Barber's interdigital pilonidal sinus of the hand: A foreign body hair granuloma Interdigital pilonidal sinus of the hand is an occupational disease of male barbers. Customers' hairs penetrate the supple interdigital skin, cause a sinus, and later a cyst. Through the sinus, the hairs get entrapped and may occasionally be expressed. Excision of the sinus or the cyst is curative. (J HAND SURG 1990;15A:652.5.)
M. R. Patel, MD, Lynn Bassini, MA, OTR, Rifat Nashad, MD, and M. T. Anselmo, MD, Brooklyn, N.Y.
T
he term pilonidal is derived from the Latin terms pitas which mean hair and nidus which mean nest. Pilonidal sinus is an acquired condition, most commonly encountered in the sacrococcygeal region, and is usually referred to as jeep disease, inasmuch as it occurred in jeep drivers in the World War n. I It occurred in hairy individuals when broken hairs in the sacrococcygeal region penetrated the local skin after prolonged jeep driving. Pilonidal sinuses of the sacrococcygeal region, L umbilicus," chest wall,' anal canal," ear," penis," and scalp? all occur in hair-bearing areas. In the interdigital spaces of the hands the skin does not bear hair. The pilonidal sinus occurs as an occupational disease in barbers. The embedded hair in the pilonidal sinus belongs to the customer, not the patient. Interdigital pilonidal sinus in barbers was first described in 1942 8 • 9 as a foreign body reaction or granuloma to the customer's hairs implanted in the interdigital skin of the barbers. Since then cases have been described as hair-bearing sinus," barber's interdigital pilonidal sinus, 11-25 and barber's disease." We describe a case of pilonidal cyst discharging hairs into the first web space in a male barber who was a men's hairdresser for 35 years.
From the Hand Surgery Service, Division of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, N.Y. Received for publication May 25, 1989; accepted in revised form Aug. 9, 1989. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mukund R. Patel, MD, 4901 Fort Hamilton Pkwy, Brooklyn, NY 11219. 3/1/16409
652
THE JOURNAL OF HAND SURGERY
I I , I I II
I
J
I I If ; u II r I II !II
23
4
Fig. 1. Excised specimen showing hair inside the bisected cyst. The straight, short, and thick hair clippings have pointed ends. They are of different lengths and color. Scale, Centimeters.
Case report A 48-year-old righthanded male hairdresser had a painful mass of 2 months' duration develop on the right thenar eminence. The mass intermittently discharged purulent material containing hairs through a sinus into the first web space palmarly at its junction with the metacarpophalangeal (MP) joint crease. On examination the mass was 2.5 em X 2 em X 1/2 em, tender, and indurated. A I mm sinus emerged from it into the first web space at the MP joint flexor crease. Hairs were
Vol. 15A, No.4 July 1990
Barber's interdigital pilonidal sinus of hand
653
Fig. 2. Photomicrograph showing hair shafts (arrows) surrounded by acutely and chronically inflamed granulation tissue. (Magnification x 250.)
also embedded in the skin epidermis and dermis on the palmar side of the thumb between the MP joint and the interphalangeal (IF) joint and on the dorsal side of the second, third, and fourth webs of the left hand, all without sinus formation. The hairs were easily pulled out with forceps. The patient stated that it was common for hairs to become embedded in the webs of his fingers when he cut hair short. At operation the sinus contained short, stiff, sharp, and pointed hairs. The hairs were different colors-white, black, and gray. The sinus led into a large cyst, which contained numerous hairs (Fig. 1). The cyst had an ill-defined capsule and was lined with irregular granulation tissue. The entire cyst was excised. Additional loose hairs found embedded in the normal soft tissue outside the pseudocapsule of the cyst were removed. Hairs embedded in the skin on the palmar side of the thumb were also excised, but these did not have a sinus. They were embedded in the epidermis and the dermis, with thickening of the surrounding skin. Histologically, hair shafts were found embedded in the granulation tissue of the cyst's pseudocapsule (Fig. 2). After operation the wound healed well. The patient was advised to wear gloves without tips to preserve pulp sensibility during work. He has had no recurrences of the interdigital pilonidal sinuses for 2 years.
