Osteochondromas of the scapula are rare, constituting around 3–5% of all osteochondromas and usually occur on the ventral surface [1,2]. Symptomatic solitary osteochondroma on dorsal aspect of scapula is even more sparsely documented ^[3]. We conducted a literature search of SCOPUS and PUBMED for osteochondroma or exostosis of dorsal scapula which yielded 11 published articles with a total of 13 reported cases till 2022. However, merely one article by Frost et al. ^[4] analyzed Patient-Reported Outcome Measures (PROMs) after surgical excision of the osteochondroma of dorsal scapula. PROMs assessment is prerequisite for improving patient health care and for clinicians, regulators, health-care management teams, commissioners, and policymakers ^[5]. Here, we report a case of diagnosis, treatment, and successful Patient-Reported Outcome of osteochondroma of dorsal scapula in a 10-year-old boy as per the CARE© [6,7] case reporting guidelines. Rarity of the site of the tumor and the urge to stress upon the necessity of analyzing PROMs after surgical treatment of benign tumors of bone instigated us to write the report.

A 10-year-old boy presented to us with a history of painless swelling over the right upper back since 3 years of age and discomfort over the area while sleeping on his back for 6 months. The swelling was insidious in onset and very slowly increasing in size but was not associated with any impairment of function. The patient denied any history of similar complaints in past, trauma, fever, weight loss, cough, breathing difficulty, constitutional signs and symptoms, or any other known disease or any other swelling in the body. There was no other significant history. Examination revealed a single smooth, ovoid swelling of size 5.5 cm × 4.5 cm on the dorsal aspect over right lower scapula (Fig. 1.)

It was bony hard, non-tender with smooth edges, and was fixed to the underlying bone but free from overlying skin. There was pain free and full range of right scapulothoracic and shoulder joint motion with no neurovascular deficit in the right upper limb. There was no regional lymph node enlargement. No other similar or palpable swelling was found anywhere else in the body. QuickDASH© questionnaire ^[8] (copyright
property of the Institute for Work &Health) ^[9] was used to analyze the Patient-Reported Outcome. It is a shortened version of DASH© ^[9] Outcome measure and consists a subset of 11 items from the 30-item DASH© ^[9] and is a self-reported questionnaire where the response options are graded as 5-point Likert scales. The scores range from 0 (no disability) to 100 (most severe disability). This score measures physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb. Pre-operative QuickDASH© ^[9] score was 6.818. Diagnosis of pedunculated osteochondroma of lower end of dorsal right scapula was confirmed with X-ray (Fig. 2) and subsequently magnetic resonance imaging (MRI) (Fig. 3). As patient was symptomatic, surgical excision of tumor was decided upon.

Under general anesthesia and in prone position, an incision of 10 cm was made centered over the tumor along Langer’s line. Subcutaneous tissue dissection was done to reach the infraspinatus muscle. The muscle was split along the line of its fibers to expose the tumor and epiperiosteal elevation of muscle was carried out (Fig. 4).

The tumor was completely exposed and excised en masse along with a rim of normal scapular bone. The scapular bone edges were smoothened with a bone file. The wound was closed back in layers after achieving proper hemostasis. The postoperative neurological status was intact. Histopathological examination of the tumor confirmed it to be osteochondroma (Fig. 5).

Surgical scar was completely healed by 2 weeks after surgery (Fig. 6), and upper limb was supported with an arm sling for 3 weeks, after which gradual shoulder mobilization and muscle strengthening exercises were initiated.

Follow-up assessment of the patient is shown in Table 1.

QuickDASH© ^[9] score was zero at the end of 12 weeks. The patient is completely fine with no symptoms or signs of recurrence at 1 year of follow-up.

