentswithoutlocalpain.In

theradiographicevaluation,coracoclaviculardistanceispreservedandtherearenosigns

ofrecurrence.Tumorsoftheshouldergirdlearerareandareoftendiagnosedlate.Ahigh

degreeofsuspicionforthediagnosisoftumorsoftheshouldergirdleisneededinorderto

avoidlatediagnosis.

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Osteoma

osteóide

da

clavícula

distal

Palavras-chave:

Clavícula

Osteomaosteóide

Ombro

r

e

s

u

m

o

Oosteomaosteóideéumtumorósseoquecorrespondea10%dostumoresbenignos.Foi

descritoem1935porJaffe,comoumtumorqueacometeapopulac¸ãoadultajovem,com

predominâncianosexomasculino.Oobjetivodotrabalhoéapresentarumcasode

diag-nósticotardiodeumapacientecomosteomaosteóidedaregiãodaclavículadistalerelatar

seutratamento.Pacientede44anos,jogadoradevôleinãoprofissional,comdoresnaregião

anterioresuperiordacinturaescapular,maisespecificamentenaarticulac¸ão

acromioclav-icular,asquaispioravamanoiteequeeratratadahavianovemesescomoumatendinitedo

manguitorotadoreartritedaarticulac¸ãoacromioclavicular.Apósconfirmac¸ãodiagnóstica,

apacientefoisubmetidaaotratamentocirúrgicoabertocomressecc¸ãodaclavículadistal.

夽

StudyconductedattheSantaCasadeMisericórdiadeVitória,DepartamentodeOrtopediaeTraumatologia,Vitória,ES,Brazil.

∗ _{Corresponding}_author_.

E-mail:bernardomed@hotmail.com(B.B.Terra).

http://dx.doi.org/10.1016/j.rboe.2017.01.006

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Atualmenteapacienteencontra-secomdoisanosdeevoluc¸ãosemdorlocal.Naavaliac¸ão

radiográfica,adistânciacoracoclavicularencontra-sepreservadaenãohásinaisderecidiva.

Tumoresósseosdacinturaescapularsãorarosefrequentementesãodiagnosticados

tardia-mente.Deve-seterumaltograudesuspeic¸ãoparaodiagnósticodeneoplasiasdacintura

escapular,afimdeevitarodiagnósticotardio.

EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Osteoidosteomaisabenignbonetumorthataccountsfor10%

ofbenigntumors,representingthethirdmostcommonbone

tumor.Ithasapreferenceforthediaphysisoflongbones,such

asthetibiaandfemur.Itwasdescribedin1935andlaterin

1953byJaffe;itisatumorthataffectstheyoungadult

popu-lation,inthesecondandthirddecadeoflife,predominantly

inmales.1–3

Theclinical presentationcomprises mildtoseverepain,

predominantlyatnight,whichisusuallyrelievedbytheuse

ofsalicylates.Itcanbelocatedinanyboneregion,buthalfof

casesinvolvethefemurandthetibia.

Itspresenceintheregion ofthescapula and clavicleis

extremelyrare,withfewreportsintheliterature.Aliterature

searchretrievednocasesdescribed atthedistalendofthe

clavicle.

Thisstudyaimedtopresentacaseoflatediagnosisofan

osteoidosteomaofthedistalclavicleregionandtoreportits

treatment.

Case

report

A44-year-oldfemale, recreativevolleyballplayer,presented

withanteriorandsuperiorscapulargirdlepain,more

specifi-callyattheacromioclavicularjoint,whichworsenedatnight;

thisconditionhad beentreatedforninemonthsasrotator

cufftendinitisandacromioclavicularjointarthritis.Painwas

partiallyalleviatedbysalicylates.Patientdeniedahistoryof

previoustraumaorfall.

Onphysicalexamination,noedema,deformities,or

atro-phies in the region of the shoulder girdle were observed.

Passiveandactiverangeofmotionwerenormal,exceptfor

thefactthatforcedadductionwaspainfulattheextremeend

ofthemovement.

O’Brientestwas positiveinthesemiologicalmaneuvers

andatthepalpationoftheacromioclavicularjoint.Othertests

forrotatorcuffandinstabilitywerenegative.

Patientunderwentcomplementaryexaminations,through

whichtheosteoidosteomawasevidenced,withitspeculiar

characteristicsatthedistalendoftheclavicleatthe

acromio-clavicularjoint(Figs.1–3).

Patient underwent open resection of the distal end of

the clavicle (approximately 1.5cm) in a way that did not

compromisetheinsertionofthecoracoclavicularligaments;

electrocoagulation withradiofrequencywas performeddue

to bone bleeding (Figs. 4 and 5). Tissue sample was sent

forhistopathological analysis and the diagnosis of osteoid

osteomawasconfirmed(AppendixA1,inadditionalmaterial).

Fig.1–Anteroposteriorviewradiographshowinganarea

ofsclerosisinthelateraldistalregionoftheclavicle.

Fig.2–Magneticresonanceimaging(MRI)incoronal

sectionshowingimageofthetumortogetherwithintense

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Fig.3–MRIinsagittalsectionshowingtheimageofthe

nidusalongwithintenseedemainthelateraldistalregion

oftheclavicle.

