November 12, 2025
4 min read
A 55-year-old man presented to the ED for a chronic right upper extremity wound. The lesion began as a small bump 3 years prior and had progressively enlarged and become increasingly painful.
The patient had a past medical history significant for polysubstance abuse (tobacco, cocaine, heroin), homelessness and medical noncompliance. Surgical history was significant for inguinal hernia repair. Physical examination was notable for a large circumferential indurated wound along the lateral elbow, forearm and arm, with associated purulent drainage (Figure 1). His elbow had a rigid 100° flexion contracture. Wrist and finger motion was also significantly limited due to pain and contractures.
Image: Sanjiv Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Preoperative imaging and workup
Radiographs and CT scan demonstrated destructive changes of the distal humerus with osteolysis and periostitis consistent with chronic osteomyelitis (Figure 2). MRI with and without contrast showed extensive irregularity and enhancement of the skin and subcutaneous tissues extending into the lateral epicondyle, with cortical erosion and marrow enhancement. Reactive lymphadenopathy was also noted.
Source: Sanjiv Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Labs on presentation included elevated inflammatory markers, with a white blood cell count of 13.72, erythrocyte sedimentation rate of 67 and C-reactive protein of 7.68. Urine drug screen was also positive for cocaine.
Given the chronicity and concerning appearance of the wound, interventional radiology performed image-guided biopsies of the bone and soft tissue. Pathology revealed invasive, well-differentiated squamous cell carcinoma. Staging CT chest, abdomen and pelvis, along with a bone scan, revealed no solid organ or bone metastases. Axillary lymphadenopathy was present, but biopsy of the lymph nodes was negative for malignancy.
Source: Sanjiv Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
What are the best next steps in management of this patient?
See answer below.
Shoulder disarticulation
A multidisciplinary discussion involving orthopedic surgery, orthopedic oncology, hematology-oncology and infectious disease determined that amputation was the most appropriate treatment given the extent of the disease.
After a detailed discussion of risks, benefits and alternatives, the patient consented to a transhumeral amputation, with the understanding that shoulder disarticulation might be required if the remaining skin was not viable for closure.
Surgical technique
The patient was positioned supine on a hand table. The arm was placed into a nonsterile stockinette and wrapped with foam tape, which was then prepped over. Intraoperatively, it was determined that there was insufficient viable skin for a transhumeral amputation. The decision was made to proceed with shoulder disarticulation.
A fishmouth incision incorporating an extended deltopectoral approach was created and carried laterally around the entire deltoid muscle then medially to the axilla. The brachial artery was ligated distal to the takeoff of the posterior humeral circumflex artery. The musculocutaneous, median, ulnar and radial nerves were sharply incised as proximally as possible. The tendinous insertions of the pectoralis major, latissimus dorsi, teres major, deltoid and rotator cuff muscles were detached from the proximal humerus. The arm was disarticulated and sent to pathology to confirm margins. The rotator cuff tendons were tenodesed to the long head of the triceps origin at the infraglenoid tubercle to provide soft tissue coverage over the glenoid.
The wound was copiously irrigated, and meticulous hemostasis was obtained prior to a layered closure of the deltoid muscle flap, and then a soft dressing was applied.
Postoperative course
The patient tolerated the procedure well, with immediate improvement in pain. Dressings were changed on postoperative day 2, and he was discharged on day 6 following oncology clearance. Final pathology confirmed negative surgical margins. At his 2-week follow-up, the wound was healing well without signs of infection (Figure 3). He reported minimal phantom limb pain, well controlled with gabapentin.
Source: Sanjiv Gopalkrishnan, MD, MBA; Jennifer Liu, MD; Joshua T. Woody, MD
Discussion
Chronic nonhealing wounds can undergo malignant transformation into squamous cell carcinoma, known as Marjolin’s ulcer. While most commonly affecting burn scars or chronic ulcers of the lower extremity, cases involving the upper limb have been described, particularly in association with chronic osteomyelitis and draining sinus tracts.
This patient’s long-standing wound, destructive bony changes and superimposed infection highlight the diagnostic challenge of distinguishing chronic infection from malignancy. Advanced imaging can aid in delineating soft tissue and osseous involvement, but biopsy remains essential for diagnosis.
Management requires wide local excision with negative margins. In cases with extensive soft tissue loss, osteomyelitis or circumferential involvement, amputation may be necessary to achieve local control. Although radical, shoulder disarticulation provided durable coverage, rapid pain relief and negative oncologic margins in this case.
Shoulder disarticulation is most commonly performed for high-grade sarcoma, infection or trauma when limb salvage is not feasible. The goal is to achieve complete resection with tension-free soft tissue closure over the glenoid. Techniques vary, but a deltopectoral-based incision with preservation of a viable deltoid or myocutaneous flap can optimize padding and prosthetic fitting. Tenodesis of the rotator cuff or triceps origin, as performed here, provides a stable, well-cushioned residual limb. Reported outcomes are favorable, with high rates of pain relief and local control when clear margins are achieved.
This case underscores the importance of maintaining a high index of suspicion for malignancy in any chronic wound, particularly in patients with barriers to health care or ongoing infection.
Key points:
- Chronic nonhealing wounds with bone involvement should prompt biopsy to rule out malignant transformation.
- Marjolin’s ulcer (squamous cell carcinoma arising from chronic inflammation or infection) can occur in the upper extremity and mimic chronic osteomyelitis.
- Shoulder disarticulation can provide a curative and functionally stable solution in cases where limb-sparing options are not feasible.
For more information:
Sanjiv Gopalkrishnan, MD, MBA; Jennifer Liu, MD; and Joshua T. Woody, MD, can be reached at Houston Methodist Hospital in Houston, Texas. Gopalkrishnan’s email: svgopalkrishnan@houstonmethodist.org. Liu’s email: jwliu@houstonmethodist.org. Woody’s email: jtwoody@houstonmethodist.org.
Edited by Mitchell F. Bowers, MD, and Jennifer Liu, MD. Bowers is a chief resident in orthopedic surgery at Vanderbilt University Medical Center. He will be pursuing a spine surgery fellowship at the Leatherman Spine Institute following residency completion. Liu is a chief resident in orthopedic surgery at Houston Methodist Hospital. She will be pursuing an adult reconstruction fellowship at the University of California San Francisco following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
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The authors report no relevant financial disclosures.
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