Subperiosteal
osteoid osteoma of the hamate:
A case report Osteoid osteoma is uncommon in the hand. The lesion can arise from either cortical or cancellous bone or subperiosteally. The latter localization is extremely rare in the hand, with only 4 reported cases in the English-language literature. Furthermore, characteristic radiographic findings of a central lucency surrounded by reactive sclerosis often emerge only late in the process, or not at all. Consequently, the diagnosis of osteoid osteoma of the hand can be delayed. We report a case of a subperiosteal osteoid osteoma of the hamate in which the diagnosis was delayed 2 years. (J HAND SURC 1992;17A:462-5.)
Bryon C. Chamberlain, MD, John F. Mosher, MD, E. Mark Levinsohn, Jeffrey A. Greenberg, MD, Syracuse, N.Y.
0
steoid osteoma, a frequent benign lesion of bone, is usually intraosseous but occasionally subperiosteal. It most commonly involves the appendicular long bones, with 50% of the reported cases in the tibia and femur. Only 6% to 13% of all cases occur in the hand.’ The lesion characteristically produces localized pain in the affected area, which is worse at night and is relieved by aspirin. When it occurs in the hand, it may cause local tenderness and swelling. The radiographic appearance classically reveals a radiolucent nidus, usually less than 1 cm in diameter and occasionally containing a central opacity. This is often surrounded by a reactive margin of sclerotic bone. Radiographic manifestations can vary considerably and may not emerge until many months after the onset of symptoms. Tomography, bone scanning, angiography, computed tomography, and magnetic resonance imaging have all proved useful when conventional x-ray films fail to demonstrate a nidus.* Osteoid osteoma is uncommon in the hand and rare in the carpus. Fewer than 50 cases involving the carpal
From the Departments of Orthopedic Surgery and Radiology, State University of New York Health Science Center. Syracuse, N.Y.
Received for publication May 9, 1990; accepted in revised form Sept. 29, 1991. No benefits in any form have been received or will be received from a commercial this article.
party related directly or indirectly
Reprint requests: John F. Mosher, MD, Department Surgery. 550 Harrison St., Syracuse, NY 13202. 3/l/34228
462
THEIOURNALOFHANDSURGERY
to the subject of of Orthopedic
MD, and
bones have been reported in the English-language literature since it was first described by Jaffe3 as a distinct type of bone neoplasm in 1935. Six such lesions, none of which were subperiosteal, have been described in the hamate .4-9 Because radiographic changes often emerge late in the clinical course, and because the lesion is infrequently encountered in the hand and wrist, the diagnosis may be delayed. Case report A 3%year-old left-handed carpenter experienced 2 years of gradually increasing pain and tenderness in the dorsal ulnar aspect of his dominant left wrist. There was no history of antecedent trauma or infection. The pain was described as sharp, originating near the ulnar aspect of the wrist, and radiating distally through the hand. The patient claimed he could throw a football but was unable to throw a baseball or use a hammer with his affected hand. Symptoms were worse at night and were only minimally relieved by naproxen, 500 mg twice daily. Aspirin was not taken. Hydrocortisone injection into the region of the hamate and fifth metacarpal as well as a trial of wrist splinting failed to relieve the slowly worsening symptoms. Because the symptoms were originally thought to be due to a soft tissue process, no x-ray films were taken until the patient was referred to one of us (J.F.M.) approximately 2 years after the onset of symptoms. Physical examination demonstrated a diffuse nonmobile swelling over the dorsal ulnar aspect of the wrist. Extension and flexion of the wrist were each decreased 15 degrees when compared with the contralateral side, while full radial and ulnar deviation, as well as supination and pronation, were preserved. The overlying skin was not adherent to the mass. Flexor and extensor tendon function was normal. No Tinel’s sign was present. A lateral x-ray film of the wrist (Fig. 1)
Vol. 17A, No. 3 May 1992
Subperiosteal
osteoid osteoma of hurnate
463
Fig. 1. Lateral x-ray film of left wrist showing a 3 mm round opacity surrounded by a lucent zone (urrows) directly dorsal to the distal carpal row.
