ISSN 0972-978X 

  About COAA








GCT Of Proximal  phalanx of ring finger in immature skeleton -Resection and Reconstruction by  iliac crest graft- A case report

Gadegone W M.*, Salphale YS, Sonwalkar Hemant A, Nagtode Pankaj P, Navghare Shishir M

*Chandrapur  Multispeciality Hospital, Mul Road, Chandrapur 442401, India

Address for Correspondence
Dr.Yogesh .S. Salphale
“Shushrusha”, Opp.Z.P,Chandrapur 442401  India
Tel: (C)0091 7172 250131/263773
Fax: 0091 7172  255600
E Mail:


A variety of tumors or tumorous    conditions occur in the hand, but they are usually benign. The hand has limited free space and exquisite sensitivity, and even small   histologically benign masses can cause significant swelling, pain, and disability.
Giant cell tumor [GCT] or Osteoclastoma is a benign tumor which is locally aggressive and has a tendency for local recurrence. GCT’s     form about 4-5% of all primary bone tumors. 80% of the patients are above the age of 18 years and there is a distinct female predominance.
85-90% of the cases occur in the long bones, the sites most commonly affected being the lower end of the femur, upper end of the tibia, the lower end of the radius and sacrum. Only 2% of giant cell tumors occur in the hand. We are presenting a case of a giant cell tumor of the Proximal   phalanx of ring finger which is a very rare site for such a tumor and presenting a follow up of 60 months following resection and reconstruction by  iliac crest graft .

J.Orthopaedics 2007;4(2)e5

Case Report:

A 15 year-old female presented to us with the complaints of pain and swelling of her left ring finger since  three and half  months. There was no history of trauma or any constitutional symptoms. The swelling had gradually increased in size and there was a gross restriction of movements of the affected ring   finger   . On physical examination, there was a localized swelling over the left ring finger. The skin overlying the swelling   was free and the movements of the metacarpo phalangeal   joints were painful and restricted.(Fig 1)

Radiographs revealed an expansile  osteolytic lesion of proximal  phalanx of ring finger extending upto the  metacarpo phalangeal joint. (Fig 2) Extensive local bony destruction, cortical breakthrough, and  soft tissue expansion   was noted. A fine needle aspiration cytology was done and the diagnosis   of a giant cell tumor was confirmed.

Grossly the tumor consisted of brownish cheesy material which   had involved the entire phalanx. Histopathological examination showed a well vascularized,  highly cellular tissue consisting of stromal mononuclear cells and multinucleated giant cells present in close association with each other.  Stromal cells were numerous, predominantly round to oval with foci of spindling, mild degrees of atypia and occasional mitosis. The areas of fibrous muscle tissue was seen with a few dead bony pieces . 

The tumor was carefully removed and the proximal and distal joints inspected. Articular cartilage of the metacarpophalangeal joint was not visible and therefore the decision of resecting the proximal phalanx along with the articular surface of the phalanx was carried out. The periosteal  sleeve  and the distal articular  surface of the proximal phalanx was left intact.

The fibro-osseous cartilage portion of the iliac graft  was taken mimicking the phalanx in size and shape. The graft was harvested  within the remnant of the  periosteal sleeve .Temporary fixation with K wire was done. The  K wire was removed after three months.(Fig 3) The patient was reviewed for 3,6,9 12 months initially and thereafter every yearly.

The serial xrays within  showed good incorporation and consolidation of the graft with excellent functional results. (Fig 4)There was no signs of the diseases elsewhere in the body

At 60   months follow-up, there was no signs of recurrence both clinically and radiologically with good functional recovery commensurate with her demands of daily activities. There is also a formation of good  proximal articular surface of the phalanx.

