osteoid osteoma usually a symptomatic disease in the second or third decades of life , rarely found in patients over 40 years of age , and approximately twice as many men as women are affected ( 13 ) . osteoid osteoma is also a relatively uncommon benign osteoblastic tumor , first described by jaffe in 1935 . it consists of an area of variably calcified osteoid tissue commonly called a nidus within a stroma of relatively loose vascular connective tissue with a rim of sclerotic reactive bone , less than 1 cm in diameters , surroundings the lesion ( 4 ) . the pain is more severe at night and often often relieved by nonsteroidal anti - inflammatory agents ( nsaid ) . the second most common complaint is swelling , which often occurs in form of painless osteoid osteoma ( 46 ) . ( 2 , 8) between 19% and 31% of all osteoid osteoma present in the upper extremity , and of all cases of osteoid osteoma cases , lesions in the hand and wrist comprised 5 to 15% ( 2 , 4 , 5 ) . records of the 25 patients ( who had pathological reports of osteoid osteoma for hand and wrist ) were reviewed . all patients underwent surgery by hand surgeon , in microsurgical unit of shafa yahyaian hospital between 1992 and 2011 . all patient data including signs , symptoms , history of trauma , night pain , relief of pain by nsaids and duration from onset of symptoms to operation were recorded . the diagnosis was made using plain x - rays , three- phase technetium bone scans , ct and mri , and histological examinations confirmed the diagnosis in all cases . the means and standard deviations ( sd ) were also derived to analyze the measured data statistically . the means and standard deviations ( sd ) were also derived to analyze the measured data statistically . this paper reports on 25 cases of osteoid osteoma in the hand and wrist at 20 years period . there were twenty - one men and four women , with an average age of 25.2 7.6 ( range : 16 - 46 ) years . twenty osteoid osteoma were in the right and five in the left side of hands . fifteen were in the finger phalanges ( ten proximal and five distal phalanges ) , four in the metacarpals , five in the wrist ( two in scaphoid , two in capitate and one in trapezium ) and one in the styloid of radius . the pain was gradually increased and initially intermittent , but later became more constant and severe . the pain was unaffected by activity and twenty - one of these patients had night pain and in 17 patients partial pain relief obtained by aspirin ( five patients had no relief and 3 were not investigated ) . blood analyses were normal for all patients , but a history of trauma prior to the onset of symptoms found in five patients . physical examination at presentation revealed local swelling and point tenderness . whenever the osteoid osteoma was close to a joint , restriction of motion and muscle along with atrophy were sometimes present . the physical findings varied with the site of the tumor . in the phalanges , osteoid osteoma induced marked fusiform soft tissue swelling . proximal phalanx involvement was characterized by a grossly enlarged phalanx with hypertrophy of the soft tissues , and distal phalanx involvement caused finger clubbing , with enlargement of the phalanx , and sometimes hypertrophy of the nail and obliteration of the normal angle between the base of the nail and the skin . the diagnosis was made using plain x - rays , three - phase technetium bone scans , ct and mri . only thirteen patients had the characteristic appearances of osteoid osteoma on x - ray and twelve non - specific appearances on initial x - rays . three - phase tc- 99 bone scans were done on twenty patients , showed an intense well - defined focal area increased activity during all the three - phase of the scan in eighteen patients . in two cases , eighteen ct scans were performed and showed the osteoid osteoma in every case as an obvious lytic lesion with a central granular opacity surrounded by a well - defined sclerotic margin . the mri was performed on fifteen cases , and clearly showed an intense soft tissue reaction around the lesion . the mean delay from the onset of symptoms to definitive treatment was 16.311.1 months ( range , 3months to 4 years ) . twenty - one patients were treated surgically with excisional biopsy and four with curettage and bone grafting . gender , age , range and number of cases at the wrist and hand for 25 patients with osteoid osteoma . follow up 36.646.9 months ( range , 3 months to 8 years ) , twenty patients had no pain or tenderness , and five had recurrence after first surgery in which three of them were initially operated in elsewhere . location of the primary