The presence of the abnormality in the hand made this case confusing and raises many diagnoses. Overall bone density is normal and there is no subperiosteal resorption or cortical tunnelling to suggest hyperparathyroidism with or without brown tumours. Gout can be very destructive but in this case there are no juxt-articular erosions or tophi to lead to this diagnosis. Enchondromas should not be so aggressive except perhaps in Maffuci’s syndrome when one should look for confirmatory phleboliths and chronic bone remodelling. Sudecks should cause more peri-articular osteopenia and bone lysis is in these regions predominantly. Myeloma does not as a rule affect the hands.
If one considers the differential of multiple aggressive bone lesions irrespective of site, the differential is very short: metastases and myeloma (leaukemia and lymphoma for completeness). We will exclude infection due to multifocality. None of these affect the hands do they? Well actually the commonest cause for multifocal aggressive lesions – metastases does in one condition affect the hands – lung cancer, the correct answer in this case.
Certain “rules” apply for osseous metastatic sites of involvement. The patella and mandible are for all intents and purposes never affected by metastases, the latter is affected by myeloma. Peripheral metastases in the upper limbs (beyond the elbow) and in the lower limbs (beyond the knee) are very uncommon presumably due to reduced red-marrow in these regions. Peripheral mets in the hands are almost exclusively due to lung cancer and frequently though not invariably associated with diffuse metastases elsewhere. Local symptoms of warmth and pain are common. Common sites include the distal phalanges, metacarpals, the scaphoid and lunate. In the feet lung cancer is also one of the commonest causes of metastatic disease though renal and colonic carcinoma may also metastasize to the foot, in particular the calcaneum.