EVIDENCE-BASED MEDICINE

Mark E. Jacobson, MD, Michael E. Ruff, MD

THE PATIENT
A 35-year-old woman presents with pain and swelling
of the index finger proximal phalanx after striking a
softball with a bat in a recreational league. Radiographs
reveal a lucent lesion with medullary expansion and
cortical thinning. There is a minimally displaced pathologic fracture.
THE QUESTION
What is the best treatment for a solitary enchondroma
of the phalanx associated with pathologic fracture?
CURRENT OPINION
Most surgeons treat fractures through enchondromas
nonoperatively unless there is substantial malalignment
or instability. When the fracture has healed and motion
is restored, some surgeons advise removing the enchondroma (curettage followed by autologous or allogeneic
bone graft or a bone graft substitute1,2), whereas others
recommend observation.
THE EVIDENCE
Solitary enchondroma is the most common benign tumor involving the small tubular bones of the hand3 8
and is thought to represent a persistent cartilaginous
island arising from the growth plate. Up to 40% of
enchondromas involve the hand9 and although any
bone may be involved, there is a predilection for the
ulnar digits and the proximal phalanges.7,10 Enchondroma is usually identified as an incidental finding on
radiographs or as a pathologic fracture.

From the Hand and Upper Extremity Center, Department of Orthopaedic Surgery, Ohio State University, Columbus, OH.
Received for publication April 18, 2011; accepted May 1, 2011.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Michael E. Ruff, MD, Hand and Upper Extremity Surgery, Ohio State
University Medical Center, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212; e-mail:
michael.ruff@osumc.edu.
0363-5023/11/36A11-0021$36.00/0
doi:10.1016/j.jhsa.2011.05.002

Operative versus nonoperative treatment of enchondroma

discovered by pathological fracture
Noble and Lamb12 compared 11 patients with enchondroma treated nonoperatively (6 with pathological fracture) with 29 patients treated with curettage with or
without bone graft. The operative group had 7 unsatisfactory results related to stiffness, nonunion (1 patient),
and cold intolerance (2 patients).
Operative treatment for enchondroma of the phalanx
Timing of surgery: Only 1 study4 compared immediate
operative treatment of the enchondroma before fracture
healing with delayed treatment. Early treatment was
associated with a shorter period of disability, but also
with significantly more complications (67% vs 10%),
including stiffness and rotational deformity. In the series of Yasuda and colleagues,11 1 patient who was
treated with early curettage and fixation had malunion
treated with revision osteotomy.
Curettage with autograft or allograft: Jewusiak et al13 described 23 patients treated with cancellous allograft
after curettage, with healing in all patients and no recurrence. Yercan et al14 noted that the cavities remaining after enchondroma excision consolidated after either autogenous or allogeneic cancellous bone grafting.
Bauer et al15 compared the results of 15 patients using
corticocancellous allograft with 16 patients using autogenous iliac cancellous bone; the only difference was
2 complications related to the iliac crest incision: 1
patient with persistent pain and 1 with a superficial
wound infection.
Curettage with calcium phosphate bone cement: Joosten et al2
used calcium phosphate bone cement to fill the defect
after curettage of an enchondroma in 8 patients and had
no complications except incomplete resorption of the
cement within the 1-year follow-up period. Yasuda et
al11 described 10 patients treated with calcium phosphate cement and noted complete resorption of the
cement in all but 2 patients within 41 months.
Curettage with methylmethacrylate: Bickels et al16 used a
cemented hardware construct consisting of Kirschner
wires manually contoured to the defect combined with
methylmethacrylate cement for reconstruction of large,

ASSH Published by Elsevier, Inc. All rights reserved. 1845

Evidence-Based Medicine

Solitary Enchondroma of the Phalanx

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SOLITARY ENCHONDROMA OF PHALANX