revealed a 3 mm round opacification in the dorsal portion of the hamate. An anteroposterior view (Fig. 2) suggested a 5 mm radiolucent area with a central opacity in the proximal portion of the hamate. Because of the chronicity of symptoms, the signs of inflammation, and the radiographic appearance of a well-localized superficial bony lesion, surgery was directly entertained with a preoperative diagnosis of localized osteomyelitis of the hamate. Surgical exploration revealed a hyperemic, moderately thickened, dorsal wrist capsule. Deep dissection into the carpus exposed a firm, round, reddish brown, 5 x 5 mm round, red mass nesting in the proximal portion of the hamate (Fig. 3). The mass was easily shelled out intact from the cup of bone with a small osteotome. and the surrounding intact hamate was only minimally curetted. Histologic examination showed the excised mass to contain fibroblastic hypervascular stroma lined with osteoblasts surrounded by osteoid (Fig. 4). The patient returned to work within 6 weeks and regained full use of his wrist within 3 months. He remains free of symptoms 18 months after surgery.
Discussion Fig. 2. Anteroposterior
x-ray film suggests a 5 mm radiolucent area in the hamate containing a sclerotic nidus (arrows). No reactive sclerosis is seen.
Edeiken et al. ‘” identified the two most common classifications of osteoid osteoma as arising from cortical and cancellous bone and then introduced a third. far
464
Chamberlain
The Journal ot HAND SURGERY
et al.
Fig. 3. Surgical exposure into the carpus reveals a 5 x 5 mm reddish brown mass.
Fig. 4. Photomicrograph with osteoblasts
of the excised mass demonstrates surrounded by osteoid.
fibroblastic hypervascular
stroma lined
Vol. 17A, No. 3 May 1992
less common type arising subperiosteally, which appears as a round soft tissue mass directly adjacent to bone. The cause of this rare lesion remains uncertain. The majority of reported subperiosteal osteoid osteomas appear to occur near the femoral neck, elbow, and talus. To our knowledge. only five cases of subperiosteal osteoid osteoma of the small bones of the hand, including the case we report here, have been reported in the English-language literature.‘. “-‘3 These occurred in the proximal phalanx of the small finger, the proximal phalanx of the index finger, the capitate, the distal phalanx of the thumb, and the hamate. Of the five cases, the duration of symptoms before correct diagnosis was 22 months, with a range of 10 to 42 months. The clinical presentation of subperiosteal osteoid osteoma of the hand is similar to that of the cortical and cancellous varieties, although painful swelling may be a more consistent finding in the subperiosteal lesions. Four of five patients with subperiosteal osteoid osteoma of the hand complained of painful swelling, and one complained of painless swelling. Three of the five patients were reported to awaken at night with pain. One patient found relief with aspirin, one did not try aspirin, and no mention of aspirin was made in reference to the remaining three cases. Without exception, pain subsided after surgical removal of the lesion. On x-ray examination, subperiosteal osteoid osteoma can appear as a lucent area with variable central calcification intimately associated with but not within the cortex. often causing cortical erosion. Although the literature suggests that reactive sclerosis is uncommon in subperiosteal lesions, this feature was seen on x-ray examination in three of the five reported cases of subperiosteaf osteoid osteoma of the hand.‘” An area of iucency was seen on plain films in four out of five cases. Unfortunately, these radiographic findings often emerge after the patient has suffered for many months or may not appear at all, delaying diagnosis. Technetium bone scans are valuable in the diagnosis of cortical and cancellous lesions because of their ability to localize an area of intense blush. Such scans may be less helpful in the diagnosis of subperiosteal osteoid osteomas and instead show only a diffuse area of nuclide activity that is thought to reflect reactive hyperemia of the periosteum and synovium.‘” We elected to explore the wrist
Subperiosteul osteoid osteoma
of htrmote 465
surgically without first obtaining a bone scan because the lesion was well localized on plain films, similar to the other reported cases of osteoid osteoma of the hand. REFERENCES I.
2.
3 _
4. 5.
6. 7.
8.
9. 10.
11. 12.
13.
14. 15.
