Diagnostic and Interventional Imaging (2013) 94, 395—409

ICONOGRAPHIC REVIEW / Musculoskeletal imaging

Cartilaginous tumours and calcified lesions of the

hand: A pictorial review
A. Larbi a,∗, P. Viala b, P. Omoumi a, F. Lecouvet a,
J. Malghem a, C. Cyteval b, B. Vande Berg a

a
Département d’imagerie médicale, service d’imagerie ostéoarticulaire, cliniques
universitaires Saint-Luc, 10, avenue d’Hippocrate, 1200 Bruxelles, Belgium
b
Service d’imagerie musculosquelettique, CHU Lapeyronie, 371, avenue du
Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France

KEYWORDS Abstract Cartilaginous tumours of the extremities are commonly seen in radiographs. Enchon-
Bone tumours; droma is the most frequently encountered tumour. Since the vast majority of enchondromas are
Soft tissue; asymptomatic, they are typically discovered as incidental findings or along with a pathologic
Cartilaginous matrix; fracture. The authors propose a pictorial review to illustrate the imaging features of carti-
Hands laginous bone lesions of the hand and their specificities, and discuss the main differential
diagnoses.
© 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Cartilaginous tumours of the hand are characterised by the presence of a cartilaginous

matrix. They may be found in all of the anatomic compartments of the hand. They are,
by far, the most common. The frequency is difficult to assess although it does not exceed
10% [1].
The authors propose a pictorial review to illustrate the imaging features of cartilaginous
bone lesions of the hand as well as their specificities and discuss the main differen-
tial diagnoses. This pictorial review is based on data from the literature and personal
experience.

Histology of cartilaginous bone lesions

The cartilaginous matrix is a tissue matrix consisting of chondrocytes of varying differen-
tiation. They generally produce an extracellular substance consisting of type II collagen
and proteoglycans. The production of cartilage results from the differentiation of mes-
enchymal stem cells that produce this extracellular matrix under the action of an internal

∗ Corresponding author.
E-mail address: larbi.ahmed@gmail.com (A. Larbi).

2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.diii.2013.01.012
396 A. Larbi et al.

Figure 1. Histological section. Islands of hyaline cartilage Figure 2. Conventional X-ray of the 2nd finger of a 9-year-old
organised in lobules (arrow) separated by interlobular septae child. Chance discovery of a P1, little calcified enchondroma in the
(arrowhead). form of a centromedullary osseous gap. As opposed to infarction,
note the absence of calcified or ossified limit.

or external signal. Chondrocytes tend to be arranged in

nodular masses. The cartilaginous tissue is then arranged in
nodular masses with polycyclic outlines. The islands of hya-
line cartilage organise in lobules separated by interlobular
septa (Fig. 1).

Appearance in imaging
Conventional radiology and CT-scan
The cartilaginous matrix can only be recognised in con-
ventional radiology and the CT-scan by the presence of
calcifications. The calcifications have a specific appear-
ance when arranged in compact nodules, in a ring or arc
(popcorn appearance). The degree of calcification of car-
tilaginous matrix can vary (Figs. 2 and 3). Occasionally,
the degree of calcification is very high and the typical
appearance is not easy to recognise. As opposed to an infarc-
tion, there is no calcified or ossified peripheral limit. In
the CT-scan, the multilobular outlines of cartilaginous tis-
sue may be recognised when the lesion is located in a
fatty medullary cavity or when it induces cortical notches
(Fig. 4). Figure 3. Conventional X-ray of the 4th finger in a 60-year-old,
asymptomatic patient. Calcified enchondroma of the base of P1.
Note the arrangement of the calcifications in arcs (arrowheads).
MRI
The cartilaginous matrix may easily be recognised in MRI
(Fig. 5a—d). It presents a marked hyposignal in T1 weight-
ing (Fig. 5a) that is highly contrasted by the intense signal cartilaginous matrix is in distinct hypersignal (Fig. 5b). It
of the neighbouring fatty bone marrow in case of enchon- should be distinguished from the intratumoral calcifications
droma. The hyposignal is sometimes heterogeneous after that are in hyposignal in all sequences. There is no abnormal-
the presence of calcium deposits (more distinct in T1 ity of bone marrow signal on the T2 fat saturation sequences.
hyposignal) or fatty residues (in T1 hypersignal). In the T2 After the injection of gadolinium, the contrast enhance-
weighted sequences, lobular and well-defined contours are ment of the tumour is global or inexistent (Fig. 5c), rarely
found. Since the septas are in hyposignal, the water-rich peripheral [2] (Fig. 5d).
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 397

Specificities of cartilaginous tumours of

the hand
Cartilaginous tumours may be found in all parts of the skele-
ton: medullary cavity of the bone, cortex, subperiosteal
space, intrasynovial space and even in soft tissue. Car-
tilaginous tumours may be single or multiple, benign or
malignant.

