Christopher L Forthman MDa Keith A Segalman MDb

aCurtis National Hand Center, Union Memorial Hospital, 3333 North Calvert Street, 2nd Floor,

Baltimore, MD 21218, USA hDepartment of Orthopaedic Surgery, Johns Hopkins School of Medicine, 601 North Caroline Street,

Baltimore, MD 21287-0765, USA

Wrist pain is one of the most common complaints seen by a hand or orthopedic surgeon. The proximate cause is often obvious, but a cursory examination may allow the clinician to miss significant underyling pathology (Fig. 1). A careful, thorough examination is warranted, even when the diagnosis seems apparent. The hand surgeon should be familiar with neoplasms that may affect the carpus, in order to accurately diagnose and treat patients who have wrist pain.

Evaluating a carpal lesion

The differential diagnosis for lesions and tumors within the carpus is broad. The distinguishing clinical and radiographic features of these entities seen elsewhere in the body are often absent in the wrist, owing to the diminutive size of the carpal bones. For example, pathologic fracture may occur through a carpal tumor without the antecedent pain and classic osteolytic or permeative radiographic appearance seen in a long bone. On the other hand, small lesions that are usually asymptomatic elsewhere in the body may cause significant discomfort in the wrist. A half-centimeter size intraosseous lesion will compromise a relatively large portion of the osseous architecture of a carpal bone; enough disruption to elicit pain. Nevertheless, not all lesions and tumors of the carpus are symptomatic, and they

* Corresponding author. Greater Chesapeake Hand Specialists, 1400 Front Street, Suite 100, Lutherville, MD 21093.

E-mail address: [email protected] (C.L. Forthman).

may even distract the surgeon and patient from the true diagnosis. The hand surgeon has the challenging task of not only identifying and differentiating these lesions and tumors, but also of determining which radiographic findings are incidental.

The history and physical examination should correlate with the radiographic appearance and location of the lesion. The authors have found that point tenderness over the affected carpal bone is the most sensitive indicator that a lesion is clinically significant. The degree of pain often corresponds with the metabolic activity of the lesion, as indicated by changes in the osseous architecture. Plain radiographs and CT should be examined for subtle indicators of bone turnover such as lytic or sclerotic areas. More dramatic findings such as cortical erosion or pathologic fracture are less commonly present, but suggest the possibility of a neoplasm. The authors have found a bone scan to be useful to confirm the presence of a true tumor (eg, osteoid osteoma) or other highly metabolically active processes (eg, osteomyelitis) (Fig. 2).

MRI may be obtained to further evaluate the painful wrist. The authors typically request an MRI to exclude other carpal pathology, and to evaluate the internal soft tissue architecture of the lesion. An MRI is particularly valuable in patients who have wrist pain but a physical examination that is inconsistent with the radiographically identified carpal lesion. In these cases, the MRI will commonly reveal other pathology (eg, triangular fibrocartilage complex [TFCC] tear) more compatible with the patient's symptoms. The MRI also defines the soft tissue components of the lesion itself. T1 images show fine anatomic

Fig. 1. Giant cell tumor of the carpus misdiagnosed as a dorsal wrist ganglion.

Fig. 1. Giant cell tumor of the carpus misdiagnosed as a dorsal wrist ganglion.

detail and have high signal intensity for fat (as well as gadolinium, proteinaceous fluid, methe-moblobin/blood, and melanin). T2 fat-suppressed and short tau inversion recovery (STIR) sequences are water-sensitive, and will identify fluid-filled cysts as well as the edema that accompanies injury (eg, ligament tears, pathologic fractures), infection, or infiltrating tumors. Careful review of the MRI is often the final step necessary for planning the definitive surgery for most lesions and tumors of the carpus.

Lesions that are especially destructive or that infiltrate the soft tissues may need further workup. The surgeon should exclude inflammatory processes such as rheumatoid arthritis, gout, and infection, all of which are more common than a true aggressive tumor or lesion of the carpus (Fig. 3). The wrist is aspirated for infection, serol-ogy is sent for autoimmune synovitis, anti-inflammatory drugs are prescribed for an inflammatory arthropathy, and so on. If a true aggressive or malignant lesion is suspected, the authors obtain routine laboratory studies, a chest radiograph, a CT scan of the chest and abdomen, and an incisional biopsy. At the surgeon's discretion, the biopsy may be performed before the other studies to avoid unnecessary workup. The biopsy is planned so that it can be incorporated into an extensile exposure for excision of the tumor en bloc. The sections that follow provide details to help the hand surgeon identify and treat specific lesions and tumors of the carpus.

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