Discussion Interdigital pilonidal sinus is an occupational disease of hairdressers. The hairs within the interdigital sinuses are not those of the patient but from the customers; they are consistently thick, stiff, and straight, essentially the male type. This may explain why the condition occurs in mens' hairdressers. Womens' hair is generally long,
thin, soft, and supple; the ends are more likely to bend before they penetrate the skin. This condition occurs only in males. It has never been reported in female hairdressers. The reason for this is not clear to us. The hairs have sharp pointed ends and are of different colors and length. No hair roots are seen in the sinus or the cyst" and the hairs are not immature, curly, and fine as found in a congenital cyst." Thus the pilonidal sinus is essentially an acquired, infective, and foreign body granulomatous reaction to buried hairs and is not of developmental origin. II, 15 This is additionally supported by the two facts, that it occurs in adult life and there are no hairs naturally found in the interdigital area. We believe that the hairs enter the soft and supple skin of the digital webs when the barbers use their fingers to comb the customer's snipped hair with sharp and pointed ends. Constant rubbing of the fingers against each other may also push the pointed hairs into the skin. Once inside the web space, the hairs cause a foreign body reaction and sinus formation. More hairs enter the web space through the sinus and lead to cyst formation. In due time the sinus or the cyst becomes infected and intermittently discharges purulent fluid with pieces of hairs. A similar and related condition is interdigital pilonidal sinus in sheep shearers caused by wooI,27.28 and interdigital sinuses in milker's hands caused by cow's hair.29 Reported cases of pilonidal cyst in hairdressers'
The Journal of HAND SURGERY
Patel et at.
654
Table I. Summary of cases of barber's pilonidal cyst reported in the literature Patient
18•9 2" 3 10 4" 415
27 31 52 34
M M M M
5'5
53
613
DNR DNR DNR
43 71 39
M M M M M M M M M M M M M
49 45
M M
7 12
8" 9 1• 1 '
10
11" 12" 1319 14\7
151' 1622 17 21 1721 1820 192' 1928 2Q2' 2[2'
2224
24*
L
R
n
42 39 53 40
DNR
L L
DNR L L L
R L R
R DNR R R R
47
58 36
48 48
L
M M M
R R DNR R R
M M
L L L R
2224 2224
2325
R R R
DNR 5 wk
DNR Iyr 4 yr
DNR DNR DNR 4 yr 3 days DNR DNR 18 mo Many yr 6 rno 1 rna 5 yr 3 yr DNR 2 yr DNR 10 yr 6-7 yr DNR DNR DNR 15 yr 2 rno
3 3 3 3
2 2 2 2 2 3 3
3 2 3 3 2 2 4 3 1
·Case described in-this report. DNR, Data not recorded; M, male; L, left; R, right; wk, weeks;
Yes Yes No DNR DNR Yes Yes DNR Yes No DNR Yes No Yes No No No No No Yes No No Yes Yes No Yes No No Yes
3-4 yr
2+4 4 3 3 3 3 3 I 3
rno,
Treatment
Follow-up
Excision Excision Excision Incision Excision Excision Incision None Incision None Incision Excision None Excision Incision DRN None Excision Excision Incision Excision Excision Incision None Electrodesiccation Excision Excision None Excision
DNR Healed DNR Healed Healed DNR DNR DNR DNR DNR DNR DNR DNR Healed DNR DNR DNR Healed Healed Healed Healed DNR Healed Healed Recurred after 10 mo Recurred after 10 mo DNR DNR Healed
months; yr, year.
hands are summarized in Table I. The order of predilection is the third web space, followed by the second and the fourth. The first web space has been reported to be involved only once. 12 We record the second case. Some patients have more than one web space involved." 9, 24 Excision of the lesion and primary wound closure results in less obvious scar than incision and drainage. REFERENCES 1. Patey D. Pilonidal sinus-or 'jeep disease'. Nurs Times 1971;67:534-6. 2. Allegaert WJ. Pilonidal sinus of the umbilicus. Br J Clin Pract 1967;21:201. 3. Saggar RP. Pilonidal disease of the chest wall. J Ir Med Assoc 1967;60:125-7. 4. Wilson E, Failes DG, Killingback M. Pilonidal sinus of the anal canal: report of a case. Dis Colon Rectum 1971;14:468-70. 5. Woodward WW. A pilonidal sinus of the ear. Aust N Z J Surg 1965 ;35:72-3.
