Diagnostic and Interventional Imaging (2014) 95, 1035—1044

ICONOGRAPHIC REVIEW / Musculoskeletal imaging

Non-traumatic calcifications/ossifications ofthe bone surface and soft tissues of thewrist, hand and fingers: A diagnosticapproach

S. Tourainea,∗, M. Wybiera,b, E. Sibileaua, I. Genaha,D. Petrovera,c, C. Parlier-Cuaua, V. Boussona,J.-D. Laredoa

a Radiologie ostéo-articulaire, hôpital Lariboisière, AP—HP, 2, rue Ambroise-Paré, 75475 Pariscedex 10, Franceb Imagerie médicale Léonard-de-Vinci, 43, rue Cortambert, 75016 Paris, Francec Centre d’imagerie Bachaumont, 6, rue Bachaumont, 75002 Paris, France

KEYWORDSCalcification;Ossification;Wrist;Hand;Finger

Abstract In the absence of obvious trauma, the calcifications/ossifications of the bone sur-face and soft tissues of the wrist, hand and fingers can be challenging and may not be noticed orlead to unnecessary examinations and monitoring. Although these are usually benign conditionsand despite a favorable spontaneous outcome, surgical resection may be required and recur-rence may occur. In practice, only paraneoplastic syndromes such as secondary hypertrophicosteoarthropathy (Pierre Marie-Bamberger syndrome) may reveal a malignant tumor, most oftenpulmonary. We suggest a diagnostic approach based on the initial clinical presentation (acute

pain, chronic pain, growth ± pain) and the radiological features.© 2014 Éditions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Calcifications and ossifications that develop on the surface of bone and in the softtissue of the wrist, hand and fingers are usually benign. In practice, only paraneoplastic

syndromes such as Pierre-Marie-Bamberger syndrome may reveal a malignant tumor that isusually pulmonary and cyanotic. Primary malignant tumors in the soft or paraosteal tissuesare rare in the wrist, hand and fingers. Acral metastases are rare and usually develop inadvanced, previously diagnosed tumoral diseases.

∗ Corresponding author.E-mail address: sebastien.touraine@lrb.aphp.fr (S. Touraine).

http://dx.doi.org/10.1016/j.diii.2014.07.0042211-5684/© 2014 Éditions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

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Table 1 Diagnostic table of calcifications of the soft tis-sues and the surface of the bones of the wrist, hand andfingers in relation to the initial clinical presentation.

Acute non-traumatic painHydroxyapatite depositFlorid periostitis - Nora’s lesion - Turret exostosisMyositis ossificans circumscripta

Chronic painTendinosis — Mechanical enthesopathyPsoriatic arthritisOsteochondromatosisCalcium pyrophosphate dihydrate crystal deposition

disease (CPPD)GoutConnectivitis (Scleroderma/CREST - Dermatomyositis)Chronic renal failurePierre Marie-Bamberger syndrome

Swelling ± painChondromaVascular malformationCalcifying aponeurotic fibroma

036

The morphological features of these calcifications areess discriminant than the underlying anatomical structurehere they are located, an anatomical structure that isot specific for the causative agent. The clinical featuresslow growing, swelling, acute or chronic pain) are essentialiagnostic criteria (Table 1) to help determine the locationnd morphology of these calcifications or ossifications. Inhe absence of any obvious trauma, and because of theany different possible benign conditions, it is important

o help the clinician define those that may require surgicalanagement (osteochondromatosis, Nora’s lesion, vascularalformation, calcifying aponeurotic fibroma), those thatay reveal a metabolic disorder or a systemic disease (cal-

ium pyrophosphate dehydrate crystal deposition disease,out, kidney failure, connective tissue disease, psoriaticrthritis) and those that can be treated symptomaticallyhydroxypatite crystal deposits, tendinosis).