Dahlin DC. Bone tumors: general aspects and data on 6.221 cases. 3rd ed. Springfield. Illinois: Charles C Thomas, 1978:75-86. Bell RS. O’Connor CD. Waddell JP. Importance of magnetic resonance imaging in osteoid osteoma: a case report. Can J Surg 1989;32:276-8. Jaffe HL. Osteoid osteoma: a benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935;31:709-28. Ambrosia JM. Wold LE. Amadio PC. Osteoid osteoma of the hand and wrist. J HAND SURG 1987; 12A:794-800. Nunez-Samper M, Fashho SN. Munoz JL. Ulloa J. Cabruja RM. Osteoid osteoma of the hamate bone: case report and review of the literature. Clin Orthop 1986:207:146-9. Magnini U. Tumors of the skeleton of the hand. Bull Hosp Joint Dis Orthop Inst 1967;28:61-6. O’Hara J. Tegtmeyer C, Sweet DE, McCue FC. Angiography in the diagnosis of osteoid osteoma of the hand. J Bone Joint Surg 1975;57A:163-6. Rosenfeld K, Bora FW. Lane JM. Osteoid osteoma of the hamate: a case report and review of the literature. J Bone Joint Surg 1973:.55A: 1085-7. Spinner M, Zaleski A. Weiner E. Osteoid osteoma of the hamate. Bull Hosp Jt Dis Orthop Inst 1972;33:8-14. Edeiken J. DePalma AF. Hodes PJ. Osteoid osteoma (roentgenographic emphasis). Clin Orthop 1966149: 201-6. Carrel RE. Osteoid osteoma in the hand. J Bone Joint Surg 1953:35A:888-93. Crosby LA, Murphy RP. Subperiosteal osteoid osteoma of the distal phalanx of the thumb. J HAND SURG 1988;13A:923-5. Jaffe HL. Lichenstein L. Osteoid osteoma: further experience with this benign tumor of bone. J Bone Joint Surg 1940;22:645-82. Shereff MJ, Cullivan WT, Johnson KA. Osteoid osteoma of the foot. J Bone Joint Surg 1983;65A:638-41. Brabants K. Geens S, Van Damme BV. Subperiosteal juxta articular osteoid osteoma. J Bone Joint Surg 1986:68B:923-5.
osteoid osteoma of the hamate:
A case report Osteoid osteoma is uncommon in the hand. The lesion can arise from either cortical or cancellous bone or subperiosteally. The latter localization is extremely rare in the hand, with only 4 reported cases in the English-language literature. Furthermore, characteristic radiographic findings of a central lucency surrounded by reactive sclerosis often emerge only late in the process, or not at all. Consequently, the diagnosis of osteoid osteoma of the hand can be delayed. We report a case of a subperiosteal osteoid osteoma of the hamate in which the diagnosis was delayed 2 years. (J HAND SURC 1992;17A:462-5.)
Bryon C. Chamberlain, MD, John F. Mosher, MD, E. Mark Levinsohn, Jeffrey A. Greenberg, MD, Syracuse, N.Y.
0
steoid osteoma, a frequent benign lesion of bone, is usually intraosseous but occasionally subperiosteal. It most commonly involves the appendicular long bones, with 50% of the reported cases in the tibia and femur. Only 6% to 13% of all cases occur in the hand.’ The lesion characteristically produces localized pain in the affected area, which is worse at night and is relieved by aspirin. When it occurs in the hand, it may cause local tenderness and swelling. The radiographic appearance classically reveals a radiolucent nidus, usually less than 1 cm in diameter and occasionally containing a central opacity. This is often surrounded by a reactive margin of sclerotic bone. Radiographic manifestations can vary considerably and may not emerge until many months after the onset of symptoms. Tomography, bone scanning, angiography, computed tomography, and magnetic resonance imaging have all proved useful when conventional x-ray films fail to demonstrate a nidus.* Osteoid osteoma is uncommon in the hand and rare in the carpus. Fewer than 50 cases involving the carpal
From the Departments of Orthopedic Surgery and Radiology, State University of New York Health Science Center. Syracuse, N.Y.
