Painful metacarpal bone lesion in a healthy young man: looks can be deceiving

A 33-year-old man was seen for severe pain and swelling on the dorsal side of his right hand (between the 2nd and 3rd metacarpal heads) for the last 9 months. He denied any trauma but admitted that his complaints were worse when he used his hand. The medical history was otherwise unremarkable for any systemic illness. He declared that his complaints had initially started with only pain and he had been diagnosed to have an overuse injury in another center. The hand X-rays had been inconclusive then. As he could have not improved completely with anti-inXammatory treatment, he was substantially evaluated also with regard to rheumatic disorders. Laboratory tests (including complete blood count, liver/renal function tests and acute phase reactants) were unremarkable. Due to lack of any overt diagnosis despite his persistent pain, he was seen even by a psychiatrist in the interim. He was also found to be psychosocially normal. After swelling (without erythema or warmth) had started to accompany his painful complaints, he was referred to infectious diseases department. Repeat laboratory analysis was again noncontributory. As two lymph nodes were detected in the ipsilateral axilla (0.5–1 cm), he was given cephalosporin (Wrst generation) therapy for 2 weeks (2 g/day). Since the patient did not beneWt from the treatment, the patient was consulted to us. Current physical examination revealed swelling (1.5 £ 2 cm) between the 2nd and 3rd metacarpal heads on the dorsal side of his right hand (Fig. 1a). The lesion was very painful on palpation. Lateral X-ray was suspective for a focal sclerotic thickening of the distal 2nd metacarpal bone (Fig. 1b). Sonographic evaluation disclosed an additional soft tissue reaction in the 2nd dorsal interosseous muscle. Magnetic resonance imaging was also performed but it could not demonstrate any other pathology. Eventually, the patient was decided to be operated. During surgery, a focal cortical thickening and a small reactive soft tissue lesion (3–4 mm) were detected and resected (Fig. 1c). Pathological examination was consistent with normal bone tissue and vascularized Wbroconnective tissue, respectively. On the postoperative 16th day, he was completely free of his aforementioned complaints. Although very few, there are similar cases of metacarpal bone involvement—either in the form of periostitis or in the form of osteotitis—in the literature. The spectrum encompasses stress-induced trauma [1], Paget disease [2], foreign body [3] and thyroid disease [4]. Further, the condition can easily mimic several forms of rheumatic diseases with metacarpophalangeal involvement. In this case, we could not illuminate an underlying reason for such an involvement. Accordingly, our message is simple and clear; despite every eVort including radiological, surgical and pathological procedures, it may sometimes be quite diYcult to ascertain the exact scenario. In this regard, although surgery always remains as the last resort in the management, the diagnostic/therapeutic algorithm may inevitably need to have such an end in certain patients. Clinicians should always be vigilant. M. Kurklu · O. Tatar Department of Orthopedics, Gulhane Military Medical Academy, Ankara, Turkey