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Extraarticular synovial chondrometaplasia: Locking of the proximal interphalangeal joint of the finger
Extraarticular synovial chondrometaplasia: Locking of the proximal interphalangeal joint of the finger A case of extraarticular synovial chondrometaplasia at the proximal interphalangeal joint level with intermittent locking of the ring finger is presented. The characteristics of extraarticular synovial chondrometaplasia of the acral parts are reviewed.
Chet J. Janecki, M.D., Gary Routson, M.D., and Elise W. DePapp, M.D., Rochester, N.Y.
In
the condition of synovial chondrometaplasia, cartilaginous and osteocartilaginous bodies arise from synovial membranes. This entity has been noted in joints, bursae, and tendon sheaths . The purpose of this report is to present a case of extraarticular synovial chondrometaplasia at the proximal interphalangeal joint with resultant mechanical dysfunction or locking of the finger .
Case history The patient, a 31-year-old white man , initially presented with a complaint of a painful proximal interphalangeal joint of his right ring finger. The patient noted that for 6 months he had intermittent pain and limitation of motion in this joint related to the migration of a mass on the radial dorsal aspect of the joint. Physical examination showed thickening of the proximal interphalangeal joint of the finger with a full range of motion. A small, subcutaneous mass was palpable on the dorsal radial aspect of the finger, proximal to the joint. This mass was demonstrated on roentgenograms as an extraarticular calcification (Fig. I) . One week following the initial examination, the patient returned to demonstrate an episode of limitation of proximal interphalangeal joint flexion. Examination at that time revealed that the subcutaneous mass was no longer readily palpable at its original site . The mass seemed to be under the extensor mechanism. The proximal interphalangeal joint was locked at approximately 30° of flexion . Attempts at active flexion or extension caused pain . The patient then inadvertently twisted his proximal interphalangeal joint, returning the mass to its original position . Active flexion and extension of the proximal interphalangeal joint were then restored. A complete blood count and the uric acid and sedimentation
From the Department of Orthopaedic Surgery , University of Rochester School of Medicine and Dentistry , Rochester, N. Y. Received for publication Oct. 19, 1979. Reprint requests: Chet J. Janecki, M.D. , 2Locke Dr., Pittsford, NY 14534.
0363-5023/801050473+04$00.4010
Fig. 1. A roentgenogram showing a calcified mass adjacent to the proximal interphalangeal joint.
rate s were normal. No other joints of the hand or wrist were involved on roentgenograms. At operation, a curved, longitudinal incision on the radial aspect of the joint was made. The extensor mechanism was identified. A longitudinal incision was made through the radial transverse ligament and a small , 2.2 to 3 mm oval extraarticular mass was encountered on the dorsal radial aspect of the finger, just proximal to the proximal interphalangeal joint. The mass was attached to a long , pedunculated soft tissue stalk , which did not communicate with the joint. As a result of the stalk, the mass was capable of interposing itself between the extensor hood and the proximal phalanx, resulting in a decrease in excursion of the joint in flexion (Fig . 2). Arthrotomy of the proximal interphalangeal joint did not
© 1980 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
473
474
Janecki . Routson . and DePapp
The Journal of HAND SURGERY
A
Fig. 2. A diagramatic sketch showing the changing relationship of the calcified mass to the extensor mechanism of the proximal interphalangeal joint (A), resulting in locking (B). demonstrate interarticular masses or loose bodies. The mass, including its stalk, was completely excised. Six months following excision, the patient had full proximal interphalangeal motion without recurrence of hi s sy mptoms. The patient did continue to have enlargement of the general configuration of the proximal interphalangeal joint , and small calcifications on the ulnar aspect of his finger persisted . The patient did not wish to have any further surgical intervention at this point. Hi stological review of the mass showed multiple areas of chondrometaplasia arising from tissue which appeared to be synovium. Some cartilaginous masses were partially calcified. No osteoid was noted (Fig. 3).
Discussion Synovial chondrometaplasia is characterized by metaplastic cartilage formation in synovial membranes of joints, bursae and tendon sheaths . I . 2, :1- 14 Cases involving the synovium of large joints, such as the hip, knee, and elbow, have been well-documented. Involvement of smaller joints, such as the proximal interphalangeal joint of the finger, have also been described. 7, 9. 13. 15 Synovial chondrometaplasia arising from the synovium of tendon sheaths and bursae is rare. I , 2, II, 12 . 14-17 The hands and feet are most commonly involved with such extraarticular soft tissue cartilaginous tumors . There have been a number of reports of chondrometaplasia arising from tendon sheaths in the hand and fingers. l , 12 , 14-16, 18 Dahlin and Salvador reviewed 70 tumors of hyaline cartilage in the soft tissues of the hand and feet and Chung and Enzinger2 reported on 104
such cases. Adults in middle life are most characteristically involved, with men predominating. Such cartilaginous tumors arise in close association with synovial tissue of the hands and feet. Consequently, such cartilage masses are thought to represent chondrometaplasia from the synovial membranes. Roentgengrams usually show soft tissue masses often associated with calcification or ossifications. 2. 16 Erosions of underlying bone are unusual, but have been reported. l , 2. 20 The masses are usually small, measuring less than 5 cm in diameter. The appearance is most often off-white and cartilaginous in consistency. The microscopic appearance shows lobulated hyaline cartilage masses, closely associated with tissue resembling synovium. Atypism of cellular types is often noted , as is true of other acral cartilaginous tumors . I , 2, 16, 18 As a result, diagnostic appraisal between benign and malignant states is sometimes difficult. I , 2, 4, 16, 21 However, none of the 70 tumors described by Dahlin and Salvadore 3 and 104 presented by Chung and Enzinger2 metastasized. Recurrence from inadequate excision does occur and may require multiple local excisions or more radical procedures . Most patients involved present with a history of a slow growing mass of long duration . 2 , 16, 20 In the hand such masses rarely cause significant dysfunction unless they reach large proportions . Triggering or locking is a very rare occurrenee. Rockey 17 described a single case of triggering as a result of synovial chondrometaplasia in the flexor
Vol. 5, No.5 September 1980
Extraarticular synovial chondrometaplasia
475
Fig. 3. A photomicrograph of the excised mass, showing areas of chondrometaplasia arising from synovium. (Hematoxylin and eosin; original magnification x 100.)
tendon sheath at the metacarpal phalangeal joint level. The case presented here is the only known case of locking of the finger secondary to extraarticular synovial chondrometaplasia at the proximal interphalangeal joint involving the extensor mechanism. Treatment for this condition consists of complete excision of the involved area. Recurrence may occur and is amenable to excision and, in extraordinary cases, radical excision or amputation. The differential diagnosis may be difficult. Both metastatic and dystrophic calcification may occur in the hand. The metastatic causes of calcification include disease of endocrine dysfunction, neoplasia, and disorders of calcium and phosphorous metabolism. The dystrophic causes include trauma and chronic inflammatory disease to include collagen vascular disease. REFERENCES I. Constant E, Harebottle NH, Davis DG: Synovial chondromatosis of the hand. case report. Plast Reconstr Surg 54:353-8, 1974
2. Chung EB, Enzinger FM: Chondroma of soft parts. Cancer 41:1414-24, 1978 3. Dahlin DC, Salvador AH: Cartilagenous tumors of the soft tissues of the hands and feet. Mayo Clin Proc 49:721-6, 1974 4. Goldenberg RR, Cohen P, Steinlauf P: Chondrosarcoma of the extraske1eta1 soft tissues. A report of seven cases and review of the literature. J Bone Joint Surg [Am] 49: 1487-1507, 1967 5. Halstead AE: Floating bodies in joints. Ann Surg 22:327-42, 1895 6. Henderson MS, Jones HT: Loose bodies in joints and bursae due to synovial osteochondromatosis. J Bone Joint Surg 5:400-24, 1923 7. Jaffe HL: Tumors and tumerous conditions of the bones and joints. Philadelphia, 1958, Lea & Febiger, Publishers 8. Jeffreys TE: Synovial chondromatosis. J Bone Joint Surg [Br] 49:530-4, 1967 9. Kettlekamp DB, Dolan J: Synovial chondromatosis of an interphalangeal joint of a finger. Report of a case. J Bone Joint Surg [Am] 48:530-4, 1966 10. Lewis MM, Marshall JL, Mira JM: Synovial chon-
476
II.
12.
13 . 14.
15. 16.