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ydroxyapatite crystal deposits

ydroxyapatite is one of the most stable forms of basic cal-ium phosphates (Fig. 1). It is naturally present in bone,

namel and dentin, where it is the main mineral component.n acute and solitary periarticular, peritendinous or intraar-icular hydroxyapatite deposit may occur, possibly due to

igure 1. Acute deposits of hydroxyapatite crystals in the soft tissues of P1 of the 2nd ray (arrow) (A), on axial CT scan at the distal insertion

ase (arrow) (B), on conventional radiography (arrows) (C), ultrasound (nsertion of the extensor carpi ulnaris (E). Note on ultrasound the echoD-star) and the Doppler hyperhemia consistant with the local inflamma

f three different patients: on conventional radiography at the baseof the extensor carpi radialis longus muscle on the 2nd metacarpalD) and Doppler ultrasound near the triquetral bone and the distalgenic mass with the calcium spots and no posterior shadow cone

tion (E).

1037

Figure 2. X-ray of a florid periostitis of the 5th finger at 3 monthintervals. A. Periosteal growth begins on the radial aspect ofP1(arrow). B. Large long bone growth (arrows) along the axis of thepM

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Non-traumatic calcifications/ossifications

local hypoxia leading to crystalline precipitate. Recent, orfairly recent traumas are found in certain cases when thepatient is questioned.

Theoretically this acute deposit may develop anywhere,but certain zones are more common (‘‘disease with cal-cium phosphate crystals in multiple tendons’’), such as theapophyseal insertion of the greater or lesser tuberosity ofthe humerus, the deltoid V-shaped tendinous confluence andinsertion on the deltoid tuberosity of the humerus, the inser-tion of the gluteus maximus on the linea aspera as well asthe cervical spine (periodontoid soft tissue and transverseligament of the atlas, insertion of the long muscle of neck).The calcification may be located in the tendon, its sheathor in the adjacent serous bursa. The sudden inflammatoryreaction associated with partial or total resorption of thiscalcium deposit is the cause of the violent clinical reactionas well as the biological inflammatory syndrome. These cal-cium crystal deposits may also be found in the wrist, thehand or the fingers, although this is less frequent, wherethey may mimic arthritis or tenosynovitis [1]. The insertionof the flexor carpi ulnaris on the pisiform bone is frequentlyinvolved in the wrist [2]. Whatever the location is, thesedeposits are often solitary or fragmented, fairly round oroval shaped, of irregular density, milky and without trabe-cular or cortical bone, differentiating them from a process ofossification. Cortical erosions may be found in contact withthe deposits. Intramedullary penetration with an cancellousbone edema may be observed especially on the femoral orhumeral diaphyses. The outcome is usually favorable withinseveral days. In the hand or fingers, persistent deposits mayrequire surgical resection because of discomfort, swelling,or impingement of adjacent anatomical structures.

Proliferative periostitis, Forid reactiveperiostitis, Nora’s Lesion, Turret exostosis

These entities may be expressions of the same disease. Theymay be diverse presentations of so-called reactive periosteallesions that are observed on radiographic imaging at differ-ent times [3]. A traumatic or microtraumatic origin of theseentities is a subject of debate, because trauma is not alwaysreported. These different lesions are usually found in theextremities and in particular the proximal phalanges of thefingers.

Florid periostitis (Fig. 2) begins with painful swelling ofthe soft tissues (dactylitis) associated with a periosteal reac-tion that progresses along the phalangeal diaphysis withinseveral weeks. It may be circumferential and mimic an infec-tious (osteomyelitis) or tumoral (osteosarcoma) process inthe bone [4]. The periosteal lesion is often compact andirregular with a crenelated appearance that may result infusiform enlargement of the phalanx. Cortical erosion hasoccasionally been described in contact with the periosteallesion. Unlike exostosis, the lesion progresses and producesmore mature bone with no visible continuity with themedullary canal of the underlying bone. Histologically, dif-ferent quantities of fibrous tissue, cartilage and an osteoid

matrix are visible associated with a proliferation of fibrob-last/myofibroblast cells.

Clinically, bizarre parosteal osteochondromatous prolif-eration or Nora’s lesion (Fig. 3) presents as a moderately

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halangeal diaphysis causes bone enlargement (courtesy of Dr Anneiquel, Hôpital Saint-Antoine, Paris).

ainful mass that mainly affects the hand (55%), the longones (27%) or the feet (15%). The ossified mass mayave a pedunculated or sessile attachment to the under-ying periosteum, with no periosteal reaction or medullaryontinuity. The histological analysis shows fibrous tissue,artilage, areas of enchondral ossification and a clear capf cartilage in certain cases. There is a high degree of cellu-arity with no atypia. Surgical resection is usually performedut there is a risk of recurrence.

