Soft tissue tumors and tumor-like lesions
When investigating soft-tissue masses of the hand, MRI is the leading imaging modality. A classic example of such pathology is giant cell tumor of the tendon sheath (Giant Cell Tumour of the Tendon Sheath).
For its precise verification, the axial projection is used in proton density-weighted sequences (Proton density), including mandatory fat suppression (Proton density fat-saturated). On tomograms, the pathology appears as a well-defined hypointense mass.
The typical localization of the process is the radial surface of the proximal phalanges (e.g., on the index finger). In this zone, the tumor mass spreads strictly between the bone structure and the adjacent flexor tendon (flexor tendon).
Bone dysplasias and cartilaginous tumors
Standard hand radiography remains indispensable for the initial assessment of bone structures and the detection of dysplastic processes.
- Ollier disease (Ollier Disease). Dorso-palmar (dorso-palmar / DP) radiographs visualize multiple cartilaginous tumors — enchondromas (enchondromata). They totally affect the phalanges and metacarpals, causing their marked expansion, cortical thinning, and subsequent deformation.
- Maffucci syndrome (Maffucci Syndrome). A rare condition in which multiple enchondromatosis is combined with soft-tissue hemangiomas. An important differential sign is the presence of phleboliths (phleboliths — calcified thrombi) within the soft-tissue hemangiomas.
- Nora syndrome (Bizarre Parosteal Osteochondromatous Proliferation). Lateral radiographs (e.g., of the thumb) show a bizarre ossified lesion actively originating from the dorsal surface of the proximal phalanx.
Specific arthropathy in haemochromatosis
Hand joint involvement can act as a manifesting symptom of haemochromatosis (Haemochromatosis) even before the development of the classical triad (skin pigmentation, liver cirrhosis, bronze diabetes / bronze diabetic) and laboratory confirmation (elevated ferritin).
The radiological picture externally resembles osteoarthritis, but has a highly specific distribution pattern:
- Localization: Primarily involves the metacarpophalangeal joints (MCPJs / MCP joints), most commonly of the index and middle fingers (II and III).
- Involvement spared: Interphalangeal joints remain relatively preserved (absence of severe involvement).
- Key symptom: Formation of hook-like osteophytes (hook-like osteophytes) strictly on the radial surface of the metacarpal heads.
- Associated changes: Chondrocalcinosis (chondrocalcinosis) is frequently observed, most clearly visualized in the wrist area (wrist).
The detection of a combination of MCP joint hook-like osteophytes and chondrocalcinosis requires immediate suspicion of haemochromatosis.
Imaging features of hand osteoid osteoma
Although osteoid osteoma frequently affects long tubular bones, when localized in the hand, it has a number of diagnostic features.
- Absence of periosteal reaction is a typical and specific sign for lesions located in the distal phalanges of the fingers.
- CT (Computed Tomography) is the gold standard as it reliably visualizes the tumor nidus (nidus).
- MRI may miss up to 35% of native lesions due to the small size of the nidus. However, dynamic contrast-enhanced (DCE) gradient-echo MRI demonstrates a typical pattern: rapid contrast uptake and washout (wash-in and wash-out).
The success of modern minimally invasive treatment (CT-guided radiofrequency ablation) is assessed by complete ossification of the tumor nidus.
Class and exam questions
How to radiologically distinguish haemochromatosis arthropathy from conventional hand osteoarthritis?
In haemochromatosis, the metacarpophalangeal joints of the II and III fingers are predominantly affected while the interphalangeal joints remain intact. A specific sign is hook-like osteophytes on the radial surface of the metacarpal heads.
What MRI sequence is optimal for detecting giant cell tumor of the tendon sheath?
It is best to use proton density weighting with fat suppression (PD fat-saturated), on which the tumor is visualized as a hypointense mass.
What are the specific radiological features of osteoid osteoma when localized in the fingers?
When an osteoid osteoma is located in the distal phalanges, a complete absence of periosteal reaction is typical, which can complicate standard diagnostics and necessitate a CT scan.
How does Ollier disease differ from Maffucci syndrome on radiographs?
Both diseases manifest with multiple enchondromatosis, but in Maffucci syndrome, calcified thrombi (phleboliths) are additionally visualized in the soft tissues as a sign of concomitant hemangiomas.
What else to study on this topic
- Imaging in gout (dual-energy CT / DECT application)
- Radiological patterns in rheumatoid arthritis and spondyloarthritides
- Use of ultrasound in the differential diagnosis of seronegative arthritides
- MR appearance of pigmented villonodular synovitis (intra-articular giant cell tumor)
- Local osteopenia and thickening of Adams arch in intra-articular bone tumors
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