Osteoid osteoma of the hand and wrist

Osteoid Osteoma of the Hand and Wrist NORMAN L. DUNITZ, M .D ., PAUL R . LIPSCOMB, M .D . AND JOHN C . IVINS, M .D .,

Rochester, Minnesota From the Section of Orthopedic Surgery, b9avn Clinic and Mayo Foundation, Rochester, Minnesota . The Macro Foundation is a Part of the Graduate School of the University of Minnesota .

the pisiform or the greater or lesser multangular bones . Osteoid osteoma appears to be essentially the same entity in its occurrences in the hand and

the first description by Jaffe [a] in 1935 Sbonethehaslesion known as osteoid osteoma of the been the subject of much writing and INCE

speculation . By 1945 Jaffe [3] was able to report on sixty-two proved cases . Lichtenstein [q] defined this lesion as a "small, oval or roundish tumorlike nidus which is composed of osteoid and traheculae of newly formed hone deposited within a substratum of highly vascularized osteogenic connective tissue ." Several good reports and reviews of osteoid osteoma in general have been published, but it was not until 1953 that Carroll [rj offered a thorough review of such tumors found in a rather unusual location for them-the hand and wrist . lie was able to find reports of only twenty-two cases of this type in the world literature, to which he added six cases of his own . His completed list of twenty-eight cases included tumors in the terminal and proximal phalanges, the metacarpals, and the navicular, capitate and hamate bones . He was unable to localize four tumors any more exactly than in the hand and wrist . Since then the finding of an osteoid osteoma in the terminal phalanx has been reported by Testa and Mazzoleni [y], and another similarly located tumor has been reported by Sevitt and Horn [s1 . We wish to add to the list four more cases, in which the several tumors developed in a terminal phalanx, in a proximal phalanx, in the capitate and in the triquetrum . The last, we believe, is the first case of osteoid osteoma in that bone to appear in the literature . The locations of the lesions in the hand and wrist can he seen in Figure i . As yet, to our knowledge, there has not been any unmistakable report of an osteoid osteoma of the lunate,

Fm . I . Distribution of osteoid osteomas that have been accurately localized in bones of the hand and wrist .

wrist as it is elsewhere in the body, although modified by location . Although its etiology has been confused somewhat in the past with tbeories of embryonal arrest of cells and of low grade infective processes, most writers now agree that osteoid osteoma is a benign osteohlastic neoplasm as described by Jaffe [2] . Considered generally, the lesion is more 65

American Journal of Surgery, Volume o4, Jaty, tor7

Dunitz, Lipscomb and Ivins

Case I . (a) Osteoid osteoma of the capitate bone, before operation . (b) The same area after block excision of a portion of the bone . (c) Gross specimen of bone removed, including the nidus . (d) The patient's wrist one week after operation, with the plug of iliac bone in place . FIG . 2 .

pend on the lesion's location, size and proximity to the surface or to the sensory component of nerves . On physical examination a swelling with an area of point tenderness sometimes can he noted . The patient's general health is not affected by the lesion . Roentgenographic examination is valuable if one remembers the variety of pictures which osteoid osteomas can present, depending on their location . If the lesion is in cortical bone or abutting near the cortex, a great amount of sclerosis takes place ; often this obliterates the lesion from the roentgenogram and necessitates planograms to locate the nidus . On the other hand, if the tumor is entirely in cancellous bone, it may have only a thin rim of sclerosis around it . The nidus is seen as a small round or oval area (usually less than t cm . in diameter) which may he either radiopaque or radiolucent . Jade [31 stated that early in the process the nidus was radiopaque with no surrounding sclerosis ; but as it became more mature, resorption took place and the picture became that of a radiolucent area surrounded by a sclerotic area of varying size . Treatment of the lesion is surgical ; roentgenologic and antibiotic therapy have been to no avail . Simple excision is adequate if the nidus is completely removed ; but if any remains, recurrences are almost certain to develop . Therefore we believe the ideal treatment for such a lesion in a hone of the hand or wrist is to remove a block of bone including the nidus ; recurrences have not been reported

Case ii . Sclerotic nidus of osteoid osteoma in the distal phalanx of the little finger . FIG. 3 .

common in men than in women by a ratio of approximately 2 : t . Only one case has been reported in the Negro race . According to Sherman's [6] article of 1947, the ages of the patients ranged from three to fifty-one years, although the majority fell between the ages of eleven and thirty years and the incidence was especially high in patients in their late teens and early twenties . The lesions have been reported in every location except the skull . They seem to have some predilection for long bones, especially those of the lower extremity . The location within a bone may be entirely cancellous, cortical or subperiostcal . Pain, the chief symptom, is characterized by a gradual onset over a period of two to twentyfour months . It reaches severe intensity and is worse at night . Aspirin relieves it almost in the manner of a specific agent . Other symptoms dc66

Osteoid Osteoma of Hand and Wrist

FIG. 4 . Case m . The proximal phalanx of the index finger . (a) Showing a sclerotic nidus surrounded

by an area of radiolucency . (b) After block excision of the involved portion of hone . (c) Two months later, with the edge of the cortical portion of the bone graft distinctly visible .

after complete removal . The relief of pain after complete removal is sudden . Microscopic examination of the excised specimen by a competent pathologist is required for absolute certainty of the diagnosis .

sclerosis . Surgical treatment consisted of block excision of the involved portion of bone, followed with fusion of the capitate to the hamate and the third and fourth metacarpal bones with a plug of iliac bone the exact size of the block removed . The pathologist reported an entire osteoid osteoma . (Fig. za to d .) The patient had immediate relief of pain, and three months afterward had acquired almost normal function of the wrist . Comment . This is a good example of osteoid osteoma in a carpal bone. The method of treatment used offers, when applicable, the best chance for complete relief of all the symptoms .

CASE REPORTS

i . A twenty-one year old white man, an x-ray technician, came to the Mayo Clinic in October, 1 955, because of pain of eighteen months' duration in the volar aspect of the right wrist . Inability to dorsiflex the wrist had developed gradually . Roentgenographic studies in several clinics had been reported negative until six months before admission . At that time a lesion in the capitate bone had been seen and diagnosed as a possible osteoid osteoma . Curettage of the capitate bone had been carried out, and the patient said that the lesion had been thought to be an cosinophilic granuloma . The limitation of motion continued but the pain was relieved for two months . Then, possibly in connection with a fall, the pain returned. Physical examination disclosed right hypothenar atrophy . The patient could not fully extend the wrist and he lacked i inch of being able to flex the fingers into the palm . Tenderness was diffuse over the ulnar side of the wrist . Roentgenograms showed a radiopaque nidus in the capitate bone with surrounding osteoporosis, and around this was a ring of CASE

CASE it . A seventeen year old white boy came to the clinic on March 28, ig55 . Swelling and pain involving the distal phalanx of the right little finger had been present for two years . The pain was most pronounced at night and was relieved to a marked degree by aspirin . Physical examination revealed the dorsum of the finger to he slightly swollen and tender . Roentgenograms showed an oval area of increased density surrounded by a radiolucent area . (Fig . 3 .) The diagnosis of osteomyelitis was considered . On March 29th a pea-sized nodule was removed and the pathologist reported "localized osteosclerosis ." Six months later the patient's original symptoms had returned . Roentgenograms at this time showed mottled sclerosis with a central area of in-

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Dunitz, Lipscomb and Ivins

Case iv . (a) Sclerotic nidus of the triquetral bone surrounded by an area of radiolucency . (b) The gross specimen that was removed ; arrow pointing to the nidus itself. (c) The nidus and the surrounding bone . Hernetoxylin and eosin, original magnification X 6o . FIG . 5 .

creased density . The eventual treatment was amputation of the distal phalanx of the fifth finger ; the final pathologic report was "osteoid osteoma, 5 mm . in diameter ." The patient has been free of symptoms since.

forced dorsiflcxion two years before she was seen at the clinic . Continuing pain developed in the wrist . Without roentgenograms, according to the patient, a diagnosis of fracture had been made by the doctor in her home locality, but no treatment had been given at the time . However, as the pain continued and gradual swelling became evident on the ulnar side of the wrist, immobilization of the wrist by a short plaster of paris cast was tried repeatedly, but without relief . On admission to the clinic in March, 1956, the patient was suffering from swelling and tenderness just distal to the ulna on the right, and wrist motion was limited in all directions. Roentgenograms showed the triquetrum to be deteriorated, with a dense fragment in the center . Diagnoses considered were avascular necrosis and osteoid osteoma . Surgical treatment consisted of excising the distal i inch of the ulna along with the triquetral bone . An o.8 mm . nidus of osteoid osteoma was found on pathologic examination . (Fig . 5a to c .) The pain disappeared almost immediately after operation and the patient has been free of symptoms since .

CASE iii . An eighteen year old white boy had noticed painless swelling of the proximal phalanx of the left index finger and gradual limitation of motion of the finger for one and a half years . Four months before he was seen at the clinic, a biopsy had been performed by the doctor in his home locality . The patient did not know the results . Roentgenograms taken on the patient's admission to the clinic in April, 1956, indicated rarefaction in part of the shaft of the proximal phalanx with proliferative changes surrounding this region . Treatment consisted primarily of removal of a roentgenologically localized block of bone measuring 4 by 8 mm . The resulting defect was filled with a plug of homogenous iliac hone . (Fig . 4a to c .) The patient's symptoms were completely relieved, the swelling having subsided and the motion having returned almost to normal when the patient was last seen four months later .

SUMMARY

The literature concerning osteoid osteoma has been reviewed briefly, with emphasis on

CASE iv . A nineteen year old white girl, a telephone operator, had injured her wrist by

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