Image Quiz
A Thirty-eight-Year-Old Man with Painful Lesions About the Elbow
By Hilary F. Hornbuckle, MS, Harish S. Hosalkar, MD, Michael A. Husson, MD, Richard D. Lackman, MD, and Christian M. Ogilvie, MD*, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
A thirty-eight-year-old man presented with two intermittently painful masses about the proximal portion of the right forearm. These masses had been growing in size throughout the previous year. The first mass was located over the olecranon and was minimally symptomatic. The newer mass was separate and appeared on the proximal extensor side of the ulna, causing mild to moderate intermittent pain. The patient had no precipitating or alleviating factors in association with this pain. There was no history of antecedent trauma, and the patient had no history of numbness and/or paresthesias, fevers, chills, night pain, night sweats, or weight loss during the course of the previous year.
On physical examination, there was full range of motion, full strength, and normal neurovascular findings of the upper extremities bilaterally. Both lesions were fixed and mildly tender on palpation. The first lesion contained firm areas, and the second was soft. There was no erythema or edema present over the two masses. The proximal mass was 3 cm × 3 cm, and the distal mass was 5 cm × 4 cm.
A plain radiograph of the elbow was made (Fig. 1), and T1-weighted magnetic resonance imaging (with contrast) of the right elbow was acquired (Figs. 2 and 3).
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Fig. 1 |
Fig. 2 |
Fig. 3 |
Fig. 1 Lateral radiograph of the right elbow, showing small erosion of the olecranon (arrow) with no soft-tissue deposits visible.
Figs. 2 and 3 Fat-saturated sagittal T1-weighted magnetic resonance images with intravenous gadolinium contrast of the adjacent but separate masses in the right elbow. Fig. 2 Proximal mass (gray arrow) associated with focal erosion (white arrow) of the cortex of the posterior proximal aspect of the ulna. Fig. 3 The distal mass (arrow) in the posterior region of the elbow and forearm is shown. The proximal mass has slightly heterogeneous internal enhancement and thick irregular rim enhancement. Both masses are essentially confined to the subcutaneous fat regions. However, the surrounding subcutaneous fat is edematous and exhibits some irregular enhancement. The proximal mass immediately about the distal aspect of the triceps tendon and the tendon itself contain some increased signal near the tendon insertion site. The marrow signal is unremarkable except for the focal area, where there is apparent erosion of the proximal aspect of the ulna along with a marginal spur. |
An ultrasound-guided biopsy of the mass was performed, and the histopathologic results are presented in Figs. 4, 5, and 6.
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Fig. 4 |
Fig. 5 |
Fig. 6 |
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