Turret exostosis (Fig. 4) is a bone growth that developsn the surface of the bone, usually on the dorsal aspectf the proximal or middle phalanx. It is a result of a minorrauma of the deep aspect of the extensor tendon of the fin-er resulting in a subperiosteal hematoma, which ossifies ast progresses. [5]. Turret exostosis is attached to the perios-eum with a sessile base and has a cartilage peripheral cap6] which, for some authors, suggests a lack of ossificationecause of the distance from the periosteal vascularization3].

yositis ossificans circumscriptahe term myositis ossificans circumscripta (MOC) corre-ponds to a sudden process of heterotopic ossification thats preceded in certain cases by often minor injury. In fact,he term is not accurate because this ‘‘osteogenic storm’’an occur outside the muscle, in contact with the fas-ias, the tendons or the adipose tissue. MOC usually occursn the deep tissue in contact with the large muscles ofhe extremities. Moreover, this process does not initiallynvolve inflammatory cells [7]. The pathological examinationhows that MOC is organized into zones with proliferationf fusiform pseudosarcomatous cells during the first week

ollowed by the development of annular ossification whichrogresses centripitally. The development of MOC is rare inhe hand, although a few cases have been reported in theiterature [8—11].

1038 S. Touraine et al.

Figure 3. Nora’s lesion of the 4th finger. A. and B. CT scan (A) and CT volume rendering (B) show periosteal growth on the radial aspectof P2. C. Coronal MR T2 STIR-weighted image shows the lesion with a hyperintense cartilaginous matrix (arrow). D. Axial CT scan shows apartially ossified lesion attached to the periosteum of the phalanx. E. and F. Axial MR scan shows the lesion with a cartilaginous componentin intermediate intensity on T1-weighted image (E) and hyperintensitySaint-Antoine, Paris).

Figure 4. Turret exostosis of the 2nd finger. A. Conventional radio-graphy shows bone growths (arrow) developed on the ulnar aspectof P1 with a sessile attachment to the periosteum. B. Coronal MR T1-weighted image shows a lesion with an ossified base in hypointensityand a cartilaginous cap with intermediate intensity. C. Coronal MRT2 STIR-weighted shows the peripheral cartilaginous cap in highhyperintensity (arrow) (courtesy of Dr Samir Benadjaoud, HôpitalSaint-Joseph, Paris).

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endinosis and mechanical enthesopathy

lthough it is not a separate pathological entity, mechanicalnthesopathy may be associated with calcifications and/oreriostosis. It is rare in the hands or fingers. It usuallynvolves the insertion of the extensor and flexor carpi radi-lis on the dorsal and ventral 2nd and 3rd metacarpal bases,espectively. In the wrist, it involves the flexor carpi ulnaris,hich is the only extrinsic muscle of the wrist that insertsn the carpus (pisiform). Injury to the radial extensors isavored by the presence of a carpal boss, which developsue to the presence of an accessory ossicle (os styloideum)r the presence of osteophytes due to osteoarthritis of thend or 3rd metacarpal bases in contact with the trapezoidnd the capitatum [12]. Distal enthesopathy of the flexorarpi radialis is usually associated with trapezio-metacarpalr scapho-trapezio-trapezoidal osteoarthritis.

soriatic arthritis

soriatic arthritis is an asymmetric mono- oligo- or pol-arthritis that affects the small joints, in particular thenterphalangeal joints of the hands and feet (Fig. 5). In 25%f cases, it affects one or several fingers, involving different

oints (MCP, IPP, IPD) of a same digital ray. Clinically theres dactylitis. Psoriasis of the skin, scalp or nails is an impor-ant diagnostic feature. Nevertheless, arthritis may precedehe skin condition in 10% of cases. The rheumatoid factor is

Non-traumatic calcifications/ossifications 1039

e hyperostosis involving the diaphyses and the phalangeal apical tuftsalcifications involving the distal radioulnar articulation (arrows).

