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(a) Sagittal and (b) axial proton-density magnetic resonance images of the wrist in 24-year-old National Hockey League player demonstrating an os styloideum (arrow) at the base of the long finger metacarpal. The dashed arrow in Figure 1a demonstrates the fibrous union with the base of the second metacarpal. The player presented for a triangular fibrocartilage injury and was asymptomatic. C, capitate; L, lunate; MC, metacarpal.
Source publication
Background:
Os styloideum describes an accessory carpal ossicle between the trapezoid, the capitate, and the second and third metacarpals. Injuries to this tissue have been described as part of the carpal boss syndrome. While the etiology of os styloideum remains uncertain, it may represent a physiologic response to altered loading forces in the w...
Contexts in source publication
Context 1
... Relevance: This study identified NHL players as having an increased prevalence of os styloideum compared with the general population. By doing so, these findings represent an opportunity to enhance our understanding of the etiology, clinical significance, and treatment of os styloideum. metacarpal, or both. 2 Specifically, an os styloideum was defined by the authors as either a separate bony ossicle or an ossicle that maintains a fibrous union with the carpus or metacarpal bones ( Figure 1). A carpal boss is defined as a bony protuberance fused to the base of the metacarpal bones ( Figure ...
Context 2
... doing so, these findings represent an opportunity to enhance our understanding of the etiology, clinical significance, and treatment of os styloideum. metacarpal, or both. 2 Specifically, an os styloideum was defined by the authors as either a separate bony ossicle or an ossicle that maintains a fibrous union with the carpus or metacarpal bones ( Figure 1). A carpal boss is defined as a bony protuberance fused to the base of the metacarpal bones ( Figure 2). ...
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Citations
... A study by Greditzer et al. hypothesized that os styloideum would be more prevalent in NHL hockey players than the general population as its occurrence is linked to increased loading during young age [21]. They found that 81% (13/16) of players with scanned wrist had os styloideum. ...
... They found that 81% (13/16) of players with scanned wrist had os styloideum. Most (11/13) of the players underwent MRI [21]. Several studies show that symptomatic carpal boss is more prevalent on the dominant hand [15,17]. ...
Several accessory bones can be found around the wrist, which may pose a diagnostic challenge. Hereby, we report a unique case of a traumatic fracture of an aberrant os styloideum in a 66-year-old male. The patient presented with a swollen dominant right hand and a hematoma on its anterior and posterior aspects, as a result of a fall on an outstretched hand. The diagnosis was based on a CT scan, which showed a fractured accessory bone between the distal portion of the capitate bone and the base of the third metacarpus. Due to its typical location, the ossicle was identified as os styloideum. The patient was treated conservatively and the symptoms subsided on a short forearm cast after 2 weeks. At a 12-month follow-up, no other episodes were declared. Strong anatomical knowledge and sharing of such cases is essential for proper diagnosis and treatment of this very rare condition.
... These ossicles may be partially united to the adjacent osseous structures or may be separated by a fibrous synchondrosis [3]. Although the typical age for presentation of an os styloideum is in the fourth decade, there are several reported cases in the literature of ossicles encountered in the pediatric population [4,7]. An increased incidence of os styloideum has been reported among professional hockey players and boxers; however, an association amongst volleyball players has yet to be documented in the current literature [7,8]. ...
... Although the typical age for presentation of an os styloideum is in the fourth decade, there are several reported cases in the literature of ossicles encountered in the pediatric population [4,7]. An increased incidence of os styloideum has been reported among professional hockey players and boxers; however, an association amongst volleyball players has yet to be documented in the current literature [7,8]. ...
The os styloideum is an uncommon accessory ossicle located at the dorsum of the wrist, which may present with symptoms similar to those of a ganglion cyst. The presumed etiology of the os styloideum is congenital non-fusion of cartilaginous components about the carpals. Various imaging modalities, including ultrasonography, can be used to differentiate this entity from various other sources of painful dorsal-sided wrist nodules.
A 13-year-old female presented with dorsal wrist pain and focal swelling. She reported that the symptoms began two months prior to the initial evaluation. A clinical diagnosis of a ganglion cyst was made. The initial radiographic examination was interpreted as negative. Sonographic examination revealed the presence of an accessory ossicle consistent with an os styloideum, which was later confirmed on the initial radiographic study.
The patient elected for a trial of conservative treatment, which included activity modification and functional taping. This resulted in moderate, but not complete, reduction in pain and improvement in function.
The clinical presentation of a painful dorsal nodule about the wrist should prompt the consideration of an os styloideum. This case demonstrates the use of diagnostic ultrasound as a modality for evaluating and confirming the diagnosis of an os styloideum.
