Skip to main content

Embarrassing problems

May 2013

Clinical

Painful swollen wrist

A case study

Volume 42, No.5, May 2013 Pages 301-303

Painful swollen wristLawrence Leung MBBChir, MFM(Clin), DPD(Wales), FRACGP, FRCGP(UK), CCFP, is Associate Professor, Department of Family Medicine, Queen’s University, Kingston, Ontario, Canada.

Case study

Mr L, an Asian man aged 48 years, presented to his family doctor with a 3 month history of pain and swelling of his left wrist. He described the pain as ‘dull and gnawing’, which escalated to a sharp and shooting sensation radiating to his third and fourth fingers. Pain was worsened by movement and only mildly relieved by rest. He rated the wrist pain as 5/10 severity 3 months ago, and the current pain as 8/10 severity, despite regular paracetamol and ibuprofen at maximum doses. Often the pain kept him awake at night. There was no anaesthesia or paraesthesia, but he had noticed increasing weakness of the lateral three fingers. Over the past 4 weeks, he had also noticed a swelling of the affected wrist, which felt ‘hot’ at times.

The pain started when he twisted his wrist while carrying hand luggage 3 months ago. He initially used a hot pack to relieve the pain, with limited benefit. He started taking analgesia 4 weeks before his visit to his family doctor. However, the unresolved pain and increasing agony in dressing and turning the steering wheel of his vehicle, eventually alerted him to seek medical advice.

Mr L exercised regularly and had never smoked cigarettes. He took no regular medications and had no known allergies. His mother had a history of colon cancer. One of his maternal aunts suffered from severe rheumatoid arthritis, and one maternal uncle had severe plaque psoriasis.

On examination, there was a firm swollen deformity over the distal radius, which was tender on palpation (Figure 1a and 1b).

There were no associated skin changes. Pain was elicited on hyperextension of the fingers and also on deep palpation of the volar aspect of the wrist. Power of the flexor muscles of the left forearm was reduced to 3/5 on a Medical Research Council (MRC) scale for muscle strength.

Figure 1a. Comparison of the patient’s
wrists

Figure 1a. Comparison of the patient’s wrists

Figure 1b. Swollen deformity over the
distal radius

Figure 1b. Swollen deformity over the distal radius

Question 1

What are the differential diagnoses?

Question 2

What initial investigation would you consider?

Question 3

A plain X-ray of the wrist was ordered and results are shown in Figure 2. What are the possible diagnoses and what other tests would you consider?

Figure 2. Plain X-ray of the patient’s left
wrist

Figure 2. Plain X-ray of the patient’s left wrist

Question 4

What is the management and prognosis?

Answer 1

Differential diagnoses include tendon sprain, rheumatoid arthritis, gouty arthritis, mal-union of fractured distal radius, osteoarthritis, metabolic bone disease, soft tissue tumours and bone tumours (benign and malignant). As the firm swelling arose from the distal radius and not the radio-carpal joint, the diagnoses of osteoarthritis, rheumatoid arthritis and gouty arthritis are less likely. Due to the solitary nature of the lesion and lack of other systemic symptoms, metabolic bone diseases (eg. Paget and hyperparathyroidism) are considered less likely. In view of the history of a relatively minor twisting injury without violent trauma, tendon sprain or tendonitis are more probable diagnoses than a radial fracture.

Important red flag features that should alert the general practitioner to consider more sinister diagnoses include:

  • unresolved pain over a 3 month period
  • increased pain severity
  • nocturnal pain waking the patient from sleep
  • noticeable mass over the distal radius.

Answer 2

Plain X-ray of the wrist to confirm or exclude possible bone tumours.

Answer 3

Plain X-ray of the left wrist revealed a 4 x 3 cm osteolytic lesion destroying much of the distal radius, extending to the subchondral bone with minimally displaced fracturing. Differential diagnoses include giant cell tumour, aneurysmal bone cyst or more aggressive bone tumours.

