- Benign:
- Epidermal inclusion cysts: from epidermal cells embedded in dermis (usually from trauma so they often arise in volar distal phalanges)
- treated with excision
- Mucous cyst: ganglion cysts of the DIP joint associated with nail spurs and bony grooving
- Evaluation through physical exam and Xrays (xrays wil show DIP osteophytes)
- Nail grooving occurs through compression of germinal matrix
- Treatment: excise cyst and remove bony spurs
- Digital fibromatosis: rapidly growing broad base masses on dorsal/lateral aspects of finger
- Treatment is wide excision and FTSG
- Keratocanthoma: cutaneous lesion similar to SCC (benign), round, elevated, central crater. is variant of SCC, appears as red papule on sun damaged skin, rapidly expands
- excisional biopsy and primary closure
- Retinacular cysts: ganglion cysts of tendon sheath seen at volar MCP
- Ganglion cyst: most common hand tumor.
- Most common location: 60-70% found dorsally: scapholunate ligament
- Volar: 20%. Most common: radioscaphoid > scapholunate > scaphotrapezial > metacarpotrapezial
- Lowest recurrence rates with excision
- Other means such as aspiration or rupture
- Transilluminates
- Can observe pediatric ganglions if asymptomatic, most spontaneously rupture
- Observation warranted in pediatric ganlgions unless symptomatic
- Giant cell tumor: neoplasm of histiocytes, most common benign neoplasm of the hand after ganglion cyst
- Typically on tendon sheath, rubbery mass more common on flexor surface, slow growing, tan and typically multi lobulated. Can be invasive
- Pathology: histiocytoid mononuclear cells, histiocytes, hemosiderin
- Does not transilluminate
- needs marginal excision, though has propensity for local recurrence (5-50%)
- 1-5% incidence of pulmonary metastases, for staging need CT chest
- Extensor brevis manus originates from DRC
- Can present as a tender dorsal wrist mass distal to the radiocarpal joint, can present as ganglion cyst, moves with finger movement
- Lipoma is most common tumor on body, do not transilluminate and is mobile, slow growth, soft
- Gout:
- Tophi- present as red nodules with milky white fluid
- Treat with anti-inflammatory agents IE colchicine
- Bone/tendon
- Endochondroma: benign cartilaginous tumor in bone of hand (within the lamellar bone); develop 2nd/3rd decade; pain in absence of fracture
- Xr shows Show scalloped lytic lesion within medullary canal of affected bone with scattered calcification
- Associated with Ollier’s disease (endochondromas with skeletal dysplasia); Maffucci syndrome
- Mafucci syndrome: multiple endochondromas associated with vascular hemangioma
- Treat with excision and curettage and bone grafting–> 10% will recur (most likely outcome is normal healing without recurrence)
- Can be autologous or bone graft substitute
- Most common location is proximal phalanx
- If incidental finding with fracture, treat fracture first then excise later
- Malignant degeneration into chondrosarcomas rare
- Chondromyxoid fibromas: benign cartilaginous tumors that rarely occur in upper extremity; radiolucent lesion with small sclerotic rims
- Osteoid osteomas: symptomatic, pain at night relieved with NSAIDS, xray shows target (two-o’s) like lesion
- CT will show a hypervascular nidus of osteoblasts with surrounding sclerotic cortical reactive bone formation
- Treatment is curretage and bone grafting
- Osteochondroma: have a bone stalk and cartilaginous cap growing out from the metaphysis in skeletally immature patients. The cortices are contiguous.
