Osteoid osteoma of the triquetrum: a case of four-year delay in diagnosis.

Abstract

Osteoid osteoma is a painful, benign bony tumor affecting a predominantly young patient population, with 60% occurring between ages 10 and 20 years old and a male predominance [19]. Nocturnal and rest pain are hallmarks. Symptoms vary from a mild ache to severe debilitating pain in response to excessive prostaglandin production. As such, the pain is classically responsive to aspirin due to its anti-prostaglandin effect [13]. Localized swelling and tenderness may be present on examination. Radiographically, osteoid osteoma is traditionally described as a 1–2-cm radiolucent lesion with a sclerotic border and central nidus consisting of vascular osteoid with focal mineralization. Imaging modalities including radiographs, bone scan, CT, and MRI can be helpful in the diagnosis of osteoid osteoma. Jaffe [11] first described osteoid osteoma in 1935 in five patients with “localized osteomyelitis or bone abscess” with a “nidus-like focus” of osteoid and vascularity without histologic evidence of infection. Excision resulted in symptomatic resolution in all cases. Others have since reported on osteoid osteomas scattered across the skeleton, with 6–13% occurring in the hand and 1–2% specifically occurring in the carpus [4, 5]. Lesions may be intra-articular or extra-articular, intramedullary, subperiosteal, or intracortical, the latter of which is most readily visualized on radiographs. Accurate and timely diagnosis is reliant upon a high index of suspicion. Osteoid osteoma in the carpus may be difficult to visualize on radiographs. Initial symptoms can be confused for osteomyelitis, De Quervain’s tenosynovitis, carpal tunnel syndrome, recent minor trauma, arthritis, neuroma, or, as in the case presented here, complex regional pain syndrome (CRPS) [2, 8]. Furthermore, as described herein, a missed or delayed osteoid osteoma diagnosis can lead to an unnecessary battery of tests, a litany of failed surgeries, and severely impaired quality of life.