Intra-osseous cartilaginous tumours

Enchondroma
Enchondroma corresponds to an intramedullary proliferation
of mature hyaline cartilage in the metaphyseal-diaphyseal
Figure 4. CT-scan in axial section revealing an enchondroma of regions of bones with enchondral ossification. This is a
the 2nd metacarpus in a 35-year-old asymptomatic patient. Note common tumour, accounting for almost 3% of all bone
this centromedullary lesion presenting a chondroid matrix with tumours and for 12 to 24% of all benign bone tumours.
nodular contours (arrow) and the presence of central calcification
This tumour affects the young subject. The age of dis-
(arrowheads).

Figure 5. a: MRI in axial section, in T1 weighting. Note T1 hyposignal of the cartilaginous matrix (arrow). This T1 hyposignal contrasts
with the fatty signal from the bone marrow. The central calcifications are in asignal in all sequences (tip of arrow); b: MRI in axial section,
in T2 Fat Sat weighting. Note the well-defined appearance of the cartilaginous lobules, with a very intense signal (arrows). The central
calcifications are in asignal in all sequences (tip of arrow). There is no peri-lesional oedema; c: MRI in axial section, in T1 gado Fat Sat
weighting. Note the enhancement of the septa (arrows). The central calcifications are in asignal in all sequences (tip of arrow); d: MRI in
axial section, in T1 gado Fat Sat weighting. Note the peripheral enhancement (arrows) of this small enchondroma. The central calcifications
are in asignal in all sequences (tip of arrow).
398 A. Larbi et al.

covery varies from the age of 10 to 40 years, according phalanx (Figs. 7 and 8). The extension of the lesion to the
to Dalhin [3]. The location at the extremities is the by entire diaphysis is possible (Fig. 9).
far most common (35 to 65%) according to the studies The enchondroma, often asymptomatic, is discovered
based on radiographic data [4,5]. The other classic loca- fortuitously or at the time of an X-ray, an MRI or a scintigra-
tions are the proximal humeral (13%), distal femoral (7%) and phy. Tumefaction may sometimes be the reason for the X-ray
proximal tibial (7%) metaphyses. Enchondroma is the most although the pathological fracture (Fig. 10) is most frequent
common tumour of the phalanx of the hands. In decreasing in almost one third of all cases.
order of occurrence, it is found in the proximal phalanx,
the metacarpus, the intermediate phalanx and the dis-
tal phalanx, with a preference of the ulnar edge of the
hand. The natural evolution means that it is found near
the zone of growth since the cells come from the physis
(Fig. 6): distally from the metacarpals and proximally to the

Figure 8. Conventional X-ray in a 60-year-old, asymptomatic

patient. Chance discovery of an enchondroma of P1 of the 3rd finger.
Note the location of this enchondroma proximally from the phalanx
(arrow).

Figure 6. Natural evolution of enchondromas: near the zone of

growth since these cells come from the physis (proximally from the
phalanx and distally from the metacarpals).

Figure 9. Conventional X-ray of the 5th finger in a 16-year-old

patient presenting a fracture of the base of P1 (arrowheads) on
Figure 7. Conventional X-ray in a 35-year-old patient. Fracture enchondroma. Note the extension of the enchondromas to the
on enchondroma of the 4th metacarpus. Note the location of this entire diaphysis without malignancy (as opposed to the enchondro-
enchondroma, distally from the metacarpus (arrow). mas of the long bones).
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 399