The Journal of HAND SURGER Y
Janecki . Routson. and DePapp
dromatosis of the thumb . A case report and review of literature. J Bone Joint Surg [Am] 56:180-3, 1974 Lichtenstein L, Goldman RL: Cartilage tumors in soft tissues, particularly in the hand and foot. Cancer 17:1203-8, 1964 Lynn MD, Lee J: Periarticular tenosynovial chondrometaplasia. Report of a case at the wrist. J Bone Joint Surg [Am] 56:650-2, 1972 Murphy AF, Wilson TN : Tenosy novial osteochondroma in the hand. J Bone Joint Surg [Am] 40:1236-40 , 1958 Murphy, PF, Dahlin DC , Sullivan CR: Articular synovial chondromatosis. J Bone Joint Surg [Am] 44:77-86, 1962 Paul RG, Leach RE: Synovial chondromatosis of the shoulder. Clin Orthop 68: 130-5, 1970 Roberts PH: Tenosynovial chondromatosis. An unusual case. Br J Surg 58:152, 1971
17. Rockey HC: Triggering finger due to tenosynovial osteochondroma. J Bone Joint Surg [Am] 45:387-8,1963 18. Silver MC, Simon DS, Litchman MH, Dychman J: Synovial chondromatosis of the temporo mandibular joint. J Bone Joint Surg [Am] 53:777-80, 1971 19. Someren A, Merritt WH: Tenosynovial chondroma of the hand: a case report with a brief review of the literature . Human Pathol 9:476-9, 1978 20 . Storen H: On synovial chondromatosis in the knee joint and its treatment. Acta Chir Scand 128:496-508, 1964 21 . Stout AP, Verner EW: Chondrosarcoma of extraske1etal soft tissues. Cancer 6:581-90 , 1953 22. Strong ML Jr: Chondromas of the tendon sheath of the hand. Report of a case and review of the literature. J Bone Joint Surg 57:1164-5 , 1975
Hands on Stamps To promote interest in the International Geophysical Year in 1958, the United States issued a stamp showing a picture of the sun with intense solar activity. This was an area of scientific study for 1958. Above the solar disc were hands from a segment of Michaelangelo's fresco on the ceiling of the Sistine Chapel, . 'Creation of Man . " Submitted by. Thomas Joseph Palmieri. M .D. Assistant Professor. Clinical Surgery State University of New York Stony Brook. NY 11794
Chet J. Janecki, M.D., Gary Routson, M.D., and Elise W. DePapp, M.D., Rochester, N.Y.
In
the condition of synovial chondrometaplasia, cartilaginous and osteocartilaginous bodies arise from synovial membranes. This entity has been noted in joints, bursae, and tendon sheaths . The purpose of this report is to present a case of extraarticular synovial chondrometaplasia at the proximal interphalangeal joint with resultant mechanical dysfunction or locking of the finger .
Case history The patient, a 31-year-old white man , initially presented with a complaint of a painful proximal interphalangeal joint of his right ring finger. The patient noted that for 6 months he had intermittent pain and limitation of motion in this joint related to the migration of a mass on the radial dorsal aspect of the joint. Physical examination showed thickening of the proximal interphalangeal joint of the finger with a full range of motion. A small, subcutaneous mass was palpable on the dorsal radial aspect of the finger, proximal to the joint. This mass was demonstrated on roentgenograms as an extraarticular calcification (Fig. I) . One week following the initial examination, the patient returned to demonstrate an episode of limitation of proximal interphalangeal joint flexion. Examination at that time revealed that the subcutaneous mass was no longer readily palpable at its original site . The mass seemed to be under the extensor mechanism. The proximal interphalangeal joint was locked at approximately 30° of flexion . Attempts at active flexion or extension caused pain . The patient then inadvertently twisted his proximal interphalangeal joint, returning the mass to its original position . Active flexion and extension of the proximal interphalangeal joint were then restored. A complete blood count and the uric acid and sedimentation
From the Department of Orthopaedic Surgery , University of Rochester School of Medicine and Dentistry , Rochester, N. Y. Received for publication Oct. 19, 1979. Reprint requests: Chet J. Janecki, M.D. , 2Locke Dr., Pittsford, NY 14534.
