Benign bony and soft tissue tumors of the hand

Diffuse neurofibroma with hypertrichosis in a toddler

Diffuse neurofibroma is a rare type of neurofibroma uncommonly reported in infancy. It is a slow growing tumor originating in the peripheral nerve sheath. We present the case of a 17-month-old boy with diffuse neurofibroma of the scalp associated with hypertrichosis. His genetic and clinical workup for neurofibromatosis was negative.

Post Traumatic Neuroma in Continuity of the Median Nerve in a Child: A Case Report

An 8-year-old girl suffered a wrist laceration from a sharp glass, severing the median nerve. The nerve was end-to-end repaired at the time by a pediatric orthopedic surgeon. Six months later, the girl suffered wrist pain and hyperesthesia over the previous surgical incision, significantly affecting her daily activities. Physical examination revealed a palpable mass over the median nerve with a positive Tinel sign, and the diagnosis of a painful neuroma in continuity was set. She underwent another surgery where the defective neuroma in-continuity was excised, and the median nerve was reconstructed using sural nerve cable autografts. At 18 months follow-up after the second surgery, the girl appeared with a full passive and active painless range of motion and a negative Tinel sign. This is the first case of neuroma in continuity presenting in a child in the literature, successfully managed surgically.

Simple curettage and allogeneic cancellous bone chip impaction grafting in solitary enchondroma of the short tubular bones of the hand

Enchondroma is the most common bone tumor in the hand. While standard surgical procedure is intra-lesional excision and bone grafting, there is a dispute between allogeneic bone, autogenous bone, and synthetic bone substitute grafting. Diverse adjuvant treatments have been introduced to reduce recurrence, but results are mixed with controversies. Meanwhile, whether existing descriptive classification could predict treatment outcome remains unclear. Thus, we reviewed patients with solitary enchondroma of the hand who underwent simple curettage followed by allogeneic cancellous bone chip impaction grafting. Eighty-eight patients with more than 5 years of follow-up were enrolled. Demographic data, local recurrence, and complications were reviewed. Duration of consolidation and the difference according to Takigawa classification were assessed. Range of motion (ROM), and functional scores were also evaluated. There were 51 women and 37 men, with a mean age of 37.9 years. Mean follow-up was 10.2 years. Recurrence occurred only in one patient. There was no complication. Mean postoperative total active motions of fingers and thumb were 239° and 132.9°. Mean modified Disabilities of the Arm, Shoulder, Hand score, and Musculoskeletal Tumor Society Score were 1.63, and 99.2 at the last follow-up. Consolidation, ROM, and functional scores according to Takigawa classification showed no significant differences. This study suggests that simple curettage with impaction grafting of allogeneic cancellous bone chip is a feasible method for treating solitary enchondromas involving short tubular bone of the hand with good long-term outcomes. Postoperative recurrence and complication rates were very low. Radiographic and clinical results were good regardless of the previous radiological classification.

A Rare Case of Plexiform Schwannoma of the Little Finger and Its Management: A Case Report

Schwannomas are tumors of the Schwann cells found in the myelin sheath. They cause 5% of all benign soft-tissue cancers, occur equally in males and females, and occur later in life. Since they remain asymptomatic, diagnosing and treating them becomes challenging; current guidelines recommend imaging followed by excision. Here, we present a case of a 19-year-old male who presents in an outpatient setting with a history of painless swelling of the fifth digit for the past four years. Past medical history and physicals are unremarkable. Microscopic findings from fine-needle aspiration cytology (FNAC) confirmed the schwannoma diagnosis, showing loosely arranged spindle cells with elongated nuclei with pointed ends dispersed within the myxoid stroma.