Figure 6. Articular and tenosynovial osteochondromatosis intwo different patients. A. CT scan of the thumb shows numer-ous interphalangeal articular loose bodies (arrows). B. Sagittal MR

Figure 5. Psoriatic arthritis. A. X-ray of the fingers shows reactiv(arrows) associated with bone erosions (arrowhead). B. Periosteal c

always negative. Radiography shows bone resorptions andhyperostosis. Extended periostosis appears as bone wispyand dense outgrowths (whiskering and spurs respectively)associated with marginal articular erosions and enthesitis[13] that may even be visible at a distance from the joint,for example on the radial styloid process [14]. These bonyoutgrowths should not be confused with the short bone spursthat may be visible on the tendon insertions on the lateralsides of the proximal phalanges, which are normal variants[15] and have no clinical significance.

Osteochondromatosis

Synovial osteochondromatosis is a primary or secondaryosteocartilaginous metaplasia of the synovial tissue (Fig. 6).It may involve the joint or the synovial membrane of a ten-don or bursa. In the hand and wrist, osteochondromatosismainly involves the joints of fingers or the flexor tendonsheaths [16,17].

Intraarticular osteochondromatosis is rarer in the wrist orhand than in the knee, hip, elbow, shoulder or ankle. How-ever, because of an extensive synovial territory, the tendonsheaths of the hand are frequently involved [18]. Conven-tional radiography identifies the soft tissue swelling and thepresence of more or less calcified loose bodies. Erosion ofthe cortical bone (‘‘scalloping’’) in contact with the loosebodies may be found. Treatment includes a synovectomy andexcision of the loose bodies. Postoperative recurrence is fre-quent and may occur at a distance from the initial locationalong the tenosynovial sheath. [19].

Calcium pyrophosphate dihydrate crystaldeposition disease (CPPD)

Diverse clinico-radiographic presentations are observedfrom solitary articular and para-articular calcifications toarthropathy with articular degeneration. Chondrocalcinosisis defined by the presence of hyalin cartilage and fibro-

cartilage whatever the type of crystal is, although itusually involves CPPD crystals. Most diseases involving CPPDdeposits are sporadic forms and usually involve women overthe age of 50, usually after the age of 70. In younger

T2-weighted image of the thumb shows interphalangeal articulareffusion (arrow). C. and D. Sagittal and axial CT scan show severalossified loose bodies involving the superficial flexor tendon sheath(arrows).

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atients, a family form of the disease should be looked forhich usually develops between 20 and 40 years old (with aredominance in France in Alsatian families) or a secondaryorm (revealing hyperparathyroidism, hemochromatosis orypomagnesemia in particular) [20].

The disease may be asymptomatic (10—20% of cases) andiscovered by chance on X-ray. CPPD can also mimic a degen-rative arthropathy (pseudo-arthritic appearance on X-rayn 35—60% of cases) with bilateral symmetric polyarticularnvolvement. More rarely, a rapidly degenerative arthropa-hy may also be observed. In 10—20% of cases, the clinicaleatures include pseudo-gout, acute arthritis, occasionalever, and significant local inflammation.

Calcifications of the periarticular soft tissues involve theynovial membrane, the capsule, the tendons and the lig-ments. They are thin and linear. Synovial calcificationsre located throughout the joint space and form ill-definedlurry opaque calcifications of low density. The metacarpo-halangeal joints are frequently involved in the hand. In therist, synovial calcifications are mainly radiocarpal at thearpal triangular fibrocartilaginous complex and the distaladioulnar joint. Tendinous calcifications are found along theain axis of the tendon, and may have a stratified appear-

nce. Real calcified masses may be visible in the soft tissuesnd can mimic gout [21] (Fig. 7).

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steoarticular involvement in gout corresponds to theresence of intra- or para-articular monosodium urate crys-als. This is the sign of chronic hyperuricemia, above theonosodium urate saturation point, which causes the slow

ormation of crystals. Except for secondary forms and enzy-opathies, primary gout is usually found in men over the age

f 40. Tophi usually develop several years after the onset ofymptoms and are tissue deposits of urea whose volume isorrelated to the level of hyperuricemia and the duration ofisease without treatment. Calcifications occur later with

ariable densities. Subcutaneous tissues, tendons, paraar-icular soft tissues, and osteoarticular tissues are involvedhile the joint is preserved for a long time. In the hand,

nvolvement of interphalangeal joints (proximal and distal)

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igure 7. ‘‘Pseudo-tophus’’ of calcium pyrophosphate dihydrate (CPParrows) that has eroded the metacarpal cortex and penetrated the med

S. Touraine et al.

s more frequent than that of metacarpo-phalangeal joints.nvolvement is asymmetric associating erosions and bonepurs (enthesophytosis and osteophytosis) [22].