Discussion :

Giant cell tumors of the bones of the hand are rare accounting for only 2% of cases and phalangeal   location of the tumor is more common than metacarpals .Giant cell tumor of the bone is a benign, but locally aggressive lesion. It is a relatively rare tumor composed of connective tissue stromal cells having the capacity to recruit and interact with multinucleated giant cells that exhibit the phenotypic features of  osteoclasts [1].  In a review of all cases of giant cell tumors of the bone at the Mayo Clinic over a 50 year period ending in 1994, only 13 GCTs involved the hand, and only three involved the thumb [2] . When present in the hand they generally extend to the articular cartilage and are eccentrically located.[3]

GCT of the hand seems to represent a different lesion than conventional GCT in the rest of the skeleton. There is an 18% incidence of multicentric foci indicating that a bone scan should be a part of routine workup of these tumors [4] Overall they appear in a younger age group and recur more rapidly in the hand than they do in other locations. In a series of 326 GCT’s studied , Picci et al  concluded that only six histologically proven cases had an open epiphyseal plate which accounted for 1.8% of their series. [5] The mean age of patients presenting with giant cell tumors is 32, whereas the mean age for presentation with a GCT of the hand is even less (only 22). [6]

They also have a shorter duration of symptoms averaging six months or less before a diagnosis is made as in our case [7]   Even though  cortical disruption takes place , the periosteum is rarely breached [8]

Despite the fact the GCT is not a sarcoma, the extent of tumor at the time of diagnosis and the high recurrence rate following limited resection often dictate the need of an enbloc resection through normal tissues to prevent local recurrence of the lesion. Such a treatment creates a significant skeletal defect and a challenging reconstructive problem. The various treatment modalities described in literature are curettage, curettage and bone grafting, irradiation, amputation, and resection with  reconstruction. [1,2]

Local resection of the involved phalanx with autograft or allograft replacement is the preferred surgical treatment for several reasons. In addition curettage with or without bone grafts has resulted in recurrence rates of about 90%. Thus curettage is an unacceptable form of treatment. Secondly, although amputation may prevent recurrence, it is cosmetically deforming and decreases the function of the hand . [7 ]

The proximal phalangeal joint reconstruction can be achieved by metatarsal substitution, a combined iliac crest and metatarsal head graft [9] and prosthetic replacement [10 ]. The use of radiation as the primary treatment of a giant cell tumor of bone has been associated with malignant transformation .

However, in our case we used the remnant of the periosteal sleeve for harvesting the iliac crest graft. The aim of our paper is to demonstrate   the efficacy of the iliac crest graft and the   consolidation and molding according to the functional demands of the hand. It also depicts the   effect of mobilization of the ring finger in moulding the iliac crest  graft on the metacarpal  head and also to demonstrate the molding of the iliac crest  graft similar to phalanx.  This  approach allowed wide resection for local tumour control, re-established structural integrity, preserved  metacarpophalangeal joint motion and allowed early motion.

Reference :

  1. Giant cell tumor of bone. An  analysis of 218 cases J  Bone and Joint Surgery [Am] 1970; 52:619-64.Goldenberg RR, Campbell CJ, Bonfiglio M.

  2. Giant Cell Tumors of the Bones of the Hand. Journal  of Hand Surgery1997. 22A: 91-98.Athanasian, EA.

  3. Radiology of the Hand. 254-255. 1986 Cornelis, JP

  4. Giant cell tumors of the bones of hand.  Journal of Hand Surgery 1980; 5:39-50. Averill  RM, Smith RJ, Campbell CJ

  5. Giant-cell tumor of bone in skeletally immature patients    J-Bone Joint Surg-Am. 1983 Apr; 65(4): 486-90 Picci-P, Manfrini M, Zucchi V, GherlinzoniF, RockM, BertoniF, Neff-JR

  6. Giant Cell Tumor of the Distal Phalanx of the Hand in a Child. Clinical Orthopedics and Related Research. 310: 200-207, 1995  Yin, Y.

  7. Giant cell tumor. A study of 195 cases. Cancer 1970; 25:1061-70. Dahlin DC, Cupps RE, Johnson EW Jr.

  8. Dahlin's bone tumors: general aspects and data on 11,087 cases. New York, NY: Lippincott-Raven; 1996: 463  Unni KK

  9. Experimental and clinical autogenous distal metacarpal reconstruction. Clinical Orthopedics 1971; 74:129. Kettlekamp DB, Rampsey P. 

  10. Case Report  of a Giant cell tumor of the second metacarpal bone and implantation of a cement prosthesis. Hand  Chirurgie 1979; 11:251. Dingles WR, Rolle HJ


This is a peer reviewed paper 

Please cite as :Gadegone W. M : GCT of Proximal  phalanx of ring finger in immature skeleton -Resection and Reconstruction by  iliac crest graft- A case report

J.Orthopaedics 2007;4(2)e5





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.