Diffuse Type Neurofibroma of the Forearm

Nerve sheath tumors comprise 5% of soft tissue masses of the upper limb in adults. Neurofibromas are divided into three types: localized, diffuse, and plexi- form. The diffuse type is rare and is typically found in the head and neck region. We present a rare case of diffuse type neurofibroma found in the forearm, presented to our clinic as a slowly enlarging mass of the left forearm of 3 years duration. The lesion was suspicious in the magnetic resonance imaging, and biopsy revealed diffuse type neurofibroma. We opted for total excision of the lesion that was found to be not possible due to involvement of the major nerves. The final pathology report showed no malignancy. Nerve tumors of the upper limb can be either benign or malignant. Neurofibroma associated with neurofibromatosis has malignant potential. The diffuse type is rare, and it most commonly occurs in the head and neck region. It has a low malignant transformation rate. Magnetic resonance imaging is the diagnostic modality of choice; however, it can be inconclusive. Biopsy should be taken to confirm the diagnosis and plan for management. Our case was managed by near total excision in order to preserve the major forearm nerves because of high clinical suspicion.

Benign Hand Tumors (Part I): Cartilaginous and Bone Tumors

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution's experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

Diagnosis and treatment of hand tumors

Hand tumors are a very common problem in hand surgery. While these lesions are most often benign, malignant lesions often have an atypical presentation and are discovered late, very often during an inappropriate treatment. To optimize the care of hand tumors and to reduce diagnostic and treatment errors, we will review the broad diagnostic and therapeutic principles and the most common clinical presentations.

Benign Schwannoma of the Thumb; a diagnostic challenge

Benign Schwannomas are one of the less frequently encountered soft tissue tumours of the hand. We report an interesting case of an 80-year-old gentleman with a painful soft tissue swelling on the radial aspect of his thumb. Ultrasound revealed a well-defined lesion separate from bone and tendon, with mixed echogenicity and moderate internal vascularity. Magnetic resonance imaging demonstrated a 15 × 10 × 23mm lesion with low signal on T1 and high signal on T2. Following surgical excision, histology confirmed benign schwannoma.

Outcome of Surgical Resection of Primary Malignant and Aggressive Benign Metacarpal Bone Tumors

Primary bone tumors of the hand are relatively rare. Different treatment options have been described in case reports. In this study, the authors present the diagnostic methods and treatment strategies that they used. The goal of this study is to present the oncologic and functional outcomes of surgical resection of primary malignant and aggressive benign metacarpal bone tumors. This retrospective study included 7 patients with primary malignant and aggressive benign bone tumors of the metacarpals who underwent surgical resection with or without metacarpal reconstruction between 2000 and 2017, with a minimum follow-up of 2 years. Clinical and radiologic evaluations were reviewed, and functional evaluation was performed with the Musculoskeletal Tumor Society scoring system. Seven patients (6 female; 1 male), with a mean age of 30.9±11.3 years, were included in the study. Six tumors were de novo, whereas 1 was recurrent. After resection, 5 patients had metacarpal reconstruction. Nonvascularized fibula was used for 3 patients, extracorporeal freezing of the metacarpal using liquid nitrogen was used for 1 patient, and metacarpal shift was used for 1 patient. Mean follow-up was 52.6±26.7 months. At the final follow-up, mean Musculoskeletal Tumor Society score was 27.4±1.6, and no local recurrence was documented. One patient had chest metastasis after 8 years of follow-up. The results show that surgical resection of primary malignant and aggressive benign tumors of the metacarpal bones can achieve satisfactory functional and oncologic outcomes. [Orthopedics. 2021;44(5):e633-e638.].

Early Surgical Treatment of Both Tumor and Fracture in Patients With Enchondroma of the Hand Combined With Pathologic Fracture

PURPOSE

The aims of this study were to evaluate the degree of cortical thinning and the tumor area in simple radiographs in patients with enchondroma of the hand combined with pathologic fracture and to determine the surgical outcome of simultaneous tumor curettage and internal fixation of fracture.

