Repair of a multiply recurrent giant cell reparative granuloma of the hand with wide resection and fibular grafting

A patient with multiply recurrent giant cell reparative granuloma of the third metacarpal is reported. Three prior excisions failed to prevent recurrence. A wide resection and replacement with a nonvascularized fibular bone graft resulted in elimination of the tumor at the 7-year follow-up visit.

Extra-abdominal desmoid tumor of the hand: a case report and review of the literature

Extra-abdominal desmoid tumor of the hand is rare and only 10 cases have been described in the literature. We present a 14-year-old boy with a recurrent extra-abdominal desmoid tumor in the dorsal site of the right hand. MR image demonstrated the tumor in the third dorsal interosseous muscle, and adhered to the radial side of the forth metacarpal bone. The lesion revealed iso-signal intensity on T1-weighted images and high intensity on T2. We performed a marginal excision. Histological examination of the tumor showed proliferation of the fibroblastic cells with abundant collagen bundles. He developed local recurrence for the third time. The size of the third recurrent tumor has not been changed for 2 years and 3 months. Therefore, we have not performed any additional surgery. Since extensive resection markedly diminishes the function of the hand, we consider that a marginal surgical margin is acceptable for the quality of daily life of patients with a desmoid tumor of the hand.

Nonradiopaque penetrating foreign body: "a sticky situation"

Foreign bodies within soft tissues are common in children. They may cause a chronic inflammatory reaction that can result in abnormal findings on radiographs, including lytic or blastic osseous changes. These radiographic findings can mimic both benign and malignant processes. In cases where the history is uncertain and the foreign body is not recognized, magnetic resonance (MR) imaging can make a specific diagnosis and direct appropriate therapy.

Arthroscopic surgery in a reticulated giraffe (Giraffa camelopardalis reticulata)

An 8-mo-old captive male reticulated giraffe (Giraffa camelopardalis reticulata) developed an acute lameness (grade IV/V) of the right forelimb, with swelling of the metacarpophalangeal joint. A traumatic injury was suspected based on clinical, radiographic, and arthroscopic evaluation. Several abnormalities were identified arthroscopically, including synovitis, cartilage damage, and an osteochondral fragment. Medial collateral ligament damage was also suspected based on radiographic evaluation. Arthroscopy provided a means of diagnosis and treatment of the abnormalities identified. The lameness in this giraffe resolved within 6 wk following arthroscopic surgery.

Osteonecrosis of the base of the second metacarpal: a case report

Osteonecrosis of the metacarpal is rare. Previously reported cases have only involved the metacarpal heads, with the long finger being the most commonly affected. We present a patient with avascular necrosis involving the base of the second metacarpal.

Sexing potential of fragmentary and pathological metacarpals

The use of metacarpal dimensions for determining skeletal sex is investigated. Previous studies on sexual dimorphism in the metacarpals (Scheuer and Elkington [1993]; J. Forensic Sci. 38:769-778; Falsetti [1995]; J. Forensic Sci. 40:774-776; Smith [1996]; J. Forensic Sci. 41:469-477) used multiple variables, which limits the application potential of the methodology. Using six measurements for each metacarpal, I generated 35 linear discriminant functions based on expected taphonomic or pathological preservation scenarios. The number of variables per function ranged from 2-5. Normal, jackknifed, and cross-validation classification matrices indicated a sex prediction accuracy in the 79-85% range. MC4 produced the most consistent functions. Overall accuracy in the validation samples ranged from 75-90%. ANOVA and MANOVA analyses indicated that population effects are insignificant, which may allow for the application of the functions without knowledge of the ancestral background of the individual. This, combined with the variety of preservation scenarios considered, provides accurate sex estimators for incomplete individuals. However, the population specificity of the insignificant population group effects remains untested.

Acquired flexural deformity of the metacarpophalangeal joint in five horses associated with tendonous damage in the palmar metacarpus

Five cases of acquired flexural deformity of the metacarpophalangeal joint (MCPJ) in older horses and ponies were studied. The mean age of affected horses was 14-8 years. Four deformities developed following desmitis of the accessory ligament of the deep digital flexor tendon (ALDDFT) and superficial digital flexor tendon (SDFT) and one following tendonitis of the SDFT alone. All cases were markedly lame and demonstrated variable degrees of flexural deformity. Ultrasonographic examination was performed on all cases which revealed extensive adhesion formation between the ALDDFT and SDFT and reduced cross-sectional area of the deep digital flexor tendon in each case. A variety of treatments were unsuccessfully employed to treat this condition. The prognosis for acquired flexural deformity of the MCPJ in old horses following tendonous damage in the palmar metacarpus is likely to be poor.

