Journal of Orthopaedic Surgery 2013;21(3):387-90
Fibroma of the peroneus longus tendon sheath in a child: a case report Gregory J Nason,1 Joseph F Baker,1 Patrick O’Toole,1 Anna Walsh,1 Darren F Lui,1 Francis O’Neill,1 Maureen O’Sullivan,2 Paula M Kelly1 Department of Paediatric Orthopaedics, Our Lady’s Children’s Hospital, Dublin, Ireland Department of Pathology, Our Lady’s Children’s Hospital, Dublin, Ireland
1 2
ABSTRACT Tendon sheath fibromas are rare, benign soft-tissue tumours and usually involve tendons of the upper extremities, particularly the fingers. The most common presentation is a painless, slow-growing swelling. Tendon sheath fibromas are composed of dense fibrocollagenous stromas with scattered, spindle-shaped fibroblasts and narrow, slit-like vascular spaces. Ultrasonography and magnetic resonance imaging are useful diagnostic tools. We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath. Key words: fibroma; pediatrics; tendons
INTRODUCTION Fibromas of the tendon sheath are rare, benign soft-tissue tumours predominantly occurring in the upper extremities.1,2 These tumours usually
present as a painless, slow-growing nodule arising from a synovial sheath.3,4 Histopathologic findings demonstrate sparse spindle or stellate cells, with slitlike vessels in a dense collagenous matrix.5 We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath. CASE REPORT In February 2012, an 11-year-old boy presented with a 2-month history of an enlarging, painless mass along the posterolateral aspect of the right ankle. He had no pain on walking or at night. On examination, a firm, fixed mass was palpable posterior to the right lateral malleolus. There were no overlying skin changes or tenderness or restricted movement of the ankle joint. Radiographs revealed normal bony architecture, with a subtle soft-tissue shadowing (Fig. 1). Magnetic resonance imaging revealed a 3.2x2.1x2.6 cm, welldefined, soft-tissue mass immediately posterior to the lateral malleolus and medial to the peroneal tendons. The mass abutted the anterior aspect of
Address correspondence and reprint requests to: Mr Gregory Nason, Department of Paediatric Orthopaedics, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland. Email: [email protected]
388 GJ Nason et al.
the Achilles tendon. There was an abnormal signal in the mass, with a homogeneous high signal on fluid-sensitive sequences. Little oedema was noted in the surrounding soft tissues. The mass showed enhancement with intravenous gadolinium contrast and was bright on T2 sequencing (Fig. 1). Open biopsy was performed under general anaesthesia. No tourniquet was used and intravenous cefuroxime was only administered once the appropriate samples were obtained. Histology of the sample revealed fibromyxoid proliferation that was heavily collagenised and displaying scattered spindle and stellate cells with no cytologic atypia
Journal of Orthopaedic Surgery
or appreciable mitotic rate. This was suggestive of a tendon sheath fibroma or a collagenous fibroma. Culture of the sample yielded no growth after 5 days. The patient underwent complete resection of the lesion under general anaesthesia via a curvilinear incision over the lesion. A pneumatic tourniquet was used once prophylactic cefuroxime was administered. Dissection was performed circumferentially, necessitating opening of the peroneal sheath. The entire lesion was excised en bloc from a base that was linked to the peroneal sheath (Fig. 2). The peroneal tendon sheath was repaired, conferring stability on the peroneal tendons.
Figure 1 A soft-tissue mass is located posterior to the lateral malleolus and medial to the peroneal tendons. It shows enhancement with intravenous gadolinium contrast and is bright on T2 sequencing.
Figure 2 Dissection is made posterior to the right lateral malleolus. The entire lesion is excised en bloc from a base linked to the peroneal sheath.
Vol. 21 No. 3, December 2013
Fibroma of the peroneus longus tendon sheath in a child 389
Figure 3 Histological examination of the fibroma of the tendon sheath reveals the classic chondromyxoid ground substance with bland spindled nuclei interspersed and areas of denser collagen bundles.