METHODS

We enrolled 23 bone lesions of 21 patients diagnosed with enchondroma of the hand. Of them, 9 bone lesions of 8 patients had pathologic fracture. We evaluated the degree of cortical thinning and tumor area in simple radiographs and compared them between patients with and without pathologic fracture. For patients with pathologic fracture, we performed curettage of the tumor through the fracture site and fixed the fracture using K-wires. We then evaluated the clinical outcome of these patients using the visual analog scale to measure pain intensity and Takigawa's criteria 1 year after surgery.

RESULTS

There was a significant difference in the degree of cortical thinning between the 2 groups (P < 0.001); however, there was no significant difference in the percentage of tumor area (P = 0.259). The average time from surgery to bony union was 8.5 weeks in patients with pathologic fracture. The patients reported that they could return to their previous activities of daily living within 12 weeks of surgery. The average visual analog scale score was 0.6 at 1 year after surgery, and 6 patients were graded as excellent and 2 as good according to Takigawa's criteria.

CONCLUSIONS

Cortical thinning seems to be related to pathologic fracture. Our scoring system for cortical thinning may be helpful in evaluating the risk for pathologic fracture. Early 1-stage surgical treatment for pathologic hand fracture with enchondroma is a very useful method with satisfactory outcomes that could shorten the treatment period.

Tumors of the Hand and the Wrist

Most tumors of the hand and the wrist are benign; however, malignant conditions can mimic benign tumors and must be worked up accordingly. Advanced imaging should be followed by biopsy before definitive treatment of tumors of unknown diagnosis. The most common soft-tissue masses in the hand and the wrist are ganglion cysts, whereas the most common bone tumors are enchondromas.

Hand tumors: A review of 186 patients at a single institute

PURPOSE

The spectrum of diagnoses and clinical features of hand tumors differ from those of tumors in other body parts. However, only a few reports have comprehensively referenced the diagnosis and clinical features of hand tumors. This study aimed to elucidate the diagnostic distribution and the clinical features of hand tumors undergone surgery in our institute.

PATIENTS AND METHODS

A total of 235 lesions in 186 patients diagnosed with hand tumors between 1978 and 2020 were reviewed. Age at surgery, gender, chief complaint, tumor location, and pathological diagnosis were analyzed.

RESULTS

There were 121 benign bone tumors, 98 benign soft tissue tumors, and 16 malignant tumors. Chondroma and tenosynovial giant cell tumor were common benign bone and soft tissue tumors at the proximal phalanx of the ring finger and the palm, respectively. Meanwhile, chondrosarcoma and synovial sarcoma were common malignant tumors at the dorsal part of the hand. Local pain and painless mass were the chief complaints in patients with benign bone and soft tissue tumors, respectively. Most patients with malignant tumors were referred after unplanned resection. When patients were classified into two categories by tumor size according to maximal diameter, tumors larger than 19 mm had a significantly higher risk of malignant (p = 0.031) despite being smaller than other tumors in different body parts.

CONCLUSION

When a tumor malignancy is suspected, the patient should be referred to a specialist to avoid unplanned resection or delayed diagnosis due to misdiagnosis. Knowing the distribution and clinical features should help in diagnosing hand tumors.

Imaging Features of Primary Tumors of the Hand

Musculoskeletal tumors of the hand are a rare entity and are divided into skeletal and soft tissue tumors. Either category comprises benign and malignant or even intermediate tumors. Basic radiology allows an optimal resolution of bone and related soft tissue areas, ultrasound and more sophisticated radiologic tools such as scintigraphy, CT and MRI allow a more accurate evaluation of tumor extent. Enchondroma is the most common benign tumor affecting bone, whereas chondrosarcoma is the most commonly represented malignant neoplasm localized to hand bones. In the soft tissues, ganglions are the most common benign tumors and epithelioid sarcoma is the most frequently represented malignant tumor targeting hand soft tissues. The knowledge regarding diagnostic and therapeutic management of these tumors is often deriving from small case series, retrospective studies or even case reports. Evidences from prospective studies or controlled trials are limited and for this lack of clear and supported evidences, data from the medical literature on the topic are controversial, in terms of demographics, clinical presentation, diagnosis, prognosis and therapy. The correct recognition of the specific subtype and extension of the tumor through first line and second line radiology is essential for the surgeon, in order to effectively direct the therapeutic decisions.

