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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 138-140

Traumatic bicipitoradial bursitis masquerading as an aggressive soft tissue neoplasm of the cubital fossa


1 Sports and Exercise Medicine Unit, Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Ministry of Health Malaysia, Pahang, Malaysia
2 Department of Sports Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Date of Submission14-Aug-2021
Date of Acceptance03-Sep-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Zhuang Li Lim
Sports and Exercise Medicine Unit, Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Ministry of Health Malaysia, Pahang
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mohe.mohe_27_21

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  Abstract 

This case report discusses a sudden forearm swelling in an otherwise healthy elderly female, which was initially thought to be malignant following clinical examination and imaging studies. An incisional biopsy showed native bursal tissue – bicipitoradial bursitis. Diagnosing bicipitoradial bursitis is challenging due to its intrinsic anatomical rarity. Nevertheless, merely performing radiological imaging may not adequately confirm the diagnosis since some of the characteristic changes are similar to other pathologies such as a myotendinous tear, a neoplasm or an infection. A histopathological examination may be necessary to confirm the diagnosis.

Keywords: Bicipitoradial bursitis, cubital fossa, forearm swelling


How to cite this article:
Lim ZL, Abdul-Karim S. Traumatic bicipitoradial bursitis masquerading as an aggressive soft tissue neoplasm of the cubital fossa. Malays J Mov Health Exerc 2021;10:138-40

How to cite this URL:
Lim ZL, Abdul-Karim S. Traumatic bicipitoradial bursitis masquerading as an aggressive soft tissue neoplasm of the cubital fossa. Malays J Mov Health Exerc [serial online] 2021 [cited 2022 Jan 26];10:138-40. Available from: http://www.mohejournal.org/text.asp?2021/10/2/138/333785




  Case Report Top


A healthy 77-year-old woman presented to the clinic with a 1-month history of sudden, painless swelling in the anterior aspect of the right elbow. There was a vague exacerbating incidence whereby she recalled lifting a heavy flower pot while gardening. In the subsequent days, she noted a 'fullness' developing over the anterior aspect of the proximal forearm. She denied any pain, weakness or paraesthesia over the region or distally, nor any constitutional symptoms. Clinical examination revealed a 3 cm × 5 cm soft-tissue swelling over the proximal anterolateral aspect of the forearm, which was non-tender. Her elbow range of motion was preserved. Resisted pronation of the forearm caused slight discomfort. The neurological and vascular examination was unremarkable, with no other joint involvement. Our differentials then were a radiocapitella joint ganglion cyst, an insertional bicipital tendon tear with hematoma or chondrosarcoma.

A plain radiograph of the right elbow did not demonstrate any calcified lesion or bone erosion [Figure 1]. Ultrasonography of the forearm showed a soft tissue mass of mixed solid-cystic component over the medial cubital fossa deep to the biceps tendon, measuring 3.4 cm × 2.6 cm × 1.3 cm with no demonstrable internal vascularity [Figure 2]. As the findings were suggestive of a malignancy, an urgent magnetic resonance imaging (MRI) scan was requested. This showed a heterogeneous, lobulated lesion encasing the distal biceps tendon, which demonstrates predominantly high T2/STIR signal intensity [Figure 3]. The biceps tendon is thickened at its insertion. A clear fat plane was visualised with the brachial vessels. The clinical impression then was of an aggressive soft tissue neoplasm.
Figure 1: Plain radiographs of the right elbow (anteroposterior and lateral view) showing the presence of a soft tissue swelling over the anterolateral aspect of the forearm

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Figure 2: Forearm ultrasonography image in longitudinal axis showing a soft tissue cystic mass deep to the distal biceps tendon

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Figure 3: Axial PD-weighted (a) and sagittal T2-weighted (b) magnetic resonance images of the right forearm showing a distended bicipitoradial bursa encasing the distal biceps tendon, with thickened brachialis tendon insertion and cortical destruction of the radial tuberosity

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An incisional biopsy was performed by our Orthopaedic colleagues, who identified the encasing mass as arising from the radio-capitella joint. The capsule was explored, showing a clear gelatinous material suspicious of a ganglion cyst. Part of the capsule was excised. Histopathology revealed the presence of fibro-adipose tissue surrounding fascicles of striated muscle fibres. Large undulating fibrous-walled tissues with attenuated linings were seen. These findings confirmed the diagnosis of traumatic bicipitoradial bursitis. At 12 months after the biopsy, the patient is presently well with no recurrence seen.


