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. 2020 Jun 6;17(2):346–353. doi: 10.1177/1558944720922921

Benign Hand Tumors (Part I): Cartilaginous and Bone Tumors

Kai-Lou C Yue 1, Jonathan Lans 1,✉, René M Castelein 2, David I Suster 1, G Petur Nielsen 1, Neal C Chen 1, Santiago A Lozano-CalderÓn 1
PMCID: PMC8984707  PMID: 32506966

Abstract

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution’s experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

Keywords: bone tumors, hand tumors, benign tumors, giant cell tumor, enchondroma

Introduction

Bone tumors of the hand are rare, with the vast majority being benign and painless. 1 Only 6% of all bone tumors arise in the hand. 2 Treatment depends on the tissue of origin and location of the tumor and is predominantly dictated by patient symptoms. 1 The aim of this study was to report on the epidemiology and treatment of benign bone hand tumors in adult patients treated at our institution over a period of more than 2 decades in light of published literature.

Methods

Following approval from our institutional review board, we retrospectively identified patients with benign bony hand tumors that were treated at one of our institutional hospitals from 1992 to 2015. We used International Classification of Diseases, Ninth Revision codes and selected patients with “hand”, “metacarpal”, and “finger” along with synonyms, in their pathology reports using STATA 13.0 (StataCorp, College Station, Texas) data processing program. This was followed by chart review to identify and verify patients with a benign tumor of the hand. We included all histologically confirmed tumors diagnosed by a musculoskeletal pathologist. We excluded patients younger than 18 years of age, those with cutaneous lesions, and those with ganglion cysts. We identified 154 patients with 155 tumors, with an average follow-up of 8.2 ± 7.0 years.

Statistical Analysis

Continuous variables were reported as median with interquartile range and categorical variables as percentages and frequencies. All analyses were run on STATA 13.0 (StataCorp).

Results

There were 155 bone tumors that affected 66 men (43%) and 89 women (57%), and most patients were white (n = 125, 88%). The median age of patients with a bone tumor was 39.9 ± 12.8 years (Figure 1). The most common bone tumors were enchondromas (n = 118, 76%). All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%) (Table 1).

Figure 1.

Figure 1.

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Patient age at presentation with a bone tumor (only diagnoses with >10 patients are displayed).

Note. GCT = giant cell tumor.

Table 1.

Patient Characteristics.

Total
Characteristic (N = 155)
Age, mean (SD), y 40.6 (12.8)
Location, No. (%)
 Digit 155 (100)
 Hand/Wrist 0
Pathologic fracture, No. (%) 79 (51)
Recurrence 10 (6.5)
Histology, No. (%)
 Enchondroma a 118 (76)
 Giant cell tumor of bone b 10 (6.5)
 Chondroma 9 (5.8)
 Osteoid osteoma 5 (2.7)
 Osteochondroma 3 (1.9)
 Bizarre parosteal osteochondromatous proliferation c 3 (1.9)
 Intraosseous ganglion cyst 2 (1.3)
 Aneurysmal bone cyst d 2 (1.3)
 Chondromyxoid fibroma 1 (0.6)
 Fibrous dysplasia 1 (0.6)
 Unicameral bone cyst 1 (0.6)
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a

Two were recurrences referred to our institution.

b

Three were referred recurrences.

c

One was a referred recurrence.

d

One was a referred recurrence.

Cartilaginous Tumors

Enchondroma

Enchondromas are benign, hyaline cartilage tumors that arise from abnormal intramedullary cartilaginous cell proliferation, with one-third presenting in the hand.3,4 Of the primary bone tumors of the hand, about 90% are enchondroma. 4 In our series of 155 benign bone tumors, 118 tumors (76%) were found to be an enchondroma. Of the 118 enchondromas, 14 (12%) were found to be atypical, and 2 (1.7%) were recurrences referred to our institution. Patients with an enchondroma had a median age of 39 years (range, 18-74 years). There were more women (n = 70, 59%) than men (n = 48, 41%).