[Three-year-old child with osteoid osteoma of the thumb: Diagnostic and therapeutic challenge]

A three-year-old girl experienced a fifteen-month odyssey before the surgical removal of an osteoid-osteoma at the distal phalanx of the thumb to relieve her pain. Osteoid-osteoma is a benign bone tumor rarely found in the hand and not yet described as occurring in a small child in extant literature. In one of the first x-ray examinations, a small foreign body was found in the soft tissues of the right thumb. This finding subsequently led to the assumption that trauma was the cause for the pain.We critically discuss the numerous examinations and therapies that the child underwent as well as the lack of interdisciplinary cooperation among specialists for more than a year. The thumb was immobilized for months because of pain and is slowly being reintegrated into the child's body scheme following the last successful intervention.This publication highlights this tumor's rare occurrence in a small child and the importance of interdisciplinary cooperation facilitated today by digital media. This, along with early diagnosis, could save unnecessary suffering and financial resources.

Double central ray amputation of the third and fourth digits for recurrent giant cell tumors of the hand: A case report

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Recurrent giant cell tumor of bone of hand treated by double central ray amputation.

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Double central ray amputation results in acceptable functional outcome of the hand.

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Double ray amputation aims to decrease re-recurrence rates of recurrent GCT of hand.

Introduction and importance

Recurrent giant cell tumor of the bone (GCTB) of the hand is very rare to be encountered. Our aim is to alert the surgeons to such condition and double central ray amputation of the third and fourth digits could be an option which may reduce the chance of a re-recurrence and provide an acceptable functional outcome.

Case presentation

We presented a 25-year-old woman with a recurrent GCTB of the proximal phalanx of the middle finger of the right hand. Considering the recurrent case, a high suspicion of malignancy, and apparent soft tissue extension, the lesion was treated with double central ray amputation of the third and fourth digits through metacarpals.

Clinical discussion

Extraosseous soft tissue invasion of recurrent GCTB of the hand had an important role in the treatment recommendation. A balance must be considered between the risk of re-recurrence and the impact of radical resection on function. Double central ray amputation surgery was performed in order to decrease the risk of additional recurrences. Acceptable functionality of the hand as she scored 26/30 (86 % rating) evaluated by Musculoskeletal Tumor Society (MSTS) Scoring System and no signs of local re-recurrence were found for 6 months follow up.

Conclusion

Double central ray amputation of the third and fourth digits is a good option for management of recurrent GCTB of proximal phalanx of the third digits with gross soft tissue extension to adjacent fourth digits region.

Peripheral nerve tumors of the hand: Clinical features, diagnosis, and treatment

The majority of the tumors arising from the peripheral nerves of the hand are relatively benign. However, a tumor diagnosed as malignant peripheral nerve sheath tumor (MPNST) has destructive consequences. Clinical signs and symptoms are usually caused by direct and indirect effects of the tumor, such as nerve invasion or compression and infiltration of surrounding tissues. Definitive diagnosis is made by tumor biopsy. Complete surgical removal with maximum reservation of residual neurologic function is the most appropriate intervention for most symptomatic benign peripheral nerve tumors (PNTs) of the hand; however, MPNSTs require surgical resection with a sufficiently wide margin or even amputation to improve prognosis. In this article, we review the clinical presentation and radiographic features, summarize the evidence for an accurate diagnosis, and discuss the available treatment options for PNTs of the hand.

Benign bone tumors of hand and wrist: evaluation of diagnosis and treatment

Objectives

This study aims to investigate the choice of graft or cement, the relationship between the graft types and union rates, functional results, and complications in hand and wrist benign bone lesions while also evaluating the diagnosis and treatment modalities of lesions with high recurrence potential like giant cell- containing lesions.

