Squamous cell carcinoma of the finger masquerading as paronychia

Nail dystrophy for the surgeon

Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.

Fingertip Infections

The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.

Squamous cell carcinoma complicating chronic osteomyelitis: A systematic review and case series

INTRODUCTION

Squamous cell carcinoma (SCC) is a rare but serious complication of chronic osteomyelitis. This study aimed to determine an optimum approach to diagnosis and management.

METHODS

A systematic review was performed using Medline, Embase, CINAHL and Web of Science, from 1999-present. Additional cases, meeting the eligibility criteria, were added from our hospital database. Patient demographics (age, gender, co-morbidities), osteomyelitis diagnosis (location, duration), diagnosis of SCC (method, imaging, extent of disease) and management (amputation versus wide local excision versus palliation) as well as outcome at one and five years were collected.

RESULTS

Nineteen studies involving 106 patients met strict inclusion criteria. All published studies were case reports or case series. Chronic osteomyelitis had been present for a mean of 31 years (range 3-67) prior to SCC diagnosis. SCC was most commonly treated by amputation (81%). A poorer outcome occurred in those with metastatic disease (p = 0.006 at one year; p = 0.032 at five years), an incidental diagnosis at surgery for osteomyelitis (p = 0.052; p = 0.021) and SCC after pelvic osteomyelitis (p < 0.001; p = 0.002).

CONCLUSIONS

SCC should be suspected in all cases of chronic osteomyelitis with skin changes, particularly if the duration of sinus drainage exceeds 3 years. Histological biopsy for malignancy should be taken in all suspected cases, as well as routinely during excision of osteomyelitis when chronic skin changes are present. Staging computed tomography (CT) scanning is recommended to guide adjunctive therapy. Amputation, where possible, may be considered as the definitive surgical management, after discussion with the patient.

Fingertip Infections

The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.

Clinical characteristics, treatment, and prognosis of squamous cell carcinoma arising from extremity chronic osteomyelitis: a synthesis analysis of one hundred and seventy six reported cases

PURPOSE

Squamous cell carcinoma (SCC) arising from extremity chronic osteomyelitis (COM) has not been well-understood due to its low prevalence. This study aimed to synthesize the cases recently published to clarify their clinical characteristics, treatment, and prognosis.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for English literature reporting cases diagnosed of SCC originating from extremity COM between January 1, 1990, and September 30, 2019. The National Institutes of Health (NIH) assessment tool was used to evaluate the quality of reports included, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to summarize the quality of available evidence. The data synthesized for analysis were clinical features, treatment strategy, and incidences of local recurrence, metastasis, all-cause, and SCC-related deaths. In addition, potential factors that might have influenced treatment efficacy and prognosis of SCC were also investigated.

RESULTS

Included for this analysis were 60 studies of 176 patients (a male-to-female ratio of 6.7). COM mostly occurred following trauma (73%), the tibia was the most frequent site (61%), and a sinus tract was the most common symptom (61%). The mean duration from COM to SCC was 27 years. Positive rate of pathogen culture was 90%, with 73% being polymicrobial. Limb amputation was performed in 80.5% of the patients. Incidences of local recurrence, metastasis after treatment, all-cause, and SCC-related mortalities were 16.7%, 12%, 31.1%, and 12.6%, respectively. Patients with local lymphadenopathy at diagnosis had significantly higher risks of local recurrence (P = 0.01), SCC-related (P = 0.02), and all-cause deaths (P = 0.01) than those without. Patients with moderately-to-poorly differentiated SCC types had significantly higher risks of local recurrence (P = 0.01) and all-cause death (P = 0.02) than those with a well-differentiated type.

CONCLUSIONS

SCC arising from extremity COM favoured males and the tibia. Although limb amputation was the mainstay of treatment, the overall incidences of local recurrence, metastasis, and SCC-related death exceeded 10%. Patients with local lymphadenopathy at diagnosis of SCC and those with moderately-to-poorly differentiated SCC types should be followed up closely.

TRIAL REGISTRATION

CRD42020154221.

Acute and chronic paronychia of the hand

Acute and chronic infections and inflammation adjacent to the fingernail, or paronychia, are common. Paronychia typically develops following a breakdown in the barrier between the nail plate and the adjacent nail fold and is often caused by bacterial or fungal pathogens; however, noninfectious etiologies, such as chemical irritants, excessive moisture, systemic conditions, and medications, can cause nail changes. Abscesses associated with acute infections may spontaneously decompress or may require drainage and local wound care along with a short course of appropriate antibiotics. Chronic infections have a multifactorial etiology and can lead to nail changes, including thickening, ridging, and discoloration. Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia.