Small asymptomatic lesions with a typical radiographic appearance may simply be observed.

Large
or symptomatic enchondromas or lesions that do not demonstrate a characteristic radiographic
appearance should be treated by biopsy and curettage. Pathologic fractures may be treated
acutely, but the evaluating pathologist should be given the clinical history because the presence of
osteoid seen during fracture healing may add confusion to the pathologic diagnosis. Alternatively,
the lesion may be treated after the pathologic fracture has healed. There are data to suggest that
clinical outcome may be improved if treatment is done after healing of the pathologic fracture. 2

2. Ablove RH, Moy OJ, Peimer CA, et al: Early versus delayed treatment of enchondroma, Am J Orthop 29:771-772,
2000.

Enchondromas may be approached dorsally or laterally. The initial biopsy should be done through a
limited exposure and the diagnosis confirmed on frozen section before proceeding with wider
exposure. Several reports have emphasized the need for thorough curettage, with recurrence being
attributed to inadequate curettage. Intraoperative radiographs are useful to be certain of complete
removal of all tumor (see Figure 65.49C). Iliac crest or distal radius bone graft has been most
commonly used to fill the defect left after curettage

20. Bauer RD, Lewis MM, Posner MA: Treatment of enchondromas of the hand with allograft bone, J Hand Surg [Am]
13:908-916, 1988.

224. Kuur E, Hansen SL, Lindequist S: Treatment of solitary enchondromas in fingers, J Hand Surg [Br] 14:109-112,
1989.

287. Noble J, Lamb DW: Enchondromata of bones of the hand: a review of 40 cases, Hand 6:275-284, 1974.

although fresh frozen or freeze-dried irradiated allograft has been used with similar excellent results
reported.20,195 More recently, several authors have reported excellent results with simple curettage
without filling the defect with any material.165,173,370,377 Injectable calcium phosphate bone cement
has been used to fill the defect in one small series. 397

397. Yasuda M, Masada K, Takeuchi E: Treatment of enchondroma of the hand with injectable calcium phosphate bone
cement, J Hand Surg [Am] 31:98-102, 2006.

Although data are limited, whether or not the cavity is filled with any material does not appear to
affect the risk for local recurrence. The latter methods eliminate the morbidity of graft harvest and
are an alternative to iliac crest bone graft. There is a small but real risk of disease transmission with
allograft. It is not clear whether there is an increased risk for fracture if the cavity is not grafted or
whether certain lesions are best excluded from this form of treatment. The incidence of local
recurrence after curettage was 4.5% in the largest published series. Early mobilization may be
encouraged in an effort to minimize joint stiffness, provided that there is sufficient residual bone
stock and stability. Filling the curetted cavity with methylmethacrylate cement has been advocated
to ensure immediate stability and facilitate early motion. Malignant degeneration of monostotic
enchondroma to chondrosarcoma, though rare, has been well described. 90,285,394

AUTHOR’S PREFERRED METHOD OF TREATMENT

I prefer to expose phalangeal lesions from a lateral approach rather than dorsally to minimize
scarring and contamination of the extensor mechanism. My current preference is to fill the curetted
cavity with freeze-dried irradiated allograft mixed with the patient’s bone marrow. I never use local
bone graft from the radius or ulna in treating any bone tumor in the hand because of the risk of
contamination of the donor field with tumor cells.

 Draw a limb salvage incision or amputation flaps in the event of a final diagnosis of chondrosarcoma.  Fill the cavity with autograft or allograft.  Initiate early active or active-assisted range of motion exercises under supervision.  Place needle markers in the bone cavity and obtain radiographs to confirm adequate curettage.  Consider using Kerrison rongeurs to allow the creation of precise bone windows. .  Minimize dissection or retraction of the extensor mechanism to minimize postoperative adhesions.  Apply a splint for 6 weeks or as indicated.  Monitor for local recurrence (4% to 5% risk). Postoperative Care  Confirm the diagnosis on permanent analysis. CRITICAL POINTS: TREATMENT OF ENCHONDROMA OF THE BONES OF THE HAND Indications  Same as for biopsy  Lesions at risk for pathologic fracture  Lesions in which pathologic fracture has previously occurred Technical Points  Review the case with a pathologist in advance and confirm availability of the pathologist at surgery.  Use radial or ulnar lateral incisions when possible.  Place the biopsy incision in line with the limb salvage incision or within the amputation field. as indicated.  Confirm the diagnosis of enchondroma on frozen section analysis.