Four tumors (3.4%) presented in patients with Ollier disease, a nonhereditary disease which presents as multiple enchondromatosis confirmed with bone scintigraphy3,5 (Figure 2a). Two of these patients presented with an atypical enchondroma. No patients presented with Maffucci syndrome.

Figure 2.

Figure 2.

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(a) Radiograph of a patient with Ollier disease with multiple enchondromas; (b) T1-weighted magnetic resonance (MR) images of an enchondroma of the distal phalanx; (c) T2-weighted MR images of an enchondroma of the distal phalanx; (d) microscopic images of hematoxylin and eosin–stained slides showing an enchondroma of the hand. High-power magnification shows a cartilaginous lesion with slightly increased chondrocyte cellularity and minimal atypia. Features of malignancy such as infiltrative growth pattern are not identified within this lesion.

Clinical assessment and radiographic imaging are generally sufficient to diagnose an enchondroma, as biopsies are not very useful due to sampling error and the subsequent poor intra- and interobserver agreement rates.6,7 Radiographs show a well-marginated intramedullary lytic lesion with intralesional calcifications, causing a stippled appearance. 8 Magnetic resonance imaging can show intralesional foci with high signal intensity on T1-weighted images 9 and hyperintense lesions compared with muscle on T2-weighted images 10 (Figure 2b and 2c). Histologically, enchondromas consist of bland chondrocytes with low cellularity and nuclei without atypia with a clear border 11 (Figure 2d). In patients with Ollier disease, enchondroma in the hand shows increased cellularity and is easily confused for a more aggressive lesion. However, it may still be difficult to differentiate a low-grade chondrosarcoma from an enchondroma, 12 as was seen in 1 patient in this series where the pathology was reviewed by 3 pathologists. One should be cautious of a chondrosarcoma if several recurrences occur.

It has been reported that enchondromas are most commonly found in the proximal and ulnar phalanges.3,13 This was confirmed by our findings, where 56 (48%) were found in the proximal phalanx, followed by the metacarpal (n = 24, 20%), the middle phalanx (n = 20, 17%), and finally the distal phalanx (n = 18, 15%). In addition, the tumor incidence decreased from the little finger to the thumb: 30%, 28%, 22%, 18%, and 2.5%. None of the patients had enchondromas of the carpal bones, although it has been reported that they account for about 1% to 3% of the hand enchondromas. 3 Despite the slow-growing nature of enchondromas, they can cause pain and destruction of the phalanges. This may lead to pathologic fractures as was seen in 74 (63%) tumors. Combined oncological and fracture surgery or oncological surgery after fracture healing leads to similar motion and function. 14

Treatment of symptomatic enchondromas consists of curettage with or without bone filler or adjuvant.15,16 We found that 103 tumors (87%) were treated with curettage, 12 (10%) with excision, 2 (1.7%) with amputation, and 1 (0.8%) was monitored after biopsy. One of the 2 amputations was in a patient with Ollier disease, with multiple exophytic growths emanating from the bones in several areas throughout the body including the middle finger. The second amputation was for a traumatic finger injury requiring digit amputation, where pathology later showed an enchondroma. Excision or curettage was followed by allograft (n = 48, 41%), autograft (n = 55, 47%), polymethyl methacrylate (PMMA) (n = 2, 1.7%), or combined autograft and allograft (n = 6, 5.1%). The only oncologic adjuvant used was hydrogen peroxide and was used in 67 patients.

Enchondromas recurred in 3 patients (2.5%) after undergoing surgery at our institution, similar to the reported recurrence rates ranging from 2% to 15%. 17 Recurrences occurred after 7, 18, and 158 months and were treated by curettage and allograft bone packing of the recurrent lesion. None of the patients with Ollier disease had a recurrence despite them typically having a higher rate of recurrence. 3 No malignant transformations from enchondroma to chondrosarcoma occurred, although they were reported in several case reports after long-standing enchondroma.18,19 In general, annual follow-up is only reserved for patients with Ollier or Maffucci syndrome. Follow-up in other patients is reserved for cases in which there is a change in symptoms or physical examination.

