Osteoid osteomas in the phalanges of the hand often present with atypical clinical and radiologic characteristics. These unusual presentations may cause a delay in diagnosis and treatment. In this study, seven cases (seven patients) of phalangeal osteoid osteomas in the hand were examined, six of which were misdiagnosed for long periods of time. These seven cases illustrate unusual presentations, including absence of reactive bone, monoarticular arthritis, clubbing, macrodactyly, painless swelling, and absence of bony lysis. Phalangeal osteoid osteomas also have unusual histologic features. Recognition of these unusual clinical, radiographic, and histologic features may prevent misdiagnosis and lead to prompt definitive therapy.