The patient presented with a history of trivial injury to the wrist complaining of pain around the base of the thumb. There were no other symptoms.
The patient presented to the Accident and Emergency department after sustaining an injury to his right wrist following a trivial fall onto his wrist. On clinical examination, he had tenderness over the base of the thumb near the snuff box. An x-ray examination of the hand was performed (Fig. 1). A provisional diagnosis of scaphoid fracture was made and he was treated in a scaphoid cast. He was subsequently reviewed in the fracture clinic with an x-ray of the wrist, which showed a destructive lesion in the trapezium (Fig. 2). On suspicion of a metastatic lesion, an x-ray of the chest was performed, which was highly suggestive of a primary tumour involving the middle lobe of the right lung (Fig. 3). The patient had no symptoms suggestive of lung involvement. Bronchoscopic examination and biopsy confirmed broncogenic adenocarcinoma of the lung. The patient died 5 months after the diagnosis.
Bronchogenic carcinoma is known to metastasise to the carpus. However, this is a very rare occurrence. The prognosis is extremely poor once metastasis is present in hand.
The earliest mention of a metastases to the bones of the hand was made by Handley in 1906 (3). Metastases from bronchial carcinoma comprise almost half the recorded secondary tumours to the hand (3). As with other bone metastases from a bronchial carcinoma peripheral metastases are virtually always osteolytic (3). When signs of inflammation are not present,the radiological differential diagnosis includes enchondroma, epidermoid cyst, osteoid osteoma, giant cell tumour, and gout. Primary malignant tumours of the skeleton of hand are extremely rare, but even osteosarcoma have been reported (3). The incidence of primary tumours metastasising to the hand is a little more than 0.1% (1). Amongst the 163 cases reported in the literature, the involvement of the hand as the initial presentation was found to be 16% (1), the lung being the chief source, followed by the breast and the kidney.
The mechanism of dissemination to the hand remains obscure. Several theories have been put forward including haematogenous, lymphogenous and chemotactic. It has been found that prostaglandins may facilitate osseous metastases (2). In practical terms, supradiaphragmatic neoplasms tend to metastasise to the hand, while subdiaphragmatic tumours tend to metastasise to the foot. Superficial organs such as the breasts show no particular predilection (3). This case reinforces the accepted belief that metastasis to the hand from bronchogenic carcinoma has an extremely poor prognosis. It suggests the importance of general and systemic examination of every patient on initial presentation. Moreover, one should have a high index of suspicion of a pathological fracture with trivial injuries.
Bronchogenic adenocarcinoma
Based on the provided wrist X-ray images, a markedly destructive lesion is observed at the base of the thumb (proximal first metacarpal or carpal region), presenting as bone destruction or lytic changes. The distal radius and other bones in the wrist joint appear relatively normal, with no obvious osteophytic changes or widespread inflammatory reactions. The patient reports pain following a minor trauma, suggesting a potential pathological change in the affected area.
On chest X-ray, an increased density or a mass-like lesion is seen near the pulmonary hilum; there appears to be a hazy shadow in the left upper lung region, suggesting the possibility of a pulmonary tumor or an infiltrative lesion. Observation of the overall lung fields does not reveal large-scale cavitation or other definitive secondary lesions, but a primary lung tumor cannot be ruled out.
In summary, the lytic lesion in the wrist and the mass-like lesion in the chest suggest a possible bone metastasis originating from a lung tumor.
Considering the patient's age, chest imaging findings, and the destructive nature of the bone lesion, metastatic disease from a primary lung tumor remains the primary consideration.
Based on the patient's clinical presentation (pain following a minor trauma), radiological findings (a lytic lesion in the wrist and a suspicious bronchogenic tumor on chest X-ray), and rare documented reports, the most likely diagnosis is:
“Pathological fracture in the carpal or first metacarpal region due to metastatic lung cancer (bronchogenic carcinoma).”
A definitive diagnosis still requires pathological biopsy (including histological examination of both the pulmonary and wrist lesions) and serum tumor marker tests. Prompt completion of relevant specialist evaluations is recommended.
Treatment Strategy
Rehabilitation/Exercise Prescription Recommendations
Because the wrist fracture may be pathological and there might be a considerable systemic tumor burden, a cautious approach to rehabilitation is needed, emphasizing local stability and moderate whole-body activity:
During each phase, closely monitor any changes in pain, swelling, and range of motion. If severe pain or discomfort develops, seek medical attention promptly.
Disclaimer: This report is a reference analysis based on the provided imaging and clinical history information. It does not replace an in-person consultation or professional medical advice. If you have any questions or if your symptoms change, please consult a healthcare professional promptly.
Bronchogenic adenocarcinoma
