Osteoid Osteoma o[ the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysa/idis and G. HartoIilakidis-Garo[alidis
OSTEOID O S T E O M A OF T H E T E R M I N A L P H A L A N G E S A. GIANNIKAS, G. P A P A C H R I S T O U , G. TINIAKOS, G. C H R Y S A F I D I S
and G. H A R T O F I L A K I D I S - G A R O F A L I D I S , Athens SUMMARY Four cases of osteoid osteoma of the terminal phalanx - - a very rare location are presented. The clinical picture of all cases is essentially the same, gradual swelling of the terminal phalanx With enlargement of the nail and pain, particularly at night and relievable by aspirin. The treatment was operative and of double value. 1. The osteoid osteoma is removed; 2. Cosmetic result is obtained by reduction of the size of the terminal phalanx. INTRODUCTION Osteoid osteoma is a well known clinical entity. Jaffe in 1935 described the clinical and pathological data on this benign osteoblastic tumour. It is found in most of the long bones but it is generally accepted that the tibia and femur are the most common sites for this lesion. The hand is not a frequent location and the terminal phalanx a very rare site. We have been able to find, in the available literature only seven cases (Chandler and Kaell 1950, Testa and Mazzoleni 1951, Sevitt and Horn 1954, Jaffe 1958, Lichtenstein 1959 and Rosborough 1966) with an osteoid osteoma located in the terminal phalanx. In the last ten years we have had the opportunity to treat four cases of osteoid osteoma located in the terminal phalanges in different fingers of the hand, two in children of approximately ten years of age and two in adults, one of twenty and the other fifty four years of age. These cases have many common signs and symptoms and so form a new entity which can be recognized by the clinical appearance. CLINICAL PICTURE In all four cases the clinical picture showed the following common symptoms: (a) Long standing painless enlargement of the terminal phalanx without any history of previous trauma. (b) The enlargement of the terminal phalanx had started at least two years before operation was performed and at least one year before any painful symptoms had started. (c) The nail was enlarged to such an extent that it was almost double the size of the nail of the adjacent finger. (d) Increased perspiration of the affected finger. (e) Pain was intense but relieved by aspirin. (f) X-Rays showed a density and translucent area located on one side of the phalanx indicative of an osteoid osteoma.
A. Giannikas, M.D., Department of Orthopaedics, Athens University, 5 Heraklitou Street, Athens-136, Greece. The Hand--Vol. 9
No. 3
1977
295
Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Fig. la. Case 1. Photograph of the right hand with the enlarged terminal phalanx of right index. Fig. lb. Case 1. Histological section showing the highly vascularised osteogenic connective tissue and travebulae of newly formed osseous tissue undergoing calcification. H&E, Mag.x50. CASE R E P O R T S
Case 1
A boy, ten years of age, was admitted in November 1963, with pain and enlargement of the terminal phalanx of the right index finger (Fig. la). Enlargement of the phalanx had started two years previously and pain one year before admission. No trauma was reported to this finger. Clinically that index finger was enlarged in the terminal phalanx, painful on pressure and also warmer than the other fingers. The nail was double the size of that of the adjoining finger. X-Rays showed an area of translucency near the base of the terminal phalanx surrounded by a thin zone of bone density, In the centre of the translucent area there was a small shadow. Under general anaesthetic and a tourniquet we removed a wedge-shaped portion of the pulp and nail, curetted the bone and removed the affected part with an osteotome. We remove a wedge-shaped portion of the pulp and nail in order to reduce the size of the segment, so that on closing the finger, it will assume a normal size. The portion of soft tissues and bone, removed, were examined and the diagnosis was confirmed as osteoid osteoma. (Fig. lb). Case 2
A man twenty two years old, was admitted to the Hospital in September 1971 suffering from pain in the terminal phalanx of the little finger which had been present for six months. There was no history of trauma in the affected finger. Clinically the terminal phalanx of the little finger of the left hand had a spindle shaped appearance, was flattened and the whole terminal phalanx was enlarged (Fig. 2a) reddish, warm, perspiring and very painful even to the slightest touch. X-Rays showed a unique area of translucency near the base of the phalanx, surrounded by a thin zone of density. In the centre of this translucency there was a small nidus (Fig. 2b). Other clinical and blood tests were negative. 296
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Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. ChrysaJidis and G. Hartofilakidis-Garolalidis
Fig. 2a. Case 2. Photograph showing the involved little finger and the enlargement of terminal phalanx. Fig. 2b. Case 2. X-Rays, of the affected little finger.
