Open Journal of Radiology, 2012, 2, 22-24
http://dx.doi.org/10.4236/ojrad.2012.21004 Published Online March 2012 (http://www.SciRP.org/journal/ojrad)
Synovial Hemangioma in a 2-Year Old Mimicking
Synovial Osteochondromatosis
Thomas Ray Sanchez1*, Stephen Wong2, Leonard Swischuck2, Kelly Carmichael2
1University of California, Davis, USA
2University of Texas Medical Branch, Galveston, USA
Received January 8, 2012; revised February 5, 2012; accepted February 15, 2012
ABSTRACT
We describe a rare synovial mass arising from the elbow of a 2-year old female. It was growing slowly for three months
and there was no history of trauma or fever. Plain radiographs showed a soft tissue mass around the elbow with scat-
tered nodular intraarticular calcifications. Ultrasound and MRI confirmed the synovial location of the mass and again
showed the multiple calcifications, some of which suggested intraarticular loose bodies. The imaging findings were
thought to represent synovial osteochondromatosis but subsequent biopsy revealed a synovial hemangioma and it is for
this reason that we present our case.
Keywords: Synovial Hemangioma; Synovial Osteochondroma; Synovial Tumor
1. Case Report
This healthy 2-year old girl presented with painless right
elbow swelling for 3 months with no history of fever,
weight loss, or other constitutional symptoms. On physi-
cal exam there was non-tender swelling and bogginess in
the right elbow. The patient had full range of elbow mo-
tion and could use both extremities without difficulty.
Pulses were strong and there were no sensory or motor
deficits.
Initial elbow radiographs and ultrasound studies were
obtained. The radiographs showed soft tissue swelling
along the posterior aspect of the elbow with scattered,
well defined rounded calcific densities (Figure 1). Th ere
were no underlying bony erosions, periosteal reaction, or
signs of joint effusion. Ultrasound confirmed the pre-
sence of a lobulated mass with several punctuate calcifi-
cation with extension into the joint (Figure 2). At this
point the initial working diagnosis was synovial osteo-
chondromatosis.
A subsequent contrast-enhanced MRI study was ob-
tained to further define the mass. Non-contrast sagittal
T1 and axial T2 MR images showed the posteriorly lo-
cated mass to be connected to the joint (Figure 3(a)).
After administration of gadolinium, enhancement was
mostly peripheral and within the intervening septations.
(Figure 3(b)). Excisional biopsy was performed and pa-
thology confirmed a cavernous hemangioma.
2. Discussion
Synovial hemangiomas are rare tumors of the joint. The
knee is by far the most commonly involved joint. How-
ever, they also can occur in other joints such as the elbow,
ankle and temporomandibular joint [1,2]. Typically pa-
tients are affected during the first and second decades of
life [3] and symptoms are nonspecific, including swelling,
pain, and limitation of jo int motion [4].
In terms of imaging, plain films usually are normal
except for the presence of non-specific soft tissue swell-
ing. There usually is n o bony erosion or bony d estruction.
Ultrasound evaluation of the lesion is sparsely docu-
mented [3]. In our case the lesion was homogenous with
punctuate calcifications and was associated with intraar-
ticular connection.
MRI documentation of the lesion also is somewhat
scanty [3,5] however MR will demonstrate a lobulated
soft tissue mass which is isointense, slightly hyperintense
on non-contrast T1 weighted images and markedly hy-
perintense with scattered low-intensity septations on T2
weighted images. Similar findings are seen with STIR
images and post gadolinium studies show intense and
heteroge n eous enha ncement [6].
Our patient presented with nonspecific soft tissue swe-
lling of the elbow with several well-defined and uniform-
sized calcifications seen on the plain radiographs. These
were confirmed by ultrasound which showed imbedded
calcifications within the mass and extention of the mass
into the joint. Subsequent MRI demonstrated multiple
*Corresponding author.
C
opyright © 2012 SciRes. OJRad

T. R. SANCHEZ ET AL. 23
Figure 1. Lateral radiograph of the right elbow. Soft tissue
swelling is mostly posterior with some nodular calcifications,
one of which appears intraarticular (arrow).
Figure 2. Axial sonogram through the elbow. The intraar-
ticular soft tissue mass again shows the well defined and
uniform calcifications (arrows).
nodular hypodensities on T1 and T2 weighted images.
Enhancement of the tumor was scant and patchy, mostly
occurring peripherally and along the septations. This
configuration is a little unusual for a hemangioma which
usually demonstrates diffuse enhancement.
In terms of differential diagnosis, although the age of
our patient would favor the diagnosis of a hemangioma,
it is noteworthy that rare cases of synovial osteochon-
dromatosis have been reported in the first decade of life
[7]. Although there are certain similarities in the MR
appearance of these two lesions it has been suggested
that the presence of calcified or ossified free bodies with
in the joint is pathognomonic or at least highly sugges-
tive of the diagnosis [8]. A similar statement can be made
regarding plain films [9]. In our case, however, most of
the lesion appeared to be outside the joint.
Synovial sarcoma, on the other hand, is a malignant
neoplasm that is more commo n in young adults and chil-
(a)
(b)
Figure 3. (a) Sagittal T1 weighted MR image. The T1 hy-
perintense mass is seen arising from the posterior elbow
and extends into the joint (white arrow). (b) Axial T2 wei-
ghted MR image. The lobulated mass is also hyperintense
on T2 with low intensity septations (black arrow) and low
density nodularities representing calcifications (curved ar-
rows); (b) Post gadolinium T1 weighted and fat saturated
MR images. A. Sagittal and B. Coronal images both show a
minimally enhancing soft tissue mass; most of the enhance-
ment is along the septations (arrows).
dren. Although it arises near a join t, it is v ery rare for this
tumor to originate or extend intraarticularly [10]. Unfor-
tunately, plain radiographs and even MRI show nonspe-
cific characteristics and might even suggest a benign
pathology such as a ganglion cyst if contrast is withheld.
Calcifications can be present and could be mistaken for
phleboliths of hemangioma, but they are uncommon.
Again the key differential in this case would be the ab-
sence of intraarticular extension. Synovial hemangiomas
are rather uncommon but do tend to occur in younger
patients. Because they may demonstrate intraarticular
calcifications they usually first are considered to be the
lesion of synovial osteochondromatosis. However, ultra-
sound and MR imaging findings showing the paraarticu-
lar lesion with extent into the joint should enable one to
accomplish the correct diagnosis.
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T. R. SANCHEZ ET AL. 24
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