|IMAGES IN RHEUMATOLOGY
|Ahead of print publication
Bilateral shoulder synovial chondromatosis: Multimodality imaging
D Suresh Kumar, Dillibabu Ethiraj, Venkatraman Indiran, Prabakaran Maduraimuthu
Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chromepet, Chennai - 600 044, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Keywords: Chondromatosis, shoulder, synovial
| Case History|| |
A 50-year-old male presented with chief complaints of multiple, small, hard swellings in the bilateral axillary region for the past 8 months, gradually increasing in size. He had dull pain and restriction of movements in the bilateral shoulder above 90°. He was a farmer by occupation. There was no history of trauma, fever, and systemic illness. General physical examination and systemic examination were normal. On local examination of the axillary region, obvious swellings were inspected and palpated. Each mass measured approximately 1 cm; it was globular, hard, and mobile with no associated skin changes. Resisted active motion of the shoulder was painful. Distal neurovascular status was normal. All laboratory investigations were within normal limits. Radiograph of both the shoulder joints showed multiple calcified nodules around both the shoulder joints [Figure 1]. Ultrasonography (USG) of both the shoulders showed multiple hyperechoic arc-like areas with after shadowing in both the joints consistent with loose bodies [Figure 2]a and [Figure 2]b. Magnetic resonance imaging (MRI) of both the shoulders revealed otherwise normal glenohumeral joints with multiple nodular T2 hypointense lesions seen in the subcoracoid and subdeltoid bursa [Figure 2]c and [Figure 2]d, prompting the diagnosis of bilateral shoulder synovial chondromatosis. We advised him for synovectomy and removal of free fragments.
|Figure 1: Radiograph of both the shoulder joints shows multiple calcified nodules (yellow arrow) around both the shoulder joints|
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|Figure 2: Ultrasonography (a and b) of both the shoulders showed multiple hyperechoic arc-like areas with after shadowing in both the joints consistent with loose bodies (yellow arrow). Magnetic resonance imaging (c and d) of both the shoulder joints shows multiple nodular T2 hypointense lesions (yellow arrow) in the subcoracoid and subdeltoid bursa|
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| Discussion|| |
Shoulder synovial osteochondromatosis is a rare benign articular pathology. It is characterized by proliferation of synovial membrane and metaplasia with multiple osteocartilaginous or cartilaginous nodules within the tendinous sheath, bursa, and joints. There are two forms: primary and secondary synovial chondromatosis. A primary form has unknown causes, and it is usually monoarticular, rarely seen in diarthrodial joints. The secondary form may be due to trauma, osteochondritis dissecans, neuropathic osteoarthropathy, rheumatic arthritis, and tubercular arthritis. It is three times more commonly seen in males as compared to females, and the age of presentation is in between third and fifth decades. We present a case of bilateral primary shoulder synovial osteochondromatosis with imaging studies. Patients usually present with restriction of the joint movement, local pain, and swelling over years as in our case. It most commonly involves knee joints (65%), followed by hip (20%), elbow, ankle, temporomandibular joints, and shoulder joint. Intra-articular synovial chondromatosis is classified into three stages on the basis of histopathology by Milgram. Stage 1 represents active chondroid neoplasia of synovium without intra-articular chondroid nodules. Stage 2 represents both intrasynovial chondroid and intra-articular chondral nodules. Stage 3 represents intra-articular chondroid nodules, but no active synovial-based disease. Imaging finding is pathognomonic of synovial chondromatosis. Radiographic findings include multiple intra-articular chondral nodules with “ring-and-arc” chondroid calcification as seen in our case. However, in some cases, radiograph may not show clear findings, in which MRI is needed for accurate diagnosis. Computer tomography (CT) is used to detect and characterize calcification in the intra-articular, tenosynovial, and bursa. As features of synovial chondromatosis was so obvious on radiograph, CT was not done. In MRI, usual pattern is characterized as lobulated, homogeneous, intra-articular, intermediate isointense to muscle on T1-weighted images, with high signal intensity on T2-weighted images. Focal areas of low signal intensity on all pulse sequences correspond to regions of calcification on radiographs as seen in our case. Ultrasound shows heterogeneous, predominantly hyperechoic foci representing chondral fragments within the bursa, joint, and tendon sheath of the synovium. Posterior acoustic shadowing represents mineralization or endochondral bone formation. The recurrence of synovial chondromatosis ranges from 3.2% to 22.3%. Recurrence at the same location is prone for malignant transformation to synovial chondrosarcoma. Hence, it is recommended for close follow-up.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]