Orthopedics

Case Reports 

Osteoid Osteoma of the Hamate: An Unusual Cause of Ulnar-sided Wrist Pain

Guy Rubin, MD; Alejandro Wolovelsky, MD; Micha Rinott, MD; Nimrod Rozen, MD, PhD

  • Orthopedics. 2010;33(7)
  • Posted July 1, 2010

Abstract

Ulnar-sided wrist pain is a common complaint that presents a diagnostic challenge. Determining the cause of ulnar-sided wrist pain is difficult, largely due to the complexity of the anatomic and biomechanical properties of the ulnar side of the wrist. Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Its incidence is 11% of benign tumors and 3% of all primary bone tumors, with 6% to 13% of all cases occurring in the hand.

Osteoid osteoma of the hamate can produce ulnar-sided wrist pain in the dorsal or volar aspect of the wrist, depending on the location of the tumor in the bone. In its classical and most frequent form, the osteoma may settle in the cortex or the spongiosa. A third rare form appears subperiosteally. Occasionally it destroys the articular cartilage by erosion or penetration. Most of the tumors will produce dorsal pain. A tumor located in the hook will produce volar pain.

This article describes a case of ulnar-sided wrist pain due to a rare case of osteoid osteoma of the hamate. We recommend marking the nidus with a needle intraoperatively with the aid of radiography.

Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Its incidence is 11% of benign tumors and 3% of all primary bone tumors,1 with 6% to 13% of all cases occurring in the hand.2 Osteoid osteoma can occur in any bone, but in approximately two-thirds of cases, it occurs in the appendicular skeleton. Most patients with osteoid osteoma are young. Rarely is an ossification center affected. The classic presentation is that of focal bone pain at the site of the tumor. The pain worsens at night and increases with activity; it is relieved with nonsteroidal anti-inflammatory drugs.3

The lesion initially appears as a small sclerotic bone island within a circular lucent defect. This central nidus is seldom larger than 1.5 cm in diameter and may be associated with considerable overlying cortical and endosteal bone sclerosis. The tumors may regress spontaneously.4 Indication for surgery depends on symptom severity and patient pain tolerance. It has been emphasized that surgical removal of the nidus is essential for pain relief.5 Percutaneous nidus removal has become a popular technique. Other methods such as percutaneous ablation of the lesion by computed-tomography-guided core-drill excision6 and destruction of the nidus by thermocoagulation,7 radiofrequency,8 and laser9 have recently been reported as alternative treatments.

Osteoid osteoma is rare in the carpus, with only 13 cases reported in the hamate bone.10-22 This article describes a case of ulnar-sided wrist pain due to osteoid osteoma of the hamate.

A 22-year-old man presented with a 1-year history of continuous dorsal ulnar-sided wrist pain. There was no history of trauma. He was treated unsuccessfully with 2 steroid injections at the point of maximal tenderness in the wrist. Symptoms were relieved with ibuprofen.

Physical examination demonstrated tenderness over the dorsal ulnar aspect of the wrist with no limitation in range of motion. An anteroposterior radiograph of the wrist revealed a round radiolucent area in the ulnar proximal side of the hamate near the hamate-triquetrum joint (Figure 1). A Tc-99 bone scan demonstrated intense uptake in the hamate bone. Computed tomography revealed a round, osteolytic lesion on the dorsal aspect of the hamate base (Figure 2). Within the classic zone of sclerosis, a central calcification consistent with osteoid osteoma was visualized.

Figure 1: AP radiograph of the wrist demonstrating a round radiolucent area in the ulnar proximal side of the hamate near the hamate-triquetrum joint. Figure 2: CT of the wrist…

Abstract

Ulnar-sided wrist pain is a common complaint that presents a diagnostic challenge. Determining the cause of ulnar-sided wrist pain is difficult, largely due to the complexity of the anatomic and biomechanical properties of the ulnar side of the wrist. Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Its incidence is 11% of benign tumors and 3% of all primary bone tumors, with 6% to 13% of all cases occurring in the hand.

Osteoid osteoma of the hamate can produce ulnar-sided wrist pain in the dorsal or volar aspect of the wrist, depending on the location of the tumor in the bone. In its classical and most frequent form, the osteoma may settle in the cortex or the spongiosa. A third rare form appears subperiosteally. Occasionally it destroys the articular cartilage by erosion or penetration. Most of the tumors will produce dorsal pain. A tumor located in the hook will produce volar pain.

This article describes a case of ulnar-sided wrist pain due to a rare case of osteoid osteoma of the hamate. We recommend marking the nidus with a needle intraoperatively with the aid of radiography.

Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Its incidence is 11% of benign tumors and 3% of all primary bone tumors,1 with 6% to 13% of all cases occurring in the hand.2 Osteoid osteoma can occur in any bone, but in approximately two-thirds of cases, it occurs in the appendicular skeleton. Most patients with osteoid osteoma are young. Rarely is an ossification center affected. The classic presentation is that of focal bone pain at the site of the tumor. The pain worsens at night and increases with activity; it is relieved with nonsteroidal anti-inflammatory drugs.3

The lesion initially appears as a small sclerotic bone island within a circular lucent defect. This central nidus is seldom larger than 1.5 cm in diameter and may be associated with considerable overlying cortical and endosteal bone sclerosis. The tumors may regress spontaneously.4 Indication for surgery depends on symptom severity and patient pain tolerance. It has been emphasized that surgical removal of the nidus is essential for pain relief.5 Percutaneous nidus removal has become a popular technique. Other methods such as percutaneous ablation of the lesion by computed-tomography-guided core-drill excision6 and destruction of the nidus by thermocoagulation,7 radiofrequency,8 and laser9 have recently been reported as alternative treatments.

Osteoid osteoma is rare in the carpus, with only 13 cases reported in the hamate bone.10-22 This article describes a case of ulnar-sided wrist pain due to osteoid osteoma of the hamate.

Case Report

A 22-year-old man presented with a 1-year history of continuous dorsal ulnar-sided wrist pain. There was no history of trauma. He was treated unsuccessfully with 2 steroid injections at the point of maximal tenderness in the wrist. Symptoms were relieved with ibuprofen.

Physical examination demonstrated tenderness over the dorsal ulnar aspect of the wrist with no limitation in range of motion. An anteroposterior radiograph of the wrist revealed a round radiolucent area in the ulnar proximal side of the hamate near the hamate-triquetrum joint (Figure 1). A Tc-99 bone scan demonstrated intense uptake in the hamate bone. Computed tomography revealed a round, osteolytic lesion on the dorsal aspect of the hamate base (Figure 2). Within the classic zone of sclerosis, a central calcification consistent with osteoid osteoma was visualized.

Figure 1: A round radiolucent area in the ulnar proximal side of the hamate Figure 2: A round osteolytic lesion

Figure 1: AP radiograph of the wrist demonstrating a round radiolucent area in the ulnar proximal side of the hamate near the hamate-triquetrum joint. Figure 2: CT of the wrist demonstrating a round, osteolytic lesion on the dorsal aspect of the hamate base.

Surgical excision of the mass was performed under general anesthesia with no grafting (Figure 3). To find the tumor, we inserted a needle in the center of the tumor with radiographic assistance (Figure 4). Histologic examination revealed an osteoid osteoma.

Figure 3: The lesion Figure 4: A needle inserted in the center of the tumor

Figure 3: Photograph of the lesion with the nidus in the center. Figure 4: Intraoperative photograph of a needle inserted in the center of the tumor.

Postoperatively, the patient’s wrist was immobilized in a short arm cast for 2 weeks. The sutures were then removed and physiotherapy started. At that point, the patient was asymptomatic. At 6-month postoperative follow-up, the patient was still pain free.

Discussion

Ulnar-sided wrist pain is a common complaint that presents a diagnostic challenge. The differential diagnosis of ulnar-sided wrist pain can be divided into 6 elements: osseous, ligamentous, tendinous, vascular, neurologic, and miscellaneous.23 The bones consist of the distal ulna, lunate, triquetrum, capitates, pisiform, and hamate. The 2 main joints are the distal radioulnar joint and the ulnocarpal joint (the triangular fibrocartilage complex). Tendinous structures include the extensor carpiulnaris dorsally and the flexor carpiulnaris palmarly. The ulnar artery and nerve lie in Guyon’s canal adjacent to the hamate and are subject to compression in this area. The dorsal sensory branch of the ulnar nerve supplies sensation to the ulnar aspect of the dorsal side of the wrist and hand.

Osteoid osteoma of the hamate can produce ulnar-sided wrist pain in the dorsal or volar aspect of the wrist, depending on the location of the tumor in the bone. In its classical and most frequent form, the osteoma may settle in the cortex or the spongiosa. A third rare form appears subperiosteally. Occasionally it destroys the articular cartilage by erosion or penetration.24 Chamberlain et al12 reported the first subperiosteal osteoid osteoma of the hamate. Most of the tumors will produce dorsal pain.12,15,16,18,20,22 A tumor located in the hook will produce volar pain.13,16

Surgical excision has been performed in all other cases of hamate osteoid osteoma with good results. Two cases also required additional bone grafting to the hamate.16,20 Ambrosia et al10 reported 7 of 17 cases of hand osteoid osteoma with unsuccessful surgical treatment due to failure to excise the nidus completely. We recommend marking the nidus with a needle intraoperatively with the aid of radiography.

References

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Authors

Drs Rubin, Wolovelsky, Rinott, and Rozen are from the Orthopedic Department, Ha’Emek Medical Center, Afula, and Drs Rinott and Rozen are also from the Faculty of Medicine, Technion, Haifa, Israel.

Drs Rubin, Wolovelsky, Rinott, and Rozen have no relevant financial relationships to disclose.

Correspondence should be addressed to: Guy Rubin, MD, Orthopedics Department, Haemek Medical Center, Afula, Israel (guytalr@bezeqint.net)

doi: 10.3928/01477447-20100526-17

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