Journal of Orthopaedic Surgery 2014;22(3):427-9
Giant cell tumour of the distal humerus: a case
report
Atmananda S Hegde, Ravindra M Shenoy, Mahabala P Rai
Yenepoya Medical College, Mangalore, India
ABSTRACT
Giant cell tumour of the distal humerus is rare.
We report one such case in a 30-year-old man who
underwent wide resection of the tumour followed by
total elbow arthroplasty using a cemented ‘sloppy-
hinged’ total elbow prosthesis. At the 18-month
follow-up, the patient had pain-free range of motion
of 15º to 120º and no evidence of recurrence.
Key words: giant cell tumor of bone; humerus
INTRODUCTION
Giant cell tumour (GCT) of bone accounts for 4%
to 5% of all primary bone tumours and 20% of all
benign bone tumours.1 In China, it accounts for
20% of all primary bone tumours.2 GCT of bone is
usually solitary and benign but locally aggressive,
with 5% of metastasis and 1% to 3% of malignant
transformation.2–4 It has a predilection for the
epiphyseal/metaphyseal region of the long bones3,4 in
people aged 30 to 40 years.5 GCT of bone commonly
occurs at the distal femur, proximal tibia, distal
radius, and proximal humerus6; its occurrence at the
distal humerus is rare.7
Address correspondence and reprint requests to: Dr Atmananda S Hegde, Department of Orthopaedics, Yenepoya Medical College,
Deralakatte, Mangalore, 575018, India. Email: atmanandahegde@gmail.com
CASE REPORT
In December 2012, a 30-year-old man presented with
an 8-month history of pain, swelling, and decreased
range of movement of the left elbow without
preceding trauma. On examination, there was diffuse
fullness around the distal humerus, with increased
temperature and tenderness. There was a flexion
deformity of 20º, with a painful range of motion of
20º to 90º. Supination and pronation were restricted
with pain.
Radiographs showed an expansile lytic lesion
in the olecranon fossa of the humerus with a ‘soap
bubble’ appearance. Magnetic resonance imaging
(MRI) showed a well-defined, lesion, with altered
signal intensity, involving the meta-epiphysis of the
distal humerus and extending to the articular surface
with a break in the cortex and displacement of
adjacent tendons and muscles. Results of blood tests
and chest radiographs were within reference ranges.
The patient did not attend for a planned biopsy.
Three months later, he presented with a biopsy report
from elsewhere that suggested Jaffe grade I GCT of
bone. He had increased pain and swelling around
the elbow joint with gross restriction of movement.
Radiographs showed an expansile lytic lesion with
cortical breach and soft tissue shadows. MRI also
showed a breach of the articular surface (Fig. 1).
Computed tomography of the chest showed no
428 AS Hegde et al. Journal of Orthopaedic Surgery
Figure 1 Radiographs and magnetic resonance images showing an expansile lytic lesion with cortical breach at the distal
humerus.
Figure 2 En bloc resection of the distal humerus followed
by total elbow arthroplasty using a cemented ‘sloppy-hinge’
stainless steel total elbow prosthesis.
evidence of pulmonary metastasis. According to the
Enneking staging,8 the tumour was classified as stage
IB (low grade, extra compartmental, no metastasis).
The patient underwent en bloc resection of the
distal humerus followed by total elbow arthroplasty
using a cemented ‘sloppy-hinge’ stainless steel total
elbow prosthesis (Bakshi, Sis Ortho, Bangalore,
India). A high arm tourniquet was used without
exsanguination. A posteromedial skin incision was
made, and the ulnar nerve was identified and isolated.
The tumour was excised with a rim of normal tissues
Figure 3 Histopathological photomicrograph showing
uniform mononucleate ovoid cells with multinucleate
osteoclast-like giant cells.
by sharp dissection without breaching the capsule
(Fig. 2). The radial head and olecranon process were
removed and the triceps attachment was preserved.
The cemented sloppy-hinge total elbow prosthesis
was inserted after appropriate broaching and sizing.
The tourniquet was released and haemostasis was
achieved. The wound was closed in layers over a
suction drain. The limb was immobilised in full
extension with an above-elbow plaster backslab.
Histopathological examination of the specimen
confirmed the diagnosis of Jaffe grade I GCT of bone
(Fig. 3). Postoperatively, active and active-assisted
mobilisation was started after one week. At the
18-month follow-up, the patient had pain-free range
of motion of 15º to 120º and no evidence of recurrence
(Fig. 4).
Vol. 22 No. 3, December 2014 Giant cell tumour of the distal humerus 429

spread and intramedullary extension.

Figure 4 Radiographs at the 7-month follow-up showing
no evidence of recurrence.
DISCUSSION
GCT of bone typically shows as an epiphyseal,
eccentric, expansile lytic lesion with a ‘soap-bubble’
appearance,9 cortical thinning, and delayed cortical
breach. It usually causes ‘expansile remodelling’
of the overlying bone; the cortex is usually intact
over the tumour, even if it is markedly attenuated.
The tumour may contain small foci of dystrophic
mineralisation.10 MRI is useful to assess extracortical
The key histomorphologic feature is
multinucleated giant cells with up to 100 nuclei that
have prominent nucleoli. Surrounding mononuclear
and small multinucleated cells have nuclei similar
to those in the giant cells; this distinguishes GCT of
bone from other osteogenic lesions that have benign
osteoclast-type giant cells.
Surgery is the treatment of choice. Curettage is
usually combined with cementing or bone grafting,
or both.11 When there is cortical breach with joint
invasion, en bloc resection with joint reconstruction
is the treatment of choice. Hemi-articular and total
elbow allografts have been used for reconstruction
of the defects following tumour excision, but the
complication rates are high, and these techniques are
reserved as salvage procedures following failed total
elbow arthroplasty.12 Wide resection and total elbow
arthroplasty enables good functional outcome and
lower risk for recurrence.13 Total elbow arthroplasty
is a viable option, as it provides good pain relief and
functional improvement with lower complication
rates.12,14,15
DISCLOSURE
No conflicts of interest were declared by the authors.

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