Received for publication May 9, 1990; accepted in revised form Sept. 29, 1991. No benefits in any form have been received or will be received from a commercial this article.
party related directly or indirectly
Reprint requests: John F. Mosher, MD, Department Surgery. 550 Harrison St., Syracuse, NY 13202. 3/l/34228
462
THEIOURNALOFHANDSURGERY
to the subject of of Orthopedic
MD, and
bones have been reported in the English-language literature since it was first described by Jaffe3 as a distinct type of bone neoplasm in 1935. Six such lesions, none of which were subperiosteal, have been described in the hamate .4-9 Because radiographic changes often emerge late in the clinical course, and because the lesion is infrequently encountered in the hand and wrist, the diagnosis may be delayed. Case report A 3%year-old left-handed carpenter experienced 2 years of gradually increasing pain and tenderness in the dorsal ulnar aspect of his dominant left wrist. There was no history of antecedent trauma or infection. The pain was described as sharp, originating near the ulnar aspect of the wrist, and radiating distally through the hand. The patient claimed he could throw a football but was unable to throw a baseball or use a hammer with his affected hand. Symptoms were worse at night and were only minimally relieved by naproxen, 500 mg twice daily. Aspirin was not taken. Hydrocortisone injection into the region of the hamate and fifth metacarpal as well as a trial of wrist splinting failed to relieve the slowly worsening symptoms. Because the symptoms were originally thought to be due to a soft tissue process, no x-ray films were taken until the patient was referred to one of us (J.F.M.) approximately 2 years after the onset of symptoms. Physical examination demonstrated a diffuse nonmobile swelling over the dorsal ulnar aspect of the wrist. Extension and flexion of the wrist were each decreased 15 degrees when compared with the contralateral side, while full radial and ulnar deviation, as well as supination and pronation, were preserved. The overlying skin was not adherent to the mass. Flexor and extensor tendon function was normal. No Tinel’s sign was present. A lateral x-ray film of the wrist (Fig. 1)
Vol. 17A, No. 3 May 1992
Subperiosteal
osteoid osteoma of hurnate
463
Fig. 1. Lateral x-ray film of left wrist showing a 3 mm round opacity surrounded by a lucent zone (urrows) directly dorsal to the distal carpal row.
revealed a 3 mm round opacification in the dorsal portion of the hamate. An anteroposterior view (Fig. 2) suggested a 5 mm radiolucent area with a central opacity in the proximal portion of the hamate. Because of the chronicity of symptoms, the signs of inflammation, and the radiographic appearance of a well-localized superficial bony lesion, surgery was directly entertained with a preoperative diagnosis of localized osteomyelitis of the hamate. Surgical exploration revealed a hyperemic, moderately thickened, dorsal wrist capsule. Deep dissection into the carpus exposed a firm, round, reddish brown, 5 x 5 mm round, red mass nesting in the proximal portion of the hamate (Fig. 3). The mass was easily shelled out intact from the cup of bone with a small osteotome. and the surrounding intact hamate was only minimally curetted. Histologic examination showed the excised mass to contain fibroblastic hypervascular stroma lined with osteoblasts surrounded by osteoid (Fig. 4). The patient returned to work within 6 weeks and regained full use of his wrist within 3 months. He remains free of symptoms 18 months after surgery.
Discussion Fig. 2. Anteroposterior
x-ray film suggests a 5 mm radiolucent area in the hamate containing a sclerotic nidus (arrows). No reactive sclerosis is seen.
Edeiken et al. ‘” identified the two most common classifications of osteoid osteoma as arising from cortical and cancellous bone and then introduced a third. far
464
Chamberlain
The Journal ot HAND SURGERY
et al.
Fig. 3. Surgical exposure into the carpus reveals a 5 x 5 mm reddish brown mass.
Fig. 4. Photomicrograph with osteoblasts
of the excised mass demonstrates surrounded by osteoid.