Patients and methods

Between September 2005 and May 2016, 48 benign osseous hand and wrist tumors of 48 patients (22 males, 26 females; mean age 33±13.1 years; range, 11 to 70 years) were reviewed retrospectively. Patients were evaluated according to demographic data, complaints at admission, radiological findings, surgical methods, graft type, pathological diagnosis, and complications.

Results

Although not statistically significant, there were differences between cement, allograft, and autograft according to union time and loss of range of motion. There was no statistical difference between cement, allograft, and autograft according to complications.

Conclusion

Autograft obtained percutaneously with a trephine needle may provide earlier union with minimal donor site morbidity. Wide resection and reconstruction options should be kept in mind in giant cell-containing tumors. Further investigations are needed about the relationship between soft tissue edema in magnetic resonance imaging and the recurrence risk in hand and wrist benign bone tumors.

Deep palmar tumorous conditions of the hand

PURPOSE

Deep palmar tumors of the hand are very rare, and reported cases are usually benign. The most important issue is frequent anatomical variations with challenging surgical exposure and excision of these lesions. Some case reports or a small series of patients have been reported in the literature. The aim of this study was to present our experience with the deep palmar tumors of the hand.

PATIENTS AND METHODS

In the study, retrospective analyses of 43 patients treated with deep palmar tumors of the hand between January 1998 and June 2015 were evaluated. Tumors and tumor-like pathologies of the deep palmar space of the hand were retrospectively evaluated according to age, gender, localization, preoperative symptoms, size, site, treatment methods, histopathology, and early and late complications. Statistics and data analyses were also performed.

RESULTS

All 43 pathologies were benign, and histopathologic diagnoses were 10 lipomas, 8 ganglions, 5 giant cell tumor of the tendon sheath, 4 schwannomas, 3 hemangiomas, 3 palmar fibromatosis, 2 epidermal cysts, 2 neurofibroma, 1 angiolymphoid hyperplasia with eosinophilia, 1 granuloma, 1 calcifying aponeurotic fibroma, 1 digital fibroma, 1 foreign body granuloma, and 1 lipofibromatous hamartoma. The most common complication was temporary numbness and paresthesias of the digits. Marginal excision was performed in 40 patients, excision with nerve grafting in 2 patients (with neurofibroma) and carpal tunnel release in one patient with lipofibromatous hamartoma.

CONCLUSION

In the deep palmar space of the hand, pathologies are closely associated with tendons, muscles, and neurovascular structures. Preoperative magnetic resonance imaging is helpful for the preoperative diagnosis, evaluating tumor extension, and successful surgical planning. Level of Evidence: IV Therapautic.

Osteoid Osteoma in the Thumb of an Adolescent Patient

Osteoid osteoma is a relatively common benign tumor of bone, typically presenting in the diaphysis of long bones during the second or third decades of life. This tumor is rarely reported in the hand and wrist, making up only approximately 10% of cases. When reported in the hand, osteoid osteoma tends to occur more frequently in the proximal phalanx of the index and middle fingers. We present the case of an osteoid osteoma in an adolescent male in the distal phalanx of the thumb. The presentation of this osteoid osteoma was atypical owing to its location and lack of characteristic clinical features, making the initial work-up and final diagnosis challenging and pointing to the importance of considering this diagnosis on a differential for painful bony tumors in the hand.

Painful Snapping of Thumb Caused by Osteochondroma of Trapezium

Osteochondroma is the most common benign bone tumor. Lesions occurring at the carpal bones are extremely rare. There are very few cases of osteochondroma at the trapezium had been reported in the English literature. We reported a 47-year-old patient with an osteochondroma of the left trapezium presented with painful snapping of abductor pollicis longus tendon.