6. Bervar M, Manojlovi D, Cerarnilac A. Pilonidal sinus of the penis. Vojnosanit Pregl 1968;25:199-200. 7. Moyer DG. Pilonidal cyst of the scalp. Arch Dennatol 1972;105:578-9. 8. Templeton H. Foreign body granuloma or interdigital cyst with hair formation. Arch Dermatol Syph 1942; 46:157-8. 9. Allington H. A case for diagnosis (foreign body reaction?). Arch Derm Syph 1942;45:614-15. 10. Ewing MR. Hair bearing sinus. Letter to the editor. Lancet 1947;1:427. 11. Patey DH, Scarff RW. Pathology of postnatal pilonidal sinus. Its bearing on treatment. Lancet 1946;2:484-6. 12. Wilks IM. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 13. Tait GB. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 14. Sames LP. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 15. Patey DR, Scarff RW. Pilonidal sinus in a barber's hand with observations on postnatal postnidal sinus. Lancet 1948;2:13-14.
Vol. 15A, No.4 July 1990
16. King ESJ. The interdigital pilonidal sinus. Aust N Z J Surg 1949;19:29-33. 17. Warren CM. Pilonidal sinus in a barber. Letter to the editor. Lancet 1951;1:912. 18. Raw SC. Pilonidal sinus in a barber. Letter to the editor. Lancet 1951;1:912. 19. Jenkins DR. Pilonidal sinus in a barber. Lancet 1951;1:746-7. 20. Waisman M, Olivetti RG. Pilonidal sinus of the hand. Arch Dermatol Syph 1952;66:466. 21. Hueston JT. Pathology of the inter-digital pilonidal sinus. Aust N Z J Med 1952;21:226. 22. Downing JG. Barber's pilonidal sinus. JAm Med Assoc 1952;148: 1501. 23. Currie AR, Gibson T, Goodall AL. Interdigital sinuses of barber's hands. Br J Surg 1953;41:278-86.
Barber's interdigital pilonidal sinus of hand
24. Joseph HL, Gifford H. Barber's interdigital pilonidal sinus-incidence, pathology and pathogenesis. Arch Dennatol Syph 1954;70:616. 25. Kovalcik PJ. Relevancy of the barber's interdigital pilonidal sinus. Letter to the editor. JAmMed Assoc 1973;224:1650. 26. Waris W. Barber's disease. Industr Med Surg 1953;22: 111.
27. Philips PJ. Web space sinus in a shearer. Med J Aust 1966;2:1152-3. 28. Matheson A. Interdigital pilonidal sinus caused by wool. Aust N Z J Surg 1951;21:76-7. 29. Meneghini CL, Gionitti F. Granulomatosis fistulosa interdigitalis of milker's hands. Dermatologica 1964; 128:38-50.
Chondrosarcoma of small bones of the hand arising from enchondroma We report the clinicopathologic findings in two cases of chondrosarcoma of the small bones of the hand arising from a preexisting solitary enchondroma. A critical review of the previously reported 18 cases shows that only one is actually well-documented. (J HAND SURG 1990;15A: 655·9.)
D. L. Nelson, MD, F. W. Abdul-Karim, MD, J. R. Carter, MD, and J. T. Makley, MD, Cleveland, Ohio
Chondrosarcoma of the small bones of the hand is a rare entity. Lichtenstein and Jaffe' described the first case in 1943. Chondrosarcomas accounted for only 4% of 450 cases of malignant tumors of the hand reviewed by Palmierf and only 1V2% of 635 cases of chondrosarcoma of the entire skeleton in a report by Dahlin and Unni. 3 Chondrosarcoma of the
From theDepartments of Orthopaedic Surgery andofPathology. Case Western ReserveUniversity and University Hospitals of Cleveland, Cleveland, Ohio. Received for publication May 25, 1989; accepted in revised form Sept. 2, 1989. 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: F. W. Abdul-Karim, MD, Institute of Pathology, Case Western Reserve University, 2085 Adelbert Rd, Cleveland, OH 44106. 3/1/16875
hand arising from a solitary preexisting enchondroma is generally considered a well established but rare occurrence. This notion has been based on 18 cases that have been cited repeatedly in the English-language Iiterature.v'? This occurrence is, however, even rarer than previously documented. Critical review disclosed that only one of these 18 cases is actually documented satisfactorily.!" We report here the clinico-pathologic findings in two additional well-documented cases, including the first case in which the benign cartilaginous lesion was documented histopathologically. We also analyze the previously reported alleged cases and provide justification for accepting only one as a true example of chondrosarcoma of hand bones arising from enchondroma. Case reports Case 1. In 1978, a 65-year-old woman had a minor injury to her left hand and had no symptoms, but radiographs showed typical enchondroma of the proximal phalanx of the ring THE JOURNAL OF HAND SURGERY
655
M. R. Patel, MD, Lynn Bassini, MA, OTR, Rifat Nashad, MD, and M. T. Anselmo, MD, Brooklyn, N.Y.
T
he term pilonidal is derived from the Latin terms pitas which mean hair and nidus which mean nest. Pilonidal sinus is an acquired condition, most commonly encountered in the sacrococcygeal region, and is usually referred to as jeep disease, inasmuch as it occurred in jeep drivers in the World War n. I It occurred in hairy individuals when broken hairs in the sacrococcygeal region penetrated the local skin after prolonged jeep driving. Pilonidal sinuses of the sacrococcygeal region, L umbilicus," chest wall,' anal canal," ear," penis," and scalp? all occur in hair-bearing areas. In the interdigital spaces of the hands the skin does not bear hair. The pilonidal sinus occurs as an occupational disease in barbers. The embedded hair in the pilonidal sinus belongs to the customer, not the patient. Interdigital pilonidal sinus in barbers was first described in 1942 8 • 9 as a foreign body reaction or granuloma to the customer's hairs implanted in the interdigital skin of the barbers. Since then cases have been described as hair-bearing sinus," barber's interdigital pilonidal sinus, 11-25 and barber's disease." We describe a case of pilonidal cyst discharging hairs into the first web space in a male barber who was a men's hairdresser for 35 years.
From the Hand Surgery Service, Division of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, N.Y. Received for publication May 25, 1989; accepted in revised form Aug. 9, 1989. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mukund R. Patel, MD, 4901 Fort Hamilton Pkwy, Brooklyn, NY 11219. 3/1/16409
652
THE JOURNAL OF HAND SURGERY
I I , I I II
I
J
I I If ; u II r I II !II
23
4
Fig. 1. Excised specimen showing hair inside the bisected cyst. The straight, short, and thick hair clippings have pointed ends. They are of different lengths and color. Scale, Centimeters.
Case report A 48-year-old righthanded male hairdresser had a painful mass of 2 months' duration develop on the right thenar eminence. The mass intermittently discharged purulent material containing hairs through a sinus into the first web space palmarly at its junction with the metacarpophalangeal (MP) joint crease. On examination the mass was 2.5 em X 2 em X 1/2 em, tender, and indurated. A I mm sinus emerged from it into the first web space at the MP joint flexor crease. Hairs were
Vol. 15A, No.4 July 1990
Barber's interdigital pilonidal sinus of hand
653
Fig. 2. Photomicrograph showing hair shafts (arrows) surrounded by acutely and chronically inflamed granulation tissue. (Magnification x 250.)
also embedded in the skin epidermis and dermis on the palmar side of the thumb between the MP joint and the interphalangeal (IF) joint and on the dorsal side of the second, third, and fourth webs of the left hand, all without sinus formation. The hairs were easily pulled out with forceps. The patient stated that it was common for hairs to become embedded in the webs of his fingers when he cut hair short. At operation the sinus contained short, stiff, sharp, and pointed hairs. The hairs were different colors-white, black, and gray. The sinus led into a large cyst, which contained numerous hairs (Fig. 1). The cyst had an ill-defined capsule and was lined with irregular granulation tissue. The entire cyst was excised. Additional loose hairs found embedded in the normal soft tissue outside the pseudocapsule of the cyst were removed. Hairs embedded in the skin on the palmar side of the thumb were also excised, but these did not have a sinus. They were embedded in the epidermis and the dermis, with thickening of the surrounding skin. Histologically, hair shafts were found embedded in the granulation tissue of the cyst's pseudocapsule (Fig. 2). After operation the wound healed well. The patient was advised to wear gloves without tips to preserve pulp sensibility during work. He has had no recurrences of the interdigital pilonidal sinuses for 2 years.