Magnetic resonance imaging (MRI) of the wrist would help to delineate the boundary of the tumour mass and evaluate possible invasion of the carpal bones, wrist joint or the carpal tunnel. This is particularly relevant as the patient already had signs of carpel tunnel syndrome. A radionuclide bone scintigraphy is also needed to exclude possible metastatic disease. Finally, a tissue biopsy is the gold standard for the definitive diagnosis.

Answer 4

Giant cell tumour of bone (GCTB) is a locally aggressive tumour, which is typically benign. It affects young adults aged 20–40 years with a male:female ratio of 1:1.5.1–3 Asian populations have a higher incidence than Caucasian populations. In China, GCTB accounts for 20% of all primary bone tumours4,5 as opposed to 4–8% of all primary bone tumours worldwide.2

Chronic pain unrelated to weight bearing, with warmth and palpable swelling, is the classic clinical presentation of GCTB. The extremities of long bones are most commonly affected. The three most common sites affected are distal femur, proximal tibia and distal radius in descending order of prevalence.5,6 The distal radius accounts for 8–13% of all cases.6,7 Morphologically, GCTB lesions often arise from the epiphysis and grow from an off-centred position toward the metaphysis.3 Due to its rapid expansile nature, it may be haemorrhagic and cystic with fluid levels.

Giant cell tumour of bone are predominantly benign, but 2–9% have been reported to be malignant8–10 and metastasise to areas including the lymph nodes, lungs, skin, calf muscles and pelvis, with a preponderance to the lungs.10–12 The prognosis for pulmonary metastases is variable; early detection may allow surgical resection and survival.10,11,13,14 p53 gene mutations and previous radiotherapy are associated with malignant forms of GCTB.8,15,16

The goals of GCTB management are to minimise local recurrence and maximise joint preservation.15 In general, local recurrence rate after curettage and cement is higher than with wide local excision.7,17 However, wide local excision has a higher risk of loss of functionality. Curettage of tumour is the initial treatment of choice, but when used alone, the local recurrence rate at all sites can be as high as 56–59%,6,18,19 with a 25–31% risk for lesions involving the distal end of the radius.7,20,21 Hence, additional steps have been employed to reduce local recurrence rate such as extended curettage with high speed burrs.22,23 Recent studies also support the use of ‘aggressive curettage’ where the lesional cavity is treated with adjuvant chemicals (phenol, alcohol or liquid nitrogen) or generous diathermy to eradicate possible tumour cells and hence further reduce the local recurrence rate.19,24

Typically, local recurrence occurs 12–18 months after surgery and rarely beyond 3 years. Hence, regular follow up with a thorough physical examination and plain X-rays every 3–4 months in the first 3 years is necessary.6 Should the tumour recur locally, surgical treatment options include repeat extensive curettage,19 wide local bone resection with bone graft,19 endoprosthesis18 or arthrodesis.25,26 Radiotherapy is also a possible non-surgical option for recurrent, incompletely resected, or unresectable lesions.27,28 Recently, Denosumab, a monoclonal antibody against the RANK ligand, has shown promise in a phase 2 clinical trial for recalcitrant GCTB.29,30

Case conclusion

Initial X-rays could not exclude erosion of the tumour through the bone cortex or extension of the tumour into adjacent soft tissue. Further investigations were performed: MRI of the wrist revealed multiple fluid levels in a 5 x 3 cm expansile mass eroding into the cortex of the distal radius; computed tomograhy of the chest did not detect any metastatic lesions; and bone scintigraphy of the whole body showed increased flow, pool and intense osteoblastic activity in the distal left radius, with no activity in other parts of the body.

