In-Service Exam
Hand - Tumors - 2002





A 68-year-old woman has a mass at the distal interphalangeal joint of the dorsal aspect of the right index finger. Examination of the finger shows a cyst filled with clear fluid, and there is associated nail grooving. Radiographs show joint space narrowing and the presence of an osteophyte.

Which of the following is the most appropriate management?

(A) Aspiration of the cyst
(B) Injection of a corticosteroid
(C) Laser ablation
(D) Excision of the cyst
(E) Excision of the cyst and osteophyte

The correct response is Option E.

In this patient who has a mucous cyst or ganglion of the distal interphalangeal joint, the most appropriate management is excision of both the cyst and osteophyte. Mucous cysts typically occur in middle-aged or elderly patients and are characterized by swelling and nail deformities; pain is not always present. Radiographs of the affected area typically show osteoarthritis with osteophytes. The lesion exerts pressure on the nail matrix and skin, often resulting in nail grooving or thinning of the skin, and may ultimately lead to skin breakdown and infection. Spontaneous fusion of the joint can occur in the later stages, and arthrodesis may be required in some patients.

Aspiration is not appropriate management of a mucous cyst, and excision of the cyst alone is inadequate. Injection of a corticosteroid or laser ablation has been attempted in some patients with mucous cysts but was not associated with good results.

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. Failla JM. Differential diagnosis of hand pain: tendinitis, ganglia, and other syndromes. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;1:1223-1249.

A 62-year-old woman has a 2-mm subungual area of blue discoloration of the nondominant small finger located approximately 4 mm distal to the germinal matrix. She reports intermittent episodes of pain in the finger that are exacerbated with exposure to cold. On examination, there is exquisite pinpoint tenderness in the affected area.

Which of the following is the most appropriate management?

(A) Nifedipine therapy
(B) Carbon dioxide laser ablation
(C) Radiation therapy
(D) Simple surgical excision
(E) Nail ablation

PHOTO

The correct response is Option D.

Management of subungual glomus tumors should include removal of the nail plate and simple surgical excision of the lesion. Glomus tumors are uncommon, benign vascular lesions typically located on the fingertips. Affected patients have episodic pain, cold intolerance, and exquisite point tenderness in the area of the tumor. MRI may be used in the diagnosis of those patients who have characteristic symptoms without visible evidence of tumor. Although surgical excision is curative, as many as 20% of patients can develop recurrent lesions. Multiple glomus tumors are present in approximately 25% of patients.

Nifedipine is a calcium channel blocker administered for treatment of vasospastic disorders such as Raynaud's disease. It would not alleviate this patient's symptoms. Use of a carbon dioxide laser has been recommended for ablation of glomus tumors of the reticular dermis. Radiation therapy is not recommended for glomus tumors. Nail ablation is an excessive procedure.

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;3:2223-2253.
2. Koman LA, Ruch DS, Smith BP, et al. Vascular disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;3:2254-2296.
3. Rohrich RJ, Hochstein LM, Millwee RH. Subungual glomus tumors: an algorithmic approach. Ann Plast Surg. 1994;33:300-304.

PHOTO

A 25-year-old man has painful swelling of the proximal phalanx of the right small finger after hitting it lightly against a closet door. A pathologic fracture is noted at the site of a markedly radiolucent lesion with speckled calcification. A radiograph is shown above. Which of the following is the most likely diagnosis?

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

The correct response is Option A.

The 25-year-old man has an enchondroma, a common bone tumor typically found in the metacarpals and phalanges in young adults. Most enchondromas are incidentally discovered on radiographs and/or in conjunction with pathologic fractures. Radiographs will show a radiolucent neoplasm; there is thinning and expansion of the bony cortex with widespread speckled calcification. Appropriate management includes curettage of the lesion.

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 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 the biopsy specimen should undergo intraosseous en bloc excision or ray resection.

Osteochondroma is a widespread lesion of bone that may be hereditary. In patients with 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.

Osteoid osteoma is a painful tumor usually seen in patients younger than 40 years. Pain is often relieved with 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.

References
1. Athanasian EA, Wold LE, Amadio PC. Giant cell tumors of the bones of the hand. J Hand Surg. 1997;22A:91-98.
2. Bednar MS, Weiland AJ, Light TR. Osteoid osteoma of the upper extremity. Hand Clin. 1995;11:211-221.
3. Floyd WE III, Troum S. Benign cartilaginous lesions of the upper extremity. Hand Clin. 1995;11:119-132.
4. Peimer CA, Moy OJ, Dick HM. Tumors of bone and soft tissue. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone, Inc; 1993;3:2225-2250.

A 64-year-old man has had a 10-mm lesion on the radial matrix of the thumb for the past two years. Plain radiographs suggest bony involvement. MRI shows involvement of the distal phalanx only. A punch biopsy specimen of the affected area indicates squamous cell carcinoma. There are no palpable lymph nodes.

Which of the following is the most appropriate management?

(A) Laser ablation
(B) Excision with 5-mm margins and coverage with a skin graft
(C) Mohs' excision and coverage with a skin graft
(D) Amputation of the thumb at the level of the interphalangeal joint
(E) Ray amputation of the thumb

The correct response is Option D.

The most appropriate management of this patient with squamous cell carcinoma of the thumb with involvement of the distal phalanx is amputation of the thumb at the level of the interphalangeal joint. This level of amputation allows for clear histopathologic margins while maintaining optimal thumb function. An adequate level of amputation in this patient is likely to be curative. Selective lymph node sampling may be beneficial in establishing the extent of disease and in determining the appropriate management.

Squamous cell carcinoma is the most common paronychial malignancy. Subungual squamous cell carcinoma usually involves the thumb or index finger and is more common in men. It is often mistaken for chronic paronychia.

Laser ablation is more appropriate for superficial cutaneous lesions without bony involvement. Likewise, excision of the lesion with clear margins and coverage with a skin graft is appropriate for patients with more limited disease. The bony involvement associated with this tumor precludes any type of excision with soft-tissue margins, including Mohs' excision. In addition, Mohs' excision of digital tumors has been shown to have an unacceptable five-year cure rate of 75%. Ray amputation is a functionally disabling procedure.

References
1. Carroll RE. Squamous cell carcinoma of the nail bed. J Hand Surg. 1976;1A:92-97.
2. Fleegler EJ, Zeinowicz RJ. Tumors of the perionychium. Hand Clin. 1990;6:113-135.