1 Introduction

Osteochondroma is the most common benign bone tumour, characterized by the formation of a bony projection covered by cartilage.¹ Osteochondromas typically develop in long bone juxta-articular sites such as the distal femur, proximal tibia, and proximal humerus in developing skeletons and can take either a single or multiple forms.² Scapular osteochondroma is a though recognized but a rare entity.^3,4 Unusual manifestations of scapular conditions can present with varying sites, ages of onset, and atypical signs and symptoms. The diagnosis of these uncommon manifestations might be difficult at times due to a lack of knowledge about them.⁵ Ventral scapular osteochondromas can cause scapular winging, which is frequently misinterpreted as serratus anterior muscular palsy.⁶ Also ventral scapula osteochondromas can cause chest pain due to rib cage compression due to its pressure effect.⁷ Because the mass is on the front side of the scapula, it is difficult to detect by touch and may not be evident on typical antero-posterior X-rays.^8,9 We present a case of ventral scapula osteochondroma in a 7-year-old child resulting in rib compression and chest pain since 6 months. The case highlights the successful management of this condition through surgical excision.

2 Case presentation

A 7-year-old, right-handed male child presented to our orthopedic clinic with chief complaints of chest pain and pain on right shoulder movement. The chest pain had been persistent for the past 6 months and had a dull, aching quality. The pain radiated to the right arm, including the elbow and wrist, and was aggravated by movement and deep inspiration. The child also reported pain specifically on right shoulder movement. There was no history of trauma or constitutional symptoms such as fever, weight loss, or night sweats. On physical examination, a non-tender, diffuse bony hard mass was palpated over the inferior angle of the right scapula. The mass caused fullness over the subscapular region. There were no associated regional lymph node enlargement or neurovascular deficits. An anteroposterior view of the right shoulder joint did not clearly reveal the tumour mass. However, a standard Y view of the scapula showed the tumour arising from the ventral aspect of the inferior angle of the scapula (Fig. 1).

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Fig. 1 A & B – X-rays Shoulder AP and Scapular Y view showing pedunculated tumour arising from the ventral aspect of the inferior angle of the scapula.

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Further imaging studies, including CT scan and MRI, were performed to assess the extent of the tumour. These imaging studies confirmed the presence of a scapula osteochondroma over inferior angle on ventral side with associated rib compression (Fig. 2).

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Fig. 2 A&B) CT 3D and sagittal image showing the ventral scapula osteochondroma compressing on to the rib C)T2 fat suppressed MRI sequence showing cartilage capped bony projection suggesting the diagnosis of osteochondroma.

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After a thorough discussion with the patient's parents regarding the risks and benefits of surgical intervention, informed consent was obtained. The patient underwent extraperiosteal surgical excision of the scapula osteochondroma through a direct incision over inferior angle of scapula under general anaesthesia with the patient in a lateral position. Care was taken to avoid cutting any muscle transversely to preserve function. Intraoperatively pedunculated mass arising from the ventral portion of the inferior angle of the scapula was discovered. This tumour appeared as a cauliflower-shaped with a flattened ventral side that faced the chest wall. The mass had a bony protrusion covered in cartilage, which caused compression of the adjacent ribs. The pedunculated tumour, measuring approximately 3.5 × 3 × 2.5 cms (Fig. 3 A & B). A bursa surrounding the lesion, containing straw-colored fluid was observed. The mass, along with its bursa, was excised with help of osteotome. Bone wax was applied over the pedicle base to prevent future regrowth.

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Fig. 3 A & B) Intraoperative images showing pedunculated tumour before and after excision of tumour mass (size 3.5 × 3x2.5 cms).

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The excised mass had a macroscopic appearance of pearly white nodules formed of spongy bone with a lobulated cartilaginous cap after excision. Microscopic examination revealed a neoplasm composed of bony trabeculae with fatty tissue and bone marrow intervening. Postoperatively, the child's arm was immobilized using an arm pouch for three weeks. During this period, only pendulum exercises were permitted. The child was later enrolled in a rehabilitation program to improve shoulder range of motion. The symptoms resolved dramatically in the immediate postoperative period, and there was no recurrence of symptoms or swelling over the course of 18 months. Clinical and radiological follow-up examinations did not show any evidence of tumour recurrence (Fig. 4 A&B).