Common Soft Tissue Tumors Involving the Hand with Histopathological Correlation

Soft tissue tumors involving the hand are common and most often benign. It is important to know the spectrum of soft tissue tumors of the hand and understand the typical as well as atypical imaging features are seen on different imaging modalities. The imaging features are largely determined by the tumor histopathology; thus, the basic idea about the tumor histopathology will always be useful. This article intends to focus on a comprehensive approach including demographics, clinical presentation, and imaging findings required to diagnose the tumor definitely or narrow the differentials. This article discusses common soft tissue tumor mimics of the hand as well, however, excludes the bone tumors for the sake of brevity.

Nerve Tumors of the Upper Extremity

Nerve sheath tumors of the upper extremity are among the common neoplastic pathologies encountered by hand surgeons. A majority of these tumors are benign schwannomas or neurofibromas and may be associated with neurofibromatosis. Clinical signs of malignant transformation include new onset of pain and rapid growth. Imaging characteristics, such as standardized uptake value greater than 4.0 on PET scan, may aid in the diagnosis of a malignant tumor. Surgical excision, often with intrafascicular dissection with nerve preservation, is recommended treatment of benign lesions. Wide surgical excision is recommended for malignant lesions.

A Subperiosteal Proximal Phalanx Osteoid Osteoma: A Challenging Diagnosis

A relatively rare tumor, osteoid osteoma most commonly affects the lower extremity. In 10% of the cases, it can affect the hand and wrist. We present a case of osteoid osteoma in the proximal phalanx of ring finger that was initially misdiagnosed as a soft tissue lesion. The soft tissue lesion was resected, but the symptoms recurred shortly thereafter, leading to repeat diagnostic workup. Despite X-rays, magnetic resonance imaging, and tissue biopsy, the diagnosis remained elusive until surgical re-exploration. Based on the lessons learned from this case and the experience reported in literature, we discuss the intricate nature of osteoid osteoma diagnosis in the hand, the obstacles often encountered, and how to approach these challenging patients in a stepwise and critical fashion.

Parosteal extra-axial chordoma of the second metacarpal bone: a case report with literature review

Extra-axial chordoma is a chordoma that occurs in non-axial locations. It is a very rare tumor, with 20 cases reported to date; 14 in bone and six in soft tissue. Of the 14 skeletal extra-axial chordomas, ten were intramedullary and four were intracortical. We report the first case of parosteal extra-axial chordoma arising in the second metacarpal bone, expressing brachyury on immunohistochemical analysis, and describe the pathologic and radiologic findings. We suggest that extra-axial chordoma can occur in parosteal bone lesions or the hand, without features of bone distribution or bone-specific sites.

Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management

Bone replacement might have been practiced for centuries with various materials of natural origin, but had rarely met success until the late 19th century. Nowadays, many different bone substitutes can be used. They can be either derived from biological products such as demineralized bone matrix, platelet-rich plasma, hydroxyapatite, adjunction of growth factors (like bone morphogenetic protein) or synthetic such as calcium sulfate, tri-calcium phosphate ceramics, bioactive glasses, or polymer-based substitutes. All these substitutes are not suitable for every clinical use, and they have to be chosen selectively depending on their purpose. Thus, this review aims to highlight the principal characteristics of the most commonly used bone substitutes and to give some directions concerning their clinical use, as spine fusion, open-wedge tibial osteotomy, long bone fracture, oral and maxillofacial surgery, or periodontal treatments. However, the main limitations to bone substitutes use remain the management of large defects and the lack of vascularization in their central part, which is likely to appear following their utilization. In the field of bone tissue engineering, developing porous synthetic substitutes able to support a faster and a wider vascularization within their structure seems to be a promising way of research.

A rare case of a medullary, multifocal lesion in the distal radius

In multifocal findings, the possibility of multifocal osteoid osteomas should be considered and this case helps us to be attentive for the unusual radiographical presentation of osteoid osteoma.