0363-5023/801050473+04$00.4010
Fig. 1. A roentgenogram showing a calcified mass adjacent to the proximal interphalangeal joint.
rate s were normal. No other joints of the hand or wrist were involved on roentgenograms. At operation, a curved, longitudinal incision on the radial aspect of the joint was made. The extensor mechanism was identified. A longitudinal incision was made through the radial transverse ligament and a small , 2.2 to 3 mm oval extraarticular mass was encountered on the dorsal radial aspect of the finger, just proximal to the proximal interphalangeal joint. The mass was attached to a long , pedunculated soft tissue stalk , which did not communicate with the joint. As a result of the stalk, the mass was capable of interposing itself between the extensor hood and the proximal phalanx, resulting in a decrease in excursion of the joint in flexion (Fig . 2). Arthrotomy of the proximal interphalangeal joint did not
© 1980 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
473
474
Janecki . Routson . and DePapp
The Journal of HAND SURGERY
A
Fig. 2. A diagramatic sketch showing the changing relationship of the calcified mass to the extensor mechanism of the proximal interphalangeal joint (A), resulting in locking (B). demonstrate interarticular masses or loose bodies. The mass, including its stalk, was completely excised. Six months following excision, the patient had full proximal interphalangeal motion without recurrence of hi s sy mptoms. The patient did continue to have enlargement of the general configuration of the proximal interphalangeal joint , and small calcifications on the ulnar aspect of his finger persisted . The patient did not wish to have any further surgical intervention at this point. Hi stological review of the mass showed multiple areas of chondrometaplasia arising from tissue which appeared to be synovium. Some cartilaginous masses were partially calcified. No osteoid was noted (Fig. 3).
Discussion Synovial chondrometaplasia is characterized by metaplastic cartilage formation in synovial membranes of joints, bursae and tendon sheaths . I . 2, :1- 14 Cases involving the synovium of large joints, such as the hip, knee, and elbow, have been well-documented. Involvement of smaller joints, such as the proximal interphalangeal joint of the finger, have also been described. 7, 9. 13. 15 Synovial chondrometaplasia arising from the synovium of tendon sheaths and bursae is rare. I , 2, II, 12 . 14-17 The hands and feet are most commonly involved with such extraarticular soft tissue cartilaginous tumors . There have been a number of reports of chondrometaplasia arising from tendon sheaths in the hand and fingers. l , 12 , 14-16, 18 Dahlin and Salvador reviewed 70 tumors of hyaline cartilage in the soft tissues of the hand and feet and Chung and Enzinger2 reported on 104
such cases. Adults in middle life are most characteristically involved, with men predominating. Such cartilaginous tumors arise in close association with synovial tissue of the hands and feet. Consequently, such cartilage masses are thought to represent chondrometaplasia from the synovial membranes. Roentgengrams usually show soft tissue masses often associated with calcification or ossifications. 2. 16 Erosions of underlying bone are unusual, but have been reported. l , 2. 20 The masses are usually small, measuring less than 5 cm in diameter. The appearance is most often off-white and cartilaginous in consistency. The microscopic appearance shows lobulated hyaline cartilage masses, closely associated with tissue resembling synovium. Atypism of cellular types is often noted , as is true of other acral cartilaginous tumors . I , 2, 16, 18 As a result, diagnostic appraisal between benign and malignant states is sometimes difficult. I , 2, 4, 16, 21 However, none of the 70 tumors described by Dahlin and Salvadore 3 and 104 presented by Chung and Enzinger2 metastasized. Recurrence from inadequate excision does occur and may require multiple local excisions or more radical procedures . Most patients involved present with a history of a slow growing mass of long duration . 2 , 16, 20 In the hand such masses rarely cause significant dysfunction unless they reach large proportions . Triggering or locking is a very rare occurrenee. Rockey 17 described a single case of triggering as a result of synovial chondrometaplasia in the flexor
Vol. 5, No.5 September 1980
Extraarticular synovial chondrometaplasia
475
Fig. 3. A photomicrograph of the excised mass, showing areas of chondrometaplasia arising from synovium. (Hematoxylin and eosin; original magnification x 100.)
