Tumors of the HandBy: Prof. Dr. Hussein Abdel

Fattah

The hand is the site of a great variety of benign lesions and a few malignant lesions but benign ones predominates .

Malignant skin tumors squamous cell carcinoma, basal cell carc. & malignant melanoma are not included in this survey

Tumor like conditions are mentioned

Patients seek advice early because of simplicity of recognition and the disability that attends a small lesion in the hand.

Benign lesions in the hand are first noticed as a palpable mass, an enlarged digit, or a mechanical dysfunction .

Pain may be the presenting symptom in glomus tumor,osteoid osteoma osteoblastoma

Many metabolic and degenerative processes are seen in the hand as radiolucent areas, subchondral degenerative cysts in arthropathies and in gout.

Parathyroid adenoma

DiagnosisStandard X-ray of the hand of excellent quality and definition are essential

C.T. & M.R.I. & Bone scanClinical photo prior to surgery

Angiography in the hand is a useful technique for determining the anatomical extent of the lesion and its relationship to intricate system. Particularly in vascular tumors.

Many lesions in the hand are part of systemic processes. Radioactive isotope scan serves as a total skeletal survey. Any area of increased activity must be judged in light of the over all clinical picture.

Planning Treatment for Hand Tumours

For benign lesions of the digits incisions should be placed in such a way that they do not subsequently interfere with function.

Types of Surgical Approach

Marginal excision. Curettage & graft. Wide resection and

intercalary reconstruction.

Wide ray resection.

In many instances ray resection may be a cosmetically and functionally superior method of reconstruction than composite tissue grafting.

Caution is needed against overenthusiastic reconstruction with potential loss of the remaining function of the hand.

Enchondroma:

Solitary and Multiple

The small bones of the hand and have a marked predilection

to proximal and middle phalanx and to metacarpal

Cartilagenous tumors

ECCHONDROMA ENCHONROMA

Common painless unless pathological fracture

Enchondroma fifth metacarpal

Curettage & graft after path. fracture.

Multiple chondromata

Curettage & collapse of the

wall

Preoperative

Postoperative

Ollier,s disease

Multiple chondromata

Maffuci syndrome With cavernous haemangimata showing calcified

thrombi

Big benign enchondroma distal Ulna

Bone tumorsOsteochndrma

Osteoid osteomaGiant cell tumorOsteosarcomaSecondary deposit

OSTOID OSTEOMAPAINFUL SMALL LESION

HOT IN BONE SCAN

BENIGN OSTEOBLASTOM

A

PAINFULL DENSE TUMOR

WITH TENDECY

TO RECURREN

CE

B. OSTEOBLASTOMA

REURRENCE AFTER

CURETTAGE

RADICAL EXCISION & ILIAC BONE GRAFT

OSTEOCHONDROMA

MULTIPLE HEREDITARY

EXOSTOSIS

ANEURYSMAL BONE CYST

G.C.T. OF SECOND

METACARPAL

PARATHYROID BROWN

TUMOR HEALS AFTER

EXCISON OF ADENOMA

DIFF. DIAGNOSIS

G.C.T. INDEX CURETTAGE & GRAFT POSSIBILTY OF

RECURRENCE HIGH

RAY RESECTION IS MORE RADICAL

G.C.T. DISTAL RADIUS

EXCISION & FIBUALR GRAFT

In contrast, many sarcomas in the hand and particularly on the dorsum tend to mimic an inflammatory process with diffuse swelling, local heat and erythema rather than appear as a discrete swelling.

Fibrous Tissue Tumors

Fibroma, localised well differeniated

Palmar fscia contracture, hereditary slowly growing nodules over years

Fibrous tissue localised fibroma

DUPUYTREN,S CONTRACTURE

Subcutaneous fibrosis in palmar

Facia with with progressive contracure& flexion deformity

Rt hand operated 3 months ago

Lt. hand operated 10

years ago at age of 53

Age 63 now

Fibrous Tissue Tumors Diffuse Fibromatosis

Diffuse Fibromatosis is a soft tissue tumour of neurolemmal sheath ,muscular fibrous sheath that has a nasty habit of many local recurrences if not completely excised. These tumors can be very painful and disfiguring. They show tendency to malignant destructive recurrence.

