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BENIGN HAND TUMOURS

Ganglion cysts

  • Overview

    • Most common benign mass in the hand

    • More common in women in 2nd to 4th decades

  • Aetiology​

    • Mucoid degeneration of fibrous connection tissue occurs in joint capsule or tendon sheaths​

    • Repeated minor trauma may have association

  • Clinical findings​

    • Mobile, transilluminable mass that may move with tendon​

    • May present with pain

    • Radiographs not helpful to diagnose ganglion cyst but may be useful to illicit underlying articular pathology

  • Types​

    • Dorsal carpal ganglion​

      • Overlies scapholunate ligament​

      • Very common

      • Often occurs between 3rd and 4th extensor compartments

    • Volar carpal ganglion​

      • Originates from flexor carpi ulnaris tendon sheath, radiocarpal or scaphotrapezial joints​

      • Adjacent to radial artery

    • Flexor tendon sheath ganglion​

      • Often at A1 pulley​

      • Attached to tendon sheath and does not move with tendon

    • Mucus cyst​

      • Dorsal aspect of distal phalanx is associated with extensor tendon, joint or joint capsule​

      • Associated with longitudinal grooving of nail

      • Associated with degenerative changes in the distal interphalangeal joint

      • Always remove osteophytes at the time of excision and look for occult cysts on the contralateral side

  • Management

    • Conservative​

    • Aspiration

    • Surgery

      • Indicated for pain, deformity or limitation of function

      • Complete excision of cyst wall, stalk and joint surface​

    • High rates of recurrence

Ganglion cyst

Giant cell tumour of tendon sheath

  • Overview

    • 2nd most common hand tumour​

    • Generally presents from 4th to 6th decades

    • Also known as pigmented villonodular synovitis (PVNS)

  • Aetiology​

    • May be reaction to injury​

    • Often confused with ganglion

    • Fixed to deeper tissues and may erode bone

  • Clinical findings​

    • Yellow-brown subcutaneous mass​

    • May erode bone or infiltrate dermis

  • Treatment

    • Surgical marginal excision​

    • Recurrence is common due to incomplete excision or satellite lesions

Giant cell tumour of tendon sheath

Epidermal inclusion cyst

  • Overview

    • 3rd most common tumour of the hand​

    • Palm and fingertips in patient swhose occupations predispose them to penetrating injuries

  • Aetiology​

    • Implantation of epidermal cells in the dermis through penetrating injury​

  • Clinical findings​​​

    • Firm, spherical, non-tender mass​

    • May cause bone erosion

  • Treatment​

    • Complete excision to avoid recurrence​

Epidermal inclusion cyst

Glomus tumour

  • Overview

    • 1-2% of all hand tumours​

    • Malignant glomus tumour is rare

  • Aetiology​

    • Benign hamartoma of glomus apparatus (arteriovenous anastamosis involved in regulation of cutaneous circulation​)

  • Clinical findings​

    • Triad of pain, pinpoint tenderness and cold sensitivity​

    • Subungual is most common site

    • Nail ridging and red to bluish discolouration

  • Investigations

    • Ultrasound with high frequency transducer​

    • MRI

  • Treatment​

    • Local complete excision through sterile matri​

    • Low recurrence if ​​completely excised

Glomus tumour

Peripheral nerve tumours

  • Overview

    • 1-5% of all hand tumours

  • Diagnosis​

    • Ultrasound or MRI​

  • Types​

    • Schwannoma (Neurilemmoma)​

      • Most common nerve tumour​

      • Prevalent in middle age

      • Asymptomatic nodular swellings extrinsic to nerve

      • Treatment: Enucleation

      • Recurrence is rare

    • Neurofibroma​

      • Functional abnormality possible​

      • Lesions seen before age 10 years

      • Treatment: Resection if primary repair possible

    • Neurofibromatosis (von Recklinghausen's disease)​

      • Autosomal dominant​

      • ​Associated features:​

        • Acoustic neuromas​

        • Optic gliomas

        • Meningiomas

        • Gigantism of limb

        • >6 cafe-au-lait spots

      • Plexiform pattern

      • Sarcomatous degeneration in 10-15%

      • Treatment: Excision if symptomatic or impeding function, biopsy if suspicious of sarcomatous transformation

