What is the diagnosis and management for a small lucency in the third proximal phalanx?

From the Guidelines

A small lucency in the third proximal phalanx is most likely an enchondroma, which is a benign cartilaginous tumor, and can be managed with observation and periodic radiographic follow-up every 6-12 months, as recommended by recent guidelines 1. The diagnosis of a small lucency in the third proximal phalanx is typically made based on radiographic findings, and in this case, the impression suggests that the alignment is maintained, there are no acute fractures, and no suspicious osseous lesions, which supports the diagnosis of an enchondroma.

• The patient's symptoms and medical history should be taken into consideration when determining the management approach.
• Asymptomatic enchondromas do not require immediate treatment, unless they cause pain, pathologic fracture, or show concerning features for malignancy, as noted in the guidelines for bone sarcomas 1.
• If the patient experiences pain, over-the-counter analgesics like acetaminophen or NSAIDs such as ibuprofen can be used for symptom control.
• Surgical intervention with curettage and bone grafting is only indicated for symptomatic lesions, those at high risk of fracture due to size, or lesions with suspicious features on imaging, as recommended by the guidelines for chondrosarcomas 1.
• Enchondromas are composed of hyaline cartilage and typically appear as well-defined lucent lesions with or without calcifications on X-ray, and malignant transformation is rare, except in patients with multiple enchondromas, as discussed in the guidelines for bone sarcomas 1.
• A follow-up x-ray in 7-10 days may be obtained as clinically dictated to monitor the lesion and ensure that it does not change in size or appearance, which is a reasonable approach given the low risk of malignancy in this location, as noted in the impression.

From the Research

Diagnosis

• The diagnosis is a tiny nonspecific nonaggressive appearing lucency within the central shaft of the third proximal phalanx, which could represent a tiny enchondroma 2.
• Enchondromas are benign bone tumors originating from cartilages, and they are mainly discovered incidentally in radiographs or due to symptoms like pathological fracture or pain.

Management

• The management of enchondromas can be either conservative or surgical, with conservative treatment involving regular check-ups and surgical excision using curettage 2.
• Small localized asymptomatic lesions can be treated conservatively, while most expanding or symptomatic lesions should be treated with simple curettage 2.
• A study found that surgery did not prove superior compared to conservative clinical and radiological observation, and due to the low risk of transformation into higher-grade tumors and better functional results, more lesions might just be observed if continuous follow-up is assured 3.
• Another study proposed surveillance with plain radiographic follow-up for stable enchondromas every 3-6 months for the first year and then annually for at least three years of total follow-up, with significant cost savings by limiting MRI imaging in the absence of clinical or radiographic concern 4.
• A recent study presented simple curettage and early mobilization as a safe and effective treatment for enchondromas of the hand, with no complications recorded in their cohort 5.

Follow-up

• Follow-up x-ray in 7-10 days may be obtained as clinically dictated.
• Regular follow-up is necessary to monitor the lesion and detect any potential growth or changes.
• Radiology plays an important role in the study of bone physiology and can be a useful tool for illustrating concepts of physiology that underlie the normal and abnormal radiologic appearances of bone 6.