Painless osteoid osteoma in a metacarpal

Osteoid osteoma is a benign primary tumour of bone occurring in the first two decades of life. It presents with pain and is uncommon in the hand, particularly so in the metacarpals. We report a painless osteoid osteoma affecting a metacarpal.

[Primary manifestation of hepatocellular carcinoma as osteolytic hand metastasis--a case report]

Osseous metastases to the hand are very rare. Only a single case of osseous metastasis of hepatocellular carcinoma to the hand has been reported in the literature to date. We report a case of osteolytic metastasis of the right first metacarpal as first manifestation of unresectable, alpha-fetoprotein-negative hepatocellular carcinoma (pT3, Nx, M1, UICC stage IVB, Okuda's stage I). The therapy consisted of R0-resection and hormonal therapy with tamoxifen 2 x 10 mg/d orally. Generally patients with metastatic cancer to the bones of the hand have a very poor prognosis.

Surgical treatment of congenital metacarpal synostosis of the ring and little fingers

Fifteen hands with congenital metacarpal fusions were treated operatively by osteotomy combined either with the use of a silicone block or a distraction device. The aim of the silicone block was to separate the fused metacarpals, but it was buried in the metacarpals at follow-up, with recurrence of fusion. By the distraction technique, 13 mm of lengthening was obtained. The average length of the little metacarpal was 88% of that of the long finger metacarpal. Both methods were effective in correcting the abduction deformity of the little finger by a mean of 34 degrees, and increasing the range of motion of the metacarpophalangeal joint to 28 degrees of active flexion. Although the distraction method took longer than the silicone block method, the final appearance of the hand was better.

Comparison of the combined cortical thickness of the second metacarpal with Sharp's method for scoring hand microradiographs in rheumatoid arthritis

OBJECTIVE

To compare the correlation and specificity of the combined cortical thickness of the second metacarpal (CCT-MC) with Sharp's method (SM) for scoring joint erosions and joint space narrowing in rheumatoid arthritis (RA) and to compare the degree of interobserver agreement between the 2 methods.

METHODS

Hand microradiographs of 22 women with RA, functional classes III and IV, were scored independently by 3 rheumatologists using the CCT-MC and the CCT of the middle phalanx and SM.

RESULTS

(1) There was a highly significant correlation between the total SM score and the CCT-MC for the 3 observers (r = 0.61, p = 0.0026), but not between the CCT of the middle phalanx and SM (r = 0.15, p = 0.53). There was a lower degree of agreement between the observers for SM erosion scores compared to the CCT-MC (intraclass correlation 0.88 for the CCT-MC and 0.63 for the SM); (2) Both joint space narrowing and erosion scores correlated highly with the CCT-MC (r = -0.60, p = 0.004; and r = -0.51, p = 0.014, respectively); (3) CCT-MC measurements are more closely related to the inner (d) as opposed to the outer (D) diameter of the 2nd metacarpal; (4) The mean time to obtain the CCT-MC score was 3.43 min (SD = 1.38) versus 9.83 min (SD = 3.20) for SM (p = 0.0001); (5) the derivative, (D2-d2)/D2, was significantly correlated with SM (r = -0.72, p = 0.0002) and its erosion and joint space narrowing components (r = -0.63, p = 0.0019; and r = -0.71, p = 0.0002, respectively).

CONCLUSION

The CCT-MC is a rapid, practical method with higher agreement among observers compared to SM and correlates highly with SM scores for joint damage in RA. CCT-MC appears to have a higher degree of specificity than other sites for CCT measurement. The CCT-MC is more closely related to the inner diameter than the outer diameter, which supports the notion that the principal site of accelerated bone loss due to RA in the hand occurs at the endosteal surface. The CCT-MC should be further assessed with respect to monitoring radiological progression in RA.

Lymphangioma in the metacarpal pad of a dog

A five-year-old English springer spaniel was presented with a three year history of metacarpal ulceration causing lameness. The lesion was initially thought to be caused by a foreign body, but subsequently diagnosed as lymphangioma. The dog was surgically treated with resection of the metacarpal pad and transposition of the second digital pad. A severe infection developed 11 days postoperatively but was managed with antibiotics and intensive wound therapy. The surgical technique was successful, considerable adaptation of the transposed pad occurred and the dog returned to full weightbearing on the leg. However, one year later another area of new ulceration developed on the dorsomedial aspect of the paw. This, too, was resected but recurred after a short time and the owner elected for euthanasia of the dog.

