Nerve tumors of the hand and forearm

Neurofibroma Involving a Bifid Median Nerve in a Pediatric Patient: A Case Report

Neurofibromas are benign peripheral nerve sheath tumors that typically develop within cutaneous nerve branches but can involve major nerves as well. They can be sporadic or associated with neurofibromatosis type 1. In this report, we describe the surgical treatment of a pediatric patient with neurofibromatosis type 1 presenting with a neurofibroma of a bifid median nerve. Involvement of the median nerve was not evident on preoperative examination or imaging, therefore altering the risk-benefit ratio of the procedure. After bifid nerve involvement was identified intraoperatively, the patient's parents were counseled on the risks and benefits of surgical excision before resuming the case. Ultimately, the neurofibroma was resected, and the patient experienced no neurological deficits after surgery.

Common Peroneal Nerve Compression Neuropathy Due to a Large Synovial Cyst From the Proximal Tibiofibular Joint in a Teenager

Ganglion cysts are very rare in the lower limb and when present, ganglion cysts rarely cause compression neuropathy at any site. Peripheral nerve sheath tumors as a whole, are also very rare and mostly presented as a painful lump along the nerve path. Ganglion cysts are non-neoplastic gelatinous cysts, which lack true synovial lining. They can be divided into intraneural cysts which can be found within the epineurium of a peripheral nerve and lead to signs and symptoms of peripheral neuropathy or extraneural cysts which can develop from surrounding joints or tendon sheaths causing gradual nerve compression. Intraneural tumors of common peroneal nerve (CPN) are widely reported in the literature with varying degrees of symptoms; however, there are only a few case reports describing CPN palsy due to extraneural cysts. We are reporting a rare case of atraumatic CPN palsy, which resulted in irreversible foot drop in a teenage boy who presented with right leg radiating calf and foot pain. We recommend prompt investigation and excision of the cyst to decompress the nerve to increase the chances of early recovery and favorable outcomes.

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.

Schwannoma in the extremity: clinical features and microscopic intra-capsular enucleation

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation.

Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique.

Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up.

Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

The Risk of Peripheral Nerve Tumor Biopsy in Suspected Benign Etiologies

BACKGROUND

Peripheral nerve sheath tumors (PNSTs) are tumors with unique clinical and imaging features that present to a variety of physicians. These lesions are often referred for biopsy, which can put nerve fascicles at risk. Preoperative biopsy may cause distortion of normal anatomic planes, making definitive resection difficult.

OBJECTIVE

To evaluate the neurological risks of preoperative biopsy in benign PNSTs.

METHODS

Surgical cases collected retrospectively using a prospectively established database of PNSTs treated by a single surgeon between 1997 and 2019. Patients were dichotomized depending on preoperative biopsy. The effects of biopsy were assessed via history and physical examination both pre- and postdefinitive resection.

RESULTS

A total of 151 cases were included. Only 23.2% (35) of patients underwent preoperative biopsy, but 42.9% of these experienced new or worsening neurological examination immediately following biopsy. After definitive resection, the rate of neurological deficit was significantly different between the 2 groups with 60% of biopsy patients and 19% of those patients not biopsied experiencing decline in examination (F = 25.72, P < .001). Odds ratio for any postoperative deficit for biopsy was 6.40 (CI [2.8, 14.55], P < .001). Univariate logistic regression of neurological deficit with patient age, sex, tumor type, and biopsy status showed that only biopsy was associated with the occurrence of any postoperative deficit.

CONCLUSION

Biopsy of benign PNSTs is associated with a high rate of neurological deficit both immediately following the procedure and after definitive resection. Careful selection is imperative prior to proceeding with biopsy of nerve sheath tumors exhibiting benign features given the unacceptably high rate of neurological decline.

Bilateral Plexiform Neurofibromas of the Posterior Interosseous Nerve Mimicking Dorsal Wrist Ganglions

A 33-year-old woman presented with bilateral dorsal wrist masses associated with pain and limited range of motion. On initial presentation, the masses were believed to be ganglion cysts and the patient opted for observation. Three years later, she was found to have a chest wall mass diagnosed by biopsy to be a neurofibroma. When she later returned to seek treatment for her wrist masses, magnetic resonance imaging demonstrated posterior interosseous nerve (PIN) neurofibromas. Dorsal wrist masses situated over the scapholunate interval are commonly attributed to ganglion cysts. Neurofibromas of the PIN, although rare, should be considered in the differential diagnosis when a mass elicits pain with percussion, fails to transilluminate, fails aspiration, or if the patient has a history of neurofibromas elsewhere in the body.

