We report a case of periosteal chondroma of the proximal humerus with multiple cartilaginous masses extending around two-thirds of the metaphysial circumference. The humerus was short, presumably because the tumour interfered with growth at the epiphysial plate

Ceciliani L.

Pazzaglia UE

PAZZAGLIA, Ugo

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290 THE JOURNAL OF BONE AND JOINT SURGERYPERIOSTEAL CHONDROMA OF THE HUMERUS LEADINGTO SHORTENINGA CASE REPORTUGO E. PAZZAGLIA, L. CECILIANIFrom the Clinica Ortopedica deli’ Universita di PaviaWe report a case of periosteal chondroma of the proximal humerus with multiple cartilaginous massesextending around two-thirds of the metaphysial circumference. The humerus was short, presumably becausethe tumour interfered with growth at the epiphysial plate.Periosteal chondroma is a benign tumour, many cases ofwhich have been reported since Lichtenstein and Hall(I 952) described it as arising between periosteum andcortex. It is widely recognised that the radiographs areeasily misinterpreted and thought to be those of achondrosarcoma (Lichtenstein and Hall 1952; Spjut el al.1971). The tumour is often situated in the proximalhumerus as were four of the eight cases reported byRockwell, Saiter and Enneking (1972).The following case is unusual because of the shorthumerus, and the multiple cartilaginous masses affectingmore than two-thirds of the shaft circumference.CASE REPORTA I 3-year-old boy presented with a painless hard masson the proximal shaft of his right humerus; the righthumerus was 6 cm shorter than the left (Figs I and 2).The parents had noticed the shortening six monthspreviously.Radiographs on admission showed an irregularerosion of the cortex on the medial, the anterior and thelateral aspects of the shaft, with some sclerotic reaction(Figs 3 and 4). Metaphysial remodelling proximal to thetumour was absent, but distally the bone was normal inshape. A radiographic survey showed the rest of theskeleton to be normal.Scintigraphy showed diffuse, weak uptake in theright humerus at the level of the lesion (Fig. 7).Arteriography did not demonstrate the nutrient arteryand showed the mass to be poorly vascularised (Fig. 5).The provisional diagnosis was low-grade chondro-sarcoma.U. E. Pazzaglia, MD, Assistant in OrthopaedicsL. Ceciliani, MD, Professor of OrthopaedicsClinica Ortopedica dell’Universita di Pavia, Via Taramelli, 1-27100Pavia, Italy.Requests for reprints should be sent to Dr U. E. Pazzaglia.f) 1985 British Editorial Society of Bone and Joint Surgery030l-620X/85/2057 $2.00 ______At operation three distinct masses were foundbeneath the periosteum: the largest on the medial aspectof the shaft, and the other two on the lateral and anterioraspects (Fig. 6). The affected portion of bone wasremoved en bloc and replaced by a free fibular autograft.Gross examination showed three masses of cartilagebetween the bone and the periosteum. Histologicallythese were composed of benign cartilage (Figs 8 and 9).The fIbular graft resorbed completely in fourmonths; consequently a vascularised fibular graft wasinserted and this consolidated in two months.DISCUSSIONThe difficulty in distinguishing between periosteal chon-droma and chondrosarcoma is well recognised. Radio-graphs can be misleading: in this case the three separatecartilaginous masses, involving the circumference of thehumerus extensively, gave the appearance of a lesioninvolving both cortex and medulla, leading to the.,.-.Fig. 7 Figure 8-Cartilage mass lying between the cortical bone and theperiosteum (haematoxylin and eosin, x I .2). Figure 9-Benign aspectof the cartilage (haematoxylin and eosin, x 200).PERIOSTEAL CHONDROMA OF THE HUMERUS LEADING TO SHORTENING 291VOL. 67-B, No. 2, MARCH 1985Scintigram showing slightly increased uptake in the righthumerus.Fig. 6Figures 3 and 4-Anteroposterior and lateralviews of the right proximal humerus. Figure5-The arteriogram does not demonstrate thenutrient artery of the humerus. Figure 6-Thediagram illustrates the position of the three car-tilaginous masses.The authors are grateful to Dr P. D. Byers for his advice and assistancewith this paper.REFERENCESDahlin DC. Bone tumours: general aspects and data on 6221 cases. 