SYNOVIAL CYST OF THE SHOULDER JOINT IN THE BICIPITAL
AREA IN JUVENILE RHEUMATOID ARTHRITIS
Masafumi Homma, M.D.,D.M.Sc, Research Fellow of Orthopaedic Surgery
William G. Mackenzie, M.D.,FRCS(C), Attending of Pediatric Orthopaedic
July 26, 1995
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
- HISTORY: This is a 7 year old girl who has had polyarticular
JRA for over a year. Most recent management has been with prednisone, methotrexate
and tolectin. The symptoms improved with little evidence of ongoing synovitis.
A mass in the left bicipital area was first noticed at the age of 7 years
and 9 months.
- PHYSICAL EXAM: The mass was firm, located in the antero-medial
aspect of the left upper arm and was difficult to separate from the biceps.
It did not transilluminate. Shoulder ROM was full.
- SONOGRAM AND XRAYS: The sonogram showed a solid soft tissue
mass which was fairly homogeneous in echo-genicity, and well defined with
minimal vascularity. No connection with the shoulder joint was observed.
MRI with gadolinium showed a mixed density collection which appeared to
have a narrow connection with the shoulder joint. An arthrogram of the
left shoulder joint demonstrated extension of dye down the bicipital groove
and into the mass in the upper arm. The mass was more palpable after the
arthrogram. We concluded that the mass was a synovial cyst due to chronic
- FOLLOW-UP: The synovial cyst has resolved spontaneously and
has not recurred over 3-months follow-up.
In this case, the synovial cyst was noticed while the synovitis was
well controlled atypical for synovial cysts. Several factors made the diagnosis
difficult in this case. The clinical findings and ultrasound suggested
a solid tumor. Sonography of a synovial cyst filled with proteinaceous
material would show intermediate signal intensity, so that it may be confused
with solid tissue mass. MRI was useful in this case in suggesting a connection
between shoulder joint and the mass but this connection may not always
be seen. An arthrogram may be indicated in similar cases prior to surgical
intervention such as needle or open biopsy. Synovial cysts should be considered
in the differential diagnosis of upper extremity soft tissue tumors in
children with JRA.
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