Histological examination of the lesion revealed the classic chondromyxoid ground substance with bland spindled nuclei interspersed and areas of denser collagen bundles consistent with a fibroma of the tendon sheath (Fig. 3). At the 3-month follow-up, there was no evidence of recurrence. The patient had returned to full sporting activities. Further follow-up was scheduled in 2 years owing to the potential for recurrence. DISCUSSION In a series of 138 patients, 98% of tendon sheath fibromas occurred in the extremities: 119 in the upper extremities and 17 in the lower extremities; of the latter 5 were in the foot and 3 at the ankle.3 The median patient age was 31 years and males were more commonly affected, with a ratio of 1.5:3.1.3 Tendon sheath fibromas in the lower limbs are rare; only 20 such cases have been reported: 12 at the knee, 2 at the ankle, one each in the thigh, the extensor hallucis longus tendon, the flexor hallucis longus tendon, the toe, the Achilles tendon, and the foot. Involvement of the peroneus longus tendon was first reported in our patient. The diagnosis of fibroma of the tendon sheath is mainly based on histology. Most cases are
asymptomatic, painless swellings at presentation. Radiographs are usually unremarkable unless a large lesion compresses surrounding structures, such as fat or muscle. Ultrasonography and magnetic resonance imaging are useful diagnostic tools.6 A low signal on T1-weighted images and a high signal on T2-weighted images (consistent with the findings in our patient) have been reported.6 However, low intensity signals on both T1- and T2-weighted images have also been reported.7 This varied appearance on T2-weighted images is suggested to be secondary to differences in the amount of hyalinisation and sclerosis. The number of proliferating fibroblasts may result in variations in T2-weighted sequences.8 The treatment of choice is excision, but the recurrence rate can be as high as 24%.9 Malignant transformation or metastatic spread has not been reported. High recurrence rates are due to the difficulty of complete excision owing to fibroma adherence to surrounding tendons, tendon sheaths, and nerves. Due to the benign nature, aggressive wide excision is not advocated, in order to preserve function.10 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Moretti VM, Ashana AO, de la Cruz M, Lackman RD. Tendon sheath fibroma in the thigh. Orthopedics 2012;35:e607–9. 2. Moretti VM, de la Cruz M, Lackman RD, Fox EJ. Fibroma of tendon sheath in the knee: a report of three cases and literature
390 GJ Nason et al.
Journal of Orthopaedic Surgery
review. Knee 2010;17:306–9. 3. Chung EB, Enzinger FM. Fibroma of tendon sheath. Cancer 1979;44:1945–54. 4. Hashimoto H, Tsuneyoshi M, Daimaru Y, Ushijima M, Enjoji M. Fibroma of tendon sheath: a tumor of myofibroblasts. A clinicopathologic study of 18 cases. Acta Pathol Jpn 1985;35:1099–107. 5. Yamamoto T, Marui T, Mizuno K. Fibroma of a tendon-sheath presenting as toe deformity. Foot Ankle Int 2001;22:59–61. 6. Bertolotto M, Rosenberg I, Parodi RC, Perrone R, Gentile S, Rollandi GA, et al. Case report: Fibroma of tendon sheath in the distal forearm with associated median nerve neuropathy: US, CT and MR appearances. Clin Radiol 1996;51:370–2. 7. Hitora T, Yamamoto T, Akisue T, Marui T, Nagira K, Ohta R, et al. Fibroma of tendon sheath originating from the knee joint capsule. Clin Imaging 2002;26:280–3. 8. Sundaram M, McGuire MH, Schajowicz F. Soft-tissue masses: histologic basis for decreased signal (short T2) on T2-weighted MR images. AJR Am J Roentgenol 1987;148:1247–50. 9. Maluf HM, DeYoung BR, Swanson PE, Wick MR. Fibroma and giant cell tumor of tendon sheath: a comparative histological and immunohistological study. Mod Pathol 1995;8:155–9. 10. Ciatti R, Mariani PP. Fibroma of tendon sheath located within the ankle joint capsule. J Orthop Traumatol 2009;10:147–50.
