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Simple bone cyst of the metacarpal
Vol. 12A, No.6 November 1987
ganglion of the distal ulna. Resection of the central portion of the disk and currettage and grafting of the cystic area resulted in complete resolution of symptoms. REFERENCES 1. Resnick D. Rheumatoid arthritis of the wrist: The compartmental approach. Med Radiol 1976;52:50. 2. Bowers WH, Hurst LC. An intra-articular intraosseous carpal ganglion. J HAND SURG 1979;4:375-7. 3. Mogan JV, Newberg AH, Davis PH. Intraosseous ganglion of the lunate. J HAND SURG 1981;6:61-63. 4. Pellegrino EA, Oslen JR. Bilateral carpal lunate ganglion. Clin Orthop 1972;87:225-7. 5. Plewes LW. Osteoarthritis of the hip. Br J Surg 1940;27:682-97. 6. Landells JW. The bone cysts of osteoarthritis. J Bone Joint Surg [Br] 1963;45:755-60.
7. Crane AR, Scarano 11. Synovial cysts (ganglia) of bone. J Bone Joint Surg [Am] 1967;49:355-61. 8. Ondrouch AS. Cyst formation in osteoarthritis. J Bone Joint Surg [Br] 1963;45:755-60. 9. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist anatomy and function. J HAND SURG 1981;6:153. 10. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 1984;187:26-35. 11. Coleman HM. Injuries of the articular disc at the wrist. J Bone Joint Surg [Br] 1960;42:522-9. 12. Menon J, Wood VE, Schoene H, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J HAND SURG 1984;9A:527-30.
Simple bone cyst of the metacarpal Simple bone cyst is a benign tumor-like lesion that occurs principally in the humerus and the femur. Occurrence within the hand is rare and involvement of the metacarpals is even more uncommon. Two similar cases of a simple bone cyst affecting the metacarpals were treated by complete excision of the cyst and replacement by a corti co-medullar autogenous graft. (J HAND SURG 1987;12A:1103-6.)
Avraham Baruch, M.D., Avraham Haas, M.D., Beatriz Lifschitz-Mercer, M.D., and Amir Zeligowsky, M.D., Rehovot, Israel
Simple bone cyst (solitary bone cyst, unicameral bone cyst) is an uncommon condition in the skeleton of the hand, particularly in the metacarpal bones. Recently, we treated two patients who had a simple bone cyst (SBC) in their fifth metacarpal bones. Both cases were almost identical, considering their clinical aspects, treatment, and late results. From the Department of Hand Surgery, and Department of Pathology, Kaplan Hospital, Rehovot, Israel (Affiliated with the Medical School of the Hebrew University and Hadassah, Jerusalem). Received for publication Sept. 29, 1986; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: A. Baruch, M.D., Department of Hand Surgery,
Kaplan Hospital, 76100 Rehovot, Israel.
Case reports Case 1. A 9-year-old boy was referred to our Hand Clinic in June 1983 with a large, fast-growing lump over the fifth metacarpal of the right hand. The swelling had started 6 months previously. No local trauma could be recalled. Physical examination showed a firm mass approximately 2.5 x 4 cm in size, located on the dorsal aspect of the fifth metacarpal. The overlying skin was normal. Flexion of the fifth metacarpophalangeal (MP) joint was limited to 70°. Complete blood count, sedimentation rate, serum electrolyte levels, alkaline and acid phosphatase levels and urinalysis were within normal limits. X-ray films showed a cystic enlargement of the fifth metacarpal that included the metacarpal head (Fig. 1). At operation, the metacarpal shaft was found to be significantly widened but both head and base seemed to be uninvolved. The epiphyseal plate bordered the upper rim of the cyst, whereas the base of the metacarpal represented a flat fragment. The cortex was very thin and the cavity con-
THE JOURNAL OF HAND SURGERY
1103
1104
The Journal of HAND SURGERY
Baruch et al.
