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Findings On the radiographs there is a bony prominence about the dorsum of the 3rd carpometacarpal (CMC) joint . This is seen on multiple pulse sequences on the MRI about the area of the patient’s pain as indicated by the marking capsule. Tissue is seen insinuated between a separate bone fragment and the base of the third metacarpal (MC) with edema pattern of the bone and small cyst-like changes.
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Diagnosis: Carpal Boss Syndrom/os Styloideum This is one of those pathologies that some people lump and some people split. Any osseous protuberance typically at the base of the 3rd MC, capitate, 2nd MC, and less likely trapezoid are often lumped together under the issue of carpal boss. Some people like to classify if the bone is not a separate fragment but just protruding from the posterior aspect of the bones as a carpal boss. Where if there is a separate bone fragment, most often adjacent to the base of the 3rd MC and having an adjacent fibrous union or synchondrosis, that is classified as an os styloideum. These can be painful manifest by edema on MRI and show degenerative changes as shown by sclerosis or cystic changes. Recently, articles have shown a high prevalence of os styloideum in professional athletes and not of a carpal boss as defined above. This gives some credence to the thought of a traumatic etiology particularly of an os styloideum. One other difference is also that anecdotally, patients undergoing ultrasound guided injections for painful os styloideum have fared better in our practice than those injected for a painful carpal boss. This being said the underlying etiologies as relates to either a carpal boss or os styloideum is not known. Favored is overuse/post-traumatic, developmental/congenital, and degenerative. In all cases conservative management is tried because of the difficulty in obtaining good results and lack of recurrence following surgery.
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References Prevalence of Os Styloideum in National Hockey League Players. Greditzer HG 4th, Hutchinson ID, Geannette CS, Hotchkiss RN, Kelly BT, Potter HG.Sports Health. 2017 Sep/Oct;9(5):469-473. doi: 10.1177/1941738117707914. Epub 2017 May 15. Characterization and Epidemiology of the Carpal Boss Utilizing Computed Tomography. Goiney C, Porrino J, Richardson ML, Mulcahy H, Chew FS. J Wrist Surg. 2017 Feb;6(1):22-32. doi: 10.1055/s-0036-1583941. Epub 2016 May 9. The carpal boss: review of diagnosis and treatment. Park MJ, Namdari S, Weiss AP. J Hand Surg Am. 2008 Mar;33(3):446-9. doi: 10.1016/j.jhsa.2007.11.029.
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