MRI of fractures of the distal radius: comparison with conventional radiographs

OBJECTIVE

To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury.

DESIGN AND PATIENTS

Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation.

RESULTS

Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears.

CONCLUSION

MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.

Bone measurements in asymptomatic primary hyperparathyroidism

A large proportion of patients with asymptomatic primary hyperparathyroidism (PHPT) have some degree of bone involvement which appears to be relatively greater for cortical than trabecular bone. However, the clinical meaning and pathophysiologic basis of this observation are unknown. In 77 postmenopausal women with asymptomatic PHPT, bone mineral density (BMD) was measured at the proximal and ultradistal forearm, the lumbar spine, the femoral neck, and Ward's triangle by dual-energy X-ray absorptiometry. The digitalized X-ray pictures of the nondominant hand were obtained from all patients and from 680 healthy postmenopausal women, to measure the outer (D) and inner (d) diameter of the second metacarpus. The cortical area per total area (CA/TA) and a bending breaking resistance index (D4-d4/D) were then calculated. In 29 of the patients not operated on and in 30 healthy pair-matched women, a second X-ray of the hand was obtained 5-12 years afterward. In patients with PHPT, the z score of CA/TA was significantly lower than zero [-0.97+/-0.99, standard deviation (SD)]. This is due to an enlargement of the inner diameter, despite a significant increase in the z score for the outer diameter. The z score of the DXA measurements was significantly lower than zero for the lumbar spine (-0.59+/-1.26), ultradistal radius (-1.03+/-0.91), proximal radius (-1.91+/-1.80), and Ward triangle (-1.81+/-1.07), but not for the femoral neck (-0.36+/-1.03). In subjects in whom two X-rays were obtained, per-decade endosteal resorption and periosteal apposition were statistically significant only in the PHPT patients. Both endosteal resorption and periosteal apposition were significantly greater in PHPT patients compared to healthy controls. The mean BBRI in PHPT patients was not different from that in controls, but the longitudinal changes were significantly greater than those observed in control subjects. Our radiogrammetry data may provide an original clue for understanding preferential cortical bone loss in PHPT patients. In cross-sectional and longitudinal studies, we have shown that in PHPT, both endosteal bone resorption and periosteal apposition are augmented. The former effect is predominant, which leads to significant diminution of cortical thickness. As a consequence of the enlargement of long bones, the areal BMD is somewhat underestimated, since the same amount of cortical bone is divided by a greater diameter. Furthermore, in term of mechanical properties, the increases in the cross-sectional area of appendicular bone segments might compensate in part for both the diminution of cortical thickness and a greater porosity of cortical bone.

First metacarpal osteotomy for trapeziometacarpal osteoarthritis

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications.

Stature and severity in multiple epiphyseal dysplasia

We investigated the stature and radiological findings in 15 patients with multiple epiphyseal dysplasia (MED). They were divided into normal-stature and short-stature groups according to their body height after 4 or 5 years of age. Their stature was not related to the involvement of the spine or epiphyses of long tubular bones except for the distal radius. Proximal phalanges and metacarpi were shorter in the short-stature group than in the normal-stature group, indicating that stature in MED had some relationship to the involvement of the wrist and hand. However, some patients in the normal-stature group showed involvement of distal radial epiphyses, and some patients in the short-stature group did not have stubby fingers. There are thus no clear-cut criteria to differentiate between the severe Fairbank type and the milder Ribbing type of MED.

Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer

Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone, and giant-cell tumours of bone in the hand are more likely to recur than those that arise elsewhere. Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent giant-cell tumours of bone in the hand. We describe two cases of successful transplantation of a metatarsal to a metacarpal, which was the site of a recurrent giant-cell tumour. The patients had satisfactory results 3 years later without problems in the foot. En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand.

Enchondroma protuberans: a case report

Enchondroma protuberans is a rare benign cartilaginous tumor. There have been only 5 cases previously described in the world literature. It must be differentiated from other more common and aggressive tumors to avoid radical resection. A case report of a 7-year-old boy presenting with enchondroma protuberans in the third metacarpal is presented. The patient underwent an initial incisional biopsy followed by a marginal resection of the soft tissue component and intramedullary curettage. After a 36-month follow-up period, there is no evidence of recurrence.

Carpal boss caused by an accessory capitate. Case report

A carpal boss is frequently caused by a bony anomaly of the quadrangular joint of the carpus. We present the case of a patient with a carpal boss caused by an accessory capitate.