  Discussion Top


Bursae are flat sacs of synovial membrane containing synovial fluid that is located where moving structures are within close proximity. Bursal cavities facilitate movement by minimising friction in these areas (Skaf et al. 1999). Bursa located in the cubital fossa consists of the interosseous bursa and the bicipitoradial bursa, which occasionally communicates. The bicipitoradial or cubital bursa is positioned between the distal biceps tendon and radial tuberosity, tracking along the medial cortex of the radius and may partially envelop or completely encase the distal biceps tendon (Sofka and Adler 2004). This bursa helps to reduce friction. Neither of these bursae is routinely seen on imaging unless distended with fluid (Champlin et al. 2017).

The bicipitoradial bursitis is a clinically rare entity and most often results from repetitive mechanical trauma, particularly with recurrent supination and pronation of the forearm (Choi and Lui 2014). It may accompany primary biceps tendon pathologies such as tendinosis and tear or may be associated with other inflammatory conditions such as tuberculosis, chemical synovitis, bone proliferation, psoriatic arthropathy, rheumatoid arthritis and synovial chondromatosis (Sofka and Adler 2004; Champlin et al. 2017; Choi and Lui 2014). It is imperative to note that tenosynovitis of the distal biceps tendon is not possible as the distal tendon exists as a paratenon-lined, extra synovial entity without a tendon sheath (Champlin et al. 2017).

Patients with bicipitoradial bursitis often present with a tender, cystic swelling in the cubital fossa accentuated with pronation as the space between the biceps insertion and radial tuberosity reduces (Yamamota et al. 2001). Further enlargement may not only impair normal elbow flexion and extension but may also compress adjacent nerves due to mass effect (Choi and Lui 2014). Sensory-related symptoms predominate in compression of the superficial radial nerve or the lateral cutaneous nerve of the forearm, whilst motor deficit occurs if the posterior interosseous nerve is involved.

The first line imaging for bicipitoradial bursitis is musculoskeletal ultrasonography. Ultrasonography is non-irradiating with the possibility of performing image-guided procedures in real-time (Draghi et al. 2012). Ultrasonography not only allows differentiation of cystic from solid masses but also demonstrates variable echogenicity, internal septation and increased flow within bursal lining (Choi and Lui 2014). MRI is the gold standard to visualise and assess the lesional relationship with adjacent structures (Slouma et al. 2020). On MRI, T2-weighted imaging may reveal a lesion containing an area of homogenous, increased intensity than that of fat, suggesting fluid collection, Hypointense septated structures may be visualised (Sofka and Adler 2004). Peripheral enhancement of bursa is typically seen after gadolinium administration (Champlin et al. 2017). MRI may reveal other abnormalities such as hypointense septal structures, adjacent soft-tissue oedema and marrow oedema or erosion at the radial tuberosity (Slouma et al. 2020). MRI-based differentials include cubital fossa lipoma, ganglion cysts, lipoma arborescence of the cubital bursa or malignant synovial tumours (Choi and Lui 2014). When MRI is unavailable or contraindicated, contrast-enhanced computed tomography (CECT) may be considered as it demonstrates the inflamed bursa as a sharp fusiform lesion with a variable wall thickness of homogeneous density. Nevertheless, CECT may be better at demonstrating osseous hyperostosis and spurring whilst allowing comprehensive imaging of adjacent structures in a reproducible and easily reviewed format (Slouma et al. 2020). Nonetheless, plain radiographic imaging of the elbow should also be requested to rule out other differential diagnoses such as radial head fracture, posterior elbow dislocation and osteochondritis dissecans. In bicipitoradial bursitis, occasional faint calcification within the biceps tendon and roughening of the anterior radial tuberosity may be seen (Yamamoto et al. 2001).

