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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 120-124

Osteochondroma of the scaphoid in a 5-year-old child: A rare case report


1 Department of Orthopaedics, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Radio-diagnosis, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Department of Pathology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission24-Jul-2016
Date of Acceptance24-Sep-2016
Date of Web Publication13-Jan-2017

Correspondence Address:
Shishir Murugharaj Suranigi
Department of Orthopaedics, Pondicherry Institute of Medical Sciences, Pondicherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3069.198372

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  Abstract 

Osteochondroma is a benign bone tumor commonly arising from the distal femur, proximal tibia, and the proximal humerus. The common age of presentation is in the first two decades of life, particularly during periods of rapid skeletal growth. Tumors in the scaphoid bone are a rarity. Very few case reports have been published on benign tumors arising from the scaphoid including unicameral bone cyst, osteochondroma, osteoblastoma, and osteoid osteoma. We present a case of osteochondroma arising from the scaphoid presenting with pain and deformity of the wrist in an unusual age group of the first decade. Radiographs and magnetic resonance imaging suggested osteochondroma of the scaphoid. Tumor was resected, wrist deformity was corrected, and functional range was restored. Osteochondroma emanating from the scaphoid is considered to be extremely rare, but when the lesion is large and associated with progressive painful joint deformity as in our case, it warrants surgical resection.

Keywords: Excision biopsy, osteochondroma, scaphoid, wrist


How to cite this article:
Suranigi SM, Babu AT, Rengasamy K, Palanisamy M, Kurian SS, Najimudeen S. Osteochondroma of the scaphoid in a 5-year-old child: A rare case report. J Curr Res Sci Med 2016;2:120-4

How to cite this URL:
Suranigi SM, Babu AT, Rengasamy K, Palanisamy M, Kurian SS, Najimudeen S. Osteochondroma of the scaphoid in a 5-year-old child: A rare case report. J Curr Res Sci Med [serial online] 2016 [cited 2020 Nov 30];2:120-4. Available from: https://www.jcrsmed.org/text.asp?2016/2/2/120/198372


  Introduction Top


Osteochondroma is a benign bone tumor commonly arising from the distal femur, proximal tibia, and the proximal humerus. The common age of presentation is in the first two decades of life, particularly during periods of rapid skeletal growth. The lesion usually consists of a bony mass, in the form of a stalk with a cartilaginous cap. They may occur in any bone formed by endochondral ossification but usually are found on the metaphyseal region of long bones near the physis.[1] Osteochondroma is believed to be a developmental malformation due to herniation of a portion of the epiphysis through the growth plate.[2]

Few case reports have been published on benign tumors arising from the carpal scaphoid including unicameral bone cyst, osteochondroma, osteoblastoma, and osteoid osteoma.[3] We report a case of osteochondroma arising from the scaphoid in a 5-year-old girl.


  Case Report Top


A 5-year-old, right-hand dominant girl was brought to the outpatient department with her parents complaining of swelling over the left wrist for 1 year. Swelling was insidious in onset, gradually progressing and was not associated with pain. The patient underwent native treatment for the same in the form of massaging and splinting. There was no other significant history was elicited. No significant similar family history was noted.

On local examination, there was a ulnar deviation of 20° at the left wrist with a solitary swelling measuring approximately 3 cm × 3 cm over the radial border of the wrist which was spherical with ill-defined borders, bony hard in consistency and mobile in the sagittal plane. The tumor was palpable on volar and dorsal aspects of the wrist on the radial side. There was no associated warmth or tenderness. Skin over the swelling was normal and pinchable [Figure 1].
Figure 1: (a-c) Clinical picture showing manus varus deformity of 20° at the left wrist with a swelling noted over the radial border of the wrist on the dorsum

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Palmar flexion of 0–30°, dorsiflexion of 0–15°, ulnar deviation of 0–20°, and absent radial deviation was noted. There was no ligamentous laxity or wasting of thenar muscles. There were no distal neurovascular deficits. Grip strength was reduced to 60% on the left side as measured by a hand-held dynamometer.