Chondroma

Chondromas are rare, benign lesions composed of hyaline cartilage that almost exclusively appear in the soft tissue of the extremities 20 ; they usually do not affect the bone. 21 An excisional biopsy including the tumor capsule is typically the first line of treatment. 20 All chondromas in our series (9 of 155, 5.8%) arose in the digits: 4 (44%) in the middle finger, 2 (22%) in the index finger, 2 in the little finger, and 1 (11%) in the ring finger (Figure 3). All chondromas were excised. One chondroma recurred 5 months after the initial treatment and was treated with re-excision.

Figure 3.

Figure 3.

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Chondroma at the mid-phalangeal level: (a) conventional radiograph, (b) T1-weighted magnetic resonance image, and (c) T2-weighted image.

Synovial Chondromatosis

Synovial chondromatosis (5 of 155, 3.2%) arises from the synovial tissue, tenosynovium, or bursal lining of or near joints. 22 These lesions more commonly appear near large joints such as the knees, shoulders, and hips, but joints in the fingers such as the metacarpophalangeal (MCP) joint have been reported as well. 22 Of the 5 patients with synovial chondromatosis, 2 (50%) were in the MCP joint of the index finger, 1 was in the MCP joint of the ring finger, 1 was in the distal interphalangeal joint of the middle finger, and 1 was dorsally located on an unspecified location of the hand. Treatment by excision or synovectomy of the lesion depends on its stage: early, transitional, or late, although there is no clear correlation between the type of treatment and recurrence rates. 22 Four of our institution’s patients were treated with excision and 1 with synovectomy without recurrences.

Osteochondroma

Osteochondromas (3 of 155, 1.9%) present as osseous growths protruding outward with a cartilage cap; they appear as bony exostoses on radiographs.23,24 These tumors can be either pedunculated or sessile. All were pedunculated in this series. These lesions have a predilection for the proximal phalanx, 24 although in our series tumors were located in the metacarpal, middle, and distal phalanges. Treatment of these lesions typically involves observation or surgical excision if there are related symptoms. 23 We had 2 patients (67%) patients undergo excision of their lesions. The other patient presented with a pathologic fracture and underwent curettage followed by allograft bone packing. Malignant transformation from a solitary osteochondroma into a chondrosarcoma may occur but is rare (1% of all osteochondroma cases in the body). 25 There were no malignant transformations in the patients treated at out institution.

Bizarre Parosteal Osteochondromatous Proliferation

Bizarre parosteal osteochondromatous proliferations are benign (3 of 155, 1.9%), osteocartilaginous lesions typically affecting the surfaces of bones in the hands and feet.23,24 In the hands, proximal and middle phalanges are most commonly affected. 26 In our series, all lesions were in the digits with 2 (67%) in the middle phalanx and 1 (33%) in the metacarpal. Bizarre parosteal osteochondromatous proliferations are easily removed from the phalanges with excision being favored as the main surgical treatment, although rates of recurrence can be as high as 75%. 26 All lesions were treated with excision, with 1 recurrence after 5 months that was treated with re-excision.

Chondromyxoid Fibroma

Chondromyxoid fibroma is a benign bone tumor of cartilaginous origin. 27 It typically occurs within the long bones of the body, such as those around the knee, and small bones in the foot. 28 Histologically, it is characterized by a chondroid and fibrous matrix with myxoid content. 27 Treatment options for this lesion vary from resection to curettage, although curettage is associated with a higher risk of recurrence. 28 One patient (0.65%) at our institution presented with a chondromyxoid fibroma in the metacarpal of the middle finger and underwent curettage with allograft bone packing. The patient did not experience a recurrence of the lesion.

