In-Service Exam
Hand - Tumors - 2003





A 43-year-old woman has a pinpoint area of tenderness at the base of the nail of the left ring finger. The area is painful to touch and sensitive to cold. Physical examination of the finger shows a deformity of the nail plate. Which of the following is the most likely diagnosis?

(A) Epidermal inclusion cyst
(B) Ganglion cyst
(C) Giant cell tumor
(D) Glomus tumor
(E) Neurilemmoma

The correct response is Option D.

This 43-year-old woman has a glomus tumor, or benign hamartoma of the neuromyoarterial receptor, which regulates skin temperature and blood flow. Glomus tumors are typically subungual lesions smaller than 1 cm; glomus bodies can be found in the glabrous skin and beneath the fingernail. Exquisite pain, pinpoint tenderness, and cold intolerance are characteristic. Nail deformities also may be seen. History and physical examination findings are most useful for diagnosis, although MRI may be beneficial for delineation of the tumor. T2-weighted MRI will show a bright lesion. Simple excision is the most appropriate management.

Epidermal inclusion cysts are mobile, nontender masses that are partially formed following trauma, when the epidermis is introduced under the subcutaneous tissue, resulting in the formation of a cyst that is lined with epithelial cells and filled with carotene. Some authors suggest that these cysts develop from embryologic epithelial cells that are stimulated by trauma. Tumors occur on the palmar surface of the hand or digits. Excision is appropriate management.

Ganglion cysts are the most common benign tumors of the hand and are believed to develop from mucoepidermoid degeneration of the joint capsule or tendon sheath. Affected patients have localized mobile swelling and weakness or paresthesia as a result of nerve compression.

Giant cell tumors, or localized pigmented villonodular synovitis, are the second most common tumors of the hand. These are lobulated, nontender, subcutaneous masses over the finger that may exert pressure and ultimately erode bony structures. They are typically found on the palmar surfaces of the wrist, hand, and fingers in women ages 30 to 50 years. Histologic examination is most likely to show multinucleated giant cells, foam cells, and spindle cells. Complete excision is recommended, and surgical exploration of the flexor digital sheath and adjacent joint may be required.

Neurilemmomas are the most common solitary tumors of neural cell origin in the hand. Affected patients have asymptomatic nodular swelling without associated sensory or motor abnormalities. These tumors are comprised almost exclusively of Schwann cells.

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. Fleegler EJ. Skin tumors. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2184.
3. Shapiro PS, Seitz WH. Non-neoplastic tumors of the hand and upper extremity. Hand Clin. 1995;11:133-160.

A 48-year-old woman has a nail plate deformity of the index finger resulting from a ganglion of the distal interphalangeal joint. The skin overlying the cyst is nearly translucent. A photograph is shown above. Which of the following is the most appropriate management of the nail deformity?

(A) Aspiration of the ganglion
(B) Debridement of the osteophyte of the distal interphalangeal joint
(C) Excision of the cyst wall
(D) Intralesional injection of corticosteroids
(E) Reconstruction of the nail bed scar

In this patient, the ganglion is exerting pressure on the germinal nail matrix, resulting in a grooved appearance of the nail. Because ganglions of the distal interphalangeal joint are associated with arthritic changes of the osteophyte, resulting in further progression, the most appropriate management is debridement of the osteophyte, which decompresses the ganglion stock. The ganglion cyst will subsequently resolve without excision following debridement of the osteophyte, and the appearance of the nail will improve without further treatment. Laser ablation has also been shown by some dermatologists to be effective.

Aspiration is likely to result in recurrence of the ganglion, and excision of the cyst wall alone is inadequate. Injection of a corticosteroid will not treat the underlying cause of the ganglion. Both aspiration and injection are associated with significant risk for joint infection. Reconstruction of the nail bed is not necessary because the bed is not scarred.

References
1. Gingrass MK, Brown RE, Zook EG. The treatment of nail deformities secondary to ganglions of the distal interphalangeal joint. J Hand Surg. 1995;20A:502-505.
2. Kasdan ML, Stallings SP, Leis VM, et al. Outcomes of surgically treated mucous cysts of the hand. J Hand Surg. 1994;19A:504-507.
3. Klinert HE, Kutz JE, Fishman JH. Etiology and treatment of the so-called mucous cyst of the finger. J Bone Joint Surg. 1992;54A:1955-1958.

A 76-year-old man with a history of bronchogenic carcinoma has had pain, swelling, and erythema of the long finger for the past two weeks. A radiograph shows a lytic lesion of the distal phalanx. Which of the following is the most appropriate next step in management?

(A) Administration of allopurinol
(B) Administration of cephalexin
(C) Administration of ibuprofen
(D) Biopsy and culture
(E) Irrigation and debridement

The correct response is Option D.

This patient most likely has a metastatic lesion; therefore, the most appropriate management is biopsy and culture of the tumor. Although metastasis to the bones of the hand occurs infrequently, more than 50% of patients with these tumors have a primary bronchogenic carcinoma of the lung. Because misdiagnosis is common in patients with these tumors, infectious conditions, such as osteomyelitis, felons, or tenosynovitis, as well as gout, rheumatoid arthritis, reflex sympathetic dystrophy, and traumatic fracture, should be ruled out. Bone scan can also be performed to evaluate for the presence of additional metastatic tumors.

Allopurinol is prescribed for treatment of gout, and anti-inflammatory drugs are indicated in patients with arthritis or tenosynovitis. Irrigation and debridement and administration of antibiotics are appropriate for osteomyelitis or other infections.

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. Stern PJ, Dell PC. Evaluation, staging, and principles of tumor surgery. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:2221-2263.