In view of the generally benign nature of GCTB and a lack of distant tumour spread, intra-lesional removal of tumour with bone cement was offered as the preferred management over en bloc bone resection, in order to preserve maximum functionality of the wrist.6,31,32 Mr L was promptly scheduled for a curative excision biopsy. On-table frozen section confirmed the diagnosis of giant cell tumour, and the lesion was radically curettaged with generous diathermy to the inner surfaces of the cavity. The lesional space was then packed with polymethylmethacrylate bone cement (Figure 3).

With physiotherapy, the patient recovered 95% of left wrist function when reviewed at 6 months. A second stage operation for plate-and-screw arthrodesis of the wrist would ensure adequate weightbearing capability.

Figure 3. Intra-operative X-ray of the
wrist showing curettage of the GCTB
and packing with PMMA bone cement

Figure 3. Intra-operative X-ray of the wrist showing curettage of the GCTB and packing with PMMA bone cement

Summary

Giant cell tumour of the bone is an uncommon and typically benign tumour, which is locally aggressive and which has a higher incidence among Asian people. Clinical presentations of GCTB are typically non-diagnostic, and may include chronic pain and swelling of a joint. Presentations can easily mimic musculoskeletal pain and tendon injuries, as presented in this case.

The red flags in this case included unresolving pain, increasing severity of pain, nocturnal pain and noticeable mass over the site of pain, which prompted further investigation leading to the final diagnosis.