Fibroma of the peroneus longus tendon sheath in a child: a case report Gregory J Nason,1 Joseph F Baker,1 Patrick O’Toole,1 Anna Walsh,1 Darren F Lui,1 Francis O’Neill,1 Maureen O’Sullivan,2 Paula M Kelly1 Department of Paediatric Orthopaedics, Our Lady’s Children’s Hospital, Dublin, Ireland Department of Pathology, Our Lady’s Children’s Hospital, Dublin, Ireland
1 2
ABSTRACT Tendon sheath fibromas are rare, benign soft-tissue tumours and usually involve tendons of the upper extremities, particularly the fingers. The most common presentation is a painless, slow-growing swelling. Tendon sheath fibromas are composed of dense fibrocollagenous stromas with scattered, spindle-shaped fibroblasts and narrow, slit-like vascular spaces. Ultrasonography and magnetic resonance imaging are useful diagnostic tools. We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath. Key words: fibroma; pediatrics; tendons
INTRODUCTION Fibromas of the tendon sheath are rare, benign soft-tissue tumours predominantly occurring in the upper extremities.1,2 These tumours usually
present as a painless, slow-growing nodule arising from a synovial sheath.3,4 Histopathologic findings demonstrate sparse spindle or stellate cells, with slitlike vessels in a dense collagenous matrix.5 We report on an 11-year-old boy with a fibroma involving the right peroneus longus tendon sheath. CASE REPORT In February 2012, an 11-year-old boy presented with a 2-month history of an enlarging, painless mass along the posterolateral aspect of the right ankle. He had no pain on walking or at night. On examination, a firm, fixed mass was palpable posterior to the right lateral malleolus. There were no overlying skin changes or tenderness or restricted movement of the ankle joint. Radiographs revealed normal bony architecture, with a subtle soft-tissue shadowing (Fig. 1). Magnetic resonance imaging revealed a 3.2x2.1x2.6 cm, welldefined, soft-tissue mass immediately posterior to the lateral malleolus and medial to the peroneal tendons. The mass abutted the anterior aspect of
Address correspondence and reprint requests to: Mr Gregory Nason, Department of Paediatric Orthopaedics, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland. Email: [email protected]
388 GJ Nason et al.
the Achilles tendon. There was an abnormal signal in the mass, with a homogeneous high signal on fluid-sensitive sequences. Little oedema was noted in the surrounding soft tissues. The mass showed enhancement with intravenous gadolinium contrast and was bright on T2 sequencing (Fig. 1). Open biopsy was performed under general anaesthesia. No tourniquet was used and intravenous cefuroxime was only administered once the appropriate samples were obtained. Histology of the sample revealed fibromyxoid proliferation that was heavily collagenised and displaying scattered spindle and stellate cells with no cytologic atypia
Journal of Orthopaedic Surgery
or appreciable mitotic rate. This was suggestive of a tendon sheath fibroma or a collagenous fibroma. Culture of the sample yielded no growth after 5 days. The patient underwent complete resection of the lesion under general anaesthesia via a curvilinear incision over the lesion. A pneumatic tourniquet was used once prophylactic cefuroxime was administered. Dissection was performed circumferentially, necessitating opening of the peroneal sheath. The entire lesion was excised en bloc from a base that was linked to the peroneal sheath (Fig. 2). The peroneal tendon sheath was repaired, conferring stability on the peroneal tendons.
Figure 1 A soft-tissue mass is located posterior to the lateral malleolus and medial to the peroneal tendons. It shows enhancement with intravenous gadolinium contrast and is bright on T2 sequencing.
Figure 2 Dissection is made posterior to the right lateral malleolus. The entire lesion is excised en bloc from a base linked to the peroneal sheath.
Vol. 21 No. 3, December 2013
Fibroma of the peroneus longus tendon sheath in a child 389
Figure 3 Histological examination of the fibroma of the tendon sheath reveals the classic chondromyxoid ground substance with bland spindled nuclei interspersed and areas of denser collagen bundles.
