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Endgames Picture Quiz

Pathological finger fracture

BMJ 2013; 346 doi: (Published 20 February 2013) Cite this as: BMJ 2013;346:f1024
  1. Tom Rider, core medical trainee,
  2. Irfan Baig, specialty registrar,
  3. Charlie Sayer, specialty registrar,
  4. Anna Crown, consultant endocrinologist
  1. 1Royal Sussex County Hospital, Brighton BN2 5BE, UK
  1. Correspondence to: T Rider bsms345{at}

A 75 year old white woman presented to our hospital with pain in her left hand after hearing a crack when pushing herself up from sitting. She immediately felt pain in her little finger and was unable to use her hand.

Over the preceding two years she had become increasingly tired and weak. This had necessitated a stair lift to be installed into her home and she had become unable to lift a plate down from her kitchen shelves. She had developed bone pain in her spine, knees, ankles, and shoulders. She also reported polyuria but no polydipsia. In the five months before admission she had lost two stone (12.6 kg) in weight.

Clinical examination showed no lymphadenopathy, goitre, breast lumps, or organomegaly.

Initial blood tests showed urea of 13 mmol/L (reference range 1.7-8.3; 1 mmol/L=2.8 mg/dL), creatinine 101 µmol/L (44-80; 1 µmol/L=0.01 mg/dL), corrected calcium concentration 3.19 mmol/L (2.15-2.61; 1 mmol/L=4 mg/dL), phosphate 0.79 mmol/L (0.81-1.45; 1 mmol/L=3.1 mg/dL), albumin 41 g/L (37-49), adjusted magnesium 0.54 mmol/L (0.66-0.99; 1 mmol/L=2 mEq/L), total bilirubin 7 µmol/L (0-21; 1 µmol/L=0.06 mg/dL), alkaline phosphatase 931 IU/L (<55; 1 IU/L=0.02 µkat/L), alanine aminotransferase 8 IU/L (0-33; 1 IU/L=0.02 µkat/L), haemoglobin 118 g/L (115-165), and erythrocyte sedimentation rate of 14 mm in the first hour (0-15). What does the radiograph of her hand (fig 1) show?


  • 1 What does the radiograph show?

  • 2 What is the unifying diagnosis based on the history and investigations?

  • 3 How would you confirm the diagnosis?

  • 4 How should this condition be managed?

  • 5 What are the complications of treatment?


1 What does the radiograph show?

Short answer

The radiograph shows well defined osteolytic lesions in the fourth metacarpal. The other obvious area of abnormality is the proximal phalanx of the fifth finger, where changes in trabecular pattern, cyst formation, and cortical erosions can be seen. …

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