Save the trapezium: double interposition arthroplasty for the treatment of stage IV disease of the basal joint

Twenty patients with symptomatic stage IV basal joint (pantrapezial) arthritis were treated with double interposition arthroplasty, a new technique that resurfaces the degenerative trapeziometacarpal and scaphotrapezial joints after minimal distal trapezial resection. The results of the 21 procedures were reviewed clinically and radiographically after a mean follow-up period of 34 months (minimum, 1 year). Ninety-one percent of the patients were completely satisfied. Seventy-one percent were entirely free of pain, and an additional 24% noted only occasional, mild, high-stress pain that did not limit their activities. One case was a clinical failure. Objectively, all 21 basal joints were stable, with active range of motion to within 90% of normal. Mean grip strength increased 32%, from a force of 26.1 kg to 33.9 kg (p < .01). Key pinch strength increased from a force of 5.3 kg to 6.0 kg (an 11% increase; p = .05). A new method of determining changes in basal joint height indicated a mean decrease in height of 5.3% (range, 0%-12%) at rest and 8.1% (range, 0%-20%) under axial compression. This difference was statistically but not functionally significant. Overall, there were 95% good or excellent results and 1 poor result. We believe this technique is simple and preserves the osseous foundation of the basal joints. These results compare favorably with arthroplasties that include trapezium excision for the treatment of stage IV basal joint arthritis.

[Juxta-cortical aneurysmal cyst of the 3rd metacarpal bone. Apropos of a case]

A case of a "juxta-cortical" aneurysmal bone cyst on the third metacarpal is reported with more than three years of follow-up. No recurrence was observed. The nosology and the treatment are discussed. The literature is reviewed.

[Peri-trapezial arthrotic lesions]

The usual concept of arthrosis of the base of the thumb as a carpometacarpal arthrosis has been replaced by the concept of its being a pantrapezial arthrosis involving all of the peritrapezial joint spaces. In the pathogenesis of pantrapezial arthrosis, the static role of the shaft of the thumb, and the strains from pinching movements between the thumb and fingers are of predominant importance. The lack of satisfactory radiographic technique up to now has made the evaluation of this joint difficult, but the possibility of trapezometacarpal dysplasias favoring arthrosis should be considered. The treatment of an arthrosis of the basal joint of the thumb is surgical when medical treatment has not been successful. The various techniques, which currently are numerous, are given in detail. Carpo-metacarpal arthrodesis has still some precise indications. Arthroplasties have superseded the usual trapezectomy which, nevertheless, seemed to give satisfactory results. The various techniques of arthroplasty and their respective indications according to individual patients, and the anatomic type of the arthrosis of the base of the thumb are discussed.

[Giant cell tumor of the 4th metacarpal bone of the left hand. Apropos of a case]

He is a 46 year old patient that consults on a tumor that deforms the back of his left hand. The X-ray examination shows a bone osteolytic tumor with complete dis appearance of the 4th metacarpal. Surgical removal of the tumor was practiced with immediate reconstruction of the 4th metacarpal by an oseo-iliac graft. Anatomopathological examination. It is an ovoid tumor 6.5 long and irregular surface.

A retrospective review of 115 cases of surgically-treated trapeziometacarpal osteoarthritis

The trapeziometacarpal joint is among the main targets for osteoarthritis at the hand. The objective of surgical treatment is to obtain a painless, stable, and mobile joint. One hundred fifteen cases treated either by a GUEPAR prosthesis (n = 90; group A) or by excision of the trapezium followed by ligament reconstruction and tendon interposition (n = 25; group B) were studied retrospectively. The choice between the two procedures was based on a number of clinical and radiological criteria. Of the 90 group A patients, 79 were reevaluated, after a mean follow-up of 5.75 years. Clinical results were good in 92% of cases. Loosening of the cup was seen in seven cases, of which three (3.8%) were treated by implantation of a Swanson prosthesis within three years of the first procedure. Six patients had loosening of the metacarpal component only, which was stable over time and had no adverse effect on clinical results. Of the 25 group B patients, 19 were reevaluated, after a mean follow-up of 3.5 years. Clinical results were good in 18 cases; the height of the scaphometacarpal space decreased by a mean of 51% versus its preoperative value. We conclude that the GUEPAR prosthesis provides good results with a low revision rate and deserves to be widely used in patients with a trapezium of at least 7 mm in height. Indications for the excision-reconstruction-interposition procedure include severe osteoarthritis, trapezium height less than 7 mm, younger age, and intensive hand use.