|Year : 2015 | Volume
| Issue : 3 | Page : 295-298
Simple bone cyst with pathological fracture of humerus treated with extensive curettage followed by incorporation of fibular strut-graft
Soumya Ghosh1, Chiranjit De1, Arunima Chaudhuri2, Dipankar Sen3
1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Orthopedics, Mission Hospital, Burdwan, West Bengal, India
|Date of Web Publication||2-Sep-2015|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
A simple bone cyst is an intramedullary cyst usually filled with serous and serosanguinous fluid. We hereby present a case of a 16-year-old male patient with simple bone cyst with pathological fracture of left humerus, who underwent extensive curettage of the lesion followed by incorporation of autogenous nonvascularized fibular strut-graft taken from ipsilateral limb. Simple bone cyst complicated with pathological fracture may be treated with cortical bone grafting with fibular strut-graft and synthetic fillers. Additional internal fixation with suitable implant is required to fix the pathological fracture. Therefore, by this methodology, we can take care of the disease and its complications as well in a same sitting reducing patient's morbidity.
كيسة العظام البسيط مع كسر مرضي فى العضد تم علاجها بعملية كحت واسعة تليها إدماج الشظية عظمية
كيس العظام البسيط هو الكيس داخل النقي عادة ما يكون ملوءا بسائل مصلي. هنا نقدم حالة مريض يبلغ من العمر 16 عاما لديه كيس العظام البسيط مع كسر مرضي من العضد الأيسر وقد اخضع لعملية كحت واسعة من الآفة تليها إدماج الشظية من العظم الغازي غير مشبعة بالدم أخذت من طرافه المماثل. كيسة العظام البسيطة التى يعقدها كسر مرضي يجوز ان تعالج بزراعة العظام القشرية التطعيم والحشو الاصطناعي بالاضافة الى ذلك ينبغى اجراء تثبيت داخلي إضافي مع زرع عظمى مناسب لإصلاح الكسر المرضي. لذلك، من خلال هذه المنهجية، يمكن معالجةالمرضى المرض ومضاعفاته وكذلك خفض المراضة للمريض.
Keywords: Fibular graft, pathological fracture, simple bone cyst
|How to cite this article:|
Ghosh S, De C, Chaudhuri A, Sen D. Simple bone cyst with pathological fracture of humerus treated with extensive curettage followed by incorporation of fibular strut-graft. Saudi J Sports Med 2015;15:295-8
|How to cite this URL:|
Ghosh S, De C, Chaudhuri A, Sen D. Simple bone cyst with pathological fracture of humerus treated with extensive curettage followed by incorporation of fibular strut-graft. Saudi J Sports Med [serial online] 2015 [cited 2020 Jul 8];15:295-8. Available from: http://www.sjosm.org/text.asp?2015/15/3/295/164321
| Introduction|| |
A simple bone cyst is an intramedullary cyst usually filled with serous and serosanguinous fluid. ,, It is more common in skeletally immature bones occurring mostly in the children. ,,, These cysts are of metaphyseal in origin and grows away from the physis with cortical thinning and minimal expansion. These lesions are usually asymptomatic and found incidentally, although pain, swelling and stiffness of the adjacent joint can occur. The most frequent complication is pathological fracture, and this is frequently the cause of presentation of the disease. ,,,,,,, Pathological fractures are presenting features in 80% of the patients of simple bone cyst specially with large lesions involving 50-60% of the bone diameter with cortical thinning. 
The cyst may resolve spontaneously or sometimes following fracture. Prime motto of the treatment is curettage and removal of fibrous membrane lining of the cyst. Other modalities of treatments are injection of steroid with or without autogenous bone marrow injection. Autogenous bone grafting or synthetic grafting with calcium sulfate pellets following open or percutaneous curettage remains another choice. Pathological fractures as a complication of cyst may be treated conservatively or with curettage and bone grafting (autogenous/synthetic) and sometimes may require internal fixation with suitable implants. ,,,,,,, We hereby present a case of a patient with simple bone cyst with pathological fracture of left humerus who underwent extensive curettage of the lesion followed by incorporation of autogenous nonvascularized fibular strut-graft taken from ipsilateral limb.
| Case Report|| |
A 16-year-old male attended Orthopedic Department at Burdwan Medical College and Hospital with chief complaints of sudden onset pain in the left arm following trivial trauma and restriction of all movements of that arm. Clinically, there was no bony swelling or any other obvious deformity. Bony landmarks were tender on palpation. Movement of the arm was restricted in all direction due to pain. The patient was advised detailed imaging investigation including skiagram, hematological and biochemical investigations. The patients had no endocrinal disorder. Hematological and biochemical reports were also within normal limit. Skiagram of left humerus showed sharply defined, expansile osteolytic lesions with thin sclerotic margins [Figure 1]. There was also evidence of pathological fracture within the lesion. 'U'-slab was applied immediately and the patient was sent for preanesthetic check-up.
|Figure 1: Preoperative skiagram showing simple bone cyst with pathological fracture of the humerus|
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The patient was placed in supine position on operating table under image-intensifier. The operation was performed under general anesthesia. A long segment of fibula (about 15 cm) was harvested from ipsilateral (left) lower limb. Only anterior half of fibula was taken out with the help of oscillating electric saw. Surgical approach was through the conventional antero-lateral aspect of the middle third of humerus. A longitudinal incision was given approximately 15 cm long on the antero-lateral aspect and extending downward to sufficiently visualize the whole lesion including the pathological fracture. A cortical fenestration was made on the lateral side of humerus on the affected area wide enough to curette the whole lesion. Underlying whole material including the fibrous membrane of the cyst was removed by curettage and removed material was sent for histopathological examination. The cavity was thoroughly irrigated with normal saline and harvested nonvascularized fibular strut-graft was inserted along anatomical alignment. The remaining cavity was filled with synthetic calcium sulfate pellets. Bridging of the fracture site was done using a 10 hole 4.5 mm narrow LC-DCP (Synths) with 3 proximal and distal cortical screws on each side. Finally, the wound is closed in layers after applying suction drain under strict aseptic precaution.
