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Case studies in diagnostic imaging
Soft tissue mass around the shoulder
    1. H S Reid,
    2. E McNally,
    3. A Carr
    1. Nuffield Orthopaedic Centre NHS Trust, Oxford
    1. Dr H S Reid, Nuffield Orthopaedic Centre NHS Trust, Windmill Road, Headington, Oxford OX4 4LD.

    https://doi.org/10.1136/ard.57.1.6

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      Clinical history

      A previously fit 47 year old female school teacher presented with a six month history of a painful swelling over her right shoulder. There was rapid development of the swelling initially, which then stabilised. On examination she was apyrexial with a large, firm, non-tender mass around the right shoulder, which clinically had some cystic features. There was no significant limitation of movement. Other findings on clinical examination included some minor soft tissue capsular swelling of the second and third metacarpophalangeal joints of the right hand. Otherwise the remainder of the locomotor system was normal.

      Her erythrocyte sedimentation rate was increased at 51 mm 1st h, but C reactive protein remained normal at <0.6. Full blood count was normal with a haemoglobin of 13.4 g/dl, white blood cell count 7.5 × 109 /l, platelet count 424 ×109/l. The rheumatoid factor, however, was positive with a titre of 1:1280.

      Imaging

      QUESTIONS

      (1) What does the plain film (fig 1) show? Suggest a list of diagnoses that would fit this clinical context.

      Figure 1

      Anteroposterior radiograph of the right shoulder.

      (2) Which of your diagnoses does ultrasound (fig 2) support?

      Figure 2

      Ultrasound showing transverse section through the right shoulder.

      (3) Describe the magnetic resonance imaging findings (figs3-5).

      (4) Using all the evidence what are the most probable diagnoses?

      Plain film

      There is a large, homogeneous soft tissue mass superolateral to the right shoulder joint, in the region of the subdeltoid bursa. There is no calcification or ossification within the mass. Irregularity of the inferior surface of the acromion and the greater tuberosity suggests some degree of impingement syndrome otherwise there is no bony or joint abnormality.

      The diagnostic possibilities in this case can be divided into those conditions arising from …

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