PMC4899883_01
17-year-old male with scapular stress fracture. Radiograph of the shoulder shows lesion in the scapula with aggressive features including lysis of the inferior border of the body of the scapula and adjacent new bone formation (arrow).
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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).
17-year-old male with scapular stress fracture. Comparison of a healing fracture (A and B) and lymphoma of the scapula (C) both in two separate 17-year-old-males. Axial imaging through the scapula in the youth with the healing fracture shows marrow edema and enhancement with periosteal reaction throughout the scapula. (A) T2-weighted, fat-saturated image shows increased signal intensity in the marrow cavity and periosteal reaction (arrow). (B) T1-weighted, fat-saturated imaging shows enhancement of the marrow and periosteum. A second male with lymphoma of the scapula shows similar findings on enhanced T1-weighted, fat-saturated imaging (C).
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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).
17-year-old male with scapular stress fracture. CT with bone-reconstruction algorithm shows a nonaggressive lesion with smooth periosteal reaction along the margins of the fracture (arrows in A). An oblique reformatted image reveals the fracture line as an oblique lucency through the neck of the scapula (arrow in B). A followup shoulder CT four weeks later shows interval healing of the stress fracture (C).
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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).