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Synovial chondrometaplasia of the hand: Case report and review of the literature
Synovial chondrometaplasia of the hand: Case report and review of the literature A case of synovial chondrometaplasia of the hand is described. Histologic differentiation from chondrosarcoma may be difficult. Recurrences are common, but no instance of malignant change is known. Nonetheless, adequate surgical excision of the lesion is recommended. (J HAND SURG 9A:269-72, 1984.)
George L. Lucas, M.D., and Paul D. Sponsellar, M.D., Madison. Wis.
Synovial chondrometaplasia is rare in any location, but particularly in the hand, where it may present in variable forms. The histologic picture is often confusing, and a wide spectrum of cartilage maturity may be represented.
Case report A 58-year-old fanner presented with a large painless mass in his left palm that had been slowly enlarging over the past several years. Despite the large size of the lesion the patient reported no functional impairment. There was no history of injury. On physical examination, the mass was found to be located over the area of the fourth metacarpophalangeal (MP) joint in the distal palm but was not fixed to the skin or underlying structures. (Fig. 1). He had full range of finger motion and no sensory loss. Radiographs revealed a lobulated lesion with fine irregular calcification volar to the joint and not eroding bone (Fig. 2). At operation, a lobulated light-grey mass, 5 by 3.5 by 3 cm. was found superficial to the palmar aponeurosis. with no substantial deep connections. There were white nodules 1 to 2 mm in size, in its substance. The lesion was removed in its entirety. The histologic diagnosis was synovial chondrometaplasia, on the basis of the finding of synovial tissue containing foci of chondroid and hyaline cartilage of varying degrees of development (Fig. 3).
Discussion Synovial chondrometaplasia (or the more traditional term' 'synovial chondromatosis' ') refers to the development of cartilage from synovial connective tissue. From Madison General Hospital and the University of Wisconsin Clinical Science Center. Madison. Wis. Received for publication September 27. 1982; accepted in revised form May 23. 1983. Reprint requests: George L. Lucas. M.D .. 2704 Marshall Court. Madison. WI 53705.
Cartilage and synovium have a common mesenchymal precursor, but it is not known whether the cartilage arises from scattered rests of precartilaginous cells or by differentiation of synovial cells. McCarthy and Dorfman 1 believe that these tumors arise from transformed synovial fibroblasts that begin to produce cartilage rather than collagen. In three synovial chondromas they have identified intermediate fibroblast-like cells that have the ultrastructural features of chondroblasts, including a prominent Golgi apparatus. The stimulus for the metaplasia is also unknown. The knee, followed by the hip and elbow, are the most common locations. Rarely the synovium of tendon sheaths and even bursae can undergo such change. 2 Thus the presentation of chondrometaplasia in the hand, with its many synovial surfaces, is understandably quite variable. Three groups can be defined: lesions arising from synovium of diarthrodial joints of the hand, from tenosynovium, and from bursal or other tissue. Dahlin and Salvador3 state that cartilaginous tumors of the soft parts of the hand are usually of synovial origin. The origin in our case may have been the flexor tendon sheath, suggested by some flimsy attachments to the sheath of the ring finger. In a review of the English-language literature, several reports of cases or small series of synovial chondrometaplasia of the hand were found (Table I), although precise location was not mentioned in all cases. Chung and Enzinger4 reported the Armed Forces Institute of Pathology experience with chondroma of the soft parts. Although some of their cases should probably be included in the table, the report did not specify the number having the appearance of synovial origin, and they specifically excluded "synovial chondromatosis. "
THE JOURNAL OF HAND SURGERY
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270
The Journal of HAND SURGERY
Lucas and Sponsel/or
Fig. 1. Clinical appearance of large palmar mass.
Table I. Sites of chondrometaplasia in the hand Site Finger IP joint Flexor or extensor tendon Other or unspecified MP joint Palm Wrist
I .
No. reported
2 14 38 8 10 II
I .
Reference No .