Median Nerve Schwannoma of the Hand and Wrist: 3 Cases

Tumors of the median nerve are difficult to diagnose and median nerve schwannomas are rare. During a ten-year period, we treated eleven median nerve schwannomas found on the hand (nine) and wrist (two). All the tumors were treated by enucleation under loupe magnification and tourniquet application. All had a favorable result at a mean follow up of five years. We present three of our most typical cases, with schwannomas found on the wrist, palm and thumb. We also review the literature offering a wider view on the pathology, diagnosis and treatment of schwannomas in general.

Isolated medial plantar neuropathy caused by a large ganglion cyst diagnosed with MRI: A case report

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Compression neuropathy caused by a ganglion cyst is a rare entity.

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MRI remains an excellent diagnostic modality to evaluate the masses in the foot.

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This is a very rare report of isolated medial plantar neuropathy by a ganglion cyst.

Introduction

Although ganglion cysts are common soft tissue tumors, nerve compression syndrome caused by a ganglion cyst in the lower extremities is very rare. Herein, we report a 57-year-old man who presented with hypoesthesia in the sole of his right foot for 6 months. We believe that reporting this rare case will help clinicians update their knowledge on possible causes of the plantar neuropathy, and avoid diagnostic delay.

Presentation of case

The patient had pain and numbness in the inner right sole, as well as a tingling and dull sensation. Tenderness around the area of abnormal sensation was not evident. Percussion at the abductor tunnel gave a positive Tinel’s sign in the medial plantar nerve. No mass was palpable in the right foot. Based on the electrophysiological findings, we diagnosed medial plantar nerve entrapment in the right foot. Magnetic resonance imaging (MRI) was conducted to identify a 5.5-cm long elongated cystic lesion as the cause of entrapment. The patient underwent surgical removal of the cystic mass, with histologic examination confirming the diagnosis of a large ganglion cyst.

Discussion

The feasibility of nerve conduction studies and electromyography for detection of nerve entrapment is still controversial. MRI is considered the best diagnostic modality, if biopsy is not feasible.

Conclusion

We suggest that foot imaging and electrophysiological studies should be considered for patients with isolated median plantar neuropathy to exclude the presence of space-occupying lesions, especially when conservative treatment is not effective.

Axillary Nerve Schwannoma: A Rare Case Report

Primary tumors of the brachial plexus are a rare cause of an axillary swelling. Schwannomas are benign tumors arising from Schwann cells. Most of the schwannomas occur in the head and neck region and in the flexor aspect of the limbs. We present a case of a 60-year-old female who presented with pain in the left axilla radiating to the left upper limb since 2 years and a painful swelling in her left axilla for 3 months. The diagnosis is made by fine needle aspiration cytology and magnetic resonance imaging, and confirmed by histopathological examination as schwannoma.

Perineurial Vascular Hamartoma

Perineural vascular proliferations are extremely rare, and only a few cases have been reported in the literature, usually under the designation of "intraneural hemangioma." We report a case of a 28-year-old man with a nodule in the right palm of his hand that developed over an 8- to- 12-month period. Microscopic examination revealed a vascular proliferation growing within connective tissue and entrapping small nerve bundles. The features of the lesion are consistent with an unusual hamartomatous growth of small vessels and nerves rather than a hemangioma arising within a nerve. Clinical and histological details, and a discussion of the relevant literature on this unusual lesion, are provided.

Giant Schwannoma of ulnar nerve: case report

Schwannomas are the most common benign neoplasms of the peripheral nerves in the upper limbs.

Although many are asymptomatic, they can produce a mass effect, thus impinging against soft tissues or interfering with joint function.

The authors present a case report and a review of a giant Schwannoma in the ulnar nerve.

