Transcript No Slide Title

Tumors of the Hand
Fingertip and Nail Injuries
Injection Injuries
Doug Humphreys BSc. MD
Division of Plastic Surgery
Dalhousie University
Halifax, Nova Scotia
Fingertip and Nail
Injuries
Fingertip Injury
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Most common hand injury
Predisposed to injury
Males > females
Important for tactile, aesthetic function
Types of Injury
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Simple Laceration
Crush
Avulsion
Amputation
Fingertip Anatomy
Nailbed Anatomy
Nailbed Injury
• Remove nail plate to assess underlying injury
– if necessary
• Stabilize distal phalanx, if required
• Repair nail bed
• Replace sterile matrix with graft at the primary
procedure
• Replace nail / Stent
Nailbed Injury
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Nailbed lacerations repaired
6-0 or 7-0 plain gut
Loupe magnification
Stenting of nail
Nailbed Avulsion
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Can replace as graft
Leave small segments on nail
Remove larger segments from nail
Split thickness grafts
Full thickness grafts
Phalangeal Tuft Fractures
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Often associated with nailbed injury
Displacement uncommon
Support of nail and pulp
Percutaneous K-wire occasionally
Fingertip Amputation
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Area
Depth
Location
Orientation
Bone exposure
Fingertip Amputation
Orientations
Fingertip Amputation
Goals
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Achieve wound closure
Maximize sensory return
Preserve length
Maintain joint function
Obtain Satisfactory Appearance
Conservative Treatment
Advantages
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Good for smaller defects ( < 1 cm2 )
Good in children
Durable cover
Sensation maintained
No tender scars
Conservative Treatment
Disadvantages
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Requires patient compliance
Longer time to wound closure
Not preferred with bone exposure
Hook nail deformity
Skin Grafts
Advantages
• Quick coverage
Skin Grafts
Disadvantages
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High rate of difficulties
Instability
Poor sensibility
Hypersensitivity
Donor site morbidity
Lateral V-Y Advancement
Kutler (1944)
Lateral V-Y Advancement
Kutler (1944)
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For vertical amputations
Typical advancement 5mm
Unreliable vascularity
Places tender scars on fingertips
Volar V-Y Advancement
Tranquilli-Leali (1935)
Volar V-Y Advancement
Atasoy (1970)
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For transverse midnail or dorsal oblique amputations
Advances 10 mm
Good vascularity, sensation
Hyperesthesia, hypersensitvity, cold intolerance
Hook nail deformity
Volar Neurovascular Flap
Moberg (1964)
Volar Neurovascular Flap
Moberg (1964)
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Entire palmar skin and neurovascular bundles
Preserves sensation
Digit must be flexed to close
Joint contracture
Tip