7, 14,15 5, 16-19 3,6 ,8,14 3,6,8,12,13 1-3,19,20 14.16,19-23
Several unusual cases and interesting generalizations were found . The greatest number of lesions occurred in the finger . Most patients presented at 30 to 60 years of age. More of the younger patients had a clear-cut history of trauma. For example, one case was preceded by a dislocation of the involved joint and another by crushing in a machine _Several of these histories suggest that trauma may have at least a partial role in inducing metaplasia in some circumstances. Two patients presented with "trigger finger " resulting from an osteochondroma of tendon near the MP joint. 5, 6 Another patient presented with exquisite pain in the interphalangeal joint of the thumb, believed to be caused by pressure on the extensor tendon by a loose body, 7 Most of the cartilaginous tumors were several millimeters to several centimeters in size, but the largest measured 21 cm, in a patient who for 9 years had been reluctant to seek help. s This lesion was at first thought to be a chondrosarcoma, but consideration of location, history, and histology prompted the diagnosis of synovial chondromatosis_ The appearance in many other cases was that of a small , smooth body or a diffuse mass .
Fig. 2. Radiograph showing fine , irregularly calcified cauliflower-shaped mass in the palm .
Microscopically the lesions had islands of cartilage or chondroid, usually lobulated, surrounded by synovial tissue . The histologic appearance of these lesions was often worrisome. Cells with large irregular or multiple nuclei, as well as areas with a myxoid or xanthoma-like appearance, were often noted , Dahlin and Salvador:! remarked that the nuclei were' 'suggestive of malignancy in most cases" in their series, although all actually proved benign . In context, these were believed to represent areas of active growth. Because of the histologic appearance , one might question the presence of, or eventual transformation to, chondrosarcoma. Only one widely accepted case of transformation of synovial chondrometaplasia to chondrosarcoma has been reported, however, and it occurred in the knee. 9 Also, chondrosarcoma arising primarily from normal synovium is rare; the Mayo Clinic reported only one case,1O and Goldman and Lichtenstein" reported only three. None of these malignant tumors arose in the hand, and none of the cases reviewed for this report behaved in a malignant fashion . The differentiation of chondrometaplasia from chondrosarcoma should be made mainly on the basis of behavior and gross characteristics of the lesion. Chondrosarcomas usually arise from medullary bone; chondrometaplasia usually arises from synovial tissues, although there have been instances of soft-tissue chondrosarcoma reported.
Vol. 9A, No.2 March 1984
Synovial chondrometaplasia of hand
271
Fig. 3. Microscopic appearance of the lesion. Note loosely arranged synovial tissue with islands of hyaline cartilage and chondroid. (Original magnifications: A, x25, B, x JOO.)
In only 14 of the 83 cases of chondrometaplasia of the hand was ossification of the cartilaginous mass described histologically. Calcification was present in approximately half of the cases. Radiographically, fuzzy or well-marginated opacities may be seen. Several of the lesions, however, lacking calcification, showed no abnormality on x-ray examination. In a few cases there was indentation of bone by the lesion, presumably by pressure ,3. 12, 1:3 and cases reported by Constant and Harebottle 8 demonstrated frank destruction of bone. Local recurrence was not uncommon, occurring in 15 (18%) of the cases reviewed.:!' 12, 14 One patient suffered ten recurrences. Lichtenstein and Goldman l4 noted that in their patients recurrences were only among those with a more "chondroid" appearance. Thus a thorough marginal excision is the appropriate treatment. Differential diagnosis of synovial chondrometaplasia in the hand includes osteochondral fracture, cartilage tumor of bony or periosteal origin, neuropathic arthritis, subungual exostosis, and tumoral calcinosis. REFERENCES 1. McCarthy EF, Dorfman HP: Primary synovial chondromatosis-an ultrastructural study. Clin Orthop 168: 178-86, 1982 2. Sim FH, Dahlin DC, Ivins JC: Extra-articular synovial chondromatosis. J Bone Joint Surg[Am] 59:492-5,1977