Results of surgical treatment of schwannomas arising from extremities

Schwannomas are benign neoplasms derived from Schwann cells. In this work, we present our experience in operative management of schwannomas and analyse results of treatment. Clinical material consisted of 34 patients, in whom 44 schwannomas located in extremities were excised between 1985 and 2013. Thirty-five tumours originated from major peripheral nerves and 9 from small nerve branches. Postoperatively, in the first group of tumours, pain resolved in 100%, paresthesias in 83.3%, and Hoffmann-Tinel sign in 91.6% of the patients. Improvement in motor function was noted in 28.5% of the cases, in sensory function: complete in 70%, and partial in 15%. The most frequently affected major peripheral nerves were the ulnar (11 tumours) and median (5 tumours) nerves. Schwannomas originating from small nerve branches were removed without identification of the site of origin. After their resection, definitive healing was achieved. Conclusions. (1) Schwannomas located in extremities arise predominantly from major peripheral nerves, most commonly the ulnar and median nerves. (2) Gradual tumour growth causes exacerbation of compression neuropathy, creating an indication for surgery. (3) In most cases, improvement in peripheral nerve function after excision of schwannoma is achieved. (4) The risk of new permanent postoperative neurological deficits is low.

Results of surgical treatment of schwannomas arising from extremities

Schwannomas are benign neoplasms derived from Schwann cells. In this work, we present our experience in operative management of schwannomas and analyse results of treatment. Clinical material consisted of 34 patients, in whom 44 schwannomas located in extremities were excised between 1985 and 2013. Thirty-five tumours originated from major peripheral nerves and 9 from small nerve branches. Postoperatively, in the first group of tumours, pain resolved in 100%, paresthesias in 83.3%, and Hoffmann-Tinel sign in 91.6% of the patients. Improvement in motor function was noted in 28.5% of the cases, in sensory function: complete in 70%, and partial in 15%. The most frequently affected major peripheral nerves were the ulnar (11 tumours) and median (5 tumours) nerves. Schwannomas originating from small nerve branches were removed without identification of the site of origin. After their resection, definitive healing was achieved. Conclusions. (1) Schwannomas located in extremities arise predominantly from major peripheral nerves, most commonly the ulnar and median nerves. (2) Gradual tumour growth causes exacerbation of compression neuropathy, creating an indication for surgery. (3) In most cases, improvement in peripheral nerve function after excision of schwannoma is achieved. (4) The risk of new permanent postoperative neurological deficits is low.

Schwannomas of the upper extremity: analysis of 34 cases

BACKGROUND

Schwannomas are the most common benign tumours developing in peripheral nerves. They usually present as a slow-growing mass, sometimes associated with pain and paraesthesia. The aim of this study is to define the correct preoperative diagnosis, to review the surgical treatment employed and to evaluate short- and long-term neurological deficits.

METHODS

Thirty-four patients affected by schwannoma in the upper limbs were treated in the period 1995-2011. In 15 patients the tumour was located on the ulnar nerve, in 8 on the median nerve, in 2 on the radial nerve, in 1 on the anterior interosseous nerve, in 1 on the muscle-cutaneous nerve, and in the remaining 7 on the digital nerves. All patients were surgically treated using a microsurgical approach.

RESULTS

The enucleation of the mass was possible without fascicle lesion in 12 cases. In 22 cases resection of the indissociable fascicles was performed. Postoperative paraesthesia was present in 28 out of 34 treated patients; this clinical sign regressed in a mean period of 12 months in 27 patients.

CONCLUSIONS

When approaching a palpable mass in the upper limbs, the possibility of a peripheral nerve tumour should always be considered. It is important to look for typical signs of schwannomas, such as a positive Tinel sign and peripheral paraesthesia. Imaging assessment with magnetic resonance imaging (MRI) and ultrasonography enables the determination of where the tumour takes its origin and from which nerve. Microsurgical techniques and know-how are recommended in approaching the resection in order to respect as many nerve fibres as possible.

[Neurofibroma of the forearm: report of a case]

Les tumeurs des nerfs périphériques sont rares et mal connues. Le diagnostic en est rarement fait avant l'intervention. Le traitement chirurgical est difficile, et risque d'entrainer des dégâts nerveux irréversibles s'il est mal conduit. Nous rapportons un cas de neurofibrome de l'avant bras dont la symptomatologie est souvent discrète associé à des taches café au lait sur la peau. De ce fait, l'imagerie et l'examen anatomopathologique ont une place importante dans la prise en charge de ces tumeurs.

