This article has Open Peer Review reports available.
Distal defect of the humerus, a possible normal variant: a case report
© The Author(s). 2017
Received: 10 November 2016
Accepted: 20 July 2017
Published: 17 August 2017
Many normal variants of bones on plain radiographs have been reported.
In the current report, a 14-year-old Asian girl noticed an occasional slight elbow pain. She had no traumatic episode. Plain radiographs showed a well-defined osteolytic lesion with a sclerotic rim, which was continuous with the normal subarticular bone in the distal humerus. Magnetic resonance imaging revealed that the defect area seen on the plain radiograph showed low-signal to iso-signal intensity on T1-weighted images and slightly high-signal intensity on T2-weighted fat suppression images. Bone edema was not observed. The association between her elbow pain and the lesion was not conclusive.
The findings from the images suggested that the lesion was a normal variant rather than osteochondritis dissecans or a neoplastic lesion, and possibly an anatomical counterpart of a dorsal defect of the patella.
Normal variants can be defined for lesions with atypical findings, and are normally found in some percentage of the population. Normal skeletal variants identified from plain radiographs have been listed in the well-known book Atlas of Normal Roentgen Variants That May Simulate Disease .
The current report describes a characteristic osteolytic lesion with a clear osteosclerotic rim at the distal humerus. This lesion, previously unreported, may be an anatomical counterpart of a dorsal defect of the patella. A distal defect of the humerus is a normal variant, and the discussion about the current case was made in light of a dorsal defect of the patella .
The osteolytic lesion had a differential diagnosis of osteochondrosis dissecans as an osteocartilaginous defect. In the current case, the osteolytic area was rather deep and the osteosclerotic rim was clear. Our patient had no traumatic episode, and a clinical symptom of rocking at the elbow was not observed. No free body was detected in her elbow joint space on MRI. These image and clinical findings did not meet the diagnostic criteria for osteochondrosis dissecans.
A neoplastic lesion was also a differential diagnosis in the current case. Osteolytic bone tumors that involve the epiphysis include chondroblastoma, chondromyxoid fibroma, and giant cell tumor of bone. An osteosclerotic rim is not usually seen in giant cell tumor of bone. Although chondroblastoma and chondromyxoid fibroma may have an osteosclerotic rim, the osteosclerotic rim would not be as clear as that in the current case. Furthermore, the absence of bone marrow edema suggested a lower probability of a neoplastic lesion.
After excluding the possible differential diagnoses of traumatic and neoplastic lesions, a normal variant condition was considered. Biopsy was not performed for the diagnosis. The plain radiograph at follow-up at 2 years had not changed, and pain was not noticed at that time.
The diagnosis of dorsal defect of the patella can be made from a plain radiograph, and invasive diagnostic procedures including a biopsy should be avoided . In the current report, the diagnosis of distal defect of the humerus was made in light of the dorsal defect of the patella. Because there was no bone marrow edema in MRI, the lesion was unlikely to be a neoplastic lesion. Therefore, the diagnosis was made based on the image, and a biopsy was judged to be unnecessary.
Most cases with dorsal defect of the patella cause no pain, and the lesions are usually found incidentally. However, dorsal defect of the patella causing knee pain has been reported [9–11]. In the current case, the absence of objective findings over the elbow and of bone marrow edema made it less likely as the cause of the elbow pain. Furthermore, the elbow pain spontaneously disappeared. However, the absence of association is not conclusive, and the current occasional elbow pain might be associated with the lesion, taking into consideration cases of a painful dorsal defect of the patella.
The characteristic imaging findings at the distal humerus suggest that this lesion is a normal variant and possibly an anatomical counterpart of dorsal defect of the patella.
Availability of data and materials
The dataset supporting the conclusions of this case report is included within the case report.
AS and SM drafted the manuscript. Both authors read and approved the final manuscript.
Ethics approval and consent to participate
The patient and her family were informed that data from the case would be submitted for publication, and consent was provided (including dorsal defect of the patella case).
Consent for publication
Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Theodore E. Keats MD and Mark W. Anderson MD. Atlas of Normal Roentgen Variants That May Simulate Disease. Philadelphia: Elsevier Inc.: Saunders; 2013.Google Scholar
- Locher S, Anderson S, Ballmer FT. Noninvasive management of a dorsal patellar defect. Arch Orthop Trauma Surg. 2002;122(8):466–8.View ArticlePubMedGoogle Scholar
- Goergen TG, Resnick D, Greenway G, et al. Dorsal defect of the patella (DDP): a characteristic radiographic lesion. Radiology. 1979;130(2):333–6.View ArticlePubMedGoogle Scholar
- Haswell DM, Berne AS, Graham CB. The dorsal defect of the patella. Pediatr Radiol. 1976;4(4):238–42.View ArticlePubMedGoogle Scholar
- Denham Jr RH. Dorsal defect of the patella. J Bone Joint Surg Am. 1984;66(1):116–20.View ArticlePubMedGoogle Scholar
- Johnson JF, Brogdon BG. Dorsal effect of the patella: incidence and distribution. AJR Am J Roentgenol. 1982;139(2):339–40.View ArticlePubMedGoogle Scholar
- Owsley DW, Mann RW. Bilateral dorsal defect of the patella. AJR Am J Roentgenol. 1990;154(6):1347–8.View ArticlePubMedGoogle Scholar
- van Holsbeeck M, Vandamme B, Marchal G, et al. Dorsal defect of the patella: concept of its origin and relationship with bipartite and multipartite patella. Skeletal Radiol. 1987;16(4):304–11.View ArticlePubMedGoogle Scholar
- Gamble JG. Symptomatic dorsal defect of the patella in a runner. Am J Sports Med. 1986;14(5):425–7.View ArticlePubMedGoogle Scholar
- Hunter LY, Hensinger RN. Dorsal defect of the patella with cartilaginous involvement. A case report. Clin Orthop Relat Res. 1979;143:131–2.Google Scholar
- Narváez J, Narváez JA, Clavaguera MT, et al. Dorsal defect of the patella: an uncommon cause of knee pain. Arthritis Rheum. 1996;39(7):1244–5.View ArticlePubMedGoogle Scholar