Evidence-Based Medicine

curetted tumor cavities in 13 patients; all returned to

SHORTCOMINGS OF THE EVIDENCE
normal function within 4 weeks without complication.
To date, the literature available regarding treatment of
17
enchondroma consists of retrospective case series. The
Curettage alone: Tordai et al described 44 patients
focus has been on operative treatment with mostly good
treated with curettage alone and reported no postoperresults and rare recurrence; however, most have followative fractures and only 1 recurrence. Schaller and
6
up less than 2 years. Because enchondromas may recur
Baer compared the osseous healing of 8 patients
many years after curettage,
treated with autograft and 8
the true recurrence rate is unwithout graft augmentation
known. The role of bone
using radiographic densitom- EDUCATIONAL OBJECTIVES
List the presenting signs and symptoms on an enchondroma within the
grafts or bone graft substietry, and found no differ3
hand.
tutes in filling the cavity creence. Morii et al demonstrated that resolution of Discuss the advantages and disadvantages of operative treatment of an ated by curettage of an enenchondroma before and after fracture healing.
chondroma is debatable.
bony tenderness correlated
State the possible bone products or synthetics that have been used to fill
with new bone formation in a
DIRECTIONS FOR
the void after curettage.
series of 38 patients treated
FUTURE RESEARCH
with curettage alone. Com- Summarize the results of curettage with and without bone grafting.
pared with matched controls Earn up to 2 hours of CME credit per JHS issue when you read the related The risk of a second fracture
treated with hydroxyapatite, articles and take the online test. To pay the $20 fee and take this months through an enchondroma is
there was no significant dif- test, visit http://www.jhandsurg.org/CME/home.
unknown. A long-term outference in time to bone forcome study of patients
mation and no patient sustreated nonoperatively would
tained a postoperative fracture or recurrence. Goto et
be useful to determine the incidence of and risk factors
al18 described 23 patients with curettage alone and
for a second fracture.
thought that cortical continuity was restored more rapA prospective, randomized trial comparing operative
idly when they replaced the cortical window.
and nonoperative treatment is needed to determine
whether the risks and temporary disability related to
surgery are warranted by a decrease in the rate of
Local recurrence and malignant degeneration
recurrent pathologic fracture. In addition, a prospective
Reported recurrence rates vary widely in the literature
study evaluating the outcome of curettage with and
(2% to 15%), with the largest published series reporting
19,20
without filling the resultant void with bone graft or graft
In 2 retrospective studies
a 4.5% recurrence rate.
substitute would help determine the necessity of costly
evaluating long-term outcomes, no recurrence was
treatment adjuncts.
noted before 6 years in 1 study and 11 years in the
10,21
Inadequate curettage was thought to be the
other.
OUR CURRENT CONCEPTS FOR THIS PATIENT
predominant cause of recurrence.22 OConnor and Ban20
croft suggested that recurrence may indicate maligAssuming no angular or rotational malalignment exists,
nancy and that careful review of pathology is warwe would treat this fracture nonoperatively with initial
ranted.
brief immobilization in a functional position in a handMalignant degeneration of isolated enchondroma to
based splint. Within 3 weeks, active, self-assisted mochondrosarcoma has been described but is extremely
tion exercises along with buddy taping are initiated and
rare.16,23 Few case reports of malignant degeneration
continue until radiographic evidence of union. When
have existed since Nelson et al23 critically reviewed 18
the fracture is healed and the finger is mobile, we
case reports of chondrosarcoma of the small tubular
discuss operative and nonoperative treatment options.
bones of the hand. They found that only 3 cases deBecause most enchondromas are asymptomatic, we ofscribed a well-documented enchondroma with late defer operative treatment when we think the likelihood of
generation to chondrosarcoma. Clinical features indirepeat fracture is high based on its radiographic appearcating chondrosarcoma include rapid growth with soft
ance. These may include polycentric (diffuse and lobtissue mass and pain in a previously asymptomatic
ulated) and giant lesions (significant cortical expansion)
digit. Radiographic evidence of cortical destruction
as classified by Takigawa,22 in addition to central lesions demonstrating significant cortical thinning.
with soft tissue extension suggests a more aggressive
When operative treatment is undertaken, we use eineoplasm. Both Patil et al24 and Bovee et al5 noted the
limited potential for metastasis of solitary phalangeal
ther a dorsal extensor-splitting approach or a midlateral
chondrosarcoma.
approachwhichever gives better access to the tumor
JHS Vol A, November

cavity. A cortical window is created using an osteotome

and the lesion is removed with small curved and
straight curettes. Fluoroscopy is used to confirm complete tumor removal. The endosteum of the cortical
window is debrided and the window is replaced and
sutured to the adjacent cortex with a simple absorbable
suture when needed. We do not use bone graft or bone
graft substitutes unless the remaining cortical shell is
too fragile to support active motion. We immobilize the
finger in a splint for 3 weeks, then advise active, selfassisted exercises to regain motion. Support with buddy
straps is continued until there is radiographic evidence
of bony consolidation. We check radiographs in both
operatively and nonoperatively treated patients 3, 5, and
12 months after injury or surgery.
REFERENCES
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320 330.
2. Joosten U, Joist A, Frebel T, Walter M, Langer M. The use of an in
situ curing hydroxyapatite cement as an alternative to bone graft
following removal of enchondroma of the hand. J Hand Surg 2000;
25B:288 291.
3. Morii T, Mochizuki K, Tajima T, Satomi K. Treatment outcome of
enchondroma by simple curettage without augmentation. J Orthop
Sci 2010;15:112117.
4. Ablove RH, Moy OJ, Peimer CA, Wheeler DR. Early versus delayed
treatment of enchondroma. Am J Orthop (Belle Mead NJ) 2000;29:
771772.
5. Bovee JV, van der Heul RO, Taminiau AH, Hogendoorn PC. Chondrosarcoma of the phalanx: a locally aggressive lesion with minimal
metastatic potential: a report of 35 cases and a review of the literature. Cancer 1999;86:1724 1732.
6. Schaller P, Baer W. Operative treatment of enchondromas of the
hand: is cancellous bone grafting necessary? Scand J Plast Reconstr
Surg Hand Surg 2009;43:279 285.
7. Gaulke R. The distribution of solitary enchondromata at the hand.
J Hand Surg 2002;27B:444 445.
8. Payne WT, Merrell G. Benign bony and soft tissue tumors of the
hand. J Hand Surg 2010;35A:19011910.

1847

9. Plate AM, Lee SJ, Steiner G, Posner MA. Tumorlike lesions and
benign tumors of the hand and wrist. J Am Acad Orthop Surg
2003;11:129 141.
10. Montero LM, Ikuta Y, Ishida O, Fujimoto Y, Nakamasu M. Enchondroma in the hand retrospective studyrecurrence cases. Hand Surg
2002;7:710.
11. Yasuda M, Masada K, Takeuchi E. Treatment of enchondroma of the
hand with injectable calcium phosphate bone cement. J Hand Surg
2006;31A:98 102.
12. Noble J, Lamb DW. Enchondromata of bones of the hand. A review
of 40 cases. Hand 1974;6:275284.
13. Jewusiak EM, Spence KF, Sell KW. Solitary benign enchondroma of
the long bones of the hand. J Bone Joint Surg 1971;53A:15871590.
14. Yercan H, Ozalp T, Coskunol E, Ozdemir O. [Long-term results of
autograft and allograft applications in hand enchondromas]. Acta
Orthop Traumatol Turc 2004;38:337342.
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the hand with allograft bone. J Hand Surg 1988;13A:908 916.
16. Bickels J, Wittig JC, Kollender Y, Kellar-Graney K, Mansour KL,
Meller I, et al. Enchondromas of the hand: treatment with curettage
and cemented internal fixation. J Hand Surg 2002;27A:870 875.
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Surg 1990;15B:331334.
18. Goto T, Yokokura S, Kawano H, Yamamoto A, Matsuda K,
Nakamura K. Simple curettage without bone grafting for enchondromata of the hand: with special reference to replacement of the
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bones of the hand. J Hand Surg 2003;28B:602 608.

JOURNAL CME QUESTIONS

Solitary Enchondroma of the Phalanx
What is the most common presentation of an
enchondroma in the hand?
a. Incidental finding on x-ray
b. Spontaneous swelling
c. Pain about enchondroma
d. Numbness in the finger
e. Trauma leading to fracture

Following curettage of a small nger

enchondroma, lling the void with what product
has the lowest consolidation rate?
a. Allograft
b. Autograft
c. Calcium phosphate bone cement
d. Nothing
e. All similar

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.

JHS Vol A, November

Evidence-Based Medicine

SOLITARY ENCHONDROMA OF PHALANX