Radiograph of the left wrist showed a well-defined dense osseous lesion with irregular margins occupying the region of the scaphoid bone with adjacent cortical erosion and some calcification [Figure 2]. Based on the initial history, clinical examination and radiographic appearance, a benign lesion like the osteochondroma or chondroblastoma was considered. Computed tomography scan showed a bony expansile “popcorn”-like nonhomogenously dense mass in the scaphoid region extending anteroposteriorly, measuring 50 mm × 32 mm × 42 mm and involving the distal part of the scaphoid bone. It also showed the continuity of the trabecular cortex with the scaphoid bone. Rest of the carpal bones were noted to be normal [Figure 3].
Figure 2: Radiograph of the left wrist showed a well-defined dense osseous lesion with irregular margins occupying the region of the scaphoid bone with adjacent cortical erosion and some calcification

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Figure 3: Axial (a) and coronal (b) sections of computed tomography scan showing a bony expansile “popcorn” like nonhomogenously dense mass in the scaphoid region measuring 50 mm × 32 mm × 42 mm

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Magnetic resonance imaging of wrist reported a relatively well-defined heterointense pedunculated mass lesion (signal intensity near to that of the adjacent bones) with a thin hypointense cartilaginous rim surrounding it, arising from the scaphoid bone. The diagnosis of osteochondroma was considered [Figure 4]. Chest X-ray and blood tests were normal.
Figure 4: Sagittal (a) and coronal (b) sections of magnetic resonance imaging of wrist showing well-defined heterointense pedunculated mass lesion with a thin hypointense cartilaginous rim surrounding it, arising from the scaphoid bone

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After taking consent from the parents, the patient underwent excision biopsy of the swelling under general anesthesia. A dorsal approach between the 2nd and 3rd extensor compartments was employed. Intraoperatively, a capsule-like thin fibrous tissue was found on the lesion which was cut, and the osseous lesion was found to emanate from the dorsal, volar, radial sides of the scaphoid measuring about 50 mm × 30 mm × 40 mm. The mass seemed to be covered by a layer of cartilage on gross examination [Figure 5]. The proximal pole was well defined and unaffected. The entire scaphoid with the growth was excised as two pieces and sent for histopathological examination [Figure 6]. In the process, lunate was devoid of any ligamentous or soft tissue attachments after scaphoid excision and hence had to be removed even though not planned. The capsule was closed. Completeness of excision was confirmed using intraoperative fluoroscopy. Postoperative period was uneventful, and radiograph taken later showed complete removal of the scaphoid with the mass.
Figure 5: Intraoperative images: Exposure (a), capsule-like thin fibrous tissue covering the lesion (b), mass exposure after capsule excision (c), and tumor excision (d)

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Figure 6: Excised mass in two pieces showing a thick cartilaginous cap

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Decalcified section with hematoxylin and eosin staining showed fibrous covering, cartilaginous cap with underlying mature bony trabaculae containing bone marrow. The histopathological diagnosis was consistent with a solitary osteochondroma [Figure 7]. No signs of malignant transformation were seen in any of the resected specimens.
Figure 7: Scan power view of lesion showing a thick cap of cartilage overlying cancellous bone (H and E, ×40)

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Postoperatively, the patient was given a volar slab for 3 weeks after which the wrist was mobilized. At 6 weeks follow-up, the patient had regained the preoperative range of motion and grip strength improved. No obvious deformity was noted. Radiographs done at 1 year of follow-up showed no recurrence [Figure 8]. Palmar flexion of 0–85°, dorsiflexion of 0–15°, ulnar deviation of 0–20°, and radial deviation of 0–5° was noted [Figure 9]. Grip strength improved to 80%. There was no obvious deformity or wrist instability noted at the end of 1 year of follow-up.
Figure 8: Radiographs done at 1 year of follow-up showed no obvious deformity, carpal collapse, or recurrence

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Figure 9: (a-e) Clinical images showing the range of motion at wrist at 1 year of follow-up

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  Discussion Top


Tumors in the scaphoid bone are a rarity. The most common tumors arising in the scaphoid include enchondroma, osteoblastoma, and osteoid osteoma. The scaphoid plays an important role in wrist biomechanics and function, hence it is imperative to provide optimum treatment and restore function of the wrist.[4]

The common age of presentation of these tumors is around the third decade of life. However, in our case, the tumor was diagnosed in a 5-year-old girl making it a rare occurrence.