Surgical removal in the form of curettage with local adjuvants is the preferred initial treatment for maximum preservation of joint function. Follow up every 3–6 months with clinical examination and plain X-ray is necessary for 3 years post-operatively.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Campanacci M. Giant Cell Tumor. In: Gaggi A, editor. Bone and soft-tissue tumors. Bologna, Italy: Springer-Verlag, 1990;117–53.
  2. Unni KK. Dahlin’s bone tumors: general aspect and data on 11087 cases. 5th edn. Philadelphia: Lippincott-Raven, 1998.
  3. Szendroi M. Giant-cell tumour of bone. J Bone Joint Surg Br 2004;86:5–12.
  4. Guo W, Xu W, Huvos AG, Healey JH, Feng C. Comparative frequency of bone sarcomas among different racial groups. Chin Med J (Engl) 1999;112:1101–4.
  5. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: analysis of two hundred and eight cases in Chinese patients. J Bone Joint Surg Am 1982;64:755–61.
  6. Turcotte RE. Giant cell tumor of bone. Orthop Clin North Am 2006;37:35–51.
  7. Liu YP, Li KH, Sun BH. Which treatment is the best for giant cell tumors of the distal radius? A meta-analysis. Clin Orthop Relat Res 2012;470:2886–94.
  8. Gong L, Liu W, Sun X, et al. Histological and clinical characteristics of malignant giant cell tumor of bone. Virchows Arch 2012;460:327–34.
  9. Bertoni F, Bacchini P, Staals EL. Malignancy in giant cell tumor of bone. Cancer 2003;97:2520–9.
  10. Qureshi SS, Puri A, Agarwal M, Desai S, Jambhekar N. Recurrent giant cell tumor of bone with simultaneous regional lymph node and pulmonary metastases. Skeletal Radiol 2005;34:225–8.
  11. Gupta R, Seethalakshmi V, Jambhekar NA, et al. Clinicopathologic profile of 470 giant cell tumors of bone from a cancer hospital in western India. Ann Diagn Pathol 2008;12:239–48.
  12. Viswanathan S, Jambhekar NA. Metastatic giant cell tumor of bone: are there associated factors and best treatment modalities? Clin Orthop Relat Res 2010;468:827–33.
  13. Kremen TJ Jr., Bernthal NM, Eckardt MA, Eckardt JJ. Giant cell tumor of bone: are we stratifying results appropriately? Clin Orthop Relat Res 2012;470:677–83.
  14. Kay RM, Eckardt JJ, Seeger LL, Mirra JM, Hak DJ. Pulmonary metastasis of benign giant cell tumor of bone. Six histologically confirmed cases, including one of spontaneous regression. Clin Orthop Relat Res 1994;302:219–30.
  15. Oda Y, Sakamoto A, Saito T, et al. Secondary malignant giant-cell tumour of bone: molecular abnormalities of p53 and H-ras gene correlated with malignant transformation. Histopathology 2001;39:629–37.
  16. Saito T, Mitomi H, Izumi H, et al. A case of secondary malignant giant-cell tumor of bone with p53 mutation after long-term follow-up. Hum Pathol 2011;42:727–33.
  17. Chanchairujira K, Jiranantanakorn T, Phimolsarnti R, Asavamongkolkul A, Waikakul S. Factors of local recurrence of giant cell tumor of long bone after treatment: plain radiographs, pathology and surgical procedures. J Med Assoc Thai 2011;94:1230–7.
  18. Balke M, Ahrens H, Streitbuerger A, et al. Treatment options for recurrent giant cell tumors of bone. J Cancer Res Clin Oncol 2009;135:149–58.
  19. Niu X, Zhang Q, Hao L, et al. Giant cell tumor of the extremity: retrospective analysis of 621 Chinese patients from one institution. J Bone Joint Surg Am 2012;94:461–7.
  20. O’Donnell RJ, Springfield DS, Motwani HK, Ready JE, Gebhardt MC, Mankin HJ. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am 1994;76:1827–33.
  21. McGough RL, Rutledge J, Lewis VO, Lin PP, Yasko AW. Impact severity of local recurrence in giant cell tumor of bone. Clin Orthop Relat Res 2005;438:116–22.
  22. Ofluoglu O. Aggressive treatment of giant cell tumour with multiple local adjuvants. Acta Orthop Belg 2008;74:831–6.
  23. Muramatsu K, Ihara K, Taguchi T. Treatment of giant cell tumor of long bones: clinical outcome and reconstructive strategy for lower and upper limbs. Orthopedics 2009;32:491.
  24. Errani C, Ruggieri P, Asenzio MA, et al. Giant cell tumor of the extremity: A review of 349 cases from a single institution. Cancer Treat Rev 2010;36:1–7.
  25. Bhagat S, Bansal M, Jandhyala R, Sharma H, Amin P, Pandit JP. Wide excision and ulno-carpal arthrodesis for primary aggressive and recurrent giant cell tumours. Int Orthop 2008;32:741–5.
  26. Vidyadhara S, Rao SK. Techniques in the management of juxta-articular aggressive and recurrent giant cell tumors around the knee. Eur J Surg Oncol 2007;33:243–51.
  27. Bhatia S, Miszczyk L, Roelandts M, et al. Radiotherapy for marginally resected, unresectable or recurrent giant cell tumor of the bone: a rare cancer network study. Rare Tumors 2011;3:e48.
  28. Kriz J, Eich HT, Mucke R, et al. Radiotherapy for giant cell tumors of the bone: a safe and effective treatment modality. Anticancer Res 2012;32:2069–73.
  29. Branstetter DG, Nelson SD, Manivel JC, et al. Denosumab induces tumor reduction and bone formation in patients with giant-cell tumor of bone. Clin Cancer Res 2012;18:4415–24.
  30. Thomas D, Henshaw R, Skubitz K, et al. Denosumab in patients with giant-cell tumour of bone: an open-label, phase 2 study. Lancet Oncol 2010;11:275–80.
  31. Panchwagh Y, Puri A, Agarwal M, Anchan C, Shah M. Giant cell tumor – distal end radius: Do we know the answer? Indian J Orthop 2007;41:139–45.
  32. Karpik M. Giant Cell Tumor (tumor gigantocellularis, osteoclastoma) – epidemiology, diagnosis, treatment. Ortop Traumatol Rehabil 2010;12:207–15.

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software

Advertisement

Topics

Oncology & haematology Orthopaedics & sports medicine Rheumatology & musculoskeletal medicine

Type

Clinical

2013