1 ".-.•..."". ,. 'f
•
Fig. 2. Case I. The excised cyst.
normal. X-ray films showed a cystic enlargement of the fifth metacarpal similar to the previous case. The operation and postoperative regime were identical to that used in case 1. At the last follow-up, 3 years after operation, flexion of the MP joint was limited to 45° and it deviated ulnarly 20°. X-ray films showed an acceptable condition of the graft (Fig . 4), which has fused firmly to the epiphyseal plate .
Pathology
Fig. 1. Case I. Preoperative x-ray appearance of the cyst. Note the contours ofthe metacarpal head covered by the cyst.
Macroscopically, the two cases were similar and consisted of simple unilocular cystic cavities 4 cm in diameter surrounded by bony cortex and soft tissue. The inner surfaces of the cysts were smooth and brownishgray. Microscopically, the cysts were lined with a thin fibrous membrane, surrounded by cortical bone with osteoblastic rimming (Fig. 5). Discussion
tained sanguinous fluid. Fine trabeculae were noted within the cyst. The lesion was completely removed by resecting the shaft of the metacarpal, leaving in place only the base and the head (Fig. 2). Corticomedullary bone was obtained from the olecranon and inserted in the gap. Care was taken to preserve the epiphyseal plate during insertion of the graft. The graft was fixed with Kirschner wires. Postoperatively, the hand was kept in a plaster cast for 7 weeks. At the end of that period, radiographs showed solid union of the bone graft to both the epiphyseal plate at the head and to the base. Follow-up 3 years later showed no evidence of recurrence and solid fusion. Active and passive flexion of the MP joint remained slightly limited but in the same range as on admission. Case 2. A lO-year-old girl was admitted in August 1983 with a hard mass over her left fifth metacarpal (Fig. 3). The swelling was painless and of similar dimensions as in the first case . The tumor had first been noticed 10 months before admission. Laboratory analysis of the blood and urine were
Simple bone cyst is a unicameral cavity filled with clear or sanguinous fluid and lined by a membrane of variable thickness, which consists of loose vascular connective tissue showing scattered osteoclast giant cells and sometimes areas of recent or old hemorrhage or cholesterol clefts.' Mikulicz presented the original description of SBC in 1906. In more than 80% of the patients these cysts are located in the humerus and femur. It is extremely rare to find them in the metacarpal bones. Schajowicz' reported only four SBC in the metacarpals out of a series of 167. In the literature at our disposal we were able to find only one similar case. 2 Most of the cysts are diagnosed in patients between the ages of three and 14 years. There is a 2 ; 1male-tofemale relationship. 3 Children below the age of ten tend to have a four-fold higher recurrence rate than adolescents. These lesions were classified by laffe4 into active
Vol. 12A, No . 6 November 1987
;
Simple bone cyst of metacarpal
1105
r
Fig. 4. Case 2. Follow-up radiograph showing the bone graft and ulnar deviation of the small finger. Fig. 3. Case 2. Photograph of the hand before operation .
or latent on the basis of their proximity to the growth plate. The cause is still unclear. Several theories are proposed, two of which are most popular. Cohens claimed that formation of the cyst represents the inability of the interstitial fluid to escape from the bone because of blockage of the drainage system. Mirra et al. 6 believed that these cavities represent interosseous synovial cysts. Radiologically, a SBC is difficult to differentiate from an aneurysmal bone cyst, giant-cell tumor or enchondroma. Diagnostic aspiration of the cyst is of doubtful value. The various treatment methods mentioned in the literature are curettage and bone grafting,7 partial resection with or without grafting, 8. 9 multiple drilling, 10 total resection and cortical bone graft , II filling with plasterof-paris , 12 fracture immobilization and observation alone,13 and injection to the cyst with steroid. 14 The choice of treatment may vary according to the patient's age , the involved bone, the dimension and location of the cyst within the bone, and according to its type-whether it is active or latent.
Fig. 5. Higher magnification of the cyst wall showing bone with osteoblastic rimming and thin fibrous lining membrane. (Hematoxylin and eosin stain. Original magnification X 150.)