... Os hypolunatum: between the lunate and the capitate, just ulnar to the site of the os epilunatum. 15 All radiographs were analyzed by a radiologist and anatomist for the presence of accessory ossicles and Fig. 3 Posteroanterior radiograph of the wrist shows an os styloideum (circled) located between the capitate, trapezoid, and bases of second and third metacarpal bones. confirmed by a radiologist who had 20 years of experience in musculoskeletal radiology. ...
... Greditzer et al conducted a study with 16 National Hockey League players and found os styloideum in 13 of the players (81%). 15 Similar to the results obtained in the present study, this incidence was markedly higher than the results of previous studies conducted with the general population. Although the etiology of os styloideum is not entirely clear, the authors explained it with adaptive and reactive bone formation, similar to the formation of cam type deformity in the hip due to increased loading and repeating microtrauma in these athletes. ...
Objective Accessory ossicles of the wrist are generally asymptomatic and detected incidentally as radiological findings. These bones are rarely symptomatic but can produce pain in cases of impingement or direct trauma. More frequently, these bones are misinterpreted as avulsion fractures in trauma patients, which may lead to unnecessary immobilization and overtreatment. The aim of this study is to determine the incidence of accessory ossicles of the wrist and also determine if the incidence is related to age, gender, or ongoing wrist pain.
Materials and Methods A total of 1146 wrist radiographs were included in the study. All radiographs were analyzed for the presence of 20 different accessory ossicles of the wrist. Patients were also divided into two groups, as with and without accessory ossicle. Two groups were compared in terms of age, gender, and side.
Results About 113 accessory ossicles were detected in 111 (9.7%) radiographs. The most common accessory ossicles were os triangulare and os ulnostyloideum, and the least common accessory ossicles were os gruberi and os praetrapezium. Patients who had accessory ossicle had a significantly higher age than those who did not have accessory ossicle. There was no significant difference between the patients with and without accessory ossicle in terms of gender and side.
Conclusions The results of this study showed that the most common accessory ossicles in the wrist were os triangulare and os ulnostyloideum, and the incidence of accessory bones increased with age.
Clinical Relevance Since accessory ossicles of the wrist can be confused with fractures in trauma patients and are frequently ignored in patients presenting with pain, it is very important to know the incidence and distribution of these ossicles. Therefore, this study is important, in that it provides potentially guiding anatomical data for clinicians in terms of diagnosis and management.
... A recent study reported the appearance of bony abnormalities in the joints in 13 of 16 professional ice hockey players, and indicated a potential mechanism of the occurrence: repetitive loading at the originally rigid CMC joints might cause the pathology. 6 Based on these reports on carpal boss, we hypothesized that the second CMC joint could cause persistent pain not only in patients with bony pathologies such as carpal boss, but also in those without obvious radiographic abnormalities, which might result from mechanical stresses due to repetitive hand activities. We therefore focused on the patients with persistent, localized pain at the second CMC joint and their characteristic clinical findings. ...
The purposes of this study were to demonstrate the clinical characteristics of patients with persistent second carpometacarpal (CMC) joint pain without bony abnormalities known as the carpal boss, and to assess the clinical efficacy of surgical stabilization of the second CMC joint. Eleven patients had persistent wrist pain with characteristic symptoms, including tenderness over the second CMC joint, increased symptoms when the involved hand was placed on the ground or gripped strongly with the involved hand, a positive metacarpal stress test and temporary pain relief with the intra-articular injection of the lidocaine. The patients underwent arthrodesis of the second CMC joint. All cases showed radiologically confirmed fusion of the second CMC joint. At the final followup examination, 10 of 11 patients resulted in satisfactory clinical outcomes, excepting one patient with remnant pain and restricted range of wrist motions. This report highlights the importance of conducting a careful assessment of patients who present with persistent second CMC joint pain without the bony abnormalities, such as carpal bossing. Surgery to stabilize the second CMC joint may be an option to improve their symptoms when conservative treatment fails.
... Os styloideum is an accessory ossicle that is connected by fibrous union to the dorsal 2nd or 3rd metacarpal or capitate. 57 It is thought to be a response to repetitive microtrauma, similar to bone formation that occurs in the hip of ice hockey players with the Cam bump or a Bennett's lesion seen in baseball throwers. 57 "Carpal bossing" is a bony dorsal protuberance at the base of the 2nd and 3rd metacarpals that presents with varying symptomatology. ...
... 58 Os styloideum and carpal bossing are not synonymous terms. 57 A carpal boss is easily palpated on the dorsal aspect of a flexed wrist. It can be distinguished from a ganglion cyst as it has a characteristic hard consistency and cannot be transilluminated. ...
... 59 Further imaging is often required to definitively diagnose a carpal boss as benign bony lesions or, less frequently, malignant masses can have similar findings on exam (Figure 8). There have been no large studies examining the efficacy of conservative treatment for Os styoideum or carpal bossing, but in the case series from Greditzer et al, 57 all the involved ice hockey players with Os styloideum returned to sport within a week. Treatment with NSAIDs, rest and, local corticosteroid injections are usually attempted initially but have been shown in multiple small series to be ineffective at providing long-term symptomatic relief. ...