A usual cause of tumoural mass of the index finger

We present a case of an unusual appearance of a tumoural mass on the right index finger. A 52-year-old farmer was administered to our outpatient clinic due to a large tumoural mass in his right index finger. He has been reporting of the mass for 32 years. Upon examination there was a rubbery soft, fixed, painless tumoural mass on the right index finger, covering all proximal phalanx volar and dorsal causing no surface skin reaction. The entire mass was excised and sent for pathological examination. The pathological result was a fatty degenerated fibroma. This kind of tumour may easily be misinterpreted as a lipoma even radiologically. So it is believed that any surgeon should always be suspicious of the diagnosis of long-term masses of any kind.

Therapeutic effect and risk factors for complications of excision in 76 patients with schwannoma

BACKGROUND

Benign schwannoma is the most common tumor of peripheral nerves. However, the clinical course of excision and risk factors associated with postoperative neurological deficits are not well known. We evaluated the incidence of preoperative symptoms, the incidence of postoperative neurological deficits, and the risk factors of neurological deficits.

METHODS

We retrospectively reviewed data of 76 patients with schwannomas treated at our institution. We reviewed the clinical characteristics, and postoperative results, and determined the possible risk factors influencing the development of complications.

RESULTS

Excision of schwannoma improved the Tinel-like signs in 47 of 51 patients and spontaneous pain in 14 of 15. Eleven of 17 patients with sensory deficits showed complete recovery, but six continued to show deficits with or without improvement. Motor deficits that were observed in four patients persisted in one. New neurological deficits developed in 21 patients and persisted until final follow-up in 8. Tinel-like signs was the risk factor of surgery-related neurological deficits (p = 0.009).

CONCLUSIONS

New deficits developed predominantly in patients with preoperative Tinel-like signs. Attention should be given to patients with the factor.

A rare cause of deep peroneal nerve palsy due to compression of synovial cyst - Case report

INTRODUCTION

Synovial cyst is a rare cause of compression neuropathy and its differential diagnosis can be misleading.

PRESENTATION OF CASE

This article presents clinical, radiological, and histological findings of deep peroneal nerve palsy due to compression of a synovial cyst in a 30-year-old patient admitted with sudden drop foot.

DISCUSSION

Focal nerve entrapment in lower extremity due to synovial cystis a rare entity. Differential diagnosis is important. Surgical excision is the main treatment method with high success rate.

CONCLUSION

Synovial cyst compression which can be treated easily with surgical excision should be considered in rapidly progressed drop foot.

Deep ulnar intraneural ganglia in the palm

BACKGROUND

While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood.

MATERIALS

We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation.

RESULTS

A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts.

CONCLUSION

Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.

Intraneural lipoma of the ulnar nerve at the elbow: A case report and literature review

Intraneural lipomas of the ulnar nerve or its branches are rare benign tumours. Although most intraneural lipomas present as asymptomatic tumours, some may present as compression neuropathies due to their location. In the majority of cases these tumours can be enucleated without damage to the nerve fibres.

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.

Surgical outcome of schwannomas arising from major peripheral nerves in the lower limb

PURPOSE

The treatment of symptomatic Schwannoma is surgical excision. However, in the case of major peripheral nerves with motor function, there are concerns including neurological complications following surgery. This study was designed to evaluate the surgical outcome of Schwannomas originating from major peripheral nerves of the lower limb. Additionally, we sought to find out the predictable factors for permanent neurological deficits.

METHODS

Between 2004 and 2008, 30 consecutive Schwannomas underwent simple excision or enucleation. Surgical outcomes after excision were evaluated with an emphasis on neurological deficits and recurrence. Neurological complications were classified as major or minor neurological deficits and evaluated immediately after surgery and at final follow-up. Risk factors for development of neurological deficits were identified.