Discussion Interdigital pilonidal sinus is an occupational disease of hairdressers. The hairs within the interdigital sinuses are not those of the patient but from the customers; they are consistently thick, stiff, and straight, essentially the male type. This may explain why the condition occurs in mens' hairdressers. Womens' hair is generally long,
thin, soft, and supple; the ends are more likely to bend before they penetrate the skin. This condition occurs only in males. It has never been reported in female hairdressers. The reason for this is not clear to us. The hairs have sharp pointed ends and are of different colors and length. No hair roots are seen in the sinus or the cyst" and the hairs are not immature, curly, and fine as found in a congenital cyst." Thus the pilonidal sinus is essentially an acquired, infective, and foreign body granulomatous reaction to buried hairs and is not of developmental origin. II, 15 This is additionally supported by the two facts, that it occurs in adult life and there are no hairs naturally found in the interdigital area. We believe that the hairs enter the soft and supple skin of the digital webs when the barbers use their fingers to comb the customer's snipped hair with sharp and pointed ends. Constant rubbing of the fingers against each other may also push the pointed hairs into the skin. Once inside the web space, the hairs cause a foreign body reaction and sinus formation. More hairs enter the web space through the sinus and lead to cyst formation. In due time the sinus or the cyst becomes infected and intermittently discharges purulent fluid with pieces of hairs. A similar and related condition is interdigital pilonidal sinus in sheep shearers caused by wooI,27.28 and interdigital sinuses in milker's hands caused by cow's hair.29 Reported cases of pilonidal cyst in hairdressers'
The Journal of HAND SURGERY
Patel et at.
654
Table I. Summary of cases of barber's pilonidal cyst reported in the literature Patient
18•9 2" 3 10 4" 415
27 31 52 34
M M M M
5'5
53
613
DNR DNR DNR
43 71 39
M M M M M M M M M M M M M
49 45
M M
7 12
8" 9 1• 1 '
10
11" 12" 1319 14\7
151' 1622 17 21 1721 1820 192' 1928 2Q2' 2[2'
2224
24*
L
R
n
42 39 53 40
DNR
L L
DNR L L L
R L R
R DNR R R R
47
58 36
48 48
L
M M M
R R DNR R R
M M
L L L R
2224 2224
2325
R R R
DNR 5 wk
DNR Iyr 4 yr
DNR DNR DNR 4 yr 3 days DNR DNR 18 mo Many yr 6 rno 1 rna 5 yr 3 yr DNR 2 yr DNR 10 yr 6-7 yr DNR DNR DNR 15 yr 2 rno
3 3 3 3
2 2 2 2 2 3 3
3 2 3 3 2 2 4 3 1
·Case described in-this report. DNR, Data not recorded; M, male; L, left; R, right; wk, weeks;
Yes Yes No DNR DNR Yes Yes DNR Yes No DNR Yes No Yes No No No No No Yes No No Yes Yes No Yes No No Yes
3-4 yr
2+4 4 3 3 3 3 3 I 3
rno,
Treatment
Follow-up
Excision Excision Excision Incision Excision Excision Incision None Incision None Incision Excision None Excision Incision DRN None Excision Excision Incision Excision Excision Incision None Electrodesiccation Excision Excision None Excision
DNR Healed DNR Healed Healed DNR DNR DNR DNR DNR DNR DNR DNR Healed DNR DNR DNR Healed Healed Healed Healed DNR Healed Healed Recurred after 10 mo Recurred after 10 mo DNR DNR Healed
months; yr, year.
hands are summarized in Table I. The order of predilection is the third web space, followed by the second and the fourth. The first web space has been reported to be involved only once. 12 We record the second case. Some patients have more than one web space involved." 9, 24 Excision of the lesion and primary wound closure results in less obvious scar than incision and drainage. REFERENCES 1. Patey D. Pilonidal sinus-or 'jeep disease'. Nurs Times 1971;67:534-6. 2. Allegaert WJ. Pilonidal sinus of the umbilicus. Br J Clin Pract 1967;21:201. 3. Saggar RP. Pilonidal disease of the chest wall. J Ir Med Assoc 1967;60:125-7. 4. Wilson E, Failes DG, Killingback M. Pilonidal sinus of the anal canal: report of a case. Dis Colon Rectum 1971;14:468-70. 5. Woodward WW. A pilonidal sinus of the ear. Aust N Z J Surg 1965 ;35:72-3.
