ANEURYSMAL

BONE

CYST

OF THE

N. H. M. MORTENSEN

PROXIMAL

PHALANX

and E. KUUR

From the Division of Hand Surgery, Department of Orthopaedic Surgery, Odense University Hospital, Denmark

A case of aneurysmal bone cyst of the proximal phalanx in a young boy with unfused epiphysial plates is reported. Curettage failed, so diaphysectomy and cortical bone grafting were performed, sparing the epiphysial plate. This resulted in normal length and function, and the graft remodelled completely to a normal appearance of tubular bone. Journal of Hand Surgery (British Volume, 1990) 15B: 482-483

Aneurysmal bone cyst, which accounts for less than 5% of all bone tumours, is rare in the hand (Burkhalter, 1978). In a review of 516 cases, Fuhs (1979) found that only 3% involved the hand, these being equally distributed between the metacarpals and the phalanges. Surgery is the treatment of choice. The recurrence rate after curettage is high (20-50x) and total excision is the most successful treatment (Burkhalter, 1978; Clough, 1968). Only a few cases of diaphysectomy and cortical bone grafting have been reported in the treatment of aneurysmal bone cyst affecting metacarpal bones in the hand and even fewer in children or young adults with unfused epiphyses (Burkhalter, 1978). As far as we know, diaphysectomy in a phalanx, sparing the epiphysial plate, has never been described as the treatment of histologically-verified aneurysmal bone cyst. We here report a case. Case report A six-year-old boy was seen with a bony swelling of the proximal phalanx of the left middle finger. Six months earlier he had trapped his finger, and one or two months after that noticed aching and increasing swelling. On examination, there was a large, bony and painful swelling of the proximal phalanx. The ranges of motion of the M.P and I.P. joints were found to be normal. Xray examination revealed a central lytic lesion, expanding the cortex of the whole diaphysis almost symmetrically but not involving the epiphysis. Only the articulating part of the phalangeal head was uninvolved (Fig. 1). Bone scintigraphy (99mTc) showed increased uptake in that phalanx but the rest of the skeleton was normal. Curettage was performed and methylprednisolone was installed into the cavity. Histology was uncertain, but interpreted as suspicious of osteoclastoma. After six months, there were no signs of healing so it was decided to perform diaphysectomy. An incision was made on the dorso-radial border of the proximal phalanx. After subperiosteal dissection, diaphysectomy was performed, leaving only the epiphysial part proximally and the small articulating part of the head distally. A cortical bone graft was taken from the proximal part of the ulna and fixed between the two bone 482

Fig. 1

(a & b). Pre-operative X-rays showing and expanding radiolucent lesion.

a central,

symmetrical

remnants by two Kirschner wires (Fig. 2). A plaster-ofParis splint was applied for four weeks. After another two weeks, the Kirschner wires were removed and the patient started active exercises. The histological diagnosis after this second operation was aneurysmal bone cyst, Six months later, X-rays showed continued growth of the proximal epiphysis and 18 months post-operatively an incipient tubular appearance of the graft was seen. Six years after the last operation, the patient (now 13 years old) had excellent function and no pain. The range of motion was normal apart from an extension defect of less than 10” at the metacarpo-phalangeal joint. The strength was normal and the left middle finger was the same length as the right middle finger. X-ray showed now complete remodelling of the THE JOURNAL

OF HAND SURGERY

ANEURYSMAL

Fig.

2

(a & b). X-rays taken at the diaphysectomy and bone grafting.

end

of the

BONE

operation

CYST

of

proximal phalanx, with a normal appearance of the bone and no sign of recurrence (Fig. 3). Discussion

The cause of aneurysmal bone cysts is still in dispute. The most favoured view is that of a vascular anomaly which is usually primary but may be secondary to bone

OF THE

PROXIMAL

PHALANX

lesions. In our case, the patient had an injury a few months before symptoms started. Many different methods of treatment, including radiation therapy, curettage with or without bone graft and en bloc resection have been recommended. However, radiation can damage a growing epiphysis (Kartzman, 1969) and there have also been reports of post-radiation sarcoma (Lichtenstein, 1953) so this method of treatment is unacceptable, since 75% of aneurysmal bone cysts occur in patients under the age of 20 (Besse, 1956). Curettage, with or without grafting, is relatively simple but the recurrence rate is high. Some authors therefore recommend total excision if possible (Clough, 1968). Burkhalter et al. (1978) have described two cases of aneurysmal bone cysts in metacarpals where diaphysectomy and cortical bone graft were performed, sparing the epiphysial plates. In both, normal growth of the epiphysis was evident years after operation: in each instance, the bone graft remodelled to a significant degree and satisfactory function was obtained after secondary soft tissue release. Miyakawa (1961) described a case of simple bone cyst in proximal phalanx in a young boy, for which diaphysectomy and cortical bone graft was performed. Histological examination was considered to show a simple cyst of bone, but the X-rays in his article are very similar to those of our patient. Miyakawa spared the proximal epiphyseal plate and, after years of continued growth, normal length was attained and progressive remodelling of the graft took place to resemble a normal phalanx. In our patient, too, growth continued after operation, resulting in a finger of normal length. Function was excellent without any further operation and the graft remodelled completely to have a normal appearance of tubular bone.

References BESSE, B. E., DAHLIN, D. C., PUGH, D. G. and GHORMLEY, R. K. (1956). Aneurysmal Bone Cysts: Additional Considerations. Clinical Orthopaedics and Related Research, 7: 93-102. BURKHALTER, W. E., SCHROEDER, F. C. and EVERSMANN, W. W. (1978). Aneurysmal bone cysts occurring in the metacarpals: A report of three cases. Journal of Hand Surgery, 3: 6: 579-584. CLOUGH, J. R. and PRICE, C. H. G. (1968). Aneurysmal bone cysts. Review of twelve cases. Journal of Bone and Joint Suraerv. SOB: 1: 116-127. FUHS, S. E. and HERNDON, J. H. (1979). Aneurysmal bone cyst involving the hand: A review and report of two cases. Journal of Hand Surgery, 4: 2: 152159. KATZMAN, H., WAUGH, T. and BERDON, W. (1969). Skeletal Changes Following Irradiation of Childhood Tumors, Journal of Bone and Joint Surgery, 51A: 5: 825-842. LICHTENSTEIN, L. (1953). Aneurysmal bone cyst. Cancer, 6: 1228-1237. MIYAKAWA, G. (1961). Replacement of the Shaft of the Phalanx with Iliac Bone. Journal of Bone and Joint Surgery, 43A: 6: 905-907

b Fig. 3

VOL.

(a & b). The final X-ray, six years after operation, good remodelling and no recurrence.

15B No. 4 NOVEMBER

1990

Accepted: 13 June 1989 Niels Henrik Maagaard Mortemen,

showing

Q 1990 The British

Society

Klovervaenget

for Surgery

20B, 401,500O Odense

C, Denmark

of the Hand

0266-7681/90/0015-0482/%10.00

483

Aneurysmal bone cyst of the proximal phalanx.

A case of aneurysmal bone cyst of the proximal phalanx in a young boy with unfused epiphysial plates is reported. Curettage failed, so diaphysectomy a...
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