RESULTS

Twenty-three patients (23/30, 76.7 %) developed neurological deficits immediately after surgery. After a mean of 58.8 months (32-79 months), 19 patients (19/30, 63.3 %) showed no residual neurological deficits. Among the remaining 11 (11/30, 36.7 %), nine patients had tolerable symptoms and two patients had major neurological deficits including significant motor weakness and sensory impairments. Larger tumours tended to be at greater risk of neurological deficit after surgery. One recurrence of the tumour was seen two years after surgery. There were no cases of reoperation or malignant transformation

CONCLUSIONS

In the majority of cases, Schwannomas in the lower limb can be excised with acceptable risk for neurological deficits. However, meticulous dissection is required in large-sized Schwannomas because these tumours seem to have a higher frequency of fascicular injury during dissection.

The intraneural hemangioma of the digital nerve: case report

Intraneural Hemangioma of the digital nerve is rare and so far three cases have been reported in the literature. We present a case of 12- year- old boy with painless soft tissue mass in the right hand and numbness on the radial aspect of the index finger. Magnetic Resonance Imaging showed an isointense subcutaneous lesion without discrete borders in the first web space classically of hemangioma with the radial digital nerve extension. On exploration, the intraneural extension of the hemangioma was confirmed and total resection, microsurgical primary digital nerve repair was done. The patient became better and at 6 months follow up the index finger sensation improved. The patient had no reccurence and he is still under follow up.

Advantages of intra-capsular micro-enucleation of schwannoma arising from extremities

BACKGROUND

Schwannoma is the most common tumor of the peripheral nerves, with surgical enucleation being the established treatment modality. However, some schwannomas cannot be easily enucleated and this sometimes results in iatrogenic nerve injury even with atraumatic procedures. Here we present a retrospective review of the management of schwannoma in the extremities and compare clinical outcomes from the two techniques of extra-capsular and intra-capsular enucleation.

METHODS

We reviewed 36 schwannomas from 35 patients who underwent surgical excision of schwannomas arising from the extremities. Twenty had undergone extra-capsular resection and 16 had undergone enucleation using the intra-capsular technique. The post-operative neurological deficits were graded as minor, major, and transient. The duration of symptoms, maximum tumor diameter and site of occurrence were compared between patients with the three grades of deficit.

RESULTS

In total, 22 patients developed no sensory changes following enucleation of schwannoma or only temporary and minor changes that had fully resolved within 6 months. Ten patients developed new neurological deficits following surgery that took longer than 6 months to resolve. Four patients experienced new motor deficits or paresthesia following operation that had still not recovered at the final follow-up, all of whom underwent enucleation using the extra-capsular technique. Neurological deficit after enucleation was significantly lower using the intra-capsular compared with the extra-capsular technique. Patient age, duration of symptoms, maximum diameter of the tumor and site of occurrence did not influence the neurological deficit following enucleation of schwannoma.

CONCLUSION

These results support intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection. Thorough pre-operative counseling of patients to inform them of the potential occurrence of neurological deficit is important.

Compression neuropathy of the peroneal nerve secondary to a ganglion cyst

Peripheral neuropathies caused by ganglion cysts are rare, particularly in the lower extremities. The case of a 45-year-old man with a two-month history of foot drop and swelling in the region of the right fibular head is presented. Physical examination and electromyogram studies verified a peroneal nerve palsy. Magnetic resonance imaging revealed a lobulated, multilocular, cystic-appearing mass extending around the fibular neck. Surgical decompression of the nerve with removal of the mass and careful articular branch ligation was performed. Surgical pathology reports confirmed the diagnosis of a ganglion cyst. The patient regained full function within four months of the decompression. Pertinent findings on physical examination are discussed, as well as electromyogram and magnetic resonance imaging results. If symptoms persist, early surgical decompression (between the third and fourth months) is recommended.

Compression neuropathy of the peroneal nerve secondary to a ganglion cyst

Peripheral neuropathies caused by ganglion cysts are rare, particularly in the lower extremities. The case of a 45-year-old man with a two-month history of foot drop and swelling in the region of the right fibular head is presented. Physical examination and electromyogram studies verified a peroneal nerve palsy. Magnetic resonance imaging revealed a lobulated, multilocular, cystic-appearing mass extending around the fibular neck. Surgical decompression of the nerve with removal of the mass and careful articular branch ligation was performed. Surgical pathology reports confirmed the diagnosis of a ganglion cyst. The patient regained full function within four months of the decompression. Pertinent findings on physical examination are discussed, as well as electromyogram and magnetic resonance imaging results. If symptoms persist, early surgical decompression (between the third and fourth months) is recommended.