Following surgery the patient was advised passive shoulder and active elbow exercises from 2 nd postoperative day. After 2 weeks of operation, stitches were removed. Proper wound care and limb physiotherapy was advised for better postoperative recovery. Skiagram was taken at 6 weeks interval [Figure 2] and [Figure 3]. The patient had significant relief of his left arm pain postoperatively. Skiagram showed incorporation of the fibular cortical graft after about 1½ year of operation. There was no residual pain and functional incompetence [Figure 4] and [Figure 5]. Donor site (ipsilateral fibula) also shows no postoperative complication including any neurovascular deficit.
|Figure 3: Follow-up skiagram at 18 months showing incorporation of fibula|
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| Discussion|| |
Most diagnosed bone cysts occur in childhood, ,,,, but the present case presented at the age of 16 years. Etiology remains unknown. ,, They account for 3% of all bone tumors, and usually involve the metaphysis of long bones, and have a predilection for the proximal humerus and proximal femur, but in our case, the cyst was at mid shaft. Bone cysts usually present with a pathological fracture or a complaint of mild pain in the affected region and our patient also presented with pathological fracture.
Solitary bone cysts are common benign fluid-filled cystic lesions that occur mostly in the metaphysis of long bones and rarely found in the vertebra. Varun et al. in 2014  reported a case of a 28-year-old female with upper back pain. On further evaluation with MRI dorsal spine revealed a lesion in the posterior elements of the 3 rd dorsal vertebra. On surgical treatment, the biopsy revealed solitary bone cyst. The patient symptoms were relieved postoperatively and returned to normal activities within 4 weeks.
Gündes et al. in 2008  reported a case of a symptomatic unicameral (simple) bone cyst of the lunate in a 42-year-old woman. The lesion was treated with curettage and cancellous autogenous iliac bone grafting. At 5 years of follow-up, the wrist was pain-free, there were no limitations of motion, and the radiographs showed complete obliteration of the cavity.
A case of a simple bone cyst in the spinous process of the fourth cervical vertebra in a 26-year-old woman was reported by Coskun et al. in 2004.  According to the radiologic findings, the lesion was identified as a simple bone cyst, and the diagnosis was verified by surgical and histopathological examinations.
In our case, the simple bone cyst with pathological fracture of left humerus underwent extensive curettage of the lesion followed by incorporation of autogenous nonvascularized fibular strut-graft taken from ipsilateral limb. Then the void space within the cyst was filled up with synthetic calcium sulfate pellets. The whole lesion was then bridged with 4.5 mm narrow dynamic compression plate and screws. At routine follow-up at 9 months, the patient showed normal full range of motion of the left arm without any pain or functional incompetence. The fibular donor site was also functionally sound.
| Conclusions|| |
Simple bone cyst complicated with pathological fracture may be treated with cortical bone grafting with fibular strut-graft and synthetic fillers. Additional internal fixation with suitable implant is required to fix the pathological fracture. Therefore, by this methodology, we can take care of the disease and its complications as well in a same sitting reducing patient's morbidity.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Coskun B, Akpek S, Dogulu F, Uluoglu O, Eken G. Simple bone cyst in spinous process of the c4 vertebra. AJNR Am J Neuroradiol 2004;25:1291-3.
Gündes H, Sahin M, Alici T. Unicameral bone cyst of the lunate in an adult: Case report. J Orthop Surg Res 2010;5:79.
Sponer P, Urban K. Treatment of juvenile bone cysts by curettage and filling of the cavity with BAS-0 bioactive glass-ceramic material. Acta Chir Orthop Traumatol Cech 2004;71:214-9.
Varun GB, Veerappan V, Prashanth LL. A solitary bone cyst of the dorsal spine: An unusual presentation. Int J Health Inf Med Res 2014;1:35-7.
Ikeda M, Oka Y. Cystic lesion in carpal bone. Hand Surg 2000;5:25-32.
Yanagawa T, Watanabe H, Shinozaki T, Takagishi K. Curettage of benign bone tumors without grafts gives sufficient bone strength. A case-series of 78 patients. Acta Orthop 2009;80:9-13.
Sung AD, Anderson ME, Zurakowski D, Hornicek FJ, Gebhardt MC. Unicameral bone cyst: A retrospective study of three surgical treatments. Clin Orthop Relat Res 2008;466:2519-26.
Tey IK, Mahadev A, Lim KB, Lee EH, Nathan SS. Active unicameral bone cysts in the upper limb are at greater risk of fracture. J Orthop Surg (Hong Kong) 2009;17:157-60.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]