We chose to treat our patients' cysts radically by complete excision and reconstruction of the shaft by a cortico-medullary, autogenous graft. Our rationale was that according to Jaffe, these cysts were active as dem-
The Journal of HAND SURGERY
Baruch et al.
onstrated by complete destruction of the metacarpal, and both patients were below age of 10 and statistically more susceptible to recurrencies . The authors thank the staff of the photo-laboratory at Kaplan Hospital for the illustrations.
REFERENCES 1. Schajowicz F. Tumors and tumor-like lesions of bone and joints, New York: Springer-Verlag, 1981:417-8. 2. Head SA . Unicameral bone cyst located in metacarpal bone . J Am Osteopath Assoc 1984;84:372-3 . 3. Oppenheim LW, Galeno H. Operative treatment versus steroid injection in management of unicameral bone cyst. J Ped Orthop 1984;4:1-7. 4. Jaffe HL. Tumors and tumorous conditions of the bone and joints. Philadelphia: Lea & Febiger, 1958:72. 5. Cohen J. Simple bone cyst. Studies of cyst fluid in six cases with a theory of pathogenesis. J Bone Joint Surg [Am] 1960;42:609-16. 6. Mirra JM, Bernard GW, Bullough PG, Johnston W, Mink G. Cementum-like bone production in solitary bone cyst (so-called "Cementoma" of long bones): Report of three cases. Electron microscopic observations supporting a synovial origin of the simple bone cyst . Clin Orthop 1978;135:295.
7. Garceau GJ, Gregory CF. Solitary unicameral bone cyst. J Bone Joint Surg [Am] 1954;36:267-380. 8. McKay OW, Nasson SS. Treatment of unicameral bone cysts by subtotal resection without grafts . J Bone Joint Surg [Am] 1977;59:515-9. 9. Fahey 11, O'Brien ET. Subtotal resection and grafting in selected cases of solitary unicameral bone cysts . J Bone Joint Surg [Am] 1943;55:59-68. 10. Kuboyama KK, Shido T, Narada A, Yokoe S. Therapy of solitary unicameral bone cyst with percutaneous trepanation . Rinsho Seikei Geka 1981;18:288-93. 11 . Agerholm JC, Goodfellow JW. Simple cyst of the humerus treated by radical excision. J Bone Joint Surg [Br] 1965;47:714. 12. Peltier L. The use of plaster of paris to fill defects in bone . Clin Orthop 1961 ;21: 1-31. 13. Neer CS , Francis KC, Markove RC, Terz J, Carbonara PN. Treatment of unicameral bone cyst. A follow-up study of 175 cases . J Bone Joint Surg [Am] 1966;48: 731-45 . 14. Scaglietti 0, Marchetti PG, Bartolozzi P. The effects of methylprednisolone acetate in the treatment of bone cysts. J Bone Joint Surg [Br] 1979;61 :200.
Spontaneous rupture of the extensor pollicis longus tendon An extensor pollicis longus tendon, ruptured after treatment of a giant cell tumor of the distal radius by packing the cavity with polymethylmethacrylate cement. The lack of extension was treated successfully with tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Pathophysiology of the rupture is discussed. (J HAND SURG 1987;12A:1106·9.)
David Siegel, M.D., Mark Gebhardt, M.D., and Jesse B. Jupiter, M.D., Boston, Mass.
From the Department of Orthopaedic Surgery, The Massachusetts General Hospital, and Harvard Medical School, Boston, Mass . Received for publication March 12, 1987; accepted in revised form May 15, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: David Siegel, M.D., Department of Orthopaedic Surgery, The Massachusetts General Hospital, 15 Parkman SI., ACC 427, Massachusetts General Hospital, Boston, MA 02114.