Peripheral neural sheath tumors (PNST)--what a radiologist should know

Peripheral neural sheath tumors (PNST) are rare and the common goal of management focuses on eliminating pain and maximizing function of the affected nerve. Therefore preoperative assessment of the specific morphological behaviour of such tumors regarding the nerves internal architecture is of utmost importance. PNSTs may affect one or more fascicles of a peripheral nerve resulting in a significant functional loss after resection and the necessity of functional reconstruction in one step. Enhancement of preoperative information should also address the biological behaviour of the tumor regarding its dignity and the resulting implications on amount of radical resection, additional treatment and prognosis. Since high-resolution techniques promise more and more detail resolution in many fields of imaging, delineation of intra- and extraneural processes as well as biological informations shall lead towards a well prepared and foreseeable image-guided treatment of PNSTs.

Intraneural lipoma of the ulnar nerve: A case report and review of literature

Intraneural lipomas of the peripheral nerve or its cutaneous branches are rare benign tumours. These slow-growing tumours present as asymptomatic swelling, and diagnosis is usually made at the time of exploration. In most cases, these tumours can be enucleated without damage to the nerve fibres.

Neural fibrolipoma of the digital nerve: a case report

A 32-year-old woman underwent microsurgical resection of a neural fibrolipoma of the digital nerve of the ring finger. At the 6-month follow-up, the patient had good recovery, no recurrence, and preservation of neural function. Caution should be exercised while planning microsurgical dissection on soft-tissue masses of fingers and hands. Total resection of the lesion and nerve grafting should be avoided.

Neurological deficit after surgical enucleation of schwannomas of the upper limb

We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness. This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this.

Intraneural Lipoma of the Radial Nerve Presenting As Wartenberg Syndrome: A Case Report and Review of Literature

The superficial branch of the radial nerve is highly vulnerable to trauma, irritation and compression due to its anatomical location. Intraneural lipomas and fibrolipomas arising from the supporting tissues of this peripheral nerve can cause compression of the adjacent nerve leading to symptoms of neuritis of the radial nerve or Wartenberg syndrome.

Lipofibromatous hamartoma of the median nerve in patients with macrodactyly: diagnosis and treatment of a rare disease causing carpal tunnel syndrome

Lipofibromatous hamartoma is a very rare benign peripheral nerve tumour. It is mostly encountered in the proximal extremities of young adults, involving the median nerve in the majority of cases. We present two patients with macrodactyly and carpal tunnel syndrome caused by lipofibromatous hamartoma of the median nerve and discuss diagnosis and treatment of the disease. A 10-year-old girl with a congenital progressive macrodactyly of her right index finger presented with a slowly growing mass in her right palm and pain and numbness, along with motor and sensory deficits in the median nerve distribution. Treatment consisted of carpal tunnel release, epineurolysis and partial excision of the fibrofatty tissue. The second patient, a 25-year-old man presented with a swelling in his left palm and findings compatible with carpal tunnel syndrome. Intraoperatively, the lesion presented as sausage-shaped enlargement of the median nerve by fibrofatty tissue. After carpal tunnel release, a partial excision of the mass with epineurolysis was performed. In both patients, histology showed nerve bundles separated by abundant fibrofatty tissue. In the girl, a proliferation of dysplastic perineurial cells could be observed. The suspected diagnosis for patients with macrodactyly and clinical signs of carpal tunnel syndrome should be lipofibromatous hamartoma. A carefully taken history, physical examination, X-ray, and MRI are important for its correct diagnosis. The surgical management remains controversial. Treatment should include decompression of the median nerve at points of compression, partial excision of the fibrofatty tissue, and debulking of soft tissue. In some cases, an epineurolysis can be additionally performed.

Magnetic resonance imaging of peripheral nerve tumours in the upper extremity

Clinical assessment and various diagnostic tools, particularly magnetic resonance imaging (MRI), of tumours of peripheral nerves are used to get an accurate diagnosis and to plan surgical intervention. Our purpose was to examine the usefulness of MRI in assessing nerve tumours in the upper extremity. Medical records of 19 patients (20 MRI examinations) with 29 histopathologically verified benign nerve tumours were examined retrospectively. In 12/20 cases MRI suggested a correct diagnosis of the type of nerve tumour. An additional 3/20 cases had an uncertain diagnosis, but nerve relations to the tumour were established. In 5/20 cases MRI gave a doubtful diagnosis with no suspicion of the tumour being located in a nerve trunk. MRI can localise and diagnose a nerve tumour in the upper extremity in 75% of cases, but it is difficult to specify the type of tumour.

