See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/285369350

Fracture of phalanx from simple bone cyst: A rare bone lesion in the hand

Article  in  Hand and Microsurgery · January 2015

DOI: 10.5455/handmicrosurg.203499

CITATION READS

1 171

5 authors, including:

Emre Inozu Ugur Horoz

Dışkapı Yıldırım Beyazıt Training and Research Hospital Dr Ugur Horoz Clinic
16 PUBLICATIONS   43 CITATIONS    24 PUBLICATIONS   26 CITATIONS   

SEE PROFILE SEE PROFILE

Ali Teoman Tellioglu

Ankara Yildirim Beyazit University
95 PUBLICATIONS   608 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Ugur Horoz on 01 May 2016.

The user has requested enhancement of the downloaded file.

 Case Report
Original Article

Hand & Microsurgery

Hand Microsurg 2015;X:X-X
Hand Microsurg 2014;X:X-X
doi:10.5455/handmicrosurg.203499
doi:10.5455/handmicrosurg.163944

Enhancement of Palmar Advancement Flap:

A Simple Modification
Oguz Kayiran1, Ercan Cihandide2

Fracture of phalanx from simple bone cyst:

ABSTRACT
A rare bone lesion in the hand
Background: Distal fingertip amputations with exposed bone is challenging for the surgeon to manage. In order to re-
construct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar
Emre Inozu, Ugur Horoz, Ergin Seven, Hulda Rifat Ozakpinar, Ali Teoman Tellioglu
advancement flap, first described by Moberg in 1964, comprises one of the most popular options.
Methods: Thirteen patients (11 male, 3 female) with fingertip injuries were operated. Following the elevation of Moberg
flap, proposed modifications were carried out. Joint mobility and pulp sensitivity were recorded as well and advancement
ABSTRACT
scores were noted before and after the modification. These scores were assessed statistically.
Solitary bone cysts, also known as unicameral bone cysts or simple bone cysts, are benign tumors of the bone full of liq-
Results: No complications were noted and there was no need for additional surgery. Excellent joint mobility and pulp
uid. While typically seen on proximal humerus and femur bones, they are rarely seen on other bones. Simple bone cysts,
sensitivity were maintained. This modification showed a statistically significant improvement in the advancement (p<0.05).
diagnosed with X-ray. incidentally or for other reasons, are usually asymptomatic. In this case, a 25-year-old male patient
Conclusions: Moberg flap is a good option for the closure of fingertip defects. Some simple modifications, as described in
with pathologic fracture of the proximal phalanx from an undiagnosed simple bone cyst was reported and referred to the
here, can enhance the advancement while securing the entire advantages of the flap.
authors’ clinic to be treated with curettage.
Key words: Enhancement, Moberg flap, modification
Key words: Simple bone cyst, phalanx, pathologic fracture

