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.
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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.
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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 patients 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.
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 Guyons 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.
- Frassica FJ, Waltrip RL, Sponseller PD, Ma LD, McCarthy EF Jr. Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am. 1996; 27(3):559-574.
- Dahlin DC, Unni KK. Bone Tumors: General Aspects and Data on 8,542 Cases. 4th ed. Springfield, IL: Charles C Thomas Pub Ltd; 1986.
- Dockerty MB, Ghormley RK, Jackson AE. Osteoid osteoma; a clinicopathologic study of 20 cases. Ann Surg. 1951; 133(1):77-89.
- Moberg E. The natural course of osteoid osteoma. J Bone Joint Surg Am. 1951; 33(1):166-170.
- Campanacci M, Ruggieri P, Gasbarrini A, Ferraro A, Campanacci L. Osteoid osteoma. Direct visual identification and intralesional excision of the nidus with minimal removal of bone. J Bone Joint Surg Br. 1999; 81(5):814-820.
- Assoun J, Railhac JJ, Bonnevialle P, et al. Osteoid osteoma: percutaneous resection with CT guidance. Radiology. 1993; 188(2):541-547.
- de Berg JC, Pattynama PM, Obermann WR, Bode PJ, Vielvoye GJ, Taminiau AH. Percutaneous computed-tomography-guided thermocoagulation for osteoid osteomas. Lancet. 1995; 346(8971):350-351.
- Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am. 1998; 80(6):815-821.
- Gangi A, Dietemann JL, Guth S, et al. Percutaneous laser photocoagulation of spinal osteoid osteomas under CT guidance. AJNR Am J Neuroradiol. 1998; 19(10):1955-1958.
- Ambrosia JM, Wold LE, Amadio PC. Osteoid osteoma of the hand and wrist. J Hand Surg Am. 1987; 12(5 Pt 1):794-800.
- Baron J, Scharizer E. Tumors and tumor-like diseases of the carpal bones [in German]. Handchir Mikrochir Plast Chir. 1987; 19(4):195-205.
- Chamberlain BC, Mosher JF, Levinsohn EM, Greenberg JA. Subperiosteal osteoid osteoma of the hamate: a case report. J Hand Surg Am. 1992; 17(3):462-465.
- Glickman LT, McCabe SJ, Murray JF. Osteoid osteoma of the hamate: report of a case and review of the literature. Ann Plast Surg. 1993; 31(1):87-90.
- Helzel MV, Kreiskother E. Osteoid osteoma recurrence/persistence of the hamate bone. A case report [in German]. Rontgenblatter. 1990; 43(8):362-364.
- Jackson WJ, Markiewitz AD. Osteoid osteoma of the hamate. Orthopedics. 2008; 31(5):496.
- Nuñez-Samper M, Fashho SN, Muñoz JL, Ulloa J, Martínez Cabruja R. Osteoid osteoma of the hamate bone. Case report and review of the literature. Clin Orthop Relat Res. 1986; (207):146-149.
- OHara JP III, Tegtmeyer C, Sweet DE, McCue FC. Angiography in the diagnosis of osteoid-osteoma of the hand. J Bone Joint Surg Am. 1975; 57(2):163-166.
- Rosenfeld K, Bora FW Jr, Lane JM. Osteoid osteoma of the hamate. A case report and review of the literature. J Bone Joint Surg Am. 1973; 55(5):1085-1087.
- Segmoller G. Osteoid-osteoma of the hand skeleton [in German]. Handchirurgie. 1975; 7(4):149-152.
- Spinner M, Zaleski A, Weiner E. Osteoid osteoma of the hamate. Bull Hosp Joint Dis. 1972; 33(1):8-14.
- Mangini U. Tumors of the skeleton of the hand. Bull Hosp Joint Dis. 1967; 28(2):61-103.
- Mondolfo S. Osservazioni cliniche ed anatomo-Istologiche suit infiammazione primitiva cronica della spongiosa ossea. Chir Organi Mov. 1939; (24):133-147.
- Shin AY, Deitch MA, Sachar K, Boyer MI. Ulnar-sided wrist pain: diagnosis and treatment. Instr Course Lect. 2005; (54):115-128.
- Edeiken J, DePalma AF, Hodes PJ. Osteoid osteoma. (Roentgenographic emphasis). Clin Orthop Relat Res. 1966; 49:201-206.
Drs Rubin, Wolovelsky, Rinott, and Rozen are from the Orthopedic Department, HaEmek 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 (email@example.com)