3. Dahlin DC, Salvador AH: Cartilaginous tumors of the soft tissues of the hands and feet. Mayo Clin Proc 49: 721-5, 1974 4. Chung EB, Enzinger FM: Chondroma of the soft parts. Cancer 41:1414-24,1978 5. Rockey HC: Trigger-finger due to a tenosynovial osteochondroma. J Bone Joint Surg [Am] 45:387-8, 1963 6. Cremone JC, Wolff TW, Wolfort FG: Synovial chondromatosis of the hand. Plast Reconstr Surg 69:871-4, 1982 7. Lewis MM, Marshall JL, Mirra JM: Synovial chondromatosis of the thumb. J Bone Joint Surg [Am] 56:180-3,1974 8. Constant E, Harebottle NH: Synovial chondromatosis of the hand: case report. Plast Reconstr Surg 54:353-7, 1974 9. Mullins F, Berard CW, Eisenberg SH: Chondrosarcoma following synovial chondromatosis. Cancer 18: 1180-8, 1965 10. Murphy FR, Dahlin DC, Sullivan R: Articular synovial chondromatosis. J Bone Joint Surg [Am] 44:77-86, 1962 11. Goldman RL, Lichtenstein L: Synovial chondrosarcoma. Cancer 17:1233-9, 1964 12. Linden 0: Case of chondromatosis of a metacarpophalangeal joint. Acta Chir Scand 75:181-4, 1934 13. Szepsi J: Synovial chondromatosis of the metacarpophalangeal joint. Acta Orthop Scand 46:926-30, 1975 14. Lichtenstein L, Goldman RL: Cartilage tumors in soft
The Journal of HAND SURGERY
Lucas and Sponsellar
15.
16. 17 .
18 . 19.
tissues, particularly in the hand and foot. Cancer 17: 1203-8, 1964 Kettelkamp DB, Dolan J: Synovial chondromatosis of an interphalangeal joint of a finger. J Bone Joint Surg [Am] 48:329-32, 1966 Aegerter E, Kirkpatrick JA : Orthopedic diseases, ed 5. Philadelphia, 1975 , WB Saunders Co, p 685 Henderson MS, Jones HT: Loose bodies in joints and bursae due to synovial osteochondromatosis. J Bone loint Surg 5:400-24, 1923 Strong ML : Chondromas of the tendon sheath of the hand. J Bone Joint Surg [Am] 57: 1164-5,1975 Murphy AF: Tenosynovial osteochondroma in the hand. J Bone Joint Surg [Am] 40:1236-40,1958
20. Someren A, Merritt WH: Tenosynovial chondroma of the hand: a case report with a brief review of the literature. Hum Pat hoi 9:476-9, 1978 21. Lynn MD, Lee J: Periarticular tenosynovial chondrometaplasia: report of a case at the wrist. J Bone Joint Surg [Am] 54:650-2, 1972 22 . Milgram JW: Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg [Am] 59:792-801, 1977 23 . Roberts PH: Tenosynovial chondromatosis-an unusual case. Br J Surg 58 :152, 1971
Giant cell tumor of the capitate A case of giant cell tumor of the capitate is presented. Its recurrence and the problem of reconstruction after resection are discussed. Recommended treatment of this tumor if it occurs within the carpals is resection of the carpus with intercarpal arthrodesis if the distal row is involved or proximal row carpectomy if the scaphoid or lunate is involved. (J HAND SURG 9A:272·4, 1984.)
Francis M. Howard, M.D., and Keith Lassen, M.D., Tampa and Bradenton, Fla.
Giant cell tumors of the carpal bones are rare . Three have been reported in the hamate, 1.2 one in the lunate,3 and one in the trapezoid. 2 A giant cell tumor of the capitate is reported in this article. This case is reported not only because of its unusual location but also because of its recurrence after curettement and bone grafting . Total excision of this tumor where possible is the recommended treatment. 4
Case report A 16-year-old girl came to the emergency room complaining of left wrist pain beginning 4 weeks previously while performing handstands in gymnastic class. She thought she had incurred a wrist sprain, but the pain became constant. Tenderness over the dorsum of the left wrist was the only physical finding. The range of motion was normal. There was no swelling or temperature change. Laboratory results, inFrom the University of South Rorida Medical School , Tampa, Ra . Received for publication Nov . 29, 1982; accepted in revised form March 31, 1983. Reprint requests: Francis M. Howard. M.D .. 5837 21st Ave . W ., Bradenton, FL 33529.