Introduction
Introduction which are more
ment flap aggressive
proximally basedprogress and cause
on an intact short-
skin pedicle
Simple
The handboneis acysts,
uniquealsopart
known as body
in the unicameral
in andbone plays ness of bones
including bothinneurovascular
the growth phase by influencing
bundles. This techniquethe
cysts, are surrounded by a fibrotic capsule
important and often irreplaceable functions. In the in-filled with growth of plaques
establishes [4]. Simple
a successful bone cysts
neurosensation thatpulp
of the do with
not
yellowish serous
dustrialized world, liquid and are generally
occupational located
hand injuries needon to cause pathologic
a limited advancement fracture do not
as well. have any
However, symptoms
a simple mod-
the metaphysis of long bones [1,2]. It was
be healed as soon as possible. Meanwhile, several heal- first iden- except moderate pain and sensitivity, in general
ification as described here, and never been reported [4,6].
tified by Virchow
ing techniques in various
with 1876 [2,3].
optionsTypically,
are being it is seen
applied Usually,
elsewhere,theycanareenhance
diagnosed incidentally
additional with imaging
advancement.
among 5-15-year-old
to hundreds of thousandschildren and is doubly
of patients common
by experienced methods for various
Patients reasons. While plain radiography
and Methods
among males versus females[1,4]. Ninety percent of
practitioners. is quite
Theuseful,
study was computerized
performed withtomography,
informedmagnetic
consents
casesUnlike
are located
otherinhandthe proximal humerusamputations
injuries, fingertip and femur. resonance imaging, and
obtained from all participants. nuclear imaging methods
[1,3]
need Although
additionalrarely seenin
attention inorder
small to
bones, the most
establish fre-
a normal can be put to use for differential diagnosis. Aneurys-
Technique
quent location being
pulp sensibility and the calcaneus,
maximum the of
range hand and pha-
motion, and mal bone
Thirteencyst,patients
enchondroma,
(11 males, intraosseous
3 females) ganglion
with fin-
lanx location is exceptionally rare [5]. Furthermore,
like others to maintain the upmost level of hand func- cyst,
gertip injuries were operated under regional chon-
giant cell tumor, chondrosarcoma, and anaes-
though
tioning.the actual incidence of illness is not clearly un- dromicsoid fibroma are all components
thesia. Palmar advancement flap was raised over theof differential
derstood, 3% isthe
In 1964, seen among
volar all bone lesions
advancement [2].first
flap was Whilede- diagnosis
parathenon [1,4].
(1) The objective
(Figure of treatment
1a). Both of simple
neurovascular bun-
the cysts that appear may cause invasive
scribed by Moberg for the reconstruction of pulp de- pathologic bone cysts is to prevent pathologic fractures
dles were included in the flap so that neurosensible while also
fracture through
fects of the thumb reaching
(1). Thistheflap
bone
is ametaphysis, those
pedicled advance- treat already
coverage fractured bones.
is accomplished In treatment,
(Figure curettage
1b). To increase the
Author affiliations : Department of Plastic, Reconstructive and Aesthetic Surgery, Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
Correspondence : Ugur Horoz, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Yıldırım Beyazıt Education and Research Hospital, Ankara,
Author affiliations : Department of Plastic, Reconstructive and Aesthetic Surgery,1 Izmir University, Izmir/Turkey, 2 Bahcesehir University, Istanbul/Turkey
Turkey. e-mail: ugur_horoz@hotmail.com
Correspondence : Oguz Kayiran, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Izmir University, Izmir/Turkey. E-mail: droguzk@yahoo.com
Received / Accepted : October 01, 2015 / October 23, 2015
Received / Accepted : July 08, 2014 / August 12, 2014
© 2015 Turkish Society for Surgery of the Hand and Upper Exremity www.handmicrosurgeryjournal.com
© 2014 Turkish Society for Surgery of the Hand and Upper Exremity www.handmicrosurgeryjournal.com
Inozu E et al.
and bone grafting, strictly curettage, steroid injection,
bone marrow injection, and decompression are report-
ed methods from the literature that have been widely
used [3,4,7]. Here, a simple bone cyst, diagnosed with
a pathologic fracture, and located on proximal phalan-
ges, as described a rare location, is reported.
Case Presentation
A 25-year-old male patient was referred to the au-
thors’ clinic with the complaint of sudden pain located
in the proximal phalanx of the left hand’s 4th finger that
had an angulation deformity. In the physical examina-
tion, hypersensitivity with palpation, flexion difficulty,
and ulnar deviation on the 4th finger were identified.
X-ray imaging of the lesion revealed a fracture line and
8 mm lytic bone cyst with cortical thinning and mar-
ginal sclerosis around the cyst (Figure 1a). The patient
was operated on under local anesthesia. The bone cyst
was exposed with a dorsal incision lateral to the exten-
sor tendon and the bony window was opened by drill-
ing. Afterwards, a yellowish, serous cyst liquid drained
spontaneously from the cavity. After curettage of the
cyst cavity, operation ended with reduction of fracture
lines. The patient followed up by hand splinting for four
weeks. Pathologic examination was documented as a
simple bone cyst (Figure 2). During follow-up, healing
of the fracture line and new bone formation filling the
A B
Figure 1. (A) X-ray image of lesion showing a transverse fracture line and lytic bone lesion with marginal sclerosis, (B) post-operative 4th week:
view of healing fracture line and cyst cavity after curettage, (C) postoperative 1st year: new bone formation filling the cyst cavity.
XX | Hand and Microsurgery
cavity was seen in the plain graphs (Figure 1b, 1c). The
post-operative period was uneventful.
Discussion
Simple bone cysts are benign, solitary lesions of-
ten seen on long bones’ metaphysis. More than 90%
of cases are on the femur or proximal humerus. They
can also be seen on the pelvis, jaw, cranium and ribs.
Although it is rarely seen on carpal bones, if they arise,
they are seen more on the skafoid, lunat, and capitatum
[1]. Simple bone cysts have been seen to be extremely
rare on proximal phalanges. In the literature, few cases
are reported that feature simple bone cysts located on
the metacarps or phalanges [3]. Etiologically, an actual
cause is not currently known. There are a variety of the-
ories suggesting that simple bone cysts can occur after
growth plaque irregularities, local vascular anomalies
causing venous obliterations, or traumatic bone inju-
ries [1,8]. It is not openly stated that trauma has a role
in cyst creation.
Simple bone cysts have no specific symptoms ex-
cept a steady and moderate pain. Usually, they are diag-
nosed in patients who have a symptomatic pathologic
fracture or through incidental imaging methods for un-
related symptoms [5]. More common than not, they are
diagnosed through radiologic and pathologic examina-
tion. With this, plain radiographies are frequently used
C
Year 2015 | Volume X | Issue X | X-X