As a general rule, the destruction of more than two thirds

of the thickness of the cortex is a sign of malignity. This
concept does not apply to enchondromas of the extremities
in which more important endosteal erosion is not necessar-
ily prejudicial (Fig. 11). In case of a large lesion, the bone
outlines are swollen but there is neither a focal cortical rup-
ture, nor a periosteal reaction, in the absence of a fracture.
There is no extension to the soft tissue.
The enchondroma is classically recognised by the
presence of chondroid calcification within the lesion (calci-
fication in rings or arc). These calcifications may be totally
absent, in particular in the fingers (Fig. 12a, b).
The CT-scan can discern the cortical anomalies and the
matrix calcifications. It allows for an evaluation of the
non-calcified cartilaginous areas, replacing the normal fatty
medullary density by zones of tissue density correspond-
ing to zones of residual tumoral activity (Fig. 13). It is of
precious help in the search for signs of aggressivity: corti-
cal lysis or extension to the soft tissue, highly evocative of
chondrosarcoma.
Bone scintigraphy with Technetium 99m is not a very
specific examination. Homogenous and moderate hyperfixa-
Figure 10. Conventional X-rays revealing a pathological frac-
tion is often found, more peripherally in the childhood and
ture on enchondroma of the 4th (left) and 3rd (right) metacarpals
(arrows). The means for the detection of enchondroma in over one adolescent forms. This hyperfixation may persist until adult-
third of all cases. hood. An increase in the hyperfixation, compared with a
previous examination, should call to mind a sarcomatous
In conventional radiography, the enchondroma may transformation or a fracture. In addition, bone scintigra-
resemble a lytic osseous lesion of slow or no growth and phy enables the search for other possible locations. Murphey
metaphyseal or metaphyseal-diaphyseal topography. This et al. [6] propose comparing the tumoral fixation with that
metaphyseal-diaphyseal location is a very good sign of diag- of the iliac spines. A more intense fixation than that of the
nostic orientation: the lesion is rarely epiphyseal although iliac spines points to a possible chondrosarcoma.
it may sometimes extend to the entire medullary cavity From the anatomopathological point of view, an enchon-
(Figs. 7—9). A small enchondroma is only detected if it droma consists of islands of hyaline cartilage organised
induces the destruction of the endosteal side of the cor- in sometimes confluent lobules of variable size and shape
tex. These endosteal cortical erosions are well-limited and (Fig. 1). These tumours may present seats of calcification
do not generate a periosteal reaction. and certain lesions appear extensively calcified and ossified

Figure 11. Conventional X-ray in a 35-year-old patient. Enchondroma of P1 of the 3rd finger. Note the endosteal erosion (arrowheads)
covering more than two third of the thickness of the cortex. This appearance is not a sign of malignancy (as opposed to enchondromas of
the long bones).
400 A. Larbi et al.

Figure 12. a: X-ray of the hand in a 40-year-old, asymptomatic patient. Note the presence of a partially calcified enchondroma on the
base of the 1st metacarpus (arrow) and a non-calcified enchondroma of the base of P1 (arrowheads); b: MRI in T1 weighting and T1 gado
FS. Note the location of the enchondroma (arrows) at the base of the 1st metacarpus (the area of the physa) versus in distally from the
metacarpals for the other fingers.

Figure 13. CT-scan with sagittal and coronal reconstruction in

Figure 14. Histological section revealing a partially calcified
a 45-year-old patient. Pathological fracture on partially calcified
enchondroma (black arrow: hyaline cartilage, white arrowheads:
enchondroma of the 3rd metacarpus (arrow). Note the replacement
calcifications).
of the fatty bone marrow by zones of tissue density corresponding to
zones of residual tumoral activity (arrowhead). Absence of cortical
lysis or extension to the soft tissue.
of the type of cartilaginous tumour. All fragments obtained
should be studied because the histology (cellularity, appear-
(Fig. 14). The cortex is often thin and slightly repressed ance of the cells) may vary considerably from one area to
by the tumour, especially in chondroma of the fingers. another. The histological analysis of the chondrocytes should
The chondrocytes are small cells, usually with single, small be carried out in variable, non-rearranged and non-necrotic
round and even nuclei and are similar to the chondro- territories.
cytes observed in non-tumoral cartilage. Mitoses are rare The degree of cellularity may vary considerably accord-
or absent. The histological and cytological characteristics ing to the topography of the tumour and the age of the
of chondrocytes are of basic importance in the diagnosis patient, but also within the same tumour. The enchondromas
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 401

