A 30-year-old male patient presented with complaints of a gradually progressive swelling around his wrist joint for 3 months. Given below is the image of the swelling and the X-ray film. What is the most likely diagnosis? La d

Correct Answer: A. Osteoclastoma

Osteoclastoma (giant cell tumor of bone, GCT) is the correct diagnosis based on the clinical presentation and radiological findings. The key discriminating features are: (1) location at the epiphyseal-metaphyseal region of the distal radius — GCT has a pathognomonic predilection for the epiphysis of long bones, especially around the knee and distal radius; (2) age 20–40 years — GCT typically presents in young adults after physeal closure, unlike other bone tumors; (3) gradual progressive swelling over 3 months — GCT grows slowly and insidiously, not acutely like Ewing's sarcoma. Radiologically, GCT appears as an eccentric, lytic lesion with a soap-bubble or honeycomb pattern, often extending to the articular surface. The tumor is benign but locally aggressive, with a recurrence rate of 10–65% depending on treatment. In the Indian context, GCT is managed with curettage and bone grafting (or cement) as first-line treatment, with adjuvant therapy (phenol, cryotherapy, or high-speed burring) to reduce recurrence. Malignant transformation is rare (<5%) but must be monitored. The clinical pearl is that any young adult with an eccentric epiphyseal lytic lesion near the knee or wrist should raise suspicion for GCT.

Why the other options are wrong

B. Osteochondroma — Osteochondroma is a benign cartilage-capped bony projection that arises from the metaphysis (not epiphysis) and typically presents in adolescents with a painless bony lump. It does not produce the lytic, soap-bubble appearance seen here. Osteochondroma is the most common benign bone tumor but the radiological pattern and age-location mismatch rule it out. NBE trap: both are benign, but location and imaging pattern differ. C. Ewing's sarcoma — Ewing's sarcoma is a malignant small round cell tumor that typically presents in children and adolescents (peak 10–20 years) with acute onset pain, fever, and systemic symptoms. It arises in the diaphysis (shaft) of long bones, not the epiphysis. The 3-month gradual swelling without constitutional symptoms and epiphyseal location rule out Ewing's. NBE trap: both are aggressive tumors, but age and location differ fundamentally. D. Osteosarcoma — Osteosarcoma is the most common primary malignant bone tumor in adolescents and young adults, but it arises in the metaphysis (not epiphysis) and presents with acute pain, rapid swelling, and systemic symptoms. The slow 3-month progression and epiphyseal location are atypical for osteosarcoma. Additionally, osteosarcoma shows a sclerotic 'sunburst' pattern, not the lytic soap-bubble appearance. NBE trap: both occur in young adults, but location, imaging, and clinical tempo differ.

High-Yield Facts

Mnemonics

GCT Location: AFTER Physeal Closure Around the knee (distal femur, proximal tibia) — most common. Femur and Tibia account for 50–65% of cases. Epiphyseal location is pathognomonic. Radius (distal) is the third most common site. Use this when you see an epiphyseal lytic lesion in a 20–40-year-old. Bone Tumor Location by Zone (DAMS mnemonic) Osteochondroma = Metaphysis (cartilage cap). Osteosarcoma = Metaphysis (sclerotic). Ewing's = Diaphysis (onion-skin). GCT = Epiphysis (soap-bubble). Memorize: metaphysis has two tumors; epiphysis has one (GCT); diaphysis has one (Ewing's).

NBE Trap

NBE pairs benign tumors (osteochondroma, GCT) to test whether students confuse location: both are benign, but osteochondroma is metaphyseal with a cartilage cap, while GCT is epiphyseal with a lytic pattern. The trap is assuming "benign = osteochondroma" without checking the radiological location.

Clinical Pearl

In Indian orthopedic practice, any young adult (20–40 years) presenting to OPD with a slowly enlarging swelling around the wrist or knee should trigger a reflex X-ray looking for an eccentric epiphyseal lytic lesion — this is GCT until proven otherwise. Early diagnosis allows limb-sparing curettage rather than late-stage wide resection.

_Reference: Bailey & Love Ch. 40 (Bone Tumours); Robbins Ch. 26 (Musculoskeletal Pathology)_