1106
THE JOURNAL OF HAND SURGERY
Spontaneous rupture of the extensor pollicis longus (EPL) tendon, while uncommon, has been described in association with rheumatoid arthritis; "" Colles' fracture/· 8 occupational trauma,9.11 infection,12,13 and tumors. 14 We report a case of spontaneous rupture of the EPL tendon 8 weeks after curettage and polymethylmethacrylate packing of a giant cell tumor of the distal radius.
ganglion of the distal ulna. Resection of the central portion of the disk and currettage and grafting of the cystic area resulted in complete resolution of symptoms. REFERENCES 1. Resnick D. Rheumatoid arthritis of the wrist: The compartmental approach. Med Radiol 1976;52:50. 2. Bowers WH, Hurst LC. An intra-articular intraosseous carpal ganglion. J HAND SURG 1979;4:375-7. 3. Mogan JV, Newberg AH, Davis PH. Intraosseous ganglion of the lunate. J HAND SURG 1981;6:61-63. 4. Pellegrino EA, Oslen JR. Bilateral carpal lunate ganglion. Clin Orthop 1972;87:225-7. 5. Plewes LW. Osteoarthritis of the hip. Br J Surg 1940;27:682-97. 6. Landells JW. The bone cysts of osteoarthritis. J Bone Joint Surg [Br] 1963;45:755-60.
7. Crane AR, Scarano 11. Synovial cysts (ganglia) of bone. J Bone Joint Surg [Am] 1967;49:355-61. 8. Ondrouch AS. Cyst formation in osteoarthritis. J Bone Joint Surg [Br] 1963;45:755-60. 9. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist anatomy and function. J HAND SURG 1981;6:153. 10. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 1984;187:26-35. 11. Coleman HM. Injuries of the articular disc at the wrist. J Bone Joint Surg [Br] 1960;42:522-9. 12. Menon J, Wood VE, Schoene H, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J HAND SURG 1984;9A:527-30.
Simple bone cyst of the metacarpal Simple bone cyst is a benign tumor-like lesion that occurs principally in the humerus and the femur. Occurrence within the hand is rare and involvement of the metacarpals is even more uncommon. Two similar cases of a simple bone cyst affecting the metacarpals were treated by complete excision of the cyst and replacement by a corti co-medullar autogenous graft. (J HAND SURG 1987;12A:1103-6.)
Avraham Baruch, M.D., Avraham Haas, M.D., Beatriz Lifschitz-Mercer, M.D., and Amir Zeligowsky, M.D., Rehovot, Israel
Simple bone cyst (solitary bone cyst, unicameral bone cyst) is an uncommon condition in the skeleton of the hand, particularly in the metacarpal bones. Recently, we treated two patients who had a simple bone cyst (SBC) in their fifth metacarpal bones. Both cases were almost identical, considering their clinical aspects, treatment, and late results. From the Department of Hand Surgery, and Department of Pathology, Kaplan Hospital, Rehovot, Israel (Affiliated with the Medical School of the Hebrew University and Hadassah, Jerusalem). Received for publication Sept. 29, 1986; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: A. Baruch, M.D., Department of Hand Surgery,
Kaplan Hospital, 76100 Rehovot, Israel.
Case reports Case 1. A 9-year-old boy was referred to our Hand Clinic in June 1983 with a large, fast-growing lump over the fifth metacarpal of the right hand. The swelling had started 6 months previously. No local trauma could be recalled. Physical examination showed a firm mass approximately 2.5 x 4 cm in size, located on the dorsal aspect of the fifth metacarpal. The overlying skin was normal. Flexion of the fifth metacarpophalangeal (MP) joint was limited to 70°. Complete blood count, sedimentation rate, serum electrolyte levels, alkaline and acid phosphatase levels and urinalysis were within normal limits. X-ray films showed a cystic enlargement of the fifth metacarpal that included the metacarpal head (Fig. 1). At operation, the metacarpal shaft was found to be significantly widened but both head and base seemed to be uninvolved. The epiphyseal plate bordered the upper rim of the cyst, whereas the base of the metacarpal represented a flat fragment. The cortex was very thin and the cavity con-
THE JOURNAL OF HAND SURGERY
1103
1104
The Journal of HAND SURGERY
Baruch et al.