About 90% of patients have a single lesion; however, 5%–10% of patients have multiple hereditary exostosis which is an autosomal dominant condition. Most of these lesions are discovered incidentally, however some may cause mechanical symptoms due to irritation of surrounding structures or pain due to a fracture.[1]

Tumors of the scaphoid may lead to pathologic fractures and subsequent carpal collapse. Because of its intraarticular location, tumors arising from the scaphoid can present with synovitis, deformity, and progressive loss of motion.[2],[4]

To our knowledge, review of literature revealed only a few cases of osteochondromas arising from the scaphoid. Less than 1% of solitary osteochondromas undergo malignant transformation into chondrosarcomas. However, in hereditary multiple exostosis this value is as high as 5%–10%.[2] Osteochondromas arising from the metacarpal and phalanges have been reported by Forest.[5] Malhotra et al. reported a case of osteochondroma arising from the capitate.[6]

Osteochondroma arising from the scaphoid causing rupture of the flexor pollicis longus tendon was reported by O'Dwyer and Jefferiss.[7] Spinner and Spinner [8] reported a case where the scaphoid tumor was compressing the superficial radial nerve causing symptoms. Rimmer et al.[9] reported scaphoid exostosis that went on to cause secondary arthritis and carpal instability.

Surgical resection through a dorsal approach is the gold standard treatment for symptomatic exostosis. Failure to completely resect the lesion or curettage may lead to recurrence of the lesion.[2] The overall recurrence rate reported by Unni was 2% for all osteochondromas.[10]

There was no recurrence of the tumor in our case at 1 year of follow-up. We recommend regular follow-up, both short term and long term to avoid wrist stiffness as well as to rule out recurrence.


  Conclusion Top


Osteochondroma arising from the scaphoid in the first decade is a rare occurrence. If symptomatic needs surgical intervention. Long-term follow-up is mandatory, especially in our case as the chances of deformity recurrence is high.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
van Alphen JC, te Slaa RL, Eulderink F, Obermann WR. Solitary osteochondroma of the scaphoid: A case report. J Hand Surg Am 1996;21:423-5.  Back to cited text no. 1
    
2.
Uchida K, Kobayashi S, Takamura T, Yayama T, Inukai T, Baba H. Osteochondroma arising from the scaphoid. J Orthop Sci 2007;12:381-4.  Back to cited text no. 2
    
3.
Karantanas A, Dailiana Z, Malizos K. The role of MR imaging in scaphoid disorders. Eur Radiol 2007;17:2860-71.  Back to cited text no. 3
    
4.
Bhardwaj P, Sharma C, Sabapathy SR. Synovitis of the wrist joint caused by an intraarticular perforation of an osteoid osteoma of the scaphoid. Indian J Orthop 2012;46:599-601.  Back to cited text no. 4
  Medknow Journal  
5.
Forest M. Osteochondroma. In: Frost M, Tomeno B, Vanel D, editors. Orthopaedic Surgical Pathology: Diagnosis of Tumors and Pseudotumoral Lesions of Bone and Joints. Edinburgh: Churchill Livingstone; 1997. p. 177-89.  Back to cited text no. 5
    
6.
Malhotra R, Maheshwari J, Dinda AK. A solitary osteochondroma of the capitate bone: A case report. J Hand Surg Am 1992;17:1082-3.  Back to cited text no. 6
    
7.
O'Dwyer KJ, Jefferiss CD. Scaphoid exostosis causing rupture of the flexor pollicis longus. Acta Orthop Belg 1994;60:124-6.  Back to cited text no. 7
    
8.
Spinner RJ, Spinner M. Superficial radial nerve compression due to a scaphoid exostosis. J Hand Surg Br 1996;21:781-2.  Back to cited text no. 8
    
9.
Rimmer SG, Bhoora IG, Hooper G. Scaphoid exostosis and radio-carpal osteoarthrosis. J Hand Surg Br 1995;20:741-4.  Back to cited text no. 9
    
10.
Unni KK, editor. Osteochondroma. In: Dahlin's Bone Tumours: General Aspects and Data on 11,087 Cases. Philadelphia: Lippincott-Raven; 1996. p. 11-23.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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