In-Service Exam
Hand - Tumors - 2001





A 27-year-old woman has had localized pain and tenderness at the tip of the right index finger for four months. She has a history of severe sensitivity to cold but no history of trauma. Examination shows a normal-appearing index finger; no mass is noted. There is a slight bluish discoloration under the nail and a localized area of exquisite pinpoint tenderness in this area over the nail. Radiographs show a cortical indentation of the dorsal aspect of the middle of the distal phalanx.

Which of the following is the most likely diagnosis?

(A) Enchondroma
(B) Epidermal inclusion cyst
(C) Giant cell tumor of the tendon sheath
(D) Glomus tumor
(E) Mucous cyst

The correct response is Option D.

The findings in this patient are most consistent with a glomus tumor, a benign lesion of the neuromyoarterial apparatus whose presence is characterized by exquisite pain, pinpoint tenderness, and extreme sensitivity to cold. Other occasional findings include a faint blue spot as well as erosion of the distal phalanx. MRI is best for delineation of occult glomus tumors.

Excision and primary closure are recommended for management. In patients who have subungual lesions, the nail plate is removed and the tumor is excised via a longitudinal incision in the nail matrix.

Enchondromas, which are the most common primary solid tumors of the hand, are typically asymptomatic and are often only discovered in conjunction with a pathologic fracture. Radiographs will show a stippled, radiolucent lesion with distinct margins in the metaphysis or diaphysis. Appropriate management is curettage with fixation and bone grafting as needed.

Epidermal inclusion cysts are painless, slow growing benign masses that are thought to develop following a traumatic episode in which epithelial cells are implanted into the subcutaneous tissues. Tumor growth can impair hand function. Excision is appropriate management.

Giant cell tumors of the tendon sheath are lobulated, firm, nontender, slowly enlarging masses firmly fixed to the deep soft tissue. They are typically found on the palmar surfaces of the wrist, hand, and fingers. Excision is recommended although recurrence is common.

Mucous cysts are ganglions of the distal interphalangeal joint that initially appear in patients age 50 to 70 years. Heberden's nodes are frequently associated; longitudinal nail grooving may develop from pressure on the nail matrix. Radiographs will show evidence of osteoarthritic changes within the joint. Appropriate management is excision with removal of the arthritic spur.

References
1. Angelides AC. Ganglions of the hand and wrist. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2171-2183.
2. Athanasian EA. Bone and soft tissue tumors. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2223-2253.
3. Koman LA, Ruch DS, Paterson Smith B, et al. Vascular disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2254-2302.
4. McClinton MA. Tumors and aneurysms of the upper extremity. Hand Clin. 1993;9:151-169.

PHOTO

A 19-year-old woman has pain especially at night in the middle phalanx of the left little finger that is relieved with administration of aspirin. Examination shows swelling in this area. A radiograph of the hand is shown above. Which of the following is the most likely diagnosis?

(A) Chondroma
(B) Giant cell tumor of bone
(C) Multiple enchondromatoses
(D) Osteochondroma
(E) Osteoid osteoma

The correct response is Option E.

This 19-year-old woman has findings consistent with osteoid osteoma, a painful tumor usually seen in patients younger than age 40 years. Pain frequently occurs at night and is typically relieved with oral administration of nonsteroidal anti-inflammatory drugs. Radiographs of the tumor will show a radiolucent zone with a dense nidus surrounded by a distinctive area of cortical sclerosis. Complete excision is usually curative and recurrence is rare.

Chondromas (extraosseous tumors) and enchondromas (endosteal tumors) are common bone tumors typically found
tex with widespread speckled calcification. Appropriate management includes curettage of the lesion with autogenous bone grafting as necessary and internal fixation of any associated fractures.

Giant cell tumor of bone is a common multifocal hand tumor. Radiographs show an irregular, expansile radiolucent lesion typically in the epiphyseal region of a tubular bone. Ray resection or en bloc removal combined with bone grafting is recommended because recurrence is common.

Multiple enchondromatoses (Ollier's disease) are larger than solitary enchondromas and are associated with axial skeletal deformities. Because patients with multiple enchondromatoses are at increased risk for malignant degeneration to chondrosarcoma, incisional biopsy should be performed if pain or swelling develops in the area of the lesion. Any patient with chondrosarcoma confirmed by histologic examination of a biopsy specimen should undergo intraosseous en bloc excision or ray resection.

Osteochondroma can be either a solitary lesion or an autosomal dominant condition consisting of multiple tumors. Deformity and impaired motion are typically associated. In patients with multiple osteochondromas, endochondral ossification may lead to the formation of secondary bone mass. Appropriate management includes resection of all tumors with reconstructive surgery to repair any bone or joint malalignment.

References
1. Athanasian EA. Bone and soft tissue tumors. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2223-2253.
2. Athanasian EA, Wold LE, Amadio PC. Giant cell tumors of the bones of the hand. J Hand Surg. 1997;22A:91-98.
3. Bednar MS, Weiland AJ, Light TR. Osteoid osteoma of the upper extremity. Hand Clin. 1995;11:211-221.
4. Floyd WE III, Troum S. Benign cartilaginous lesions of the upper extremity. Hand Clin. 1995;11:119-132.