A 17-year-old high-school football player fell on his shoulder during practice. When the pain continued for several weeks, the boy saw his primary-care physician, who obtained radiographs that showed a mixed lytic and sclerotic lesion at the inferior border of the body of the scapula with adjacent, disorganized, new bone formation (Fig. 1). These aggressive features prompted further evaluation with MR imaging, which showed a large region of bone-marrow edema and adjacent periostitis that was suspicious for Ewing sarcoma, lymphoma, or infection (Figs. 2A and 2B). The only abnormal activity on bone scan was increased uptake in the body of the scapula.
The youth continued to lift weights and participate in football despite the persistent shoulder pain that was somewhat decreased by the time of his scheduled bone biopsy one week following the MRI. One hour before the biopsy, a screening chest CT for pulmonary metastasis showed smooth periosteal reaction around the inner and outer surfaces of the scapula (Fig. 3A), which would be atypical for an aggressive bone neoplasm. Reformatted coronal oblique images of the scapula also showed a fracture line as an oblique linear lucency through the neck of the scapula (Fig. 3B).
Given the chest CT findings and the patient's slight symptomatic improvement, the biopsy was deferred. The patient was instructed to cease all athletic activity for four weeks and then return for a repeat chest CT, which confirmed healing of the fracture.