545040 research-article2014
JHS0010.1177/1753193414545040The Journal of Hand SurgeryShort report letter
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
Osteoid osteoma of the distal pole of the scaphoid mimicking flexor carpi radialis tendinitis Dear Sir, A 21-year-old woman presented with diffuse pain of the left wrist of several months duration. She did not have any trauma to the wrist. Her pain initially occurred after strenuous activity, but had become constant by the time of presentation. Her pain improved after administration of non-steroidal antiinflammatory drugs. Physical examination revealed focal tenderness of the distal pole of the scaphoid. We observed a small, round radio-opaque mass in the distal pole of scaphoid on posteroanterior (PA) and lateral plain radiographs, which was thought to be a simple bony island (Figure 1(A)). We initially diagnosed flexor carpi radialis tendinitis as the cause of her radial wrist pain, and recommended steroid injection at the point of tenderness. However, the patient requested further imaging studies due to the prolonged duration of her symptoms. Computerized tomography (CT) and magnetic resonance imaging (MRI) were subsequently performed. MRI demonstrated a homogeneous, hypointense lesion on the distal scaphoid, but did not show evidence of a radiolucent core (Figure 2(A)). Her CT scan revealed a well-demarcated radiolucent core with an associated sclerotic margin, consistent with osteoid osteoma of the distal pole of the scaphoid (Figure 2(B)). We performed additional radiographs taken from different angles, and identified the radiolucent core in the centre of the bony sclerotic lesion on ulnardeviated plain radiographs, which was not initially observed on PA and lateral radiographs (Figure 1(B)). We subsequently performed an en-bloc excision under ulnar-deviated fluoroscopic image guidance. The specimen was sent for histopathologic examination, which confirmed the diagnosis of osteoid osteoma. Her symptoms improved 2 weeks after surgery. She was able to return to normal activities 3 months after surgery, and there was complete resolution of pain with no evidence of local recurrence 12 months after surgery.
Figure 1. (A) A small round radio-opaque mass in distal pole of the scaphoid was observed on PA and lateral pain radiographs. This lesion was initially misunderstood as a simple bony island (enostos). (B) The ulnar-deviated PA view of plain radiographs demonstrated the radiolucency core (nidus) at the centre of bony sclerosis in the distal pole of scaphoid, which could not be observed on PA and lateral plain radiographs initially.
Only 2% of all osteoid osteomas involve the carpus, and their rarity makes this a challenging diagnosis (Katolik, 2009). Plain radiographs typically demonstrate a central, well-demarcated oval or round radiolucent area, surrounded by a variable zone of uniform sclerotic bone. However, in the hand and wrist, these
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2
The Journal of Hand Surgery (Eur) 2010). The CT scan was also superior to MRI for preoperative planning and localization of the osteoid osteoma in the small bones of the hand. The appearance of osteoid osteomas is variable on MRI, often showing oedema of the involved bone, but not providing more specific information for diagnosis or localization (Smet, 2001). In this case, we initially misdiagnosed osteoid osteoma of the distal pole of the scaphoid as flexor carpi radialis tendinitis. Osteoid osteoma of the scaphoid is difficult to diagnose, and is frequently confused with De Quervain’s disease, scaphoid fracture, intersection syndrome, or tendinitis. It is important that the physician evaluate plain radiographs carefully in a patient with chronic unexplained wrist pain. If the radiographs are inconclusive, additional views or CT imaging should be considered to better identify the nidus of osteoid osteoma in the small bones of the hand. Conflict of interests None declared.
Figure 2. (A) Magnetic resonance image (MRI) demonstrated a homogeneous hypointense signal lesion on the distal scaphoid, but did not demonstrate the radiolucent core with hypointense lesion. (B) The computerized tomography (CT) scan revealed a well-demarcated radiolucent core with associated sclerotic margin, consistent with osteoid osteoma of distal pole of scaphoid.
findings are sometimes absent or missed, even in retrospectively reviewed films (Smet, 2001). A preoperative radiographic diagnosis of osteoid osteoma in the small carpal bones is often difficult to make because the reactive sclerotic bone may mask the underlying radiolucent nidus (Themistocleous et al., 2005). In these cases, another diagnostic imaging study or plain radiographs taken from a different angle are necessary to confirm the initial impression. If plain radiographs are non-diagnostic, a radionuclide bone scan, MRI, or CT scan may improve diagnostic accuracy and help to better define and localize the lesion prior to operative management. In our case, the CT images were more helpful than MRI for diagnosing osteoid osteoma of the scaphoid due to more accurate detection of the nidus (Shukla et al.,
References Katolik LI. Osteoid osteoma of the scaphoid presenting with radiocarpal arthritis: a case report. Hand (NY). 2009, 4: 187–90. Shukla S, Clarke AW, Saifuddin A. Imaging features of foot osteoid osteoma. Skeletal Radiol. 2010, 39: 683–9. Smet LD. Osteoid osteoma of the wrist and hand. J Am Soc Surg Hand. 2001, 1: 267–74. Themistocleous GS, Chloros GD, Mavrogenis AF, Khaldi L, Papagelopoulos PJ, Efstathopoulos DG. Unusual presentation of osteoid osteoma of the scaphoid. Arch Orthop Trauma Surg. 2005, 125: 482–5.