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Fig. 4 A&B) X-rays AP and scapular Y view after 18 months of follow up, showing no recurrence of tumour as well as remodeling of the ribs.

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The child regained normal functional range of movement in the right shoulder, and there was no pain reported at the 1.5-year follow-up (Fig. 5A and B,C).

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Fig. 5 A,B,C) Clinical follow up of the patient at 18 months with full range of motion and healed scar over inferior angle of scapula.

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3 Discussion

Osteochondromas are most common benign bone tumors that commonly occur in the proximal humerus, pelvis, and knee but are rarely found on flat bones like the scapula.⁹ They are usually asymptomatic and primarily cause cosmetic concerns or difficulties while sleeping in a supine position. Scapular lesions account for a small percentage (around 4%) of all reported osteochondromas.¹⁰ In rare cases where osteochondromas develop on the ventral surface of the scapula, they can cause static winging and snapping shoulder syndrome, which is characterized by pain, crepitus, and movement-related symptoms.¹¹

Presenting manifestations of scapular tumors vary by location, Tittal et al. reported two benign lesions of ventral scapula causing pseudo winging of scapula.⁸ Another study reported ventral scapula osteochondroma causing winging with large bursa formation.¹² Conversely, a dorsal scapular osteochondroma can lead to cosmetic deformity and difficulty while sleeping in supine position.¹³

Osteochondroma occurring on the ventral scapula, leading to chest pain from rib cage compression, is an extremely rare occurrence. Chun et al. reported a case of a 14-year-old male with intermittent, dull, and diffuse aching pain in the left chest wall due to an osteochondroma.⁷ Authors reported the patient experienced complete resolution of symptoms postoperatively and remained symptom-free with no tumour recurrence during the one-year follow-up. Similarly, in our case also patient reported chest pain relief and was without any recurrence at 18 months follow-up.

Diagnosis of subscapular osteochondroma typically relies on clinical features and imaging, with confirmation through histopathologic evaluation. While this condition may not always be visible on a regular X-ray, early diagnosis usually requires a CT scan or MRI. MRI is particularly valuable for evaluating subscapular osteochondroma, as it is effective in identifying soft tissue lesions, including bursal tissue. Additionally, MRI can help rule out the rare occurrence of malignant transformation in solitary osteochondroma, which is a concern in about 1–2% of cases. Signs of potential malignancy include a cartilaginous cap larger than 2 cm, stippled calcification in the cap, an increase in size after skeletal maturity, and a sudden escalation in pain.⁸ However, in our specific case, despite the patient experiencing increased deformity and pain after skeletal maturity, the symptoms were primarily attributed to mechanical causes. Further histological examination confirmed the absence of any malignant changes.

Scapular osteochondromas are uncommon conditions that can cause complications such as rib compression, scapular winging, chest pain, and functional limitations in paediatric patients.^6,14 Early diagnosis and prompt surgical intervention are crucial for effective management. Surgical excision of the osteochondroma is the recommended treatment, offering a generally favourable prognosis. However, incomplete excision can result in the possibility of recurrence.⁴

4 Conclusion

The presented case emphasizes the importance of timely recognition and intervention to prevent complications and restore normal function. Long-term follow-up is necessary to ensure proper healing and monitor for recurrence or complications. Further research is needed to enhance our understanding of scapular osteochondromas and optimize their management in paediatric patients. Despite their rarity, scapular osteochondromas should be considered in the differential diagnosis, and appropriate measures should be taken for accurate diagnosis and treatment.

Informed consent

Informed consent has been taken.

Institutional ethical committee approval

Taken from the institution.

Authors contribution

A. All authors have contributed equally in writing the manuscript.

B. All authors have read and agreed to the published version of the manuscript.

Declaration of informed consent

There is no information (names, initials, hospital identification numbers or photographs) in the submitted manuscript that can be used to identify patients.

Consent for publication

Appropriate consent taken form child's parents for the publication.

Author contributions

Kishor Munde - Conception and design, Acquisition of data, Analysis and interpretation of data Drafting of the article.

Ashok Rathod – Surgical supervision, Proofreading of manuscript, Drafting of the article.

Bhushan Hadole - acquisition of data, Drafting of the article, Analysis and interpretation of data.

Kishan Panjwani - acquisition of data, Drafting of the article.

All authors provide final approval for the manuscript submitted.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgments

None reported