Bone Tumors

Giant Cell Tumor of Bone

Giant cell tumor of bone (GCTB) is a locally aggressive benign bone tumor with a high recurrence rate. 29 The tumors arise in the metaphyseal and epiphyseal regions of bones, such as the humerus, femur, and tibia, with only 1% to 5% presenting in the hand.23,24,29 In our series, 10 patients (6.5%) had a GCTB located in hand, where 1 patient presented with multicentric GCTB with other tumors located on the right proximal femur, acetabulum, and pubic bone. Of those 10 lesions, 4 were recurrent lesions referred to our institution. Patients presenting with a GCTB had a median age of 47 years (range, 21-73 years). There were an equal number of men and women—5 patients each.

In the hands, GCTB has a predilection for the metacarpals. 30 At our institution, 7 (70%) of the GCTBs were in the metacarpals with the other 3 spread between the proximal, middle, and distal phalanges. One (10%) patient presented with a pathologic fracture. Less than 1% of all GCTB cases are multicentric, and those that are have a propensity for arising in the bones of the hands and feet. This was seen in 1 patient in this series. 30

On radiographs, GCTB typically appears radiolucent with cortical thinning, giving a “soap bubble” appearance 23 (Figure 4a). On T1- and T2-weighted magnetic resonance imaging scans, the lesion looks dark and bright, respectively. 31 Location is usually metaphyseal, with very occasional extension into the epiphysis. Because of the possibility of GCTB metastasizing to the lungs, chest computed tomographic scans or radiographs are recommended for initial staging and subsequent surveillance. 23 Histologically, these lesions appear to be a combination of multinucleated giant cells with either round or spindled mononuclear stromal cells 30 (Figure 4b).

Figure 4.

Figure 4.

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(a) Radiograph of giant cell tumor (GCT) of bone of the first metacarpal. (b) Microscopic images of hematoxylin and eosin–stained slides show a GCT of bone. High-power magnification (×200) shows the typical feature of GCT including an admixture of neoplastic mononuclear cells and multiple multinucleated giant cells with innumerable nuclei.

Surgical treatment includes curettage with or without adjuvants, resection, or amputation and depends on the extent of the tumor. 32 Five tumors (50%) were treated with curettage and packing, 2 (20%) with amputation, 2 (20%) with resection, and 1 with curettage alone. One patient with a tumor resection of the thumb metacarpal underwent reconstruction followed by allograft reconstruction, and the other underwent a toe-to-finger transfer from the distal phalanx of the middle toe followed by a soft tissue reconstruction. Six (60%) patients received bone packing, either after curettage of the lesion or for reconstruction: 2 received PMMA and 4 received an allograft bone packing. Two patients (20%) were treated with an adjuvant of hydrogen peroxide and 1 (10%) with phenol. Both the patient with the multicentric GCTB and the patient who did not undergo surgical treatment after biopsy received denosumab treatment. In general, denosumab is used in unresectable GCTB. 29

The recurrence rate of GCTB depends on the initial surgical treatment; recurrence rates after curettage are between 34% and 37%, whereas wide local excision has lower rates: 5% to 7%. 30 Four (40%) patients had recurrences after receiving treatment at our institution. Two (20%) of them had a second recurrence: one 4 months postoperatively and the other at 40 months, both after undergoing curettage. The recurrences were treated with an amputation of the digit in 1 patient and resection in the other. No malignant transformations occurred, but 1 patient had pulmonary metastases that occurred 8 months after the most recent surgery. Risk of pulmonary metastases from general GCTB has been found to be between 2% and 5%. 31

Osteoid Osteoma

Osteoid osteomas are benign but painful bone tumors that are characterized by the formation of mature bone by the tumor. 33 These lesions are typically found within the long bones, but 5% to 15% of them can be found in the hands and wrist, typically in the proximal phalanx and carpus. 34 Four patients (2.6%) presented with an osteoid osteoma and 1 (0.65%) with the histologically similar osteoblastoma; osteoblastomas differ from osteomas in that they can be locally aggressive, are typically larger, and have a higher rate of recurrence. 33 Three (60%) patients presented with lesions in the metacarpals of the thumb, middle, and little finger, 1 in the middle phalanx of the index finger, and 1 in the distal phalanx of the middle finger.