272
THE JOURNAL OF HAND SURGERY
Fig. 1. Roentgenogram of the left wrist in a 16-year-old girl. Capitate shows extensive lytic area with loss of trabeculations.
George L. Lucas, M.D., and Paul D. Sponsellar, M.D., Madison. Wis.
Synovial chondrometaplasia is rare in any location, but particularly in the hand, where it may present in variable forms. The histologic picture is often confusing, and a wide spectrum of cartilage maturity may be represented.
Case report A 58-year-old fanner presented with a large painless mass in his left palm that had been slowly enlarging over the past several years. Despite the large size of the lesion the patient reported no functional impairment. There was no history of injury. On physical examination, the mass was found to be located over the area of the fourth metacarpophalangeal (MP) joint in the distal palm but was not fixed to the skin or underlying structures. (Fig. 1). He had full range of finger motion and no sensory loss. Radiographs revealed a lobulated lesion with fine irregular calcification volar to the joint and not eroding bone (Fig. 2). At operation, a lobulated light-grey mass, 5 by 3.5 by 3 cm. was found superficial to the palmar aponeurosis. with no substantial deep connections. There were white nodules 1 to 2 mm in size, in its substance. The lesion was removed in its entirety. The histologic diagnosis was synovial chondrometaplasia, on the basis of the finding of synovial tissue containing foci of chondroid and hyaline cartilage of varying degrees of development (Fig. 3).
Discussion Synovial chondrometaplasia (or the more traditional term' 'synovial chondromatosis' ') refers to the development of cartilage from synovial connective tissue. From Madison General Hospital and the University of Wisconsin Clinical Science Center. Madison. Wis. Received for publication September 27. 1982; accepted in revised form May 23. 1983. Reprint requests: George L. Lucas. M.D .. 2704 Marshall Court. Madison. WI 53705.
Cartilage and synovium have a common mesenchymal precursor, but it is not known whether the cartilage arises from scattered rests of precartilaginous cells or by differentiation of synovial cells. McCarthy and Dorfman 1 believe that these tumors arise from transformed synovial fibroblasts that begin to produce cartilage rather than collagen. In three synovial chondromas they have identified intermediate fibroblast-like cells that have the ultrastructural features of chondroblasts, including a prominent Golgi apparatus. The stimulus for the metaplasia is also unknown. The knee, followed by the hip and elbow, are the most common locations. Rarely the synovium of tendon sheaths and even bursae can undergo such change. 2 Thus the presentation of chondrometaplasia in the hand, with its many synovial surfaces, is understandably quite variable. Three groups can be defined: lesions arising from synovium of diarthrodial joints of the hand, from tenosynovium, and from bursal or other tissue. Dahlin and Salvador3 state that cartilaginous tumors of the soft parts of the hand are usually of synovial origin. The origin in our case may have been the flexor tendon sheath, suggested by some flimsy attachments to the sheath of the ring finger. In a review of the English-language literature, several reports of cases or small series of synovial chondrometaplasia of the hand were found (Table I), although precise location was not mentioned in all cases. Chung and Enzinger4 reported the Armed Forces Institute of Pathology experience with chondroma of the soft parts. Although some of their cases should probably be included in the table, the report did not specify the number having the appearance of synovial origin, and they specifically excluded "synovial chondromatosis. "
THE JOURNAL OF HAND SURGERY
269
270
The Journal of HAND SURGERY
Lucas and Sponsel/or
Fig. 1. Clinical appearance of large palmar mass.
Table I. Sites of chondrometaplasia in the hand Site Finger IP joint Flexor or extensor tendon Other or unspecified MP joint Palm Wrist
I .
No. reported
2 14 38 8 10 II
I .
Reference No .
