Answer to the last #DiagnosticDilemma
Young Boy With a Mid-line Swelling of the Hand

Final Diagnosis: SPINA VENTOSA

A 9-year-old boy with right paratracheal lymphadenopathy, developed a 4x4 cm, non-tender, soft, non-fluctuant, midline swelling over the dorsum of left hand with diffuse margins and normal overlying skin. There was no restriction of range of movement of hands and distal neurovascular status was normal.

Key Takeaways:-
• Spina Ventosa Or Tuberculous Dactylitis is a rare skeletal manifestation of tuberculosis in young children that commonly involves the short tubular bones of the hands and feet. The predisposition for short tubular bones of the hands and feet is explained by the hematogenous spread of bacilli to the hematopoietic marrow in these bones before the epiphyseal centers are well-established.

• Thereafter, the infection spreads rapidly to involve the entire marrow space and expanding the overlying soft cortex. The resultant fusiform cystic diaphyseal swelling with thinned cortex, radiolucent core, trabecular destruction, and minimal periosteal reaction was christened “spina ventosa” (spina [a thorn], ventosa [full of wind or distended]).

• Diagnosis is often delayed owing to the rarity of this presentation, lack of awareness, and clinical confusion with other pathologies, such as chronic pyogenic osteomyelitis, Brodie abscess, fungal abscess, old trauma, and tumors.

• Common but nonspecific radiologic features include lytic or cystic diaphyseal expansion, cortical erosion, soft tissue swelling and later cortical destruction, sclerosis, sequestrum formation with periosteal reaction, chronic discharging sinus, joint involvement, and pathologic fracture.

• Early diagnosis and appropriate antitubercular treatment prevents unnecessary investigations and further complications.