The association of gout and para-articular CPPD depositss possible in particular in the fingers. In this case, the cal-ifications are related to CPPD crystals, and not the resultf gout tophus calcifications.

onnectivitis

alcinosis of the soft tissues (calcinosis cutis) is frequentlyssociated with connectivitis and more particularly with sys-emic scleroderma and dermatomyositis [23] (Fig. 8).

Scleroderma is a disease of the connective tissue, arte-ioles and microvessels resulting in fibrosis and vascularbliteration. It is characterized by the presence of anticen-romere or antitopoisomerase I antibodies. There is a diffusend progressive form and a form that is more limited tohe cutaneous tissues named CREST syndrome (abbreviationor Calcinosis, Raynaud’s syndrome, Esophageal dysmotility,clerodactylia and Telangiectasia). Both forms can presentith calcinosis of the soft tissues, which is frequent in theand, and which corresponds to aggregates of sometimesarge, pseudotumoral hydroxyapatite crystals. The phys-opathogenisis of these deposits is a subject of debate. Theyre painless, may become ulcerated and in this case have ahalky appearance. Osteoarticular involvement is possiblend includes erosive and degenerative arthritis with epi-hyseal erosions, joint space narrowing and acro-osteolysis24].

Dermatomyositis is a diffuse inflammatory myopathy thats found in children in 50% of cases and adults around0 years old, especially men. There is a bilateral symmet-ic and proximal motor deficit of the limbs associated withutaneous symptoms including subcutaneous calcinosis. Thisalcinosis is especially frequent in the pediatric form ofhe disease. Calcifications are linear and curved, mainlybserved in the knee, elbow and fingers, sometimes asso-

iated with a milky liquid discharge and resorption of theips of the distal phalanx. Muscle calcifications are mainlybserved in the proximal limbs and intermuscular fascias25].

D) crystals. Coronal (A) and axial (B) CT scans of the calcified massullary canal.

Non-traumatic calcifications/ossifications 1041

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Figure 8. Numerous calcifications (arrows) of the soft tissues of(B).

Chronic Renal failure

Hydroxyapatite deposits are found in the soft tissues ofpatients with chronic renal failure (Fig. 9). The frequencyseems to increase with the duration of the renal fail-ure and dialysis of patients. They are due to secondaryhyperparathyroidism, the increase in phosphocalcium andalkalosis. These deposits form round or oval radio-opaqueaggregates, usually located in the para-articular areas ofthe shoulder and wrist and the interphalangeal joints of thefingers, hips and ankles [26]. They are usually asymptomaticbut may be associated with joint pain and osteodystrophy.Calcium oxalate crystals may also be visible in cartilage, thesynovial membrane, the joint capsule and the periarticularand subcutaneous soft tissues [27]. These calcifications maybe cloudy, reticulated, or punctuate depending on the tis-sue they are located in. Secondary oxalosis is favored byvitamin C supplements, for which oxalate is a catabolite.Finally, vascular calcifications are frequent in chronic renalfailure in relation to arteria media calcification, which maybe seen on radiography and earlier on ultrasound [28].

Hypertrophic pulmonary osteoarthropathy(Pierre Marie-Bamberger syndrome)

This syndrome is generally associated with a cyan-otic pulmonary condition, which may or may not betumoral (Fig. 10). Non-tumoral causes include cyanotic car-diopathies, chronic respiratory failure, and cystic fibrosis.However, this syndrome is frequently paraneoplastic, asso-ciated with lung cancer, which it may reveal [29]. VEGF(Vascular Endothelial Growth Factor) and PDGF (Platelet-Derived Growth Factor) are probably involved in thepathogenesis of this disease. VEGF is secreted during chronichypoxia and by the tumor itself. Clinically, joint stiffness

is frequent. Arthralgia and joint effusion associated withhypertrophic wrists, hands and digital clubbing are alsoobserved. Periostitis is visible on conventional radiogra-phy with a periosteal proliferation forming peridiaphyseal

