Nora's lesion of 2nd metacarpal treated by wide excision, autologous fibular grafting and metacarpophalangeal joint replacement: A rare case report

Abstract

Bizarre paroxysmal osteochondromatous proliferation (BPOP) is a rare benign neoplastic lesion predominantly affecting small bones of the hand and known for its recurrence after local excision. We describe a rare case of BPOP involving second metacarpal of the dominant hand which was treated using a novel technique. Wide excision and reconstruction with non-vascularised fibular autograft was performed along with metacarpophalangeal joint replacement. At a follow up of two years, there was no evidence of recurrence and patient had good functional outcome. Hence this modality of treatment could be considered in dealing such cases of BPOP involving the small bones of hand.

Keywords: Fibular grafting; Metacarpal; Metacarpophalangeal joint replacement; Nora’s lesion.

Fig. 1

Clinical photograph of the lesion. A diffuse bony hard swelling of size 4 × 4 cm was localised to the dorsal aspect of the index metacarpal of the right hand.

Fig. 2

Plain radiograph of the right hand. A well defined heterogenous radiolucent lesion appear to be arising from the surface of 2nd metacarpal with matrix calcification.

Fig. 3

NCCT scan with 3D reconstruction of the right hand. A well defined lytic destructive lesion arising from the extensor aspect of the 2nd metacarpal contiguous with the medullary cavity of the underlying bone.

Fig. 4

MRI of the right hand. T2 Sagittal and axial MRI images showing well defined hyperintense mass lesion contiguous with the medullary cavity.

Fig. 5

Histopathological microphotographs of the lesion. a) Microscopic view showing bone trabecula associated with fibrous tissue (40× magnification), b) Microscopic view showing a tumoral proliferation with osseous, cartilaginous and fibrous components (40× magnification).

Fig. 6

Post-operative radiograph. Anteroposterior and lateral views of the right hand showing fibular graft fixed with 2.4 mm locking compression condylar plate and the metacarpophalangeal joint replacement.

Fig. 7

Post-operative clinical photographs of the patient. The patient can actively make a fist and do pinching action with the index finger.