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Predicting the Risk of Pathologic Fracture for Enchondromas of the Hand Using Reproducible Clinical and Radiographic Criteria
Scott Riester, MD; Rishi Ramaesh, MD; Doris Wenger, MD; Andre van Wijnen, PhD; Sanjeev Kakar, MD
Orthopedic Surgery, Mayo Clinic, Rochester, MN

Hypothesis: The risk of pathologic fracture for enchondromas of the hand can be determined using reproducible radiographic measurements and clinical observations.

Methods: 76 surgical cases of enchondromas involving the hand were retrospectively reviewed to determine if radiographic and clinical criteria could be used to determine the likelihood of a patient having a pathologic fracture. The presence or absence of fracture for each case was determined based on preoperative radiographs and intraoperative findings. Cases without preoperative radiographs and syndromic cases of enchondromatosis were excluded. Criteria examined in this study included the hand involved (left vs right), bone involved (distal phalanx, middle phalanx, proximal phalanx, metacarpal), the digit involved (small, ring, long, index, thumb), and longitudinal percentage of the occupied up by the lesion on AP radiographs. Preoperative radiographs and clinical criteria were evaluated independently by two physicians. Odds ratios were calculated for each clinical criterion, statistical significance was evaluated using the chi-squared test.

Results: There was a statistically significant difference between the fracture and non-fracture group in regards to age (p=0.0271), the digit involved (p = 0.0075), bone involved (p = 0.0307), and percentage of the bone invaded by the lesion on AP radiographs (p = 0.0168). The small finger was the most common finger associated with fracture (19 of 20 cases). The distal phalanx and proximal phalanx were the bones most likely to present with a fracture (distal phalanx 10 of 11 cases, proximal phalanx 18 of 23 cases). There was a direct relationship between percentage of longitudinal bone involvement on AP radiographs and presence of fracture.

Summary Points: Enchondromas are the most common primary bone tumor of the hand, often found incidentally at presentation. Conservative treatment with observation and serial radiographs is often successful, but a subset of patients exist who with will go on to develop a pathologic fracture. Objective criteria to predict the likelihood of fracture in these patients is currently lacking, making it difficult for clinicians and patients to make appropriate treatment decisions. This investigation provides evidence that age, the affected finger, the affected bone, and the percentage of the bone occupied by the pathologic lesion on AP radiographs can be used as objective criteria to predict fracture risk and guide clinical decision making.

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