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ngers in scleroderma (CREST syndrome) (A) and dermatomyositis

heaths involving the phalanges, the metacarpal and carpalones and the diaphysis of the long bones.

ore or less painful swelling

hondromas

one chondromas (enchondromas, subperiosteal chondro-as) frequently involve the fingers (Fig. 11). They may be

olitary or multiple in enchondromatosis (Ollier’s disease).hey may be asymptomatic or revealed by a stress fracture.hey can grow within the bone and expand it presentingxtraosseous growth that clinically appears as a deformednger. Chondromas with an epicenter in soft tissues areare except for chondromas of the respiratory tract andemnants of cervical cartilage of the brachial fissures. Inost cases, they occur in the extremities, the hands in

4—64% and the feet in 20—28% of cases. This benign tumor,hich is usually solitary, is a firm, mobile, slow growingass that may be painful, and may adhere to the joint cap-

ule or the tendon sheath [30]. The MR scans show a lesionith hyperintensity on T2-weighted images and a hypo- or

sointensity on T1-weighted images that is more or less het-rogeneous depending on the extent of mineralization [31].ost-contrast enhancement is usually peripheral and septal,ighlighting the lobulated architecture of the tumor [32].alcifications are visible in 33% - 77% of cases on radiogra-hy or CT scans and may suggest the mineralization patternf a chondroid matrix [33]. These calcifications are usually‘pop-corn’’ like with rings and arcs but may be punctiformepending on the maturity of the tumor. They are central oreripheral defining the lobulated architecture of the lesion.he chondromas in fingers are less often calcified which maye due to an earlier clinical diagnosis.

ascular malformation

ascular malformations may be found throughout the bodyut are more often found in the pelvis, the limbs and thekull (Fig. 12). Fifty to sixty-six percent of the lesions are

1042 S. Touraine et al.

Figure 9. Calcium deposits in a dialysis patient with chronic renal failure. Oval shaped, cloudy calcified masses (arrows) of the phalangesof the toes (A) and fingers (B).

Figure 10. Hypertrophic pulmonary osteoarthropathy (Pierre Marie-Bamberger syndrome) associated with a bronchopulmonary carcinoma.Periosteal proliferation with peridiaphyseal sheaths involving the radius and ulna (A) and the metacarpal bones (B).

Figure 11. Enchondromatosis (Ollier’s disease) involving the fingers (amputation of the right 5th and left 3rd fingers). A. On conventionalradiographs, the enchondromas appear as bone radiolucent and expanding lesions of the phalanges particularly visible on the 3rd and 4thrays of the right hand and phalanges of the 2nd left finger. B. The extraosseous expansion of the chondromas of the 2nd left finger accountsfor the swelling and calcifications of the soft tissues (arrows).

Non-traumatic calcifications/ossifications 1043

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Figure 12. Numerous phleboliths related to a large venous malforon conventional radiographs in anterior-posterior view (A) and sagit

venous malformations. In the hands and feet, only 10% ofvascular malformations are arteriovenous [34].

Venous malformations or those with a main venous com-ponent (because they may be associated with lymphatic orcapillary vessels) are usually diagnosed in the upper limbdistal extremity because of their coloration that is more orless blue when it is superficial. These venous malformationsfrequently show phleboliths (visible on X-ray or CT scans)that must not be confused, on MR images, with flow voidsthat are related to the rapid flow in arterial vessels [35].

Calcifying aponeurotic fibromas

Calcifying aponeurotic fibromas are rare (< 1% of the benignsoft tissue tumors) and usually develop in children and youngadults with a peak between 8 and 14 years old predomi-nantly in males (ratio of males to females of 2:1). In 70%of cases, they develop in contact with aponeuroses, fasciasand tendons of the palmar side of the hands. The secondmost frequent location is the foot (plantar side). They areslow-growing painless tumors that do not limit the joint.They are poorly differentiated and heterogeneous on MRI.Calcifications are not always present at first; they are thin,punctiform and generally centrally distributed. Before sur-gical removal, a biopsy should be performed to exclude asynovial sarcoma, which is the main differential diagnosis[36].

