Hand Masses

Front 1

Most common site for ganglion cysts? Where can it be found?

Back 1

Dorsal carpal ganglion

▸Overlies scapholunate ligament

▸70% of all ganglia

▸Often occurs between third and fourth extensor compartments

Front 2

Most common ganglion cyst location in children < 10? Which major structure can it be next to?

Back 2

Volar carpal ganglion

▸Most frequent site in children <10 years old and in 15%–20% of adult cases

▸Originates from flexor carpi radialis (FCR) tendon sheath, radiocarpal, or scaphotrapezial joint. Next to the radial artery.

Front 3

Where are flexor tendon sheath ganglions most likely to occur? Do they move with the tendon?

Back 3

Flexor tendon sheath ganglion (volar retinacular)

▸Often at A1 pulley (or between A1 and A2 pulleys), base of digit

▸3–8 mm diameter

▸Attached to tendon sheath and does not move with tendon

▸Result of direct damage to fibrous sheath

▸Possibly delay or obviate need for surgery by using needle aspiration, steroid injection, and massage until rupture

Front 4

Mucous cysts at the DIP can be associated with which additional deformities? What must be done at the time of surgery?

Back 4

Mucous cysts

▸Dorsal aspect of P3 (digital phalanx) is associated with extensor tendon, joint, or joint capsule.

▸Longitudinal grooving of the nail is possible.

▸Cysts are found mostly in older women, associated with degenerative changes in the distal interphalangeal (DIP) joint.

▸Radiographs show narrow space and osteophytes.

▸Skin is thin and may rupture.

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

Front 5

Name the mass:

•Yellow-brown subcutaneous mass usually evident

•Fine-needle aspiration (FNA) may help in difficult cases

•Histology: Cells of fibrous xanthoma, spindle cells, foam cells

•May erode into bone, infiltrate dermis

Treatment?

Back 5

Giant cell tumor of tendon sheath; treat with marginal excision.

Front 6

Name the hand mass:

Firm, spherical, nontender mass

May cause bone erosion

Treatment: Must excise completely to avoid recurrence

Most common location?

Back 6

Epidermal inclusion cysts, which occur following trauma.

Epidermal cysts have a 2:1 male-to-female ratio with a peak incidence at age 39. They are located in the distal phalanges, usually palmar index and long.

Front 7

Which mass is this?

•Pulsatile mass

•Digital ischemic changes

•Emboli

•Tinel's sign of ulnar nerve often present

Back 7

Ulnar artery aneurysm caused by hypothenar hammer syndrome.

Front 8

Which disease displays peripheral nerve tumors?

Back 8

Neurofibromatosis (von Recklinghausen's disease)

Front 9

Most common malignancy of nail bed?

Back 9

squamous cell tumor

Front 10

Name the mass:

•Painless mass with recent growth

•Innocuous at presentation (may mimic ganglion cyst)

•Plain radiographs may demonstrate:

▸Soft tissue calcification

▸Fat density

▸Bony involvement

First step?

Back 10

Soft tissue sarcoma. Biopsy it, but later on must excise the tract through which the biopsy was taken.

Front 11

What is the most common benign bone tumor of the hand? Treatment?

Back 11

Enchondroma

Curettage with or without cancellous bone grafting

▸If fracture present, allow to heal before curettage

Front 12

What is the disease of multiple enchondromas called? What can happen (rarely)?

Back 12

20% degenerate into chondrosarcoma in Ollier's disease

Front 13

Name the neoplasm:

Originate from the physis and maintain a cartilaginous cap

Back 13

Osteochondroma, common in kids

Front 14

Pain is worse at night. What can be used to treat this?

Back 14

Osteoid osteoma (benign) symptoms are relieved by NSAIDs.

Front 15

Where do giant cell tumors most commonly occur? Do they invade bone?

Back 15

These growths are common in adults younger than 50 years of age. These masses are slow-growing, firm, lobulated, and painless. Giant cell tumors are the second most common tumor of the hand, after ganglion cysts. Unlike ganglion cysts, giant cell tumors cannot be transilluminated. Moreover, they usually occur on the volar aspect of the hand, and bone invasion is not commonly seen.

Front 16

Most common treatment for pediatric ganglions?

Back 16

Observation: most will rupture and resolve on their own.

Front 17

A 44-year-old woman comes to the office because of a 2-year history of a painless mass in the volar aspect of the forearm that has been enlarging gradually. She has no history of skin lesions or neurologic symptoms. Physical examination shows a 1.5-cm mass that is mobile in a transverse direction. Light tapping over the mass results in tingling of the index and long fingers. MRI shows a well-circumscribed area of enlargement within the median nerve that is hyperintense on T2 imaging. Which of the following is the most appropriate management?

A) En bloc resection with nerve grafting

B) Excision with nerve preservation

C) Incisional biopsy

D) Percutaneous needle biopsy

E) Segmental resection with primary nerve repair

Back 17

The most appropriate course of treatment is excision with microsurgical nerve preservation.

Neurilemoma (schwannoma) is the most common benign nerve tumor of the upper extremity. These tumors result from a proliferation of Schwann cells. Lesions often present on the flexor surface of the hand and forearm and are generally painless; however, they may sometimes be accompanied by paresthesia. In some cases, there may be neurologic deficits. Neurilemomas are typically mobile in a transverse direction but not longitudinally. On MRI, they appear isointense with muscle on T1-weighted images but are hyperintense to subcutaneous fat on T2 imaging.

Front 18

52-year-old woman comes to the office because of a 9-month history of the nail deformity shown. Physical examination shows thinned skin overlying an eponychial mass. The finger is nontender to palpation. She is dissatisfied primarily by the appearance of the nail. Which of the following is the most appropriate initial step in management?

Back 18

Excision of the ganglion cyst deep to the nail fold

Front 19

An 18-month-old boy is brought to the office because of a 3-month history of rapidly enlarging lesions on the long and ring fingers (shown). Examination of a specimen obtained on incisional biopsy of the lesion on the ring finger shows histology with interlacing fibroblasts and characteristic intracytoplasmic eosinophilic inclusion bodies. Diagnosis & most appropriate next step?

Back 19

Neurofibromatosis, excise & full thickness skin graft.

Front 20

Initial treatment of epitheliod sarcoma?

Back 20

Preoperative radiation should be administered for epithelioid sarcomas, as it will help decrease tumor size and local recurrence rates. Chemotherapy is appropriate for tumors that are high grade, greater than 10 cm in diameter, involve the lymph node, or are metastatic. As chemotherapy plays an important role in epithelioid sarcomas, it is usually given postoperatively. Excisional biopsy is reserved for low-grade tumors. Epithelioid sarcomas are usually high grade, so excisional biopsy would not be appropriate. Forearm amputation should be considered if negative margins cannot be achieved. Wide excision with negative margins is a mainstay of surgical treatment.