Liana J Tedesco,1 Hasani W Swindell,1 Forrest L Anderson,1 Eugene Jang,1 Tony T Wong,2 Jonathan K Kazam,2 R Kumar Kadiyala,3 Charles A Popkin1 1Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, NY, USA; 2Department of Radiology, New York Presbyterian Hospital, New York, NY, USA; 3Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USACorrespondence: Charles A PopkinColumbia University Medical Center, 622 West 168 St, PH – 11, New York, NY 10032, USAEmail cp2654@columbia.eduAbstract: Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men’s ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.Keywords: ice hockey, dorsal ulnotriquetral ligament, olecranon bursitis, Os styloideum, gamekeeper’s thumb
... Interestingly, some studies suggest that the symptomatic carpal boss might be more likely to be on the dominant hand of an individual in their early 30s [3,4,6]. In the diagnosis of a symptomatic carpal boss, the magnetic resonance imaging (MRI) plays an essential role [8]; nevertheless, only a few case series on the MRI features of carpal boss exist in the literature [9,10]. Moreover, the clinical syndrome of a symptomatic carpal boss has been reported and described with an emphasis on osseous anatomy [9,11]. ...
... Regional soft-tissue anatomy, however, is complex and the extensor carpi radialis brevis (ECRB) tendon generally inserts on the base of the 3rd metacarpal, in close proximity to a carpal boss. Anecdotally, we noted several cases of symptomatic carpal boss that had clinical and MRI findings indicating stress or avulsive injury at the ECRB insertion [10]. Along with osseous and soft-tissue edema, there were varying degrees of osseous fragmentation and varying patterns of ECRB insertion. ...
... This likely reflects subject selection criteria, as all of our subjects reported dorsal wrist pain and previous trauma or history of wrist overuse. A similarly high incidence of regional BME has been shown by a small study by Greditzer et al. on National Hockey League players, reporting that 91% (10 out of 11) of the players with carpal boss show regional BME [10]. In our group, regional BME was more common with younger patients. ...
Objective
To report patterns of MRI findings involving carpal boss and extensor carpi radialis brevis (ECRB) tendon insertion in individuals with overuse-related or post-traumatic wrist pain.
Materials and Methods
Eighty-four MRI cases with carpal bossing between December 2006 and June 2015 were analyzed by two fellowship-trained musculoskeletal radiologists. The following MRI findings were reviewed: type of carpal bossing (bony prominence, partial coalition, os styloideum), insertion of ECRB tendon (to the 3rd metacarpal, to carpal boss or to both), bone marrow edema (BME), insertion site, and tenosynovitis/tendinosis of ECRB tendon. Clinical information on wrist pain was available on 68 patients.
Results
Fused carpal bossing was detected in 21%, partial coalition in 35%, and os styloideum in 44% of the cases. Regional BME was observed in 64% of the cases. When BME specifically at the carpal boss was assessed, 78% of stable and 50% of unstable bosses showed BME (p = 0.035). ECRB tendon inserted on a carpal boss in 20%, on the 3rd metacarpal bone in 35%, and on both sites in 45% of the cases. As BME at the carpal boss was assessed, BME was detected at the respective insertion sites in 71%, 35%, and 66% of the cases (p = 0.015). Dorsal wrist pain was associated with BME as 75% of the patients had regional BME in the vicinity of the carpal boss (p = 0.006).
Conclusion
A spectrum ranging from complete fusion of a boss to an entirely unfused os styloideum exists with a variable ECRB insertional anatomy. BME at the carpal boss is a consistent MRI finding.
Background
Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes.
Purpose
Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used.
Study Design
Scoping review; Level of evidence, 4.
Methods
PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms “hockey” and “injuries” using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men’s ice hockey athletes of all levels. We excluded case reports and articles evaluating women’s ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article.
Results
A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases).
Conclusion
This scoping review provides men’s hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.
Sesamoid bones and accessory ossicles are normal anatomic variants with varying morphological appearances and incidences. They are usually small osseous fragments with well-corticated margins located adjacent to the joint space and bone. Patients with sesamoid bones and accessory ossicles are usually asymptomatic and commonly encountered in clinical practice. These sesamoids and accessory bones are occasionally painful because of fractures, dislocations, degenerative changes, avascular necrosis, accessory bone infections, or abnormalities of the adjacent tissue, such as nerve entrapment, tenosynovitis, or soft tissue impingement. This article aimed to illustrate the imaging features of symptomatic sesamoids bones and accessory ossicles at various anatomic locations and describe their clinical features and radiological differential diagnosis.