M.R.I. coronal section

M.R.I. AXIAL CUTS

Ray resection of the medial two RAYS to save good

function of the hand

AFTER THREE YEARS

FIBROMATOSIS OF SECOND RAY FOR

RESECTION

Recurrent malignant Triton tumor

Diffuse fibromatosis

M.R.I.showing extensive infiltration in the sole of

the foot

Symes amputation was mandatory after four

previous excisions

Synovial TumorsPigmented villonodular

synovitisA REACTIVE LESION OF

TENDON SHEATH USUALLY ON THE PALMAR ASPECT OF DIGIT SLOWLY GROWING 20% SHOWS

BONE EROSION, 2O% LOCAL RECURENCE

Pigmented villonodular synovitis

in the index

MARGINAL EXCISION

Longstanding tumor with pressure

bone atrophy

P.V.N.S. THUMB

Flap incision

Tendons nerves,

vessels intact

PVNS in the

SECOND

toe

Chondromatosis Synovii

Unique case in the radial and ulner synovial

bursa in the distal forearm and palm of the

hand

SLOWLY DEVELOPING HARD NODULES

WITH SLIGHT PAIN & CREPITUS ON MOVING THE FINGERS

Excision of chondromatous masses

Nerve tumorsNeurofibroma

Glomus tumorElephantiasis nurofibromatosis

Nerve sheath tumor in dorsal

digital nerve of little finger

Dorsal digital nerve

neurofibroma painful

excision

Nerve sheath tumor fo median nerve presenting as C.T.S. simple

decompression Unique case

Multiple neurofibromatosis tender sheath tumor for

excision preserving the nerve trunk

Tumor Like Conditions

Simple ganglion Inclusion dermoid Megalodactylia Vascualar anomalies Lymphatic obstruction anomalous Gouty arhropathy,tophi Rheumatoid tenosynovitis T.B. tenosynovitis & spina ventosa

Simple dorsal Palmer ganglion

Muscinous filled cyst adjacent to joint caopsule or tendon sheath, with an outer

fibrous wall and inner synovial lyning filled with clear colorless gelatenous

fluid

Implantation Dermoid

Skin epithelial cells implanted through a small skin puncture

MegalodactyliaIn the Hands and Feet

Hyperplastic, giant overgrowth of one or more digit usually the middle, index, or thumb, including the phalanges.

Some are due to bony overgrowth with normal appearing soft tissue parts, others from excess fat, lymphatic and fibrous tissue.

Large neurofibromata with trophic effect on the overgrowth may be associated with angiomata and lymphomata

Elephantiasis neurofibromatosis

Megalodactylia

Child two years Middle and ring fingers

Second and third Toes

Ring finger

Megalodactylia ray-resection

Megalodactylia ring finger ray resection

short

Short metacar

pal

Elephantisis neurofibromatosis good function leave alone

MEGALODATYL second &

third ray

MEGALODATYLIA

RESECTED BIG TOE , SECOND & THIRD RAYS

MEDIAL LATERAL

Three months postoperative

Vascular TumorsHaemangioma

Arterial aneurysmArteriovenous aneurysm

Lymphatic obstruion

TRAUMATIC ARTERIAL ANEURYSM

ANGIOGRAM FOR ANEURYSM ULNER

ARTERY

Artriovenous fistula in forearm

veins were arterialized, with distal

ischemia loss of distal end of

the index

Cavernous Haemangio

ma

Congenital lymphatic obstruction with elephantiasis

Congenital Lymphatic Obstruction

Neonatal

Adult lymphoede

ma

Chronic Gouty Tophi Eroding I.P.

Joints

Gouty Tophi in Hands and Feet

Rheumatoid Tenosynovitis Melon

Seed Bodies

Rheumatoid Tenosynovitis around Extensor Tendons

Tuberculous Dactylitis age 2 yrs

T.B.

TENOSYNOVITIS in tendon sheath of flexor group

Early Leprotic Late Nerve Palsy

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