A 10-year-old male with no past medical nor family history presented with a one-year history of progressive pain, swelling, and reduced range of motion of the left shoulder. Initially, patient started complaining of intermittent shoulder pain with an 8/10 intensity, more prominently at night without preceding trauma nor weight changes. Patient was referred to our pediatric upper extremity clinic after an interventional radiologist performed a percutaneous biopsy that revealed GCTB.
During the physical examination, patient was anxious with left shoulder guarding. The left proximal humerus had a diffuse hard consistency mass with warmth, tenderness, visible vascularity and painful range of motion. Distal pulsation (+2) was palpable with adequate capillary refill. Neurological status was intact with an adequate gross sensation and two-point discrimination, and no paresthesia.
Preoperative radiographs showed an expansive lytic lesion at the left proximal humerus without any "soap bubble" appearance nor any visible fracture or dislocation. See Fig. 1. A magnetic resonance image (MRI) showed a primary heterogenous lesion surrounding the epiphyseal area of the lateral proximal humerus; with a minor involvement of periarticular subchondral bone, and displacement of the adjacent tendon and muscles. See Fig. 2. Chest radiographs and computerized tomography (CT) scan did not presented any evidence of pulmonary metastasis. Based on the previous biopsy and imaging, surgery was schedule for tumor resection by a pediatric upper extremity orthopaedic surgeon with more than 10 years of experience.
At surgery, a deltopectoral approach was used to demarcate the tumor. A synovectomy and interval split lateral to bicep tendon was performed to access the greater tuberosity. A friable grayish tissue in the periarticular area of subacromial and subdeltoid bursa was seen with intact cortical bone of greater tuberosity. Limited to no extension to metaphyseal was seen with intact subchondral bone at periarticular humeral head. Extensive curettage and bone saucerization of atypical tissue was performed with augmentation therapy of phenol through the bone window. See Fig. 3. Shoulder reconstruction was deferred as the joint appeared to be stable intraoperatively. Proximal humerus cavity was then filled with four milliliters of cement. Wound was closed in layers without complication. See Fig. 4. Finally, the shoulder was immobilized with a Velpeau Arm sling. Histopathological examination showed a red to brown, soft friable tissue (measuring 3.0 x 0.4 x 0.2 cm) with hemosiderin laden mononuclear cells; confirming the diagnosis of GCTB.
During the two-week postoperative visit at the outpatient pediatric orthopaedic clinics, patient started on rehabilitation therapy with active-assisted mobilization. Lastly, the six-month follow up evaluation showed that the patient had no guarding and reported significant pain improvement. Despite a limited improvement of active ROM, full passive ROM was preserved. Follow up radiographs showed filled cavity of epiphysis and subchondral bone of articular humeral head without evidence of recurrence. Patient is currently evaluated every 6 months for recurrence or metastasis of GCTB. See Fig. 5.
This manuscript was structured according to the Updating Consensus Surgical Case Report (SCARE) Guidelines.