Reticular Perineurioma of the Hand: Diagnosis and Treatment of a Rare Case of Hand Mass

Reticular perineurioma is a rare and recently delineated morphologic variant of benign perineurioma of skin and soft tissues. Because of its nonspecific gross appearance, varying histologic patterns, and potential range of cellularity, perineurioma of the hand is likely to be confused with more commonly encountered tumor or tumor-like conditions such as schwannoma, neurofibroma, fibromyxoid tumors, and giant tumor of tendon sheath. We report the case of a 20-year-old woman who presented with a slowly growing mass of the hand, which was eventually identified as a reticular perineurioma.

Patients with benign hand tumors are indicated for surgery according to patient-rated outcome measures

INTRODUCTION

This study assessed the treatment outcomes of upper extremity benign tumors using the patient-rated outcome measures of Hand20 questionnaire.

METHODS

In total, 304 patients who underwent surgery for benign bone and soft tissue tumors of the upper limb were included. Tumors were classified into three size groups: <1 cm, 1-3 cm, and >3 cm. Tumors were divided with respect to location: digit, hand, wrist, forearm, elbow, upper arm, or axilla. We prospectively assessed responses to the Hand20 questionnaire that was administered both before and after surgery.

RESULTS

The mean Hand20 and pain scores significantly improved after surgery in patients with ganglion cysts, giant cell tumors of the tendon sheath, enchondromas, or pyogenic granulomas. For patients with hemangiomas, schwannomas, or glomus tumors, although the mean pain scores improved significantly following surgery, there were no significant changes in the mean Hand20 scores. However, the statistical power for this analysis was low. The mean Hand20 and pain scores improved significantly, regardless of the size grouping. The mean Hand20 scores significantly improved after surgery in patients with finger, thumb, hand, or wrist tumors. Except for elbow to axillary tumors, the mean pain scores significantly improved in all patients.

CONCLUSION

The results of Hand20 and pain scores suggest that most patients with benign hand tumors are indicated for surgery, but the degree of improvement differs according to tumor pathology and location but not size.

The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study

Bone defects are a very common problem in hand surgery, occurring in bone tumor surgery, in complicated fractures, and in wrist surgery. Bone substitutes may be used instead of autologous bone graft to avoid donor site morbidity. In this article, we will review our experience with the use of Cerament bone void filler (Bonesupport, Lund, Sweden) in elective and trauma hand surgery. A prospective clinical study was conducted with 16 patients treated with this bone graft substitute in our department over a period of 3.5 years. Twelve patients (2 female, 10 male; with an average age of 42.42 years) with monostoic enchondroma of the phalanges were treated and 4 patients (1 female, 3 male; with an average age of 55.25 years) with complicated metacarpal fractures with bone defect. Data such as postoperative course with rating of pain, postoperative complications, functional outcome assessment at 1, 2, 3, 6 months, time to complete remodeling were registered. Postoperative redness and swelling after bone graft substitute use was noticed in 7 patients with enchondroma surgery due to the thin soft-tissue envelope of the fingers. Excellent total active motion of the involved digit was noticed in 10 of 12 enchondroma patients and in all 4 fracture patients at 2-month follow-up. In summary, satisfying results are described, making the use of injectable bone graft substitute in the surgical treatment of enchondromas, as well as in trauma hand surgery a good choice.

Ancient schwannoma of the thumb pulp

A 21-year-old woman had become aware of a mass on the palmar aspect of the distal phalanx of her left thumb 11 years earlier. Her medical history was unremarkable, with no traumatic injury of the left thumb. Initial examination revealed a hard but elastic, immovable tumor of 30 × 25 mm on the palmar aspect of the distal phalanx of the left thumb, with an ulcer formed at the center. No pain, sensory disturbance, or motor dysfunction was noted. The patient underwent punch biopsy at the outpatient clinic, and the tumor was histopathologically diagnosed as benign schwannoma. Total excision of the tumor was performed with digital nerve block under surgical microscope. Histopathological findings revealed a fibrous capsule covering the tumor, directional growth of tightly organized spindle-shaped cells, and mixed Antoni A and B patterns. The tumor also contained many various sized cysts and showed histological degenerative changes not observed in ordinary schwannoma, such as hemorrhage and prominent blood vessels with hyalinized walls. The S-100 stain was positive. Based on these findings, the patient was diagnosed as having ancient schwannoma. There was no evidence of infection, pain, complications such as ulcer formation, or recurrent tumor at 6 months postoperative.