- Treat non operatively unless symptomatic
- Can occur with multiple hereditary exostosis (if other lesions are present)
- WLE and reconstruction to prevent symptoms (even if on the chest)
- Nerve involvement
- Glomus tumor: benign hamartomatous neoplasm. most frequently in fingertip, subungually –> they are neurovascular so symptoms include pain, sensitivity to cold, tenderness on palpation, purple mass can sometimes be observed
- Love sign: extreme pain on direct focal pressure
- Hildreth sign: decrease in pain with proximal tourniquet inflation
- Ice bath immersion test – highly sensitive to cold
- MRI
- Treatment is complete excision, recurrence rates up to 20%
- Neurofibroma: tumor arising within the nerve fascicles. Usually solitary and benign
- Evaluate with MRI
- Can cause deficits
- Think NF1 or vonrecklinghausen disease if have neurofibroma and café au lait spots – may be malignant
- Neurilemmoma (schwannoma): tumor of Schwann (glial) cells on nerve surface
- Schwannoma: benign nerve tumor, painless, typically in proximal wrist; can be painful if in digits –> diagnose with tinel and MRI (hyperintense on T2) –> can perform marginal excision if non-infiltrative
- Usually does not affect nerve function
- NF2- associated with b/l acoustic schwannomas
- Vascular
- Pseudoaneurysms from arterial wall perforation treated with exploration and vascular repair (if arterial perfusion needed) otherwise can be excised
- AV malformations of hands: selective intralesional embolization followed by surgical resection
- Low flow malformations: like venous malformations
- Present with soft, compressible, swelling with dependency, rapid growth with hormonal changes (ie pregnancy)
- Sclerotherapy may be used for larger or more diffuse lesions
- If symptomatic with pain, surgical excision is treatment
- Pyogenic granuloma: reactive vascular tumor that rapidly grows in response to minor trauma –> treatment is excision and cauterization of base, management can be chemical cauterization, currettage, silver nitrate
- Hemangiopericytoma: derives from vascular zimmerman pericytes –> biopsy with wide local excision
- Malignant:
- SCC is the most common malignant tumor in the hand
- Subungual melanomas
- Pigmented streak under fingernail (biopsy if is present >4wk)
- Malignant peripheral sheath tumors metastasize to lung (from nerve elements) and are the malignant form of neurofibroma
- They are classified as sarcomas
- Osteoblastoma
- Night pain, CT with radiolucent nidus surrounded by sclerosis
- Soft Tissue Sarcomas: rare tumors representing less than 1% malignancies
- Most common type is malignant fibrous hystiocytomas
- Work up includes MRI, biopsy, and CT of chest
- Incisional biopsy through longitudinal incision for soft tissue masses after MRI, other things may spread
- For incisional biospy, longitudinal incision with tourniquet no esmarch
- Treatment includes wide excision, primary reconstruction, and radiation therapy
- Need at least a 1cm biopsy
- Transverse biopsies lend itself to higher recurrence rate in sarcomas and need for flap coverage
- Exsanguination of arm is not recommended in those with neoplastic tumors; can elevate and compress brachial artery; typically 250mmHg, 50-75 higher than SBP
- Primary amputation: consider when tumor infiltrates major neurovascular structures, resection would result in the sacrifice of more than one major peripheral nerve, major comorbidities limiting reconstructive options
- Osteosarcoma: most common location is the humerus, most common malignant tumor of bone
- Symptoms include pain and edema
- Radiographs reveal a sunburst pattern with periosteal elevation at codman’s triangle
- Chondrosarcoma – low grade and slow growing
- Dx – Xr – intralesional lysis, endosteal scalloping, cortical thinning
- Tx – ablative therapy or wide excision
- Ewing sarcoma – actually a type of neural tumor, usually presents in males 5-25yo
- Dx – xr shows onion skin periosteal reaction and soft tissue mass overlying a diaphyseal lesion. Path shows small round cells in sheets
- Tx – chemotherapy, wide local excision, +/- XRT
- Epithelioid sarcoma: treatment is with pre-op radiation and WLE, chemotherapy if >10cm or high grade
- Remember preopreative radiation before WLE
- Verrucous carcinoma of fingernails from HPV, can mohs with graft coverage if DP (bone) not involved
- Suspect NF1 with malignant peripheral sheath tumors