Fig. 2c. Case. 2. Histological-section at the periphery of the lesion. There are osteoid tissue trabeculae of newly formed osseous tissue. On the right tissue of the phalanx H & E Mag.xl00. The Hand--VoL 9
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Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Fig. 3a. Case 3. Photograph with involved ring finger. Notice the enlargement of the terminal phalanx and nail. Fig. 3b. Case 3. Typical X-Rays appearance of an osteoid osteoma of the terminal phalanx of the involved ring finger. An operation was performed in this case, amputation of the terminal phalanx; once again histology showed a typical osteoid osteoma (Fig. 2c). Case 3
A boy eleven years old, admitted in April 1972, complaining of pain, again especially at night, of a terminal phalanx of the ring finger, with enlargement of the terminal phalanx (Fig. 3a). Painless swelling was noticed about eighteen months previously and pain started some ten months later and had been relieved by aspirin. The radiological findings were identical to the previous cases (Fig. 3b). Following operation, histology confirmed the clinical diagnosis of osteoid osteoma.
Fig. 4. Case 4. (a) before, (b) during, (c) after the operation, and (d) (face and profile) X-Rays of the involved finger. The enlargement of the terminal phalanx and nail is evident. 298
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Osteoid Osteoma o / t h e Terminal Phalanges .4. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysa[idis and G. Harto[ilakidis-Garo[alidis
Fig. 4 (d)
Fig. 5.
Case 4: (a) Microphotograph showing trabeculae of newly formed osseous tissue set in a substrate of highly vascularised osteogenic connective tissue. H&E stain., Mag.x50. (b) Microphotograph noting, in according with active osteogenesis, numerous osteoblasts. There is also calcification in some areas of osteoid tissue. H&E stain. Mag.x200.
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Osteoid Osteoma oJ the Terminal Phalanges A. Giannikas, G. Papaehristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Case 4
A man fifty-four years old, was admitted to the hospital in September 1975, suffering from pain in the terminal phalanx of the right ring finger which had been present for more than a year. This case was similar to the previously described cases. An operation was performed, the lesion was excised and the size of the terminal phalanx reduced (Fig. 4a, 4b, 4c, 4d). Histology confirmed the clinical diagnosis of an osteoid osteoma (Fig. 5a, 5b). DISCUSSION
It is generally accepted that osteoid osteoma of the band is not common while the terminal phalanx of the hand is the rarest location. The clinical picture of all cases of osteoid osteoma of the terminal phalanx - including the four recorded here - - is essentially the same i.e. gradual swelling of the terminal phalanx - - with enlargement of the nail - - this swelling is at first painless but later it became painful particularly at night - - this pain is characteristically relieved by aspirin. Operative treatment is of double value. Curative by excision of the lesion and cosmetic by the reduction of the size of the terminal phalanx. The enlargement of the phalanx could be explained as has been suggested by Rosborough by the increased vascularity of the area. However it is well known that osteoid tissue dominates the field lying in a matrix of well vascularized comaective tissue with osteoblasts and usually the lesion is surrounded by a zone of well defined sclerosis. REFERENCES
CARROLL, R. E, (1953). Osteoid Osteoma in the Hand. The Journal of Bone and Joint Surgery, 35A: 888-893, 936. CHANDLER, F. A. and KAELL, H. I. (1950). Osteoid-Osteoma. Archives of Surgery, 60: 294-304. JAFFE, H. L. (1958). Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia, Lea and Febiger. LICHTENSTEIN, L. (1965). Bone Tumors. Third Ed. St. Louis. The C.V. Mosby Company. ROSBOROUGH, D. (1966). Osteoid Osteoma. Report of a Lesion in the Terminal Phalanx of a Finger. The Journal of Bone and Joint Surgery, 48B: 485-487. SEVITT, S. and HORN, I. S. (1954). A PainZe~s and CMeified Osteoid Osteoma of the Little Finger. Journal of Pathology and Bacteriology, 67: 571-574. TESTA, G, and MAZZOLENI, G. (1951). In Terma di Osteoma Osteoide. Un Caso di localizzazione falangea. Archivio di Radiologica N.S. 1: 417-426.