Conclusion

Calcifications and ossifications of the surface of bonesand soft tissues may reveal metabolic, systemic, arthritic,benign or pseudotumoral entities, requiring additionalinvestigation, surgical resection or simply treatment of

on involving the forearm and the palmar aspect of the hand, visibleew (B) (courtesy of Dr Annouk Bisdorff, Hôpital Lariboisière, Paris).

ymptoms. The clinical presentation is essential to narrowown the diagnostic possibilities and must be considered inelation with the anatomical location and imaging features.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

eferences

[1] Doumas C, Vazirani RM, Clifford PD, Owens P. Acute calcificperiarthritis of the hand and wrist: a series and review of theliterature. Emerg Radiol 2007;14(4):199—203.

[2] Torbati SS, Bral D, Geiderman JM. Acute calcific tendinitis ofthe wrist. J Emerg Med 2013;44(2):352—4.

[3] Yuen M, Friedman L, Orr W, Cockshott WP. Proliferativeperiosteal processes of phalanges: a unitary hypothesis. Skele-tal Radiol 1992;21(5):301—3.

[4] Jambhekar NA, Desai SS, Puri A, Agarwal M. Florid reactiveperiostitis of the hands. Skeletal Radiol 2004;33(11):663—5.

[5] Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH.Imaging of osteochondroma: variants and complicationswith radiologic-pathologic correlation. Radiographics2000;20(5):1407—34.

[6] Dhondt E, Oudenhoven L, Khan S, Kroon HM, Hogendoorn PC,Nieborg A, et al. Nora’s lesion, a distinct radiological entity?Skeletal Radiol 2006;35(7):497—502.

[7] Kransdorf MJ, Meis JM. From the archives of the AFIP.Extraskeletal osseous and cartilaginous tumors of the extrem-

ities. Radiographics 1993;13(4):853—84.

[8] Nuovo MA, Norman A, Chumas J, Ackerman LV. Myositis ossifi-cans with atypical clinical, radiographic, or pathologic findings:a review of 23 cases. Skeletal Radiol 1992;21(2):87—101.

1

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[9] Kusuma S, Lourie GM, Lins RE. Myositis ossificans of the hand.J Hand Surg [Br] 1999;24(1):128—30.

10] Jayasekera N, Joshy S, Newman-Sanders A. Myositis ossif-icans traumatica of the thenar region. J Hand Surg [Br]2005;30(5):507—8.

11] Goto H, Hatori M, Kokubun S, Makino M. Myositis ossificansin the tip of the thumb: a case report. Tohoku J Exp Med1998;184(1):67—72.

12] Park MJ, Namdari S, Weiss A-P. The carpal boss: reviewof diagnosis and treatment. J Hand Surg 2008;33(3):446—9.

13] Bousson V, Vande Berg B, Lecouvet F, Maldague B, Malghem J.Spondylarthrites-rhumatisme psoriasique. In: Laredo JD, et al.,editors. Imagerie rhumatologique et orthopédique — affectionsgénérales. Montpellier, France: Sauramps medical; 2013. p.625—35.

14] Martel W, Stuck KJ, Dworin AM, Hylland RG. Erosive osteoarthri-tis and psoriatic arthritis: a radiologic comparison in thehand, wrist, and foot. AJR Am J Roentgenol 1980;134(1):125—35.

15] Keats TE, Anderson MW. Atlas of normal roentgen variants thatmay simulate disease. 9th ed. Elsevier Health Sciences; 2012.p. 475 [figure 6-315].

16] Wong SH-M, Salama S, Thoma A. Synovial chondromatosis ofthe hand: three case reports and literature review. Can J PlastSurg J Can Chir Plast 2003;11(1):47—52.

17] Kamath BJ, Bhardwaj P, Shriharsha K, Sharma C. Synovial chon-dromatosis of the proximal interphalangeal joint. J Hand SurgEur Vol 2007;32(1):108.

18] Roulot E, Le Viet D. Primary synovial osteochondromatosis ofthe hand and wrist. Report of a series of 21 cases and literaturereview. Rev Rhum Engl Ed 1999;66(5):256—66.

19] Walker EA, Murphey MD, Fetsch JF. Imaging characteristicsof tenosynovial and bursal chondromatosis. Skeletal Radiol2011;40(3):317—25.