osteoid osteoma at recurrence group consisted of one in the metacarpal bone , two in the distal and two in the proximal phalanx . all patients treated surgically by excisional biopsy ( 3 patients ) or curettage plus bone grafting ( 2 patients ) , and patients at follow up of 31.211.2 month ( recurrence group ) were well and had no pain . osteoid osteomas usually turned into symptomatic disease in the second or third decades of life , and rarely occurred in patients with 40 years of age . approximately twice as many men as women are affected ( 3 , 5 , 9 ) . the men to women ratio was 5.25 and right to left side hand ratio 4 . all studied patients were in second , third or fourth decades and only in one case over 40 years of age . ghiam and bora described 3 carpal tumors in two patients and combined these in the literature to establish a series of 26 cases of carpal osteoid osteomas . the scaphoid was the most commonly involved bone , with the hamate second and the capitate the third most frequently involved carpal bone ( 10 ) . marcuzzi & leti reports of 18 osteoid osteomas of the wrist and hand , two cases was in the scaphoid , two in lunate and one in capitate , and ambrosia & wold reported of 19 cases of osteoid osteomas in which included two in capitate , one in hamate and one in the triquetrum ( 11 ) . we had only five cases in the carpal bone ( two in the scaphoid , two in the capitate and one in the trapezium bone ) . the most common complaint was pain , often described as being more severe at night . healey reported improvement of pain after aspirin treatment ( 3 ) . in the series presented by bender et al , 86% of patients with an osteoid osteoma of upper extremity also reported pain relief with aspirin use ( 2 ) . we evaluated relief of pain with nsaid only in 21 patients and found relief of pain in 16 cases ( 76% ) . when the tumor was located near a joint , it may reduce range of motion and mimic primary arthritis . in the phalanges , typically a fusiform soft - tissue swelling existed with enlargement and clubbing of the phalanges . the mechanism that developed this feature was unclear , but it appeared to be in response to a presumably humoral substance produced by the tumor . this may directly induced proliferation of connective tissue , bone changes and dilation of blood vessels . furthermore the edema , produced by local hyperaemia and inflammatory factor release , increases the distance through which oxygen must diffuse before reaching the cells , possibly causing a localized hypoxaemia . this stagnant hypoxia can indirectly induce enlargement of the finger and clubbing of the distal phalanx ( 4 ) . initial x - ray examinations were often normal , as was the case in 12 of our cases , but a three - phase technetium-99 m bone scan detected the lesion which was characterized by an intense well - defined focal area of increased uptake , and is readily apparent in all three phases and only in one patient diffuse increase in isotope uptake was seen . osteoid osteoma of trapezoid bone of 31 years old men with wrist pain since 18 month ago . c : ct scan shows nidus at trapezoid ( incidental bone iland at triquetrum ) . d : the mri shows diffuse edema at wrist . when the bone scan was positive or equivocal with normal radiographs , computed tomograms employed this was superior to conventional radiography and mri , not only for diagnosis , but also for surgical planning and follow - up of osteoid osteoma of the small bones in hand . the wrist mri showed the tissue reaction around the tumor ( 1 , 2 , 11 , 12 ) . specialized imaging techniques may hasten the diagnosis , but only an accurate clinical history with a high index of suspicion allows one to arrange the appropriate investigations . treatment of osteoid osteoma consisted of curettage or en bloc excision of the tumor , which resulted in almost immediate relief of pain . pre - operative ct assessment of the lesion greatly assist the surgeon and increases the likelihood of an adequate surgical excision . packing the defect after curettage with cancellous bone chip may not be necessary , but incomplete removal may lead to recurrence or continuation of symptoms . nowadays the operative treatment is not the only modality recommended to the patients and their family but it is also an alternative choice . osteoid osteomas , relatively rare lesions in the hand and wrist that can be a persistent source of hand and wrist pain . relief of pain with oral nsaid , most notably aspirin , should suggest the possibility of osteoid osteoma . finally , if the nidus can not be clearly visualized by radiography and bone scan , a ct scan should be recommended .