Fig.4–Photographofthesuperioraccessrouteoverthe

claviclewiththeopenedacromioclavicularjointanda

curvedKellyforcepspointingtowardtheosteoidosteoma

region.

Intwomonths,patientevolvedfromavisualanalogscale

(VAS)scoreof9inthepreoperativeperiodto1.

Currently,at24monthsoffollow-up,shepresentsnolocal

pain.Radiographicevaluationshowsthatthe

coracoclavicu-lardistanceispreservedandtherearenosignsofrecurrence

(Fig.6).

Discussion

The clavicle is a rare location for tumors.4–6 _Therefore,

orthopedistshavelittleexperienceinthediagnosisand

man-agementoftumorsandneoplasticconditionsofthisbone.The

Fig.5–Photographshowingtheosteotomyofthelateral

distalregionoftheclavicle.

oncologicalcharacteristicsofclavicletumorsresemblethose

offlatboneswhencomparedwiththoseoflongbones.Tumors

oftheclaviclearemostlymalignant;diagnosisisoftenlatedue

tothelowdegreeofsuspicionofthispathology.7

Osteoidosteomaaccountsfor10%ofbenignbonetumors,

being more common in menand inthe second and third

decadeoflife.8_In_the_superior_cingulate,_the_most_common

siteofinvolvementistheproximalhumerus.Among

imag-ing studies, osteoid osteoma presents in radiographs as a

radiolucent imagewith centralcalcification. Lesionsin the

spongy boneusuallypresentas asmallarea ofrarefaction

with an area surrounded bysclerosis. Computed

tomogra-phyaidsinthelocalizationofthetumor.Magneticresonance

imagingpresentstumorchangesasalowintensitysignalat

T1andsignsofvariableintensityatT2-weighted.Although

tomographyisthestudyofchoice,theedemasurroundingthe

tumorandthebonemarrowalterationsarebestobservedwith

magneticresonanceimaging,asdemonstratedinthepresent

case.

Kapooretal.2_reported_a_case_series_of₁₂_tumors_on_the

clavicle,the mostcommon ofwhichwasEwing’s sarcoma;

treatmentrangedfrompartialclaviculectomyto

chemother-apy. In theirseries, those authors did notreport acaseof

osteoid osteoma, despite reporting of a case with a rare

periostealdesmoidtumor.

Only 1% of all bone tumors affect the clavicle.9–11 _The

mostcommonsiteistheacromialend,whichisinagreement

withthepresentcasereport.Miyasakietal.12_reported_a_case

ofosteoidosteoma intheacromionsimulatingpain inthe

acromioclavicularjoint,whichwasresectedarthroscopically

andassociatedwithanacromioplasty;patienthadacomplete

recovery ofrange ofmotionand no signsof recurrencein

sevenyearsoffollow-up.Degreefetal.11_also_reported_a_case

inwhich theacromion wasresectedthrough theMumford

arthroscopic procedure.Inthe presentcase,openresection

was chosen due to the fact that this was a tumor, albeit

benign,andthismethodfacilitatesthecollectionofmaterial

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Fig.6–Radiographyonanteroposteriorandprofileviews,inwhichexcisionofthedistalfragmentoftheclaviclewiththe

osteoidosteomaisnoted.

Glanzmannetal.13_reported_a_case_of_osteoid_osteoma_of

thecoracoidsimulatingadhesivecapsulitis,whichwasalso

resectedbyarthroscopyandelectrocauterizationthroughthe

rotatorinterval.

The natural course of osteoma may be spontaneous

resolution over time; however, residual pain and

persis-tentsymptomsareindicativeofsurgery.Multipletreatment

optionsfor this tumorare available, suchasdrug therapy,

percutaneous radiofrequency ablation, and surgical

proce-duresinvolvingcompleteremovalofthenidus,whichcanbe

obtainedbycurettage, enbloc resectionand,morerecently,

arthroscopy,withgoodresults.Minimallyinvasivetreatments,

suchasradiofrequencythermocoagulationandpercutaneous

excisionalcorebiopsy,arethetreatmentsofchoiceinmany

centers,avoidingthecomplicationsofopensurgery.Themain

advantagesofpercutaneoustechniquesarefasterreturnto

activities,lowermorbidity,and,incasesofosteoidosteoma

ofthespine,maintenanceofstability.However,orthopedists

shouldbeawareofpossiblethermallesionstoneurological

structuresand,incasesofexcisionalbiopsy,ofincomplete

removalofthetumor,whichcouldleadtorecurrenceof

symp-tomsandlesion.4,14–17

Inordertoavoidlatediagnosis,scapulargirdleneoplasms

shouldbeconsideredinthediagnosisofrefractorypaininthe

superiorcingulateregion.

Conclusion

Theauthorsdescribedararecaseofosteoidosteomaatthe

distalendoftheclavicle.Despitetherarity,itisnecessaryto

includeneoplasmsinthedifferentialdiagnosesofpathologies

oftheshoulder.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Appendix

A. Supplementary

data

Supplementarydataassociatedwiththisarticlecanbefound,

intheonlineversion,atdoi:10.1016/j.rboe.2017.01.006.

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