6. Bervar M, Manojlovi D, Cerarnilac A. Pilonidal sinus of the penis. Vojnosanit Pregl 1968;25:199-200. 7. Moyer DG. Pilonidal cyst of the scalp. Arch Dennatol 1972;105:578-9. 8. Templeton H. Foreign body granuloma or interdigital cyst with hair formation. Arch Dermatol Syph 1942; 46:157-8. 9. Allington H. A case for diagnosis (foreign body reaction?). Arch Derm Syph 1942;45:614-15. 10. Ewing MR. Hair bearing sinus. Letter to the editor. Lancet 1947;1:427. 11. Patey DH, Scarff RW. Pathology of postnatal pilonidal sinus. Its bearing on treatment. Lancet 1946;2:484-6. 12. Wilks IM. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 13. Tait GB. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 14. Sames LP. Pilonidal sinus in a barber's hand. Letter to the editor. Lancet 1948;2:121. 15. Patey DR, Scarff RW. Pilonidal sinus in a barber's hand with observations on postnatal postnidal sinus. Lancet 1948;2:13-14.
Vol. 15A, No.4 July 1990
16. King ESJ. The interdigital pilonidal sinus. Aust N Z J Surg 1949;19:29-33. 17. Warren CM. Pilonidal sinus in a barber. Letter to the editor. Lancet 1951;1:912. 18. Raw SC. Pilonidal sinus in a barber. Letter to the editor. Lancet 1951;1:912. 19. Jenkins DR. Pilonidal sinus in a barber. Lancet 1951;1:746-7. 20. Waisman M, Olivetti RG. Pilonidal sinus of the hand. Arch Dermatol Syph 1952;66:466. 21. Hueston JT. Pathology of the inter-digital pilonidal sinus. Aust N Z J Med 1952;21:226. 22. Downing JG. Barber's pilonidal sinus. JAm Med Assoc 1952;148: 1501. 23. Currie AR, Gibson T, Goodall AL. Interdigital sinuses of barber's hands. Br J Surg 1953;41:278-86.
Barber's interdigital pilonidal sinus of hand
24. Joseph HL, Gifford H. Barber's interdigital pilonidal sinus-incidence, pathology and pathogenesis. Arch Dennatol Syph 1954;70:616. 25. Kovalcik PJ. Relevancy of the barber's interdigital pilonidal sinus. Letter to the editor. JAmMed Assoc 1973;224:1650. 26. Waris W. Barber's disease. Industr Med Surg 1953;22: 111.
27. Philips PJ. Web space sinus in a shearer. Med J Aust 1966;2:1152-3. 28. Matheson A. Interdigital pilonidal sinus caused by wool. Aust N Z J Surg 1951;21:76-7. 29. Meneghini CL, Gionitti F. Granulomatosis fistulosa interdigitalis of milker's hands. Dermatologica 1964; 128:38-50.
Chondrosarcoma of small bones of the hand arising from enchondroma We report the clinicopathologic findings in two cases of chondrosarcoma of the small bones of the hand arising from a preexisting solitary enchondroma. A critical review of the previously reported 18 cases shows that only one is actually well-documented. (J HAND SURG 1990;15A: 655·9.)
D. L. Nelson, MD, F. W. Abdul-Karim, MD, J. R. Carter, MD, and J. T. Makley, MD, Cleveland, Ohio
Chondrosarcoma of the small bones of the hand is a rare entity. Lichtenstein and Jaffe' described the first case in 1943. Chondrosarcomas accounted for only 4% of 450 cases of malignant tumors of the hand reviewed by Palmierf and only 1V2% of 635 cases of chondrosarcoma of the entire skeleton in a report by Dahlin and Unni. 3 Chondrosarcoma of the
From theDepartments of Orthopaedic Surgery andofPathology. Case Western ReserveUniversity and University Hospitals of Cleveland, Cleveland, Ohio. Received for publication May 25, 1989; accepted in revised form Sept. 2, 1989. 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: F. W. Abdul-Karim, MD, Institute of Pathology, Case Western Reserve University, 2085 Adelbert Rd, Cleveland, OH 44106. 3/1/16875
hand arising from a solitary preexisting enchondroma is generally considered a well established but rare occurrence. This notion has been based on 18 cases that have been cited repeatedly in the English-language Iiterature.v'? This occurrence is, however, even rarer than previously documented. Critical review disclosed that only one of these 18 cases is actually documented satisfactorily.!" We report here the clinico-pathologic findings in two additional well-documented cases, including the first case in which the benign cartilaginous lesion was documented histopathologically. We also analyze the previously reported alleged cases and provide justification for accepting only one as a true example of chondrosarcoma of hand bones arising from enchondroma. Case reports Case 1. In 1978, a 65-year-old woman had a minor injury to her left hand and had no symptoms, but radiographs showed typical enchondroma of the proximal phalanx of the ring THE JOURNAL OF HAND SURGERY
655