1 ".-.•..."". ,. 'f
•
Fig. 2. Case I. The excised cyst.
normal. X-ray films showed a cystic enlargement of the fifth metacarpal similar to the previous case. The operation and postoperative regime were identical to that used in case 1. At the last follow-up, 3 years after operation, flexion of the MP joint was limited to 45° and it deviated ulnarly 20°. X-ray films showed an acceptable condition of the graft (Fig . 4), which has fused firmly to the epiphyseal plate .
Pathology
Fig. 1. Case I. Preoperative x-ray appearance of the cyst. Note the contours ofthe metacarpal head covered by the cyst.
Macroscopically, the two cases were similar and consisted of simple unilocular cystic cavities 4 cm in diameter surrounded by bony cortex and soft tissue. The inner surfaces of the cysts were smooth and brownishgray. Microscopically, the cysts were lined with a thin fibrous membrane, surrounded by cortical bone with osteoblastic rimming (Fig. 5). Discussion
tained sanguinous fluid. Fine trabeculae were noted within the cyst. The lesion was completely removed by resecting the shaft of the metacarpal, leaving in place only the base and the head (Fig. 2). Corticomedullary bone was obtained from the olecranon and inserted in the gap. Care was taken to preserve the epiphyseal plate during insertion of the graft. The graft was fixed with Kirschner wires. Postoperatively, the hand was kept in a plaster cast for 7 weeks. At the end of that period, radiographs showed solid union of the bone graft to both the epiphyseal plate at the head and to the base. Follow-up 3 years later showed no evidence of recurrence and solid fusion. Active and passive flexion of the MP joint remained slightly limited but in the same range as on admission. Case 2. A lO-year-old girl was admitted in August 1983 with a hard mass over her left fifth metacarpal (Fig. 3). The swelling was painless and of similar dimensions as in the first case . The tumor had first been noticed 10 months before admission. Laboratory analysis of the blood and urine were
Simple bone cyst is a unicameral cavity filled with clear or sanguinous fluid and lined by a membrane of variable thickness, which consists of loose vascular connective tissue showing scattered osteoclast giant cells and sometimes areas of recent or old hemorrhage or cholesterol clefts.' Mikulicz presented the original description of SBC in 1906. In more than 80% of the patients these cysts are located in the humerus and femur. It is extremely rare to find them in the metacarpal bones. Schajowicz' reported only four SBC in the metacarpals out of a series of 167. In the literature at our disposal we were able to find only one similar case. 2 Most of the cysts are diagnosed in patients between the ages of three and 14 years. There is a 2 ; 1male-tofemale relationship. 3 Children below the age of ten tend to have a four-fold higher recurrence rate than adolescents. These lesions were classified by laffe4 into active
Vol. 12A, No . 6 November 1987
;
Simple bone cyst of metacarpal
1105
r
Fig. 4. Case 2. Follow-up radiograph showing the bone graft and ulnar deviation of the small finger. Fig. 3. Case 2. Photograph of the hand before operation .
or latent on the basis of their proximity to the growth plate. The cause is still unclear. Several theories are proposed, two of which are most popular. Cohens claimed that formation of the cyst represents the inability of the interstitial fluid to escape from the bone because of blockage of the drainage system. Mirra et al. 6 believed that these cavities represent interosseous synovial cysts. Radiologically, a SBC is difficult to differentiate from an aneurysmal bone cyst, giant-cell tumor or enchondroma. Diagnostic aspiration of the cyst is of doubtful value. The various treatment methods mentioned in the literature are curettage and bone grafting,7 partial resection with or without grafting, 8. 9 multiple drilling, 10 total resection and cortical bone graft , II filling with plasterof-paris , 12 fracture immobilization and observation alone,13 and injection to the cyst with steroid. 14 The choice of treatment may vary according to the patient's age , the involved bone, the dimension and location of the cyst within the bone, and according to its type-whether it is active or latent.
Fig. 5. Higher magnification of the cyst wall showing bone with osteoblastic rimming and thin fibrous lining membrane. (Hematoxylin and eosin stain. Original magnification X 150.)
