|Year : 2013 | Volume
| Issue : 3 | Page : 338-341
A rare case presentaion of osteochondroma of scapula
Anil Salgia, Samar Kumar Biswas, Tushar Agarwal, Sahil Sanghi
Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||5-Jul-2013|
Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
A 17-year-old female presented with complains of swelling in left scapular region since the age of 5 years, which had progressively increased in size. This condition was asymptomatic, but caused visible cosmetic concern to the patient and her parents as she was approaching a marriageable age. An En bloc excision of exostoses scapula was done; the patient had full functional recovery with no visible swelling. Histopathology, the diagnosis of osteochondroma was established. The patient was satisfied after the surgical resection of the tumor as, cosmetically, she looked near normal.
Keywords: Multiple hereditary exostosis, osteochondroma, En bloc excision
|How to cite this article:|
Salgia A, Biswas SK, Agarwal T, Sanghi S. A rare case presentaion of osteochondroma of scapula. Med J DY Patil Univ 2013;6:338-41
| Introduction|| |
Osteochondroma is a benign tumor that consists of cartilage and bone.  It is a benign cartilage-capped outgrowth, connected to bone by a stalk. It is the most frequently observed in the neoplasm of the skeleton. It generally occurs at the end of the growth plates of long bones and most commonly form at the shoulder or the knee, but it has also been known to occur in the long bones of the forearm (i.e., the radius and ulna). Literature on involvement of other anatomic areas is limited. Osteochondroma is a benign tumor that contains both bone and cartilage and usually occurs near the ends of long bones. This tumor, which is one of the most common benign bone tumors, takes the form of a cartilage-capped bony spur or outgrowth on the surface of the bone. It is sometimes referred to as osteocartilaginous exostosis. When an exophytic bone lesion contains a cartilaginous cap >1 cm in height or if there is associated pain, it is thought to be a higher risk for the lesion representing a chondrosarcoma.
| Case Report|| |
A 17-year-old female presented with gradually increasing swelling on dorsal aspect of left scapula since the age of 5 years. It was painless, but was a cosmetic concern to the patient and her parents. There was no history of trauma and it was not associated with fever, loss of weight, or any other constitutional symptoms. Past history and family history was non-contributory. There was no history of sudden increase in the size of the swelling.
On clinical examination, a large, hard, bony swelling of size 10 × 10 × 5 cm was palpable on the dorsum of left scapula [Figure 1]. The swelling was fixed to the underlying bone. Skin over the swelling was normal and freely mobile. There was no localized tenderness. Multiple palpable bony swellings were present at lower end of the femur, upper end of the tibia, and humerus.
There were no other musculo-skeletal abnormalities. Laboratory data was within normal limits. X-ray showed a sessile, cauliflower-like calcified growth on dorsal and medial aspect of scapula and multiple exostoses at lower end of femur and upper end of tibia [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] and [Figure 7].
|Figure 2: A sessile cauliflower, calcified growth is present on medial aspect of scapular spine and dorsal aspect of scapula on lateral X-Ray|
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|Figure 3: A sessile cauliflower, calcified growth is present on medial aspect of scapular spine and dorsal aspect of scapula on AP X-Ray|
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|Figure 4: X-ray AP right knee shows pedunculated growths on metaphyseal regions of femur and tibia, the stalk of the pedunculated growth is away from physis|
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|Figure 5: X-ray right knee lateral shows pedunculated growths on metaphyseal regions of femur and tibia, the stalk of the pedunculated growth is away from physis|
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Computed tomography (CT) scan confirmed a sessile cauliflower and calcified growth on the dorsal aspect of scapula with multiple exostoses of femur, tibia, and humerus.
Diagnosis of exostosis of scapula was made on the basis of history and clinical and radiological examination. Surgery was considered for cosmetic reason and because the patient was of a marriageable age.
Under general anaesthesia, the patient was put in a prone position. A dorsal skin incision on tumor mass in line with spine of scapula was taken. Further dissection was made with electric cautery to minimize blood loss. A dense shiny fibrous capsule was seen [Figure 8]. Muscle fibres were elevated subperiosteally. Tumor mass was excised with the help of an osteotome. Clear bone was seen after removal of tumor mass [Figure 9]. The mass so removed was 8.5 × 10.5 cm with smooth cartilage covering [Figure 10]. Postoperative immobilization was done in shoulder arm pouch. After removal of sutures on 15 th day, gentle active and passive shoulder and elbow movements were started. The patient recovered conventionally with no cosmetic deformity and discomfort.
|Figure 10: Tumour excised 10.5 cms × 8.5 cms, firm, lobulated covered with cartilagenous cap|
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| Discussion|| |
Osteochondromas accounted for 35-46% of all benign neoplasms of bone.  Osteochondromas are benign tumors composed of spongy bone covered by cartilaginous cap. They are the largest group of benign tumors. They are probably developmental malformations rather than true neoplasms and are believed to originate within periosteum as cartilaginous nodules.  They can be found in any bone preformed by cartilage. Most lesions are found during the period of rapid skeletal growth, and their growth usually ceases by skeletal maturity. Many of these lesions cause no symptoms; usually the physical finding is palpable mass. Multiple hereditary exostosis constitute an autosomal dominant condition with variable penetrance. In this condition, osteochondromas of many bones are caused by an anomaly of skeletal development. The most striking feature is the presence of multiple exostoses. Osteochondromas are of the following two types:
Pedunculated tumors are more common, with a definite stalk directed away from physis. ,
Malignant transformation of osteochondroma has been the principal concern, and its incidence in solitary osteochondroma is 1%. Malignant change is characterized by a sudden increase in the size of the tumor accompanied by pain. 
Theory of histogenesis is described as follows:
These lesions are believed to arise from abberent growth of normal epiphyseal growth plate. Typical locations include the metaphyseal regions of long bones such as the distal femur, proximal tibia, or proximal humerus. Literature on involvement of other anatomic areas is limited to few isolated case reports.  This condition is transmitted as an autosomal dominant trait with variable penetrance.  Our case was confirmed as osteochondroma of scapula with multiple exostoses. However, this is a rare occurrence of osteochondromas with no disturbance of skeletal growth. Scapular involvement accounts for 3.0-4.6% of all reported osteochondromas. ,
- Throughout life, the deep layer of the periosteum retains the potential for forming cartilage or bone
- The cambium layer produces an embryonic tissue that is common forerunner for bone and cartilage
- The tumor may represent a perverted activity of the periosteum that reverts to its role as perichondrium. 
Common presenting complaints of patients with an osteochondroma of the scapula include pain, decreased active ROM, crepitus with movements of the involved shoulder, and pseudowinging of the scapula. 
In our case, the selling was gradually progressive and painless with no sudden increase in size; hence, malignant transformation was not suspected. This was also confirmed with histopathology report. Our indication for excision in this case was mainly on the cosmetic ground. As the tumor was large, dissection was carried out down to the level of mass with the help of electro-cautrey to reduce blood loss. Muscle fibers were elevated sub-periosteally and, once the mass was clearly identified, it was excised with the aid of an osteotome. The patient was benefitted and satisfied for near normal cosmetic look after excision of the tumor and there was no evidence of recurrence of the tumor at follow-up after 18 months [Figure 11].
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]