3rded. Springfield, Illinois: CC Thomas, 1978.Langenski#{246}ld A, Edgren W. The growth mechanism of the epiphysialcartilage in the light of experimental observations. Acta OrthopScand 1949:19: 19-24.Lichtenstein L, Hall JE. Periosteal chondroma: a distinctive benigncartilage tumor. J Bone Joint Surg [Am] 1952;34-A:691-7.Moed BR, Lamont RL. Unicameral bone cyst complicated by growthretardation: report of three cases. J Bone Joint Surg [Am] 1982:64-A: 1379-8 1.Nelson JP, Foster RJ. Solitary bone cyst with epiphyseal involvement:a case report. Cliii Orthop 1976;1l8:147-50.Pratt CWM. Observations on osteogenesis in the femur of the foetalrat. JAnat 1957:91:533-44.Rockwell MA, Saiter ET, Enneking WF. Periosteal chondroma. J BoneJoint Surg [Am] 1972:54-A: 102-8.Shapiro F. Ollier’s disease: an assessment of angular deformity,shortening and pathological fracture in twenty-one patients. JBone Joint Surg [Am] 1982;64-A:95-I03.Spjut HJ, Dorfman HD, Fechner RE, Ackerman LV. Tumors of boneand cartilage. (Atlas of tumor pathology, second series, fasc. 5)Washington, DC: Armed Forces Institute ofPathology, 1971.292 U. E. PAZZAGLIA, L. CECILIANITHE JOURNAL OF BONE AND JOINT SURGERYpresumptive diagnosis of chondrosarcoma. It was onlyby gross and microscopic examination that the diagnosisof periosteal chondroma was established.Periosteal chondroma is said to arise from theperiosteum (Spjut et a!. 1971; Dahlin 1978). The fourhumeral lesions reported by Rockwell et a!. (1972) wereall located proximally; they were said not to be anatomi-cally related to epiphysial cartilage. This was true also inour case where the tumour mass was about 2.5 cm fromthe growth plate. Nevertheless, the shortening of thehumerus focuses attention on the proximal growth plate.Humeral shortening in our patient was first ob-served six months before admission. Bone growth musthave been slowed before this, but not much before,otherwise there would have been greater discrepancy inlength. It seems reasonable to assume that the delay ingrowth began two or three years before presentation.Distal to the tumour there was a normally re-modelled metaphysis; but proximally remodelling waslacking. Presumably, therefore, the bone developednormally until the tumour interfered with metaphysialremodelling. Possibly the inhibition of metaphysial re-modelling coincided with the onset of reduced growth ofthe epiphysial plate. Retardation of growth has beenreported as a rare complication of unicameral bone cysts(Nelson and Foster 1976; Moed and Lamont 1982);remarkably, in all three of Moed and Lamont’s cases thehumeral proximal metaphysis was affected. A slowing ofgrowth of the epiphysial plate and consequent shorten-ing can occur in Ollier’s disease when the full width of themetaphysis is involved; angular deformity occurs whenonly part of the metaphysis is affected (Shapiro 1982).These growth defects have been ascribed either to anabnormality of the epiphysial cartilage, or to restrictionof growth of the epiphysial plate by an abnormally thickperiosteal sleeve, arising as a reaction to the lesion(Shapiro 1982).A third hypothesis is possible: bone growth dependson the proliferative cell layer of the epiphysial plate(Langenski#{246}ld and Edgren 1949; Pratt 1957), and anyinterference with this, such as the diminution of bloodsupply, will reduce growth. In the present case thenutrient artery of the humerus was not seen on arterio-graphy; however, disruption of the blood supply was notconfirmed at operation so we cannot say if this was thecause of the growth disturbance.Study of this case has led us to think that, inretrospect, less radical treatment would have been suffi-cient and that it might have been better to retain the stripof normal cortex.

Periosteal chondroma of the humerus leading to shortening. A case report.

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