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OSTEOID O S T E O M A OF T H E T E R M I N A L P H A L A N G E S A. GIANNIKAS, G. P A P A C H R I S T O U , G. TINIAKOS, G. C H R Y S A F I D I S
and G. H A R T O F I L A K I D I S - G A R O F A L I D I S , Athens SUMMARY Four cases of osteoid osteoma of the terminal phalanx - - a very rare location are presented. The clinical picture of all cases is essentially the same, gradual swelling of the terminal phalanx With enlargement of the nail and pain, particularly at night and relievable by aspirin. The treatment was operative and of double value. 1. The osteoid osteoma is removed; 2. Cosmetic result is obtained by reduction of the size of the terminal phalanx. INTRODUCTION Osteoid osteoma is a well known clinical entity. Jaffe in 1935 described the clinical and pathological data on this benign osteoblastic tumour. It is found in most of the long bones but it is generally accepted that the tibia and femur are the most common sites for this lesion. The hand is not a frequent location and the terminal phalanx a very rare site. We have been able to find, in the available literature only seven cases (Chandler and Kaell 1950, Testa and Mazzoleni 1951, Sevitt and Horn 1954, Jaffe 1958, Lichtenstein 1959 and Rosborough 1966) with an osteoid osteoma located in the terminal phalanx. In the last ten years we have had the opportunity to treat four cases of osteoid osteoma located in the terminal phalanges in different fingers of the hand, two in children of approximately ten years of age and two in adults, one of twenty and the other fifty four years of age. These cases have many common signs and symptoms and so form a new entity which can be recognized by the clinical appearance. CLINICAL PICTURE In all four cases the clinical picture showed the following common symptoms: (a) Long standing painless enlargement of the terminal phalanx without any history of previous trauma. (b) The enlargement of the terminal phalanx had started at least two years before operation was performed and at least one year before any painful symptoms had started. (c) The nail was enlarged to such an extent that it was almost double the size of the nail of the adjacent finger. (d) Increased perspiration of the affected finger. (e) Pain was intense but relieved by aspirin. (f) X-Rays showed a density and translucent area located on one side of the phalanx indicative of an osteoid osteoma.
A. Giannikas, M.D., Department of Orthopaedics, Athens University, 5 Heraklitou Street, Athens-136, Greece. The Hand--Vol. 9
No. 3
1977
295
Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Fig. la. Case 1. Photograph of the right hand with the enlarged terminal phalanx of right index. Fig. lb. Case 1. Histological section showing the highly vascularised osteogenic connective tissue and travebulae of newly formed osseous tissue undergoing calcification. H&E, Mag.x50. CASE R E P O R T S
Case 1
A boy, ten years of age, was admitted in November 1963, with pain and enlargement of the terminal phalanx of the right index finger (Fig. la). Enlargement of the phalanx had started two years previously and pain one year before admission. No trauma was reported to this finger. Clinically that index finger was enlarged in the terminal phalanx, painful on pressure and also warmer than the other fingers. The nail was double the size of that of the adjoining finger. X-Rays showed an area of translucency near the base of the terminal phalanx surrounded by a thin zone of bone density, In the centre of the translucent area there was a small shadow. Under general anaesthetic and a tourniquet we removed a wedge-shaped portion of the pulp and nail, curetted the bone and removed the affected part with an osteotome. We remove a wedge-shaped portion of the pulp and nail in order to reduce the size of the segment, so that on closing the finger, it will assume a normal size. The portion of soft tissues and bone, removed, were examined and the diagnosis was confirmed as osteoid osteoma. (Fig. lb). Case 2
A man twenty two years old, was admitted to the Hospital in September 1971 suffering from pain in the terminal phalanx of the little finger which had been present for six months. There was no history of trauma in the affected finger. Clinically the terminal phalanx of the little finger of the left hand had a spindle shaped appearance, was flattened and the whole terminal phalanx was enlarged (Fig. 2a) reddish, warm, perspiring and very painful even to the slightest touch. X-Rays showed a unique area of translucency near the base of the phalanx, surrounded by a thin zone of density. In the centre of this translucency there was a small nidus (Fig. 2b). Other clinical and blood tests were negative. 296
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Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. ChrysaJidis and G. Hartofilakidis-Garolalidis
Fig. 2a. Case 2. Photograph showing the involved little finger and the enlargement of terminal phalanx. Fig. 2b. Case 2. X-Rays, of the affected little finger.