of the long bones of the hands and feet often present hyper- Diffuse enchondromatosis
cellularity with a cellular pleiomorphism, chondrocytes of Diffuse enchondromatosis or Ollier disease is among the
irregular size and shape that are sometimes floppy and osteo-chondrodysplasias. This non-hereditary osseous dys-
degenerative, often binucleate. These histological signs do plasia is characterised by an alteration in the enchondral
not necessarily attest to the malignant nature of these ossification with heterotopic proliferation of chondroblasts
lesions in this location. However, the presence, within either from fertile metaphyseal cartilage, or the deep layer
the hypercellular non-degenerative territories, of multi- of the periostium. It is characterised by the multiplic-
nucleate chondrocytes and/or presenting nuclear atypies ity and asymmetric distribution of chondromas (Fig. 16)
with an increase in the size of the nucleus and hyperchroma- (enchondromas and subperiosteal chondromas). The sym-
tism, are unusual in a chondroma of the long bones, of the ptomatology is early and constant involving deformation and
pelvis and the shoulder and point to a possible malignity. shortening. There is an increased risk of sarcomatous trans-
In spite of this, a differential histological diagnosis formation compared with the single forms.
between a benign or malignant cartilaginous tumour is often Maffucci syndrome is also a non-hereditary disease that
difficult. This is why anatomopathologists recommend the associates a unilateral or asymmetrical enchondromatosis
confrontation with the clinical and radiographic data and predominantly at the extremities with vascular lesions such
rely more on the topography of the lesion than its histologi- as capillary or cavernous haemangiomas of the soft tissue
cal appearance. With similar histology, certain cartilaginous (Fig. 17). Their distribution does not coincide. Phleboliths
lesions are benign or malignant depending on whether they are highly evocative of this.
are found in the hands or pelvis. Diffuse enchondromatosis is much more rare than the
Therapeutic abstention is the rule in the absence of sym- solitary forms with a slight predominance in men. The age
ptomatology of the enchondroma of the hands. If this is not of discovery is early, most often during childhood, but clas-
the case (pain, non-aesthetic deformation or pathological sically during the first three decades. The distribution of
fracture), surgery will consist of curettage, and then the fill- the diseased bones corresponds to that of the solitary chon-
ing of the residual cavity by a spongy autograft or by bone dromas with preferential impairment of the bones of the
substitutes (Fig. 15a, b). The rate of recurrence from the hands and feet. The bones of the axial skeleton may also be
periphery of the initial lesion is low and depends on the qual- affected, as may the craniofacial bones.
ity of the treatment of the walls of the chondroma during The positive diagnosis is based on the conventional
the primary curettage. radiological assessment. The other examinations (bone
The prognosis for solitary chondromas, outside of the scintigraphy, MRI) are only used to assess whether or not
orthopaedic problems raised by the pathological fractures there is a sarcomatous transformation of the lesions. The
and the problem of the possible recurrence after treatment, X-rays objectify both the central forms and the periosteal
is above all related to the risk of sarcomatous transforma- forms. The isolated forms of medullary and periosteal
tion of the lesion. However, this malignant transformation lesions do not differ from the isolated forms except that the
is exceptional in the solitary forms of the extremities. size is larger. The bones have abnormal outlines with short-
ening, angulation and asymmetrical expansion. The cortex

Figure 16. Conventional X-ray of the hand in a 6-year-old child

Figure 15. a: conventional X-ray in a 30-year-old patient. Patho- presenting diffuse enchondromatosis (Ollier disease). Note the
logical fracture on partially calcified enchondroma of the 3rd multiplicity of the chondromas with association of enchondromas
metacarpus (arrow); b: same patient after treatment by curettage (arrows) and periosteal chondromas (arrowheads). Their distribu-
and filling (arrow). tion is asymmetric.
402 A. Larbi et al.

Figure 18. X-ray of the 5th finger in a 15-year-old patient. Chance

Figure 17. X-ray of the hand in a 14-year-old child presenting
discovery during a fracture of the head of the 5th metacarpus of
Maffucci syndrome. Note the presence of multiple enchondromas
a periosteal chondroma of P1. The chondroma is separated from
(long arrows) with ‘‘ball’’ or ‘‘sausage’’ deformation (arrowheads)
the medullary by a ‘‘sign of the partition’’ cortical residue (short
and angioliths characterised by the presence of phleboliths (short
arrow). The inner limits are emphasised by a thin strip of osteoscle-
arrows).
rosis (arrowheads). Note the destruction of the subperiosteal side
of the cortex (long arrow).

