Coronal contrast-enhanced fat-suppressed T1-weighted MRI image obtained before sclerotherapy shows homogenous hyperintense lesions in the palmar soft tissue and distal phalanx of the left thumb. Abbreviation: MRI = Magnetic resonance imaging. 

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... malformations (VM) are the most common vascular malformations caused by faulty development during vascular morphogenesis [1]. Although most VM are located in the skin and subcutaneous tissues, they also involve underlying muscles, joints and bones [2]. Intraosseous VM of an extremity can cause structural weakening of the bone and chronic pain. Treatment of VM includes conservative treatment, sclerotherapy, and surgical resection [2]. However, recurrence and deformity requiring amputation are common problems. We present a patient with combined soft tissue and intraosseous VM of the thumb, treated with sclerotherapy using a bone marrow aspiration needle under fluoroscopic guidance. A 16-year-old, right-handed female patient presented with a congenital bluish swelling in the pulp of the left thumb (Figure 1). On clinical examination, the swelling was soft, painful and non-pulsatile. On Doppler ultrasonography, the swelling was composed of anechoic channels with low velocity flow. A plain radiograph showed radiolucent lesions in the distal phalanx of the left thumb (Figure 2). Magnetic resonance imaging (MRI) showed lesions in the palmar soft tissue and the distal phalanx of the left thumb (Figure 3). The interphalangeal joint of the left thumb was also involved. The lesions were hypointense on T1-weighted images, hyperintense on T2-weighted images, and enhanced after administration of contrast material. Based on the MRI findings, a diagnosis of combined soft tissue and intraosseous VM was made. Sclerotherapy using polidocanol or absolute ethanol had been performed seven times for the soft tissue lesion of the left thumb since the age of 5 years at another hospital. We performed two sessions of sclerotherapy under general anesthesia with the interval of 10 months for the relief of pain. Without a tourniquet, direct puncture of the intraosseous lesion was performed with a bone marrow aspiration needle, then water-soluble contrast material was injected under fluoroscopic guidance to confirm the absence of any dangerous venous drainage (Figure 4). Subsequently, a sclerosing solution mixture of absolute ethanol with contrast material at a 4:1 ratio was injected into the lesion, 0.5 ml at a time. The total volume of sclerosing solution used per treatment session was 7 ml and 5.5 ml, respectively. Five months after the first sclerotherapy, MRI showed reduced volume of the soft ...