Fig. 2c. Case. 2. Histological-section at the periphery of the lesion. There are osteoid tissue trabeculae of newly formed osseous tissue. On the right tissue of the phalanx H & E Mag.xl00. The Hand--VoL 9
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Osteoid Osteoma of the Terminal Phalanges A. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Fig. 3a. Case 3. Photograph with involved ring finger. Notice the enlargement of the terminal phalanx and nail. Fig. 3b. Case 3. Typical X-Rays appearance of an osteoid osteoma of the terminal phalanx of the involved ring finger. An operation was performed in this case, amputation of the terminal phalanx; once again histology showed a typical osteoid osteoma (Fig. 2c). Case 3
A boy eleven years old, admitted in April 1972, complaining of pain, again especially at night, of a terminal phalanx of the ring finger, with enlargement of the terminal phalanx (Fig. 3a). Painless swelling was noticed about eighteen months previously and pain started some ten months later and had been relieved by aspirin. The radiological findings were identical to the previous cases (Fig. 3b). Following operation, histology confirmed the clinical diagnosis of osteoid osteoma.
Fig. 4. Case 4. (a) before, (b) during, (c) after the operation, and (d) (face and profile) X-Rays of the involved finger. The enlargement of the terminal phalanx and nail is evident. 298
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Osteoid Osteoma o / t h e Terminal Phalanges .4. Giannikas, G. Papachristou, G. Tiniakos, G. Chrysa[idis and G. Harto[ilakidis-Garo[alidis
Fig. 4 (d)
Fig. 5.
Case 4: (a) Microphotograph showing trabeculae of newly formed osseous tissue set in a substrate of highly vascularised osteogenic connective tissue. H&E stain., Mag.x50. (b) Microphotograph noting, in according with active osteogenesis, numerous osteoblasts. There is also calcification in some areas of osteoid tissue. H&E stain. Mag.x200.
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Osteoid Osteoma oJ the Terminal Phalanges A. Giannikas, G. Papaehristou, G. Tiniakos, G. Chrysafidis and G. Hartofilakidis-Garofalidis
Case 4
A man fifty-four years old, was admitted to the hospital in September 1975, suffering from pain in the terminal phalanx of the right ring finger which had been present for more than a year. This case was similar to the previously described cases. An operation was performed, the lesion was excised and the size of the terminal phalanx reduced (Fig. 4a, 4b, 4c, 4d). Histology confirmed the clinical diagnosis of an osteoid osteoma (Fig. 5a, 5b). DISCUSSION
It is generally accepted that osteoid osteoma of the band is not common while the terminal phalanx of the hand is the rarest location. The clinical picture of all cases of osteoid osteoma of the terminal phalanx - including the four recorded here - - is essentially the same i.e. gradual swelling of the terminal phalanx - - with enlargement of the nail - - this swelling is at first painless but later it became painful particularly at night - - this pain is characteristically relieved by aspirin. Operative treatment is of double value. Curative by excision of the lesion and cosmetic by the reduction of the size of the terminal phalanx. The enlargement of the phalanx could be explained as has been suggested by Rosborough by the increased vascularity of the area. However it is well known that osteoid tissue dominates the field lying in a matrix of well vascularized comaective tissue with osteoblasts and usually the lesion is surrounded by a zone of well defined sclerosis. REFERENCES
CARROLL, R. E, (1953). Osteoid Osteoma in the Hand. The Journal of Bone and Joint Surgery, 35A: 888-893, 936. CHANDLER, F. A. and KAELL, H. I. (1950). Osteoid-Osteoma. Archives of Surgery, 60: 294-304. JAFFE, H. L. (1958). Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia, Lea and Febiger. LICHTENSTEIN, L. (1965). Bone Tumors. Third Ed. St. Louis. The C.V. Mosby Company. ROSBOROUGH, D. (1966). Osteoid Osteoma. Report of a Lesion in the Terminal Phalanx of a Finger. The Journal of Bone and Joint Surgery, 48B: 485-487. SEVITT, S. and HORN, I. S. (1954). A PainZe~s and CMeified Osteoid Osteoma of the Little Finger. Journal of Pathology and Bacteriology, 67: 571-574. TESTA, G, and MAZZOLENI, G. (1951). In Terma di Osteoma Osteoide. Un Caso di localizzazione falangea. Archivio di Radiologica N.S. 1: 417-426.
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