may, at this point, be thinner so that it may completely break

off without the lesion being malignant. be found, even to the extent of full calcification of the
In Ollier disease, the risk of deterioration into chon- lesion.
drosarcoma varies from 5 to 30% of the cases, depending A CT-scan or MRI, although not indispensable, enables a
on the series. In Maffucci syndrome, this risk involves the better analysis of the extension of the periosteal chondroma
enchondromas (15 to 20% of the patients) and the angiomas in the soft tissue, as well as quantification of the depth of
(3 to 5% of the patients). the cortical nature, thereby helping determine the fragility
The treatment of chondromatosis involves two steps: the of the bone involved.
care of the chondromas and that of the deviations and short- Histologically, it has a lobular cartilaginous appearance
enings engendered by the disease. with several small seats of irregularly interspersed calcifica-
tions, and sometimes areas of enchondral ossification arising
from the underlying cortical bone.
Periosteal chondroma or ecchondroma Therapeutic abstention, provided that there is regular
The periosteal chondroma corresponds to a proliferation monitoring, is legitimate in case of asymptomatic periosteal
of mature hyaline cartilage between the periosteum and chondromas of small diameter and stable size. In other
the osseous cortex, from the para osteal connective tissue, cases, or as a principle for certain professionals, in view of
thereby accounting for its higher frequency in tendinous the difficulty in the differential diagnosis with a low grade
or ligamentous insertions. It accounts for about 15% of all periosteal chondrosarcoma, it is necessary to carry out an
chondromas [3]. It is generally detected before the age of excisional biopsy for cancer.
20 years, due to tumefaction of the soft tissue. It is pre-
dominant in men with a sex ratio of 2:1. All of the bones
may be involved with, nevertheless, a predilection for the Osteocartilaginous exostosis or osteochondroma
long bones (70%) versus only 25% for the hand and foot The exostoses account for about 10% of all primary bone
[5]. tumours. It is the most common benign bone tumour. It is a
Radiologically, the periosteal chondroma destroys the metaphyseal or metaphyseo-diaphyseal lesion located near
subperiosteal side of the cortex. The inner limits are the growth cartilage. It affects the extremities in 10% of the
emphasised by a thin osteosclerotic strip. The medullary cases.
cavity of the bone is rarely impaired and, in general, The exostosis may be sessile or pedunculated. There is
the chondroma remains separated from the latter by a always a cortical and spongy continuity between the latter
‘‘sign of the partition’’ cortical residue (Fig. 18). The and the bearing bone (Fig. 19).
presence of intra-lesional calcification seems less frequent The main complication of degeneration into chondrosar-
than in the endomedullar form. Nevertheless, radio- coma is low (< 1%), although higher for the proximal or axial
opaque microgranulations such as microcalcifications may topographies.
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 403

Figure 19. Centred conventional X-ray revealing an osteogenic Figure 20. Conventional X-ray centred on the 1st finger revea-
exostosis. Note the cortical and spongy continuity between the ling a Nora lesion of the phalangeal tip (arrowhead). As opposed to
lesion and the bearing bone (arrow). extosis, the cortex of the bearing bone is well individualised and
distinct from the lesion (arrow).

Cartilaginous tumours of the soft tissue or

pseudotumours mainly develops at the extremities (96%): 72% in the upper
limb and 24% in the lower limb. The reason for consultation
Nora’s disease is generally painless tumefaction that has asymptomatically
This is an osteochondromatous para osteal proliferation that evolved for a long time. The origin is a subject of debate.
mainly affects the phalanx (middle and proximal) of the Dahlin and Salvador [7] think that the starting point is syno-
hands and feet. This lesion evolves over time, initially with vial, whereas Uehara and Becker [8] and Rosenfeld and
tumefaction of the soft tissue and then a fast-developing Kurzer [9] find its origin in the production of connective tis-
periosteal pluri lamellar reaction called ‘‘florid reactive sue by metaplasia or activation of heterotopic cartilaginous
periostitis’’. There is no bone anomaly. The cortex oppo- islands. The latter hypothesis seems most likely. It accounts
site the tumefaction is well individualised. At the end of the for the development of chondromas within the viscera (liver,
evolution, a sessile or pedunculated osteocartilaginous mass kidney, testes, fallopian tubes, tongue) where no synovial
appears, without any continuity between the lesion and the structures exist. In the hand, repeated microtraumas have
adjacent spongy bone (as opposed to exostosis) (Fig. 20). been incriminated in the development of these tumours.
Above all, this lesion affects the 30 to 60-year-old adult.
It corresponds to a slow growing nodule. The radiological
Synovial and tenosynovial chondromatosis
assessment does not reveal bone damage, but frequently
Synovial chondromatosis is a mono-arthropathy charac- arc-shaped or ring-shaped calcifications.
terised by the formation of probably metaplastic cartilagi- The reliable diagnosis is anatomopathological. This lesion
nous seats in the synovia. This disorder affects the young is benign even if it comprises atypies. However, the recur-
adult (20—40 years), most often men. It is preferentially rence after resection is not rare (15—20%) and sometimes
found in the large articulations. The location in the extrem- multiple.
ities is not frequent [7] and malignant degeneration is rare.
Tenosynovial chondromatosis is similar to synovial chon-
dromatosis as regards the histogenesis. However, the origin
Chondrosarcoma
is in the tenosynovial sheath. No cases of malignant trans-
Chondrosarcoma is a very rare cartilaginous malignant
formation have been observed, even if, in the histological
tumour of the hand. It accounts for less than 5% of all malig-
examination, nuclear hyperactivity of the cartilaginous cells
nant tumours and less than 1% of the chondrosarcomas in the
(large nucleus, bi-nuclear nucleus) may be observed. The
entire skeleton [10—12]. The chondrosarcoma is primary in
rapid multiplication only attests to a specific activity of
almost 80% of all cases. In 20% of the cases, it is secondary
growing cartilaginous cells. However, recurrences are not
to the degeneration of pre-existing chondromas: Ollier dis-
exceptional.
ease, Maffucci syndrome, and in less than 1% of the cases to
a solitary chondroma.
Chondroma of soft tissue The age of discovery of the chondrosarcoma of the hand
Chondroma of soft tissue is a rare lesion that, by definition, is between the fifth and seventh decade. The impairment
arises in soft tissue without any connection with the bone. It to the phalanx is predominant (68%) compared with that
404 A. Larbi et al.

tumours of the hand are reputed to be tumours of local

malignancy.

Differential diagnoses: calcified lesions of

the hand
Gout
Chronic tophaceous gout corresponds to the deposit of
sodium urate crystals at the surface of the cartilage, in the
synovial membrane, the capsulo-ligamentary structures and
the soft cutaneous tissue. The distribution is often polyartic-
ular and asymmetrical (Fig. 23a). The tophi are cutaneous
and attest to the presence of more or less dense masses.
However, the density does not exceed 300 UH (average of
170 UH) (Fig. 23c, d). The well-limited osseous erosions
are secondary to the tophaceous gout. They are often sur-
rounded by an osteosclerotic fringe.
These tophi may be intra-osseous. They then attest to
the presence of a well-limited osseous gaps sometimes sur-
Figure 21. 72-year-old patient, presenting evolutive tumefaction rounded by an osteosclerosis (Fig. 24).
with the appearance of pain. Conventional X-ray revealing chon-
drosarcoma of P1 of the 2nd finger. Noted the periosteal appositions Pseudo-tumoral calcinosis
in grassfire and extension of the tumour to the soft tissue (arrow-
heads). It corresponds to the deposit of calcium masses in the soft
periarticular tissue, occurring in patients suffering from
untreated kidney failure. These masses are often large in
haemodialysed patients and in transplant patients. These
of the metacarpals (32%) and the location often neighbours
calcifications are mainly found in the hips, shoulders, knees
the metacarpophalangeal joint, especially affecting the first
and elbows. They are more often found at the extremi-
phalanx.
ties. The X-rays then find dense calcifications presenting
Tumefaction is the usual inaugural symptom and pain
multilobular outlines (Fig. 25). These deposits of calcium
occurs as soon as there is a rupture in the cortex. The rapid
hydroxyapatite are well individualised in the CT-scan with,
increase in size should draw the clinician’s attention, espe-
for the largest, the detection of levels of sedimentation.
cially after the age of 40. Certain clinical elements help
differentiate chondroma from chondrosarcoma.
The conventional X-ray enables a search for the criteria Pseudo-tumoral chondrocalcinosis
of malignancy: progressive erosion of the cortex, periosteal
reaction without fracture and extension to the soft tissue It corresponds to deposits of calcium pyrophosphate crystals
(Figs. 21 and 22a—d). in the form of a solitary calcified mass with poorly defined
Histological criteria of malignancy have been estab- contours that may resemble tophaceous gout or a tumoral
lished: cell immaturity or nuclear anomalies, hypercellular- disease (Fig. 26a, b). These deposits rarely take the form of
ity in the entire specimen or in seats with defect of the a pseudotumour. It has mainly been described in the fingers,
matrix tissue and invasion of the marrow or soft tissue. There feet, elbows, acromioclavicular joint and hip [13].
are three histological grades of increasing malignancy: grade
I (very differentiated tumour, histologically very close to a Secondary osteochondromatosis
benign cartilaginous tumour), grade II (presence of 10% cell
anomalies), grade III (non-differentiated cells with nuclear This disorder is secondary to an underlying chondropathy.
anomalies and mitoses). In spite of these criteria, the histo- Differing from synovial or tenosynovial chondramotosis, the
logical difference between the grade I chondrosarcoma and size and shape of the osteochondromatous nodules are vari-
the chondroma is sometimes difficult to determine. In fact, able (Fig. 27a, b).
the chondromas of the hand and foot (especially in case of
chondromatosis and in the young subject) present a high cel- Apatite deposition disease
lularity and more nuclear atypies than the other locations
[11]. The histological appearance alone does not confirm the This is an idiopathic disorder (certain authors have
diagnosis, but all of the clinical, radiological and evolutive incriminated repeated microtraumas) that corresponds to
aspects confirm the histological diagnosis of malignancy. periarticular and articular deposits of calcium hydroxyap-
The treatment is surgical and involves the segment ampu- atite. These calcifications are often asymptomatic. Their
tation, the choice solution, enabling eradication of the clinical manifestation (intense pain settling in 48 hours) cor-
disease and avoidance of the appearance of especially pul- responds to the resorption phase of the calcification and
monary metastases. The prognosis is good and malignant therefore the cure. The most typical example is that of the
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 405

Figure 22. a: 65-year-old patient, pain at the 2nd finger. Conventional X-ray revealing a condensing chondrosarcoma of P1. Note the
extension to the soft tissue (arrowheads); b: CT-scan in coronal sections. Note the cortical rupture (arrow) and the extension to the soft
tissue (arrowheads); c, d, e: MRI in T1 coronal sections (c), T1 axial (d) and T1 axial after gadolinium (e). The MRI helps better assess the
extension to the soft tissue (arrowheads). Note the marked enhancement of the lesion (arrow); f: bone scintigraphy with Technetium 99m.
Note the intense hyperfixation of P1 of the 2nd finger related to the chondrosarcoma.
406 A. Larbi et al.

Figure 23. a: conventional X-ray of a 65-year-old patient presenting a carpal canal syndrome. Note the polyarticular and asymmetrical
distribution of the tophaceous gout represented de 65 in the form of pseudo-tumoral formations with a dense appearance (arrowheads); b:
CT-scan in axial section passing by the carpal canal. Soft tissue window. Note the density of the tophi that do not exceed 300 UH (arrow);
c: open surgery of the carpal canal. Large tophaceous gout (arrow) of chalky appearance compressing the median nerve (arrowhead) in the
carpal canal.

Figure 24. 57-year-old patient presenting painless tumefaction Figure 25. 43-year-old patient, without specific antecedents,
of the 4th finger. X-ray of an intra-osseous tophaceous gout of P1 presenting painless tumefaction of the 1st finger. The conven-
(arrowhead) represented by a well-limited osseous gap surrounded tional X-ray reveals a pseudotumour characterised by the presence
by a osteosclerotic ridge. Note the distal location of the phalange of periarticular amorphous deposits presenting multilobular out-
(contrary to the enchondroma located in proximity). Note very lines (arrowheads). The diagnosis of pseudo-tumoral calcinosis was
dense tumefaction of the soft tissue around the proximal inter confirmed in the anatomopathological examination of the surgical
phalangeal (arrow). excision.
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 407

Figure 26. a: 62-year-old patient presenting painless tumefaction of the 2nd finger evolving for several years. The conventional X-ray
reveals a pseudo-tumoral lesion in the form of a solitary, calcified and poorly limited mass (arrows), resembling a tophaceous gout (but
more calcified). This lesion is found at the metacarpal-phalangeal joint and seems to erode the head of the metacarpus (arrowheads); b:
CT-scan with axial and sagittal reconstructions enables better visualisation of the pseudotumour eroding the cortical bone of the head of
the metacarpus (arrows). The anatomopathological examination of the surgical excision concluded as to pseudo-tumoral chondrocalcinosis.

Figure 27. a: 65-year-old patient, with a past history of chondrosarcoma of the 2nd toe of the right foot that was amputated 10 years
ago. Painless tumefaction of the base of the thumb. The conventional X-ray centred on the base of the thumb, reveals secondary osteo-
chondromatous nodules (arrowhead) in a context of trapezo metacarpal osteoarthritis (arrow); b: the MRI with coronal sequences in T1,
STIR and T1 gado FS weightings, reveals the appearance in hyposignal in all of the osteochondromatous nodules (arrowheads). Note the
presence of effusion in the trapezo metacarpal joint (arrow) in relation to the osteoarthritis.
408 A. Larbi et al.

Figure 28. 56-year-old patient, with a past history of calcifying tendinopathy of the supra spinatus. Intense, inflammatory and rapidly
appearing pain in the wrist on the ulnar side: a: conventional X-ray revealing an oval calcification near the pisiform (arrow); b: the CT-scan
confirms the amorphous appearance of these calcifications and specifies their topography near the flexi carpi ulnarus tendon (arrows); c:
MRI coronal sequence in STIR weighting revealing the appearance in hyposignal of the calcification (arrow) with considerable oedematous
signal of the neighbouring tissue; d: the control X-ray reveals the full disappearance of the calcification after 2 months (arrows) confirming
the diagnosis of apatite deposition.

shoulder. In the X-ray, the calcifications are dense, amor- of sclerosis or periosteal apposition. It is found in the meta-
phous, rounded or oval. They are found at the insertion of physeal region, near zones of growth (proximal topography
the tendons but may also be found in the articular capsule, for a metacarpal and distal in the first and second phalanx).
tendon sheaths or synovial bursa. In the hand, the calcifica- The vast majority of cartilaginous lesions of the fingers are
tions are often found on the tendon of the flexi carpi ulnarus benign, in spite of the sometimes disturbing, histological
or near its insertion on the pisiform (Fig. 28a—d). appearance. Chondrosarcoma is an exceptional lesion of the
extremities and there is a well-defined clinical context and
radiological criteria.
Conclusion
Cartilaginous tumours of the extremities are often found in
X-rays. They are often found incidentally or in the case of a Disclosure of interest
fracture. The enchondroma, by far the most common lesion,
assumes the appearance of centromedullar osteolysis associ- The authors declare that they have no conflicts of interest
ated with endosteal cortical gaps, without a peripheral edge concerning this article.
Cartilaginous tumours and calcified lesions of the hand: A pictorial review 409

References [7] Dahlin DC, Salvador AH. Cartilaginous tumors of the soft
tissues of the hands and feet. Mayo Clin Proc 1974;49:
[1] Marty FL, Marteau E, Rosset P, Faizon G, Laulan J. A retro- 721—6.
spective study of hand and wrist tumors in adults. Chir Main [8] Uehara H, Becker FP. Extraskeletal cartilaginous tumors:
2010;29:183—7. report of two cases with review of the literature. Arch Surg
[2] Geirnaerdt MJ, Bloem JL, Eulderink F, Hogendoorn PC, 1960;80:319—26.
Taminiau AH. Cartilaginous tumors: correlation of gadolinium- [9] Rosenfeld N, Kurzer A. Soft tissue ‘‘chondroma’’ of the hand.
enhanced MR imaging and histopathologic findings. Radiology Hand 1980;12:189—92.
1993;186:813—7. [10] Bonnet C, Rochet N, Arnaud M, et al. [Chondrosarcoma of
[3] Dalhin DC. General aspects and date on 8542 cases. In: Bone the fingers. A propos of 2 cases]. Rev Rhum Mal Osteoartic
Tumors. 4th sub edition Charles CT Thomas pub ltd; 1986, 1990;57:427—9.
p. 33—51. [11] Bovee JV, van der Heul RO, Taminiau AH, Hogendoorn PC. Chon-
[4] Huvos MD. Solitary enchondroma, bone tumors: diagnosis treat- drosarcoma of the phalanx: a locally aggressive lesion with
ment and prognosis. Saunders edition; 1991, p. 268—76. minimal metastatic potential: a report of 35 cases and a review
[5] Resnick D. Tumors and tumor-like lesions of bone: imaging and of the literature. Cancer 1999;86:1724—32.
pathology of specific lésions, diagnosis of bone and joint disor- [12] Nelson DL, Abdul-Karim FW, Carter JR, Makley JT. Chondrosar-
ders. 3rd edition Saunders édition; 1995, p. 3746—57. coma of small bones of the hand arising from enchondroma. J
[6] Murphey MD, Flemming DJ, Boyea SR, Bojescul JA, Sweet Hand Surg Am 1990;15:655—9.
DE, Temple HT. Enchondroma versus chondrosarcoma in the [13] Luisiri P, Blair J, Ellman MH. Calcium pyrophosphate dihydrate
appendicular skeleton: differentiating features. Radiographics deposition disease presenting as tumoral calcinosis (periartic-
1998;18:1213—37 [quiz 1244—1215]. ular pseudogout). J Rheumatol 1996;23:1647—50.