J. W. Park MD, PhD1, K. H. Lee MD, PhD2 and J. I. Lee MD, PhD3 1Department
of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan, Korea 2Department of Orthopaedic Surgery, Hanyang University Seoul Hospital, Seoul, Korea 3Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Guri, Korea Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414545040 available online at http://jhs.sagepub.com
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JHS0010.1177/1753193414545040The Journal of Hand SurgeryShort report letter
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
Osteoid osteoma of the distal pole of the scaphoid mimicking flexor carpi radialis tendinitis Dear Sir, A 21-year-old woman presented with diffuse pain of the left wrist of several months duration. She did not have any trauma to the wrist. Her pain initially occurred after strenuous activity, but had become constant by the time of presentation. Her pain improved after administration of non-steroidal antiinflammatory drugs. Physical examination revealed focal tenderness of the distal pole of the scaphoid. We observed a small, round radio-opaque mass in the distal pole of scaphoid on posteroanterior (PA) and lateral plain radiographs, which was thought to be a simple bony island (Figure 1(A)). We initially diagnosed flexor carpi radialis tendinitis as the cause of her radial wrist pain, and recommended steroid injection at the point of tenderness. However, the patient requested further imaging studies due to the prolonged duration of her symptoms. Computerized tomography (CT) and magnetic resonance imaging (MRI) were subsequently performed. MRI demonstrated a homogeneous, hypointense lesion on the distal scaphoid, but did not show evidence of a radiolucent core (Figure 2(A)). Her CT scan revealed a well-demarcated radiolucent core with an associated sclerotic margin, consistent with osteoid osteoma of the distal pole of the scaphoid (Figure 2(B)). We performed additional radiographs taken from different angles, and identified the radiolucent core in the centre of the bony sclerotic lesion on ulnardeviated plain radiographs, which was not initially observed on PA and lateral radiographs (Figure 1(B)). We subsequently performed an en-bloc excision under ulnar-deviated fluoroscopic image guidance. The specimen was sent for histopathologic examination, which confirmed the diagnosis of osteoid osteoma. Her symptoms improved 2 weeks after surgery. She was able to return to normal activities 3 months after surgery, and there was complete resolution of pain with no evidence of local recurrence 12 months after surgery.
Figure 1. (A) A small round radio-opaque mass in distal pole of the scaphoid was observed on PA and lateral pain radiographs. This lesion was initially misunderstood as a simple bony island (enostos). (B) The ulnar-deviated PA view of plain radiographs demonstrated the radiolucency core (nidus) at the centre of bony sclerosis in the distal pole of scaphoid, which could not be observed on PA and lateral plain radiographs initially.
Only 2% of all osteoid osteomas involve the carpus, and their rarity makes this a challenging diagnosis (Katolik, 2009). Plain radiographs typically demonstrate a central, well-demarcated oval or round radiolucent area, surrounded by a variable zone of uniform sclerotic bone. However, in the hand and wrist, these
Downloaded from jhs.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on September 27, 2015
2
The Journal of Hand Surgery (Eur) 2010). The CT scan was also superior to MRI for preoperative planning and localization of the osteoid osteoma in the small bones of the hand. The appearance of osteoid osteomas is variable on MRI, often showing oedema of the involved bone, but not providing more specific information for diagnosis or localization (Smet, 2001). In this case, we initially misdiagnosed osteoid osteoma of the distal pole of the scaphoid as flexor carpi radialis tendinitis. Osteoid osteoma of the scaphoid is difficult to diagnose, and is frequently confused with De Quervain’s disease, scaphoid fracture, intersection syndrome, or tendinitis. It is important that the physician evaluate plain radiographs carefully in a patient with chronic unexplained wrist pain. If the radiographs are inconclusive, additional views or CT imaging should be considered to better identify the nidus of osteoid osteoma in the small bones of the hand. Conflict of interests None declared.
Figure 2. (A) Magnetic resonance image (MRI) demonstrated a homogeneous hypointense signal lesion on the distal scaphoid, but did not demonstrate the radiolucent core with hypointense lesion. (B) The computerized tomography (CT) scan revealed a well-demarcated radiolucent core with associated sclerotic margin, consistent with osteoid osteoma of distal pole of scaphoid.
findings are sometimes absent or missed, even in retrospectively reviewed films (Smet, 2001). A preoperative radiographic diagnosis of osteoid osteoma in the small carpal bones is often difficult to make because the reactive sclerotic bone may mask the underlying radiolucent nidus (Themistocleous et al., 2005). In these cases, another diagnostic imaging study or plain radiographs taken from a different angle are necessary to confirm the initial impression. If plain radiographs are non-diagnostic, a radionuclide bone scan, MRI, or CT scan may improve diagnostic accuracy and help to better define and localize the lesion prior to operative management. In our case, the CT images were more helpful than MRI for diagnosing osteoid osteoma of the scaphoid due to more accurate detection of the nidus (Shukla et al.,
References Katolik LI. Osteoid osteoma of the scaphoid presenting with radiocarpal arthritis: a case report. Hand (NY). 2009, 4: 187–90. Shukla S, Clarke AW, Saifuddin A. Imaging features of foot osteoid osteoma. Skeletal Radiol. 2010, 39: 683–9. Smet LD. Osteoid osteoma of the wrist and hand. J Am Soc Surg Hand. 2001, 1: 267–74. Themistocleous GS, Chloros GD, Mavrogenis AF, Khaldi L, Papagelopoulos PJ, Efstathopoulos DG. Unusual presentation of osteoid osteoma of the scaphoid. Arch Orthop Trauma Surg. 2005, 125: 482–5.
J. W. Park MD, PhD1, K. H. Lee MD, PhD2 and J. I. Lee MD, PhD3 1Department
of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan, Korea 2Department of Orthopaedic Surgery, Hanyang University Seoul Hospital, Seoul, Korea 3Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Guri, Korea Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414545040 available online at http://jhs.sagepub.com
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