Adherence of intraneural ganglia of the upper extremity to the principles of the unifying articular (synovial) theory

OBJECT

Intraneural ganglia are nonneoplastic mucinous cysts contained within the epineurium of peripheral nerves. Their pathogenesis has been controversial. Historically, the majority of authors have favored de novo formation (degenerative theory). Because of their rarity, intraneural ganglia affecting the upper limb have been misunderstood. This study was designed to critically analyze the literature and to test the hypothesis that intraneural ganglia of the upper limb act analogously to those in the lower limb, being derived from an articular source (synovial theory).

METHODS

Two patients with digital intraneural cysts were included in the study. An extensive literature review of intraneural ganglia of the upper limb was undertaken to provide the historical basis for the study.

RESULTS

In both cases, the digital intraneural ganglia were demonstrated to have joint connections; the one patient in whom an articular branch was not appreciated initially had evidence on postoperative MR images of persistence of intraneural cyst after simple decompression was performed. Eighty-six cases of intraneural lesions were identified in varied locations of the upper limb: the most common sites were the ulnar nerve at the elbow and wrist, occurring 38 and 22 times, respectively. Joint connections were present in only 20% of the cases published by other groups.

CONCLUSIONS

The authors believe that the fundamental principles of the unifying articular (synovial) theory (that is, articular branch connections, cyst fluid following a path of least resistance, and the role of pressure fluxes) previously described to explain intraneural ganglia in the lower limb apply to those cases in the upper limb. In their opinion, the joint connection is often not identified because of the cysts' rarity, radiologists' and surgeons' inexperience, and the difficulty visualizing and demonstrating it because of the small size of the cysts. Furthermore, they believe that recurrence (subclinical or clinical) is not only underreported but also predictable after simple decompression that fails to address the articular branch. In contrast, intraneural recurrence can be eliminated with disconnection of the articular branch.

Tumours of peripheral nerves in the upper extremity: a 22-year epidemiological study

Peripheral nerve tumours are uncommon. Our aims were to calculate the incidence and relative frequencies, to define sites of nerve tumours and to judge preoperative symptoms and outcomes of intervention. The results of 53 patients, with 68 tumours and histopathological diagnoses of true neoplasms, who had been operated on at the Department of Hand Surgery, Malmo, Sweden, between 1986 and 2007, were analysed. Schwannomas were the most common tumour (n=42). The incidence of schwannomas was 0.62/100 000 inhabitants/year in Malmo during that time period. The median nerve was most affected, closely followed by the ulnar and digital nerves. The preferred sites were the forearm, the thumb, and the digits. The most common preoperative symptom was pain. Loss of sensation was the most common postoperative complication. However, 33/53 patients (62%) were completely free of symptoms after excision. Patients should be provided with meticulous information preoperatively.

Desmoplastic fibroma of the hand: case report

Desmoplastic fibroma is a benign tumor of the soft tissue and rarely of the bone. It typically presents in the trunk and proximal limbs, but it is quite rare in the hands. We present a rare case of desmoplastic fibroma of the soft tissues of the hand that presented as a slow-growing, painless, well-encapsulated mass.

Segmental neurofibromatosis of the hand and upper extremity: a case report

A case of segmental neurofibromatosis of the upper extremity is presented. Multiple neurofibromas involving different peripheral nerves limited to a single body part or limb is a rare form of neurofibromatosis. The clinical, genetic, and histologic findings of segmental neurofibromatosis are described. The criteria for segmental neurofibromatosis are reviewed, and the differentiation of neurofibromatosis types 1 and 2 and schwannomatosis is also briefly reviewed.

Soft tissue tumors of the hand. 1. Benign

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (this article) and malignant tumors (subsequent issue) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.

Soft Tissue Tumors of the Hand. 2. Malignant

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (previous article) and malignant tumors (this article) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.