    • Malignant peripheral nerve sheath tumour​

      • 2-3% of malignant hand tumours​

      • Associated with von Recklinghausen's disease

      • Local extension or metastasis common

      • Very high mortality

      • Treatment: Wide excision if possible, may require limb amputation

    • Intraneural nonneural tumours

      • Types​:

        • Lipoma​

        • Haemangioma

        • Lipomatosis of nerve

Peripheral nerve tumours

Enchondroma

  • Overview

    • Most common benign bone tumour of the hand​

    • Multiple enchondromas associated with Ollier's disease

      • Rare risk of transformation to secondary chondrosarcoma

  • Aetiology​

    • Aberrant foci of cartilage​

  • Diagnosis​

    • Plain radiograph​

    • CT or MRI also useful

    • Asymptomatic (incidental) or presenting with pathological fracture

    • Well-demarcated, round, expansile lesions with flocculent matrix calcification on radiographs

  • Treatment​

    • Observation if asymptomatic​

    • Currettage with or without cancellous bone grafting

    • Allow fracture healing first before curretage

Enchondroma

Osteochondroma

  • Overview

    • Most common catilagenous neoplasm overall​

    • Young patients

  • Aetiology​

    • Originates from physis and maintain a cartilaginous cap​

    • Associated with hereditary multiple exostosis

  • Clinical presentation​

    • Bony protuberances extending beyond metaphyseal cortex on stalk seen on diagnostic radiographs​

    • Sessile or pedunculated

    • May be subungual

    • Medullary contents shared with the host bone

    • <1% risk of malignant transformation

  • Treatment​

    • Excision flush with cortex of bone for symptomatic lesions​

    • Recurrence is rare with complete excision

Osteochondroma

Periosteal chondroma

  • Overview

    • Only 2% of chondromas​

  • Aetiology​

    • Originating from periosteum​of the tubular bones

    • Benign hyaline cartilage neoplasm

  • Clinical findings

    • Palpable, slow-growing, often painful mass​

    • Saucerisation of underlying cortex on radiographs with adjacent buttress of cortical bone

    • CT or MRI for surgical planning

  • Treatment

    • Complete excision with burring​

    • Recurrence is rare with complete excision​

Periosteal chondroma

Osteoid osteoma

  • Overview

    • 2-3 times more prevalent in males than females​

    • 1st to 3rd decades

    • Uncommon in hands

  • Clinical findings​

    • Distal phalanx most commonly affected

    • Painful, localised area over tubular bone​

    • Pain worse at night

    • Relief of pain with nonsteroidal anti-inflammatory drugs

    • Central area of lucency surrounded by zone of sclerotic bone on radiographs

    • Bone scintigraphy and CT useful

  • Treatment​

    • Radiofrequency ablation​

    • Curettage with cancellous bone grafting

    • Recurrence​ is rare after complete excision

Osteoid osteoma

Osteoblastoma

  • Overview

    • Rare in hand​

    • 2nd to 3rd decade

  • Aetiology

    • Poorly mineralised immature bars of neoplastic osteoid​

  • Clinical findings​

    • Localised to carpus and tubuluar bones​

    • Larger than 2cm

    • Localised swelling and pain

  • Treatment​

    • Curettage with adjuvants and bone grafting​

    • Recurrence is rare with complete excision

Osteoblastoma

Giant cell tumour of bone

  • Overview

    • 2-5% occur in hand​

    • 3rd to 5th decades

    • More common in females than males

  • Aetiology​

    • Benign lesions based on histology, but locally aggressive and can metastasise to the lungs​

  • Clinical findings​​​

    • Solitary lesion​

    • Dull, constant pain, osseous expansion

    • Metaphyseal lesion with extension into the epiphysis

    • Radiolucent with thin cortex on radiographs

  • Treatment​

    • Curettage with adjuvants​

    • Wide resection of aggressive lesions

    • Recurrence is variable and can be decreased with wide resection

Giant cell tumour of bone
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