20] Deries B, Delfaut E, Cortet B, Boutry N, Paul C, Cot-ten A. Arthropathies à microcristaux (à l’exception descristaux uratiques et d’hydroxyapatite de calcium). EMcon-sulte. Radiodiagnostic-Neuroradiologie-Appareil locomoteur;2002 [13 p].

21] Chicheportiche V, Laredo J-D. Chondrocalcinose articulaire oumaladie à dépôts de cristaux de pyrophosphate de calciumdihydraté. In: Laredo JD, et al., editors. Imagerie rhuma-tologique et orthopédique — affection générales. SaurampsMédical; 2013. p. 603—22.

22] Bardin T, Ottoviani S, Richette P, Laredo J-D. Goutte. In:Laredo JD, et al., editors. Imagerie rhumatologique etorthopédique — affection générales. Sauramps Médical; 2013.p. 632—53.

[

S. Touraine et al.

23] Shahi V, Wetter DA, Howe BM, Ringler MD, Davis MDP. Plainradiography is effective for the detection of calcinosis cutisoccurring in association with autoimmune connective tissuedisease. Br J Dermatol 2013:1073—9.

24] Dieudé P. Sclérodermie systémique. In: Laredo JD, et al.,editors. Imagerie rhumatologique et orthopédique — affectionsgénérales. Sauramps Médical; 2013. p. 772—7.

25] Dieudé P, Dion E, Mercy G, Layouss W. Myopathies inflamma-toires diffuses : dermatomyosite, polymyosite et syndromes dechevauchement. In: Laredo JD, et al., editors. Imagerie rhu-matologique et orthopédique — affections générales. SaurampsMédical; 2013. p. 785—96.

26] Bardin T, Sigaux J, Laredo J-D. Complications ostéoarticulairesde l’hémodialyse. In: Laredo JD, et al., editors. Imagerie rhu-matologique et orthopédique — affections générales. SaurampsMédical; 2013. p. 267—86.

27] Lorenz EC, Michet CJ, Milliner DS, Lieske JC. Update on oxalatecrystal disease. Curr Rheumatol Rep 2013;15(7):340.

28] Marinelli A, Pistolesi V, Pasquale L, Di Lullo L, Ferrazzano M,Baudena G, et al. Diagnosis of arterial media calcification inchronic kidney disease. Cardiorenal Med 2013;3(2):89—95.

29] Yao Q, Altman RD, Brahn E. Periostitis and hypertrophic pul-monary osteoarthropathy: report of 2 cases and review of theliterature. Semin Arthritis Rheum 2009;38(6):458—66.

30] Railhac JJ, Ponsot A. Tumeurs et pseudo-tumeurs d’originecartilagineuse. In: Railhac JJ, Ponsot A, editors. Imagerie destumeurs des tissus mous. Sauramps Médical; 2010. p. 321—3.

31] Horcajadas AB, Lafuente JL, de la Cruz Burgos R, MunizSH, Roca SA, Ortega SG, et al. Ultrasound and MR findingsin tumor and tumor-like lesions of the fingers. Eur Radiol2003;13(4):672—85.

32] Parlier-Cuau C, Bousson V, Ogilvie CM, Lackman RD, Laredo J-D.When should we biopsy a solitary central cartilaginous tumor oflong bones? Literature review and management proposal. EurJ Radiol 2011;77(1):6—12.

33] Khedhaier A, Maalla R, Ennouri K, Regaya N. Soft tissues chon-dromas of the hand: a report of five cases. Acta Orthop Belg2007;73(4):458—61.

34] Railhac JJ, Ponsot A. Malformations vasculaires. Imagerie destumeurs des tissus mous. In: Railhac JJ, Ponsot A, editors.Imagerie des tumeurs des tissus mous. Sauramps Médical; 2010.p. 121—53.

35] Dubois J, Soulez G, Oliva VL, Berthiaume MJ, LapierreC, Therasse E. Soft-tissue venous malformations in adultpatients: imaging and therapeutic issues. Radiographics

2001;21(6):1519—31.

36] Murphey MD, Ruble CM, Tyszko SM, Zbojniewicz AM, PotterBK, Miettinen M. Musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics 2009;29(7):2143—83.