fibroblastic hypervascular
stroma lined
Vol. 17A, No. 3 May 1992
less common type arising subperiosteally, which appears as a round soft tissue mass directly adjacent to bone. The cause of this rare lesion remains uncertain. The majority of reported subperiosteal osteoid osteomas appear to occur near the femoral neck, elbow, and talus. To our knowledge. only five cases of subperiosteal osteoid osteoma of the small bones of the hand, including the case we report here, have been reported in the English-language literature.‘. “-‘3 These occurred in the proximal phalanx of the small finger, the proximal phalanx of the index finger, the capitate, the distal phalanx of the thumb, and the hamate. Of the five cases, the duration of symptoms before correct diagnosis was 22 months, with a range of 10 to 42 months. The clinical presentation of subperiosteal osteoid osteoma of the hand is similar to that of the cortical and cancellous varieties, although painful swelling may be a more consistent finding in the subperiosteal lesions. Four of five patients with subperiosteal osteoid osteoma of the hand complained of painful swelling, and one complained of painless swelling. Three of the five patients were reported to awaken at night with pain. One patient found relief with aspirin, one did not try aspirin, and no mention of aspirin was made in reference to the remaining three cases. Without exception, pain subsided after surgical removal of the lesion. On x-ray examination, subperiosteal osteoid osteoma can appear as a lucent area with variable central calcification intimately associated with but not within the cortex. often causing cortical erosion. Although the literature suggests that reactive sclerosis is uncommon in subperiosteal lesions, this feature was seen on x-ray examination in three of the five reported cases of subperiosteaf osteoid osteoma of the hand.‘” An area of iucency was seen on plain films in four out of five cases. Unfortunately, these radiographic findings often emerge after the patient has suffered for many months or may not appear at all, delaying diagnosis. Technetium bone scans are valuable in the diagnosis of cortical and cancellous lesions because of their ability to localize an area of intense blush. Such scans may be less helpful in the diagnosis of subperiosteal osteoid osteomas and instead show only a diffuse area of nuclide activity that is thought to reflect reactive hyperemia of the periosteum and synovium.‘” We elected to explore the wrist
Subperiosteul osteoid osteoma
of htrmote 465
surgically without first obtaining a bone scan because the lesion was well localized on plain films, similar to the other reported cases of osteoid osteoma of the hand. REFERENCES I.
2.
3 _
4. 5.
6. 7.
8.
9. 10.
11. 12.
13.
14. 15.
Dahlin DC. Bone tumors: general aspects and data on 6.221 cases. 3rd ed. Springfield. Illinois: Charles C Thomas, 1978:75-86. Bell RS. O’Connor CD. Waddell JP. Importance of magnetic resonance imaging in osteoid osteoma: a case report. Can J Surg 1989;32:276-8. Jaffe HL. Osteoid osteoma: a benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935;31:709-28. Ambrosia JM. Wold LE. Amadio PC. Osteoid osteoma of the hand and wrist. J HAND SURG 1987; 12A:794-800. Nunez-Samper M, Fashho SN. Munoz JL. Ulloa J. Cabruja RM. Osteoid osteoma of the hamate bone: case report and review of the literature. Clin Orthop 1986:207:146-9. Magnini U. Tumors of the skeleton of the hand. Bull Hosp Joint Dis Orthop Inst 1967;28:61-6. O’Hara J. Tegtmeyer C, Sweet DE, McCue FC. Angiography in the diagnosis of osteoid osteoma of the hand. J Bone Joint Surg 1975;57A:163-6. Rosenfeld K, Bora FW. Lane JM. Osteoid osteoma of the hamate: a case report and review of the literature. J Bone Joint Surg 1973:.55A: 1085-7. Spinner M, Zaleski A. Weiner E. Osteoid osteoma of the hamate. Bull Hosp Jt Dis Orthop Inst 1972;33:8-14. Edeiken J. DePalma AF. Hodes PJ. Osteoid osteoma (roentgenographic emphasis). Clin Orthop 1966149: 201-6. Carrel RE. Osteoid osteoma in the hand. J Bone Joint Surg 1953:35A:888-93. Crosby LA, Murphy RP. Subperiosteal osteoid osteoma of the distal phalanx of the thumb. J HAND SURG 1988;13A:923-5. Jaffe HL. Lichenstein L. Osteoid osteoma: further experience with this benign tumor of bone. J Bone Joint Surg 1940;22:645-82. Shereff MJ, Cullivan WT, Johnson KA. Osteoid osteoma of the foot. J Bone Joint Surg 1983;65A:638-41. Brabants K. Geens S, Van Damme BV. Subperiosteal juxta articular osteoid osteoma. J Bone Joint Surg 1986:68B:923-5.