7, 14,15 5, 16-19 3,6 ,8,14 3,6,8,12,13 1-3,19,20 14.16,19-23
Several unusual cases and interesting generalizations were found . The greatest number of lesions occurred in the finger . Most patients presented at 30 to 60 years of age. More of the younger patients had a clear-cut history of trauma. For example, one case was preceded by a dislocation of the involved joint and another by crushing in a machine _Several of these histories suggest that trauma may have at least a partial role in inducing metaplasia in some circumstances. Two patients presented with "trigger finger " resulting from an osteochondroma of tendon near the MP joint. 5, 6 Another patient presented with exquisite pain in the interphalangeal joint of the thumb, believed to be caused by pressure on the extensor tendon by a loose body, 7 Most of the cartilaginous tumors were several millimeters to several centimeters in size, but the largest measured 21 cm, in a patient who for 9 years had been reluctant to seek help. s This lesion was at first thought to be a chondrosarcoma, but consideration of location, history, and histology prompted the diagnosis of synovial chondromatosis_ The appearance in many other cases was that of a small , smooth body or a diffuse mass .
Fig. 2. Radiograph showing fine , irregularly calcified cauliflower-shaped mass in the palm .
Microscopically the lesions had islands of cartilage or chondroid, usually lobulated, surrounded by synovial tissue . The histologic appearance of these lesions was often worrisome. Cells with large irregular or multiple nuclei, as well as areas with a myxoid or xanthoma-like appearance, were often noted , Dahlin and Salvador:! remarked that the nuclei were' 'suggestive of malignancy in most cases" in their series, although all actually proved benign . In context, these were believed to represent areas of active growth. Because of the histologic appearance , one might question the presence of, or eventual transformation to, chondrosarcoma. Only one widely accepted case of transformation of synovial chondrometaplasia to chondrosarcoma has been reported, however, and it occurred in the knee. 9 Also, chondrosarcoma arising primarily from normal synovium is rare; the Mayo Clinic reported only one case,1O and Goldman and Lichtenstein" reported only three. None of these malignant tumors arose in the hand, and none of the cases reviewed for this report behaved in a malignant fashion . The differentiation of chondrometaplasia from chondrosarcoma should be made mainly on the basis of behavior and gross characteristics of the lesion. Chondrosarcomas usually arise from medullary bone; chondrometaplasia usually arises from synovial tissues, although there have been instances of soft-tissue chondrosarcoma reported.
Vol. 9A, No.2 March 1984
Synovial chondrometaplasia of hand
271
Fig. 3. Microscopic appearance of the lesion. Note loosely arranged synovial tissue with islands of hyaline cartilage and chondroid. (Original magnifications: A, x25, B, x JOO.)
In only 14 of the 83 cases of chondrometaplasia of the hand was ossification of the cartilaginous mass described histologically. Calcification was present in approximately half of the cases. Radiographically, fuzzy or well-marginated opacities may be seen. Several of the lesions, however, lacking calcification, showed no abnormality on x-ray examination. In a few cases there was indentation of bone by the lesion, presumably by pressure ,3. 12, 1:3 and cases reported by Constant and Harebottle 8 demonstrated frank destruction of bone. Local recurrence was not uncommon, occurring in 15 (18%) of the cases reviewed.:!' 12, 14 One patient suffered ten recurrences. Lichtenstein and Goldman l4 noted that in their patients recurrences were only among those with a more "chondroid" appearance. Thus a thorough marginal excision is the appropriate treatment. Differential diagnosis of synovial chondrometaplasia in the hand includes osteochondral fracture, cartilage tumor of bony or periosteal origin, neuropathic arthritis, subungual exostosis, and tumoral calcinosis. REFERENCES 1. McCarthy EF, Dorfman HP: Primary synovial chondromatosis-an ultrastructural study. Clin Orthop 168: 178-86, 1982 2. Sim FH, Dahlin DC, Ivins JC: Extra-articular synovial chondromatosis. J Bone Joint Surg[Am] 59:492-5,1977
3. Dahlin DC, Salvador AH: Cartilaginous tumors of the soft tissues of the hands and feet. Mayo Clin Proc 49: 721-5, 1974 4. Chung EB, Enzinger FM: Chondroma of the soft parts. Cancer 41:1414-24,1978 5. Rockey HC: Trigger-finger due to a tenosynovial osteochondroma. J Bone Joint Surg [Am] 45:387-8, 1963 6. Cremone JC, Wolff TW, Wolfort FG: Synovial chondromatosis of the hand. Plast Reconstr Surg 69:871-4, 1982 7. Lewis MM, Marshall JL, Mirra JM: Synovial chondromatosis of the thumb. J Bone Joint Surg [Am] 56:180-3,1974 8. Constant E, Harebottle NH: Synovial chondromatosis of the hand: case report. Plast Reconstr Surg 54:353-7, 1974 9. Mullins F, Berard CW, Eisenberg SH: Chondrosarcoma following synovial chondromatosis. Cancer 18: 1180-8, 1965 10. Murphy FR, Dahlin DC, Sullivan R: Articular synovial chondromatosis. J Bone Joint Surg [Am] 44:77-86, 1962 11. Goldman RL, Lichtenstein L: Synovial chondrosarcoma. Cancer 17:1233-9, 1964 12. Linden 0: Case of chondromatosis of a metacarpophalangeal joint. Acta Chir Scand 75:181-4, 1934 13. Szepsi J: Synovial chondromatosis of the metacarpophalangeal joint. Acta Orthop Scand 46:926-30, 1975 14. Lichtenstein L, Goldman RL: Cartilage tumors in soft
The Journal of HAND SURGERY
Lucas and Sponsellar
15.