Histological examination of the lesion revealed the classic chondromyxoid ground substance with bland spindled nuclei interspersed and areas of denser collagen bundles consistent with a fibroma of the tendon sheath (Fig. 3). At the 3-month follow-up, there was no evidence of recurrence. The patient had returned to full sporting activities. Further follow-up was scheduled in 2 years owing to the potential for recurrence. DISCUSSION In a series of 138 patients, 98% of tendon sheath fibromas occurred in the extremities: 119 in the upper extremities and 17 in the lower extremities; of the latter 5 were in the foot and 3 at the ankle.3 The median patient age was 31 years and males were more commonly affected, with a ratio of 1.5:3.1.3 Tendon sheath fibromas in the lower limbs are rare; only 20 such cases have been reported: 12 at the knee, 2 at the ankle, one each in the thigh, the extensor hallucis longus tendon, the flexor hallucis longus tendon, the toe, the Achilles tendon, and the foot. Involvement of the peroneus longus tendon was first reported in our patient. The diagnosis of fibroma of the tendon sheath is mainly based on histology. Most cases are
asymptomatic, painless swellings at presentation. Radiographs are usually unremarkable unless a large lesion compresses surrounding structures, such as fat or muscle. Ultrasonography and magnetic resonance imaging are useful diagnostic tools.6 A low signal on T1-weighted images and a high signal on T2-weighted images (consistent with the findings in our patient) have been reported.6 However, low intensity signals on both T1- and T2-weighted images have also been reported.7 This varied appearance on T2-weighted images is suggested to be secondary to differences in the amount of hyalinisation and sclerosis. The number of proliferating fibroblasts may result in variations in T2-weighted sequences.8 The treatment of choice is excision, but the recurrence rate can be as high as 24%.9 Malignant transformation or metastatic spread has not been reported. High recurrence rates are due to the difficulty of complete excision owing to fibroma adherence to surrounding tendons, tendon sheaths, and nerves. Due to the benign nature, aggressive wide excision is not advocated, in order to preserve function.10 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Moretti VM, Ashana AO, de la Cruz M, Lackman RD. Tendon sheath fibroma in the thigh. Orthopedics 2012;35:e607–9. 2. Moretti VM, de la Cruz M, Lackman RD, Fox EJ. Fibroma of tendon sheath in the knee: a report of three cases and literature
390 GJ Nason et al.
Journal of Orthopaedic Surgery
review. Knee 2010;17:306–9. 3. Chung EB, Enzinger FM. Fibroma of tendon sheath. Cancer 1979;44:1945–54. 4. Hashimoto H, Tsuneyoshi M, Daimaru Y, Ushijima M, Enjoji M. Fibroma of tendon sheath: a tumor of myofibroblasts. A clinicopathologic study of 18 cases. Acta Pathol Jpn 1985;35:1099–107. 5. Yamamoto T, Marui T, Mizuno K. Fibroma of a tendon-sheath presenting as toe deformity. Foot Ankle Int 2001;22:59–61. 6. Bertolotto M, Rosenberg I, Parodi RC, Perrone R, Gentile S, Rollandi GA, et al. Case report: Fibroma of tendon sheath in the distal forearm with associated median nerve neuropathy: US, CT and MR appearances. Clin Radiol 1996;51:370–2. 7. Hitora T, Yamamoto T, Akisue T, Marui T, Nagira K, Ohta R, et al. Fibroma of tendon sheath originating from the knee joint capsule. Clin Imaging 2002;26:280–3. 8. Sundaram M, McGuire MH, Schajowicz F. Soft-tissue masses: histologic basis for decreased signal (short T2) on T2-weighted MR images. AJR Am J Roentgenol 1987;148:1247–50. 9. Maluf HM, DeYoung BR, Swanson PE, Wick MR. Fibroma and giant cell tumor of tendon sheath: a comparative histological and immunohistological study. Mod Pathol 1995;8:155–9. 10. Ciatti R, Mariani PP. Fibroma of tendon sheath located within the ankle joint capsule. J Orthop Traumatol 2009;10:147–50.