In spite of rarity of osteochondromas in scapula, it is the most common benign bone tumor of the scapula constituting 14.4% of all tumors [1,10]. Dorsal aspect of scapula is a seldom documented site of origin for osteochondroma [11,12,13]. Moreover, majority patients with dorsal scapular osteochondroma are reported to be sessile ^[11]. Scapular osteochondroma can be an incidental finding or can also have a wide range of symptoms including swelling, cosmetic discomfort, pain, crepitus, and mechanical difficulty/ dysfunction, snapping, pseudo-winging, weakness, and pressure effects on circumferential structures including nerves and vessels [12,13]. The patient can also have difficulty/inability to sleep in supine position in case of dorsal scapular osteochondroma [3,10] as is in our case too. Pain can also occur due to irritation and inflammation of overlying soft tissues, bursitis of overlying swelling ^[14], fracture at stalk of pedunculated osteochondromas, or rarely due to malignant transformation ^[3]. Signs most concerning for malignant transformation include new onset pain, rapid growth especially after skeletal maturity, anatomical site-scapula or pelvis, and a cartilage cap thickness >2 cm. In skeletally immature bone, during spurts of growth, the cartilage cap may become quite large, and necessarily does not indicate a malignant transformation ^[15]. It is imperative to distinguish reactive bursa formation from malignant transformation. Computed tomography (CT) scan in these cases can detect the presence of a fluid-filled sac in bursa formation rather than a tumor and also delineate the mineralized portion of the tumor. Fine-needle aspiration is a reliable diagnostic modality for confirmation of a bursa ^[16]. Sites which predispose to malignant transformation are the locations obscured from general appearance and the bones with complex ossification including multiple ossification centers such as scapula and pelvic bone ^[15]. Diagnosis of osteochondroma is almost always clinicoradiologically followed by histological confirmation if necessary ^[17]. Specialized modalities such as CT scan and MRI are essential only when the tumor is not easily visible in X-rays such as in osteochondroma of flat bones [3,12]. Differential diagnosis includes subungual exostosis, Dysplasia Epiphysealis Hemimelica or Trevor’s disease, Turret exostosis, bizzare parosteal osteochondromatous proliferation or Nora lesion, parosteal osteosarcoma, juxtacortical chondroma, and subperiosteal hematoma ^[18]. Osteochondromas need not be necessarily excised unless properly indicated for ^[19]. Conservative treatments of scapular osteochondromas include physiotherapy, NSAIDs, and local anesthetic injections. Indications for surgical resection of an osteochondroma include pain, deformity, dysfunction, neural or vascular compromise, failure of conservative management, or high suspicion for malignant transformation ^[13] or for cosmetic reasons ^[20]. Surgical treatment is complete excision of tumor and any reactive bursa ^[4]. There is a predilection of surgery for osteochondromas around shoulder which is even greater for scapula ^[21]. We must be vigilant for scapular osteochondromas due to potential for malignant change as well as for scapulothoracic motion hindrance and its consequences such as impingement, rotator cuff tear, and biceps tendinopathy ^[15]. Surgical excision should be done at the earliest for symptomatic cases to reduce the risk of malignant transformation ^[11]. Recurrence per se does not occur as osteochondromas are benign cartilaginous bone tumor. Any cartilaginous remnant (a not uncommon scenario in large and very sessile lesions) in the skeletally immature bones has the potential to grow and have a “clinical recurrence” ^[22]. Finally, but most importantly, after surgical treatment, “measuring what matters to patients” is pivotal to improving patient care and service delivery. A method to evaluate it is PROMs, which are questionnaires completed by patients to assess the effects of disease or treatment (or both) on symptoms, functioning, and health-related quality of life from patient’s perspective. PROM data can be used to inform health technology assessment, pharmaceutical labeling claims, health policy, and service improvement and can support communication between patients and health-care professionals ^[5]. CARE© ^[7] case reporting guidelines also suggest patient perspective to be included in any case report, which can be aptly and successfully done through PROM. This is the first case report of using QuickDASH© ^[9] score for PROM in a rare case of osteochondroma of dorsal scapula. QuickDASH© ^[9] score returned to zero at 3 months following surgery which indicates the complete success of the surgical treatment from the patient’s perspective.

We report a rare case of osteochondroma of the dorsal scapula in a 10-year-old adolescent boy and successful Patient-Reported Outcome of surgical excision in the same and stress upon the necessity to evaluate the effects of surgical treatment using PROMs, especially in rare cases for the benefit of clinical research.

Osteochondroma of the dorsal scapula is a rare entity but should be kept in the mind while evaluating any scapular swelling. Surgical indications for osteochondromas should be precisely understood and surgical excision should be done only when properly indicated for. Outcome of surgical excision of any benign bone tumor should be evaluated by PROMs for the improvisation of patient care and service delivery and in assessing what matters to the patient, especially in rare cases and for the benefit of clinical research.