Clinical evaluation and management of benign soft tissue tumors of the extremities

Benign lesions comprise a majority of soft tissue tumors. It has been estimated that their incidence outnumbers that of malignant tumors by a factor of at least 100 [1]. While history and physical examination can start the diagnostic process, imaging including the use of magnetic resonance imaging can be more helpful. Biopsy of these tumors is sometimes necessary and can be performed in a number of ways, often in conjunction with definitive treatment. Specific diagnostic and treatment strategies for a number of the more commonly encountered benign soft tissue tumors including lipomas, pigmented villonodular synovitis and hemangiomas are reviewed. An algorithm for the management of benign soft tissue tumors is discussed.

Reconstruction with fibular autograft and silicone implant arthroplasty after resection of giant-cell tumour of the proximal phalanx: a case report with 18-month follow-up

Primary giant-cell tumour of phalanx is a rare entity. Only few cases are described in the literature. Giant-cell tumour of hand is reported to have high local recurrence rate. Curettage and bone grafting have been performed by few authors with limited success. Most of the cases have been treated with ray amputation. We report this case as the first reported case in the literature that has been treated with fibular autograft and silicone implant arthroplasty for giant-cell tumour of the proximal phalanx.

An alternative technique for the management of phalangeal enchondromas with pathologic fractures

PURPOSE

Enchondroma of the hand with a pathologic fracture is generally treated by tumor curettage and bone grafting after the fracture has healed. However, delayed surgery postpones definitive diagnosis and prolongs the period of disability. We have treated pathologic fractures in a single stage through a modified lateral surgical approach with curettage of the tumor and stabilization using injectable calcium sulfate cement. The aim of this study was to report the outcomes of treatment with this material and the modified approach.

METHODS

Between 2006 and 2010, we enrolled 8 patients with solitary hand enchondromas and pathologic fractures. The surgical procedure involved a lateral approach, an extended lateral cortical window, thorough tumor evacuation, and reconstruction of the bone defects using commercially available injectable calcium sulfate cement. We performed evaluations before surgery and in the postoperative follow-up series by radiographs and clinical assessments, including measurement of joint motion by goniometry and a visual analog pain scale.

RESULTS

The average time of follow-up was 19 months (range, 12-36 mo). The pathologic fractures of all patients healed clinically and radiographically within 8 weeks after surgery, and the mean active motion arcs of the metacarpophalangeal joints and proximal interphalangeal joints of the involved digit were 90° and 94°, respectively at 3-month follow-up. All patients returned to ordinary daily activities without obvious pain by 3 months postoperatively. We found no major complications, such as unacceptable alignment, nonunion, infection, or tumor recurrence, during follow-up.

CONCLUSIONS

This study demonstrated the outcomes of early management of phalangeal enchondromas with pathologic fractures using a lateral approach and injectable calcium sulfate cement for reconstruction. This combined approach avoided the need for supplemental internal fixation, allowed early mobilization, and resulted in minimal joint stiffness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Benign palmar schwannoma - a rare case in a handball player

Peripheral nerve sheath tumours (PNSTs) of the hand are rare. Schwannomas, also known as neurilemmomas, are the commonest benign PNSTs. They arise from a proliferation of Schwann cells. Aetiology is unclear. In this report, the authors present the case of a lifelong Rugby Fives (a handball variant) player who developed a symptomatic benign schwannoma at the impact point on his palm. To our knowledge, there are no documented cases of upper limb schwannomas which may be related to repetitive trauma from sport.