tendon sheath at the metacarpal phalangeal joint level. The case presented here is the only known case of locking of the finger secondary to extraarticular synovial chondrometaplasia at the proximal interphalangeal joint involving the extensor mechanism. Treatment for this condition consists of complete excision of the involved area. Recurrence may occur and is amenable to excision and, in extraordinary cases, radical excision or amputation. The differential diagnosis may be difficult. Both metastatic and dystrophic calcification may occur in the hand. The metastatic causes of calcification include disease of endocrine dysfunction, neoplasia, and disorders of calcium and phosphorous metabolism. The dystrophic causes include trauma and chronic inflammatory disease to include collagen vascular disease. REFERENCES I. Constant E, Harebottle NH, Davis DG: Synovial chondromatosis of the hand. case report. Plast Reconstr Surg 54:353-8, 1974
2. Chung EB, Enzinger FM: Chondroma of soft parts. Cancer 41:1414-24, 1978 3. Dahlin DC, Salvador AH: Cartilagenous tumors of the soft tissues of the hands and feet. Mayo Clin Proc 49:721-6, 1974 4. Goldenberg RR, Cohen P, Steinlauf P: Chondrosarcoma of the extraske1eta1 soft tissues. A report of seven cases and review of the literature. J Bone Joint Surg [Am] 49: 1487-1507, 1967 5. Halstead AE: Floating bodies in joints. Ann Surg 22:327-42, 1895 6. Henderson MS, Jones HT: Loose bodies in joints and bursae due to synovial osteochondromatosis. J Bone Joint Surg 5:400-24, 1923 7. Jaffe HL: Tumors and tumerous conditions of the bones and joints. Philadelphia, 1958, Lea & Febiger, Publishers 8. Jeffreys TE: Synovial chondromatosis. J Bone Joint Surg [Br] 49:530-4, 1967 9. Kettlekamp DB, Dolan J: Synovial chondromatosis of an interphalangeal joint of a finger. Report of a case. J Bone Joint Surg [Am] 48:530-4, 1966 10. Lewis MM, Marshall JL, Mira JM: Synovial chon-
476
II.
12.
13 . 14.
15. 16.
The Journal of HAND SURGER Y
Janecki . Routson. and DePapp
dromatosis of the thumb . A case report and review of literature. J Bone Joint Surg [Am] 56:180-3, 1974 Lichtenstein L, Goldman RL: Cartilage tumors in soft tissues, particularly in the hand and foot. Cancer 17:1203-8, 1964 Lynn MD, Lee J: Periarticular tenosynovial chondrometaplasia. Report of a case at the wrist. J Bone Joint Surg [Am] 56:650-2, 1972 Murphy AF, Wilson TN : Tenosy novial osteochondroma in the hand. J Bone Joint Surg [Am] 40:1236-40 , 1958 Murphy, PF, Dahlin DC , Sullivan CR: Articular synovial chondromatosis. J Bone Joint Surg [Am] 44:77-86, 1962 Paul RG, Leach RE: Synovial chondromatosis of the shoulder. Clin Orthop 68: 130-5, 1970 Roberts PH: Tenosynovial chondromatosis. An unusual case. Br J Surg 58:152, 1971
17. Rockey HC: Triggering finger due to tenosynovial osteochondroma. J Bone Joint Surg [Am] 45:387-8,1963 18. Silver MC, Simon DS, Litchman MH, Dychman J: Synovial chondromatosis of the temporo mandibular joint. J Bone Joint Surg [Am] 53:777-80, 1971 19. Someren A, Merritt WH: Tenosynovial chondroma of the hand: a case report with a brief review of the literature . Human Pathol 9:476-9, 1978 20 . Storen H: On synovial chondromatosis in the knee joint and its treatment. Acta Chir Scand 128:496-508, 1964 21 . Stout AP, Verner EW: Chondrosarcoma of extraske1etal soft tissues. Cancer 6:581-90 , 1953 22. Strong ML Jr: Chondromas of the tendon sheath of the hand. Report of a case and review of the literature. J Bone Joint Surg 57:1164-5 , 1975
Hands on Stamps To promote interest in the International Geophysical Year in 1958, the United States issued a stamp showing a picture of the sun with intense solar activity. This was an area of scientific study for 1958. Above the solar disc were hands from a segment of Michaelangelo's fresco on the ceiling of the Sistine Chapel, . 'Creation of Man . " Submitted by. Thomas Joseph Palmieri. M .D. Assistant Professor. Clinical Surgery State University of New York Stony Brook. NY 11794