Radiographs show a broad area of sclerosis surrounding a characteristic, centralized oval lucency, known as a nidus (Figure 5). 34 Treatments for osteoid osteoma range from surgical treatment, such as curettage, to minimally invasive techniques, such as radiofrequency ablation. 35 Four patients at our institution were treated with curettage, followed by PMMA bone filler in 1 patient, and 1 patient underwent excision. The patient who received the PMMA bone filler recurred after 3 months and underwent repeated curettage of the lesion followed by repacking with PMMA.

Figure 5.

Figure 5.

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Second middle phalanx osteoid osteoma: (a) conventional radiograph and (b) T1-weighted postcontrast coronal view.

Aneurysmal Bone Cysts

Aneurysmal bone cysts (ABCs) are locally aggressive, outwardly expanding, blood-filled benign lesions. 36 Less than 5% of ABCs occur in the hand; those that do typically present in the metacarpals and phalanges. In our series, 2 patients (1.3%) presented with an ABC, with one on the metacarpal of the middle finger and the other on the middle phalanx of the middle finger (Figure 6). Both patients presented with a pathologic fracture. Treatment of ABCs includes curettage with or without bone packing, excision, and, most recently, sclerotherapy 36 ; one patient underwent curettage with allograft bone packing and the other underwent resection with bone autograft. No tumors recurred.

Figure 6.

Figure 6.

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Conventional radiograph of an aneurysmal bone cyst of the middle phalanx: (a) coronal view and (b) sagittal view.

Intraosseous Bone Cyst

Intraosseous ganglion cysts consist of a highly viscous mucin surrounded by a wall of flattened, fibrous connective tissue cells within the bone. 37 Histologically, they are similar to the soft tissue ganglion cyst. 38 Two patients (1.3%) presented with an intraosseous ganglion cyst, and both were treated with curettage with allograft bone packing. The lesions were in the metacarpal of the thumb and in the proximal phalanx of the middle finger.

Unicameral Bone Cyst

Simple bone cysts, also known as unicameral bone cysts, are fluid-filled lesions caused by blockages in the venous flow of the cancellous bone. 39 One patient (0.65%) presented with this lesion on the metacarpal of the middle finger and was treated with curettage with allograft bone packing; no recurrence occurred.

Fibrous Dysplasia

Fibrous dysplasia is characterized by growth of fibrous tissue and immature bone replacing the normal bone. 40 One patient (0.65%) presented with this disease and a pathological fracture on the metacarpal of the ring finger. The patient was treated by curettage after consolidation of the fracture without recurrence.

Conclusion

Cartilaginous and bone tumors of the hand are rare; enchondromas were the most common bone tumor in this series, whereas giant cell tumors (GCTs) were the most destructive. Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients. The most common treatment for these tumors was intralesional curettage, but amputations were performed for enchondromas and GCTs where bone destruction was significant. Enchondromas had a tendency to be more common among women. The tumor with the highest recurrence rate was GCTB (40%). Close patient follow-up is needed in patients with a GCTB due to metastatic and recurrence potential.

Footnotes

Authors’ Note: This work was performed at the Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Ethical Approval: This work should follow the Massachusetts General Hospital Institutional Review Board–approved protocol no. 2017P000606, titled “Epidemiology and Survival of Malignant and Benign Neoplasms in the Upper Extremity.”

Statement of Human and Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent: There was a waiver of consent for this study.

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.C.Y., R.M.C., D.I.S., P.G.N., and S.L.-C. have nothing to disclose. J.L. is a consultant for Axogen Inc. N.C.C. is a lecturer at DePuy Synthes and consultant for Miami Device Solutions, Flexion Medical, Skeletal Dynamics, and Acumed.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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