We chose to treat our patients' cysts radically by complete excision and reconstruction of the shaft by a cortico-medullary, autogenous graft. Our rationale was that according to Jaffe, these cysts were active as dem-
The Journal of HAND SURGERY
Baruch et al.
onstrated by complete destruction of the metacarpal, and both patients were below age of 10 and statistically more susceptible to recurrencies . The authors thank the staff of the photo-laboratory at Kaplan Hospital for the illustrations.
REFERENCES 1. Schajowicz F. Tumors and tumor-like lesions of bone and joints, New York: Springer-Verlag, 1981:417-8. 2. Head SA . Unicameral bone cyst located in metacarpal bone . J Am Osteopath Assoc 1984;84:372-3 . 3. Oppenheim LW, Galeno H. Operative treatment versus steroid injection in management of unicameral bone cyst. J Ped Orthop 1984;4:1-7. 4. Jaffe HL. Tumors and tumorous conditions of the bone and joints. Philadelphia: Lea & Febiger, 1958:72. 5. Cohen J. Simple bone cyst. Studies of cyst fluid in six cases with a theory of pathogenesis. J Bone Joint Surg [Am] 1960;42:609-16. 6. Mirra JM, Bernard GW, Bullough PG, Johnston W, Mink G. Cementum-like bone production in solitary bone cyst (so-called "Cementoma" of long bones): Report of three cases. Electron microscopic observations supporting a synovial origin of the simple bone cyst . Clin Orthop 1978;135:295.
7. Garceau GJ, Gregory CF. Solitary unicameral bone cyst. J Bone Joint Surg [Am] 1954;36:267-380. 8. McKay OW, Nasson SS. Treatment of unicameral bone cysts by subtotal resection without grafts . J Bone Joint Surg [Am] 1977;59:515-9. 9. Fahey 11, O'Brien ET. Subtotal resection and grafting in selected cases of solitary unicameral bone cysts . J Bone Joint Surg [Am] 1943;55:59-68. 10. Kuboyama KK, Shido T, Narada A, Yokoe S. Therapy of solitary unicameral bone cyst with percutaneous trepanation . Rinsho Seikei Geka 1981;18:288-93. 11 . Agerholm JC, Goodfellow JW. Simple cyst of the humerus treated by radical excision. J Bone Joint Surg [Br] 1965;47:714. 12. Peltier L. The use of plaster of paris to fill defects in bone . Clin Orthop 1961 ;21: 1-31. 13. Neer CS , Francis KC, Markove RC, Terz J, Carbonara PN. Treatment of unicameral bone cyst. A follow-up study of 175 cases . J Bone Joint Surg [Am] 1966;48: 731-45 . 14. Scaglietti 0, Marchetti PG, Bartolozzi P. The effects of methylprednisolone acetate in the treatment of bone cysts. J Bone Joint Surg [Br] 1979;61 :200.
Spontaneous rupture of the extensor pollicis longus tendon An extensor pollicis longus tendon, ruptured after treatment of a giant cell tumor of the distal radius by packing the cavity with polymethylmethacrylate cement. The lack of extension was treated successfully with tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Pathophysiology of the rupture is discussed. (J HAND SURG 1987;12A:1106·9.)
David Siegel, M.D., Mark Gebhardt, M.D., and Jesse B. Jupiter, M.D., Boston, Mass.
From the Department of Orthopaedic Surgery, The Massachusetts General Hospital, and Harvard Medical School, Boston, Mass . Received for publication March 12, 1987; accepted in revised form May 15, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: David Siegel, M.D., Department of Orthopaedic Surgery, The Massachusetts General Hospital, 15 Parkman SI., ACC 427, Massachusetts General Hospital, Boston, MA 02114.
1106
THE JOURNAL OF HAND SURGERY
Spontaneous rupture of the extensor pollicis longus (EPL) tendon, while uncommon, has been described in association with rheumatoid arthritis; "" Colles' fracture/· 8 occupational trauma,9.11 infection,12,13 and tumors. 14 We report a case of spontaneous rupture of the EPL tendon 8 weeks after curettage and polymethylmethacrylate packing of a giant cell tumor of the distal radius.