Bicipitoradial bursitis should be discerned from a true neoplasm as conservative management is sufficient in most cases. Imaging patterns on ultrasonography and MRI may mimic malignant synovial neoplasia. Thus, thorough clinical history and examination must be emphasised. Nevertheless, in certain cases, the true diagnosis may not be reached until histopathological confirmation is obtained. In this case, the patient's presenting complaint was revisited of which suggested that a history of prior strenuous forearm supination-pronation and flexion-extension activities whilst reorganising the arrangements of various heavy, clay-potted shrubs around her lawn may have precipitated bursitis. As an incomplete exacerbating history was conveyed to our radiology colleagues, their imaging impression favoured a malignant presentation of which inadvertently subjected the patient to an invasive tissue biopsy.


  Conclusions Top


Though rare, bicipitoradial bursitis is a recognisable sequelae of repetitive stress injury involving the cubital fossa associated with recurrent supination-pronation type activities. This study highlights the limitation of ultrasound to diagnose bicipitoradial bursitis, especially in the elderly group. A more advanced imaging option such as MRI and CECT may provide a clearer diagnostic representation. In this case, an eventual incisional biopsy was necessary to confirm the diagnosis of a benign cubital fossa swelling.

Acknowledgement

We would like to thank the Director-General of Health Malaysia for his permission to publish this article.

Ethical statement

This study was approved by the Medical Research and Ethics Committee, Ministry of Health Malaysia (NMRR-20-2908-57826).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Champlin, J., Porrino, J., Dahiya, N., & Taljanovic, M. (2017). A visualisation of the distal biceps tendon. American Academy of Physical Medicine and Rehabilitation, 9(2), 210-215. doi: 10.1016/j.pmrj.2016.10.005.  Back to cited text no. 1
    
2.
Choi, T. L., & Lui, T. H. (2014). Bicipitoradial bursitis: A review of clinical presentation and treatment. Journal of Orthopaedics, Trauma and Rehabilitation, 18(1), 7-11. doi: 10.1016/j.jotr.2013.12.009.  Back to cited text no. 2
    
3.
Draghi, F., Gregoli, B., & Sileo, C. (2012). Sonography of the bicipitoradial bursa: A short pictorial essay. Journal of Ultrasound, 15(1), 39-41. doi: 10.1016/j.jus.2012.02.003.  Back to cited text no. 3
    
4.
Skaf, A. Y., Boutin, R. D., Dantas, R. W., Hooper, A. W., Muhle, C., Chou, D. S.,… & Resnick, D. L. (1999). Bicipitoradial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers. Radiology, 212(1), 111-116. doi: 10.1148/radiology.212.1.r99jl49111.  Back to cited text no. 4
    
5.
Slouma, M., Rahmouni, S., Dhahri, R., Litaiem, N., Gharsallah, I., Metoui, L.,… & Louzir, B. (2020). Bicipitoradial bursitis: A diagnosis challenge! Clinical Case Reports, 8(11), 2265-2268. doi: https://doi.org/10.1002/ccr30.3125.  Back to cited text no. 5
    
6.
Sofka, C. M., & Adler, R. S. (2004). Sonography of cubital bursitis. American Journal of Roentgenology, 183 (1), 51-53. doi: 10.2214/ajr. 183.1.1830051.  Back to cited text no. 6
    
7.
Yamamoto, T., Mizuno, K., Soejima, T., & Fujii, M. (2001). Bicipital radial bursitis: CT and MR appearance. Computerised Medical Imaging and Graphics, 25(6), 531-533. doi: 10.1016/s0895-6111(01) 00010-6.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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