16. 17 .
18 . 19.
tissues, particularly in the hand and foot. Cancer 17: 1203-8, 1964 Kettelkamp DB, Dolan J: Synovial chondromatosis of an interphalangeal joint of a finger. J Bone Joint Surg [Am] 48:329-32, 1966 Aegerter E, Kirkpatrick JA : Orthopedic diseases, ed 5. Philadelphia, 1975 , WB Saunders Co, p 685 Henderson MS, Jones HT: Loose bodies in joints and bursae due to synovial osteochondromatosis. J Bone loint Surg 5:400-24, 1923 Strong ML : Chondromas of the tendon sheath of the hand. J Bone Joint Surg [Am] 57: 1164-5,1975 Murphy AF: Tenosynovial osteochondroma in the hand. J Bone Joint Surg [Am] 40:1236-40,1958
20. Someren A, Merritt WH: Tenosynovial chondroma of the hand: a case report with a brief review of the literature. Hum Pat hoi 9:476-9, 1978 21. Lynn MD, Lee J: Periarticular tenosynovial chondrometaplasia: report of a case at the wrist. J Bone Joint Surg [Am] 54:650-2, 1972 22 . Milgram JW: Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg [Am] 59:792-801, 1977 23 . Roberts PH: Tenosynovial chondromatosis-an unusual case. Br J Surg 58 :152, 1971
Giant cell tumor of the capitate A case of giant cell tumor of the capitate is presented. Its recurrence and the problem of reconstruction after resection are discussed. Recommended treatment of this tumor if it occurs within the carpals is resection of the carpus with intercarpal arthrodesis if the distal row is involved or proximal row carpectomy if the scaphoid or lunate is involved. (J HAND SURG 9A:272·4, 1984.)
Francis M. Howard, M.D., and Keith Lassen, M.D., Tampa and Bradenton, Fla.
Giant cell tumors of the carpal bones are rare . Three have been reported in the hamate, 1.2 one in the lunate,3 and one in the trapezoid. 2 A giant cell tumor of the capitate is reported in this article. This case is reported not only because of its unusual location but also because of its recurrence after curettement and bone grafting . Total excision of this tumor where possible is the recommended treatment. 4
Case report A 16-year-old girl came to the emergency room complaining of left wrist pain beginning 4 weeks previously while performing handstands in gymnastic class. She thought she had incurred a wrist sprain, but the pain became constant. Tenderness over the dorsum of the left wrist was the only physical finding. The range of motion was normal. There was no swelling or temperature change. Laboratory results, inFrom the University of South Rorida Medical School , Tampa, Ra . Received for publication Nov . 29, 1982; accepted in revised form March 31, 1983. Reprint requests: Francis M. Howard. M.D .. 5837 21st Ave . W ., Bradenton, FL 33529.
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THE JOURNAL OF HAND SURGERY
Fig. 1. Roentgenogram of the left wrist in a 16-year-old girl. Capitate shows extensive lytic area with loss of trabeculations.