Simple bone cyst with pathologic fracture

Case contributed by Dr Matt Skalski

Presentation

Shoulder pain, deformity and swelling after a minor trauma.

Patient Data

Age: 50 years
Gender: Male

The proximal humeral metaphysis and visualized portion of the proximal diaphysis demonstrate a well-defined lesion with minimal trabeculation, cortical thinning and areas of varying density that appear somewhat ground-glass in nature. There is no associated periosteal reaction or soft-tissue mass. There is an obliquely oriented, cominuted fracture through the lesion with moderate offset of the most distally visualized fragment. A long-bone study of the right humerus is nececary to asses the distal extent of the lesion. 

The lesion extends from the proximal humeral physis into the distal third of the humerus. There is moderate medial angulation and lateral offset of the primary oblique fracture, with multiple smaller comminuted fragments of thin cortical bone, making the lesion appear more cystic in nature. 

Core biopsy and FNA through fracture site, taking care to avoid the cephalic vein. No solid celluar tissue was retrieved.

Following core biopsy and FNA attempts, 20 mL of 4:1 dilute contrast was injected through the coaxial needle into the cavity of the lesion without resistance. There is long segment of filling of the lytic lesion, with spillage of contrast through the fracture sites into the adjacent subcutaneous tissues, suggesting the lesion is cystic in nature. 

Case Discussion

This case is interesting to me for three reasons: The simple bone cyst is quite large, persisted for an unusually long time without fracture, and was definitely diagnosed by demonstration of the cystic nature of the cavity via contrast injection into the pathological fracture. 

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