Figure 2. Pathologic view of cyst: the wall of the cyst has thin fibrous
lining and contains connective tissue that includes giant cells, hemo-
siderin pigments, and cholesterol clefts (imaged through hematoxylin-
eosin staining, x40).
in radiologic diagnosis. Radiologically, a cyst is radio-
lucent, sharply demarcated, lytic lesion located on the
mid axis of the metaphysis. A fragmented bone cortex
can be visible in the cyst cavity, referred to as a ‘fallen
fragment’. This sign is not pathognomonic and is seen
in approximately 20% of cases. Magnetic resonance im-
aging is the other major diagnostic method employed
but not used routinely. In general, it is reserved for
cases that need extra attention in terms of surgical plan-
ning, such as for metaphyseal growth plaques that are
neighboring to the cyst. Computed tomography has no
value for diagnosis except for pelvic bone cysts.
Simple bone cysts can be diagnosed from similar
lesions with physical, radiologic, and pathologic ex-
amination. In terms of differential diagnosis, aneurys-
mal bone cysts are the most frequently seen pathologic
lesion for this location [5,6]. Aneurysmal bone cysts
are recognized according to a patient’s clinical corre-
lation and symptomatology. Patients with them have
a gradual onset of pain, swelling, and hyperemia over
the skin [5]. Macroscopically, blood absorbed sponge
images are pathognomonic for aneurysmal cysts. Mi-
croscopically, cysts are filled with blood that includes
macrophages rich in hemosiderin, fibroblasts, capil-
laries, and giant cells. The most frequent bone tumors
on the phalanx are enchondromas that demonstrate a
well-defined lytic lesion on radiographs but present as
solitary lesions containing calcified chondroid matrix.
Besides less frequent lesions, such as giant cell tumour,
chondrosarcoma, and chondromyxoid fibroma, osteo-
www.handmicrosurgeryjournal.com
Pathologic fracture of simple bone cyst
blastoma and metastatic lesions should be kept in mind
[2]. Histopathological evaluation becomes more diffi-
cult in patients who have pathologic fracture because of
repetitive changes.
Simple bone cysts are benign lesions that do not
require routine biopsy and treatment in asymptomatic
cases. Although there are many different procedures for
treatment, such as subtotal resection, curettage, repair
with bone graft, and intralesional steroid or saline in-
jection, none are widely accepted treatments [5,9,10].
In a study by Hagmann et al. where 46 patients were
followed over the course of 52 months, the most suc-
cessful results were seen with bone graft application
after curettage; there was no relapse or recurrence af-
terwards [2]. Simple bone cysts identified with a path-
ologic fracture should be treated with closed reduction
as, using this method, 25% of the cysts regress sponta-
neously [9].
Overall, simple bone cysts are benign masses that
destruct bone. They can come about by causing patho-
logic fracture or through imaging methods taken inci-
dentally. Cysts on the phalanx of the hand are reported
more rarely in the literature. Although the phalanx is
an unusual location for simple bone cysts, it should be
considered during diagnosis.
Conflict of interest statement
The authors have no conflicts of interest to declare.
References
1. Javdan M, Zareradeh A, Gaulke R, Eshaghi AM,
Shemshaki H. Unicameral bone cyst of scaphoid:
a report of two cases. J Orthop Surg (Hong Kong)
2012;20:239-42.
2. Hagmann S, Eichhorn F, Moradi B, Gotterbarm T,
Dreher T, Lehner B, et al. Mid and long term clini-
cal results of surgical therapy in unicameral bone
cysts. BMC Musculoskelet Disord 2011;12:281.
3. Sung AD, Anderson ME, Zurakowski D, Hornicek
FJ, Gebhardt MC. Unicameral bone cyst: a retro-
spective study of three surgical treatments. Clin
Orthop Relat Res 2008;466:2519-26.
4. Tey IK, Mahadev A, Lim KB, Lee EH, Nathan SS.
Active unicameral bone cysts in the upper limb
are at greater risk of fracture. J Orthop Surg (Hong
Kong) 2009;17:157-60.
Hand and Microsurgery | XX
Inozu E et al.
5. Duymaz A, Karabekmez FE, Çobanoğlu M, Karataş
C, Karabekmez LG. [Unusual locatıon of the uni-
cameral bone cyst: a proximal phalanx of the hand]
[Article in Turkish]. Turk Plast Surg 2014;22:30-4.
6. Ikeda M, Oka Y. Cystic lesion in carpal bone. Hand
Surg 2000;5:25-32.
7. Jasan M, House JH, Brand JC. Bilateral unicameral
bone cysts in the hamate bones. J Hand Surg Am
1990;15:888-90.
XX | Hand and Microsurgery
View publication stats
8. Aarvold A, Smith JO, Tayton ER, Edwards JC,
Fowler DJ, Gent ED, et al. The role of osteoblast
cells in the pathogenesis of unicameral bone cysts.
J Child Orthop 2012;6:339-46.
9. Farber JM, Stanton R. Treatment options in uni-
cameral bone cysts. Orthopedics 1990;13:25-32.
10. Gündeş H, Sahin M, Alici T. Unicameral bone cyst
of the lunate in an adult: case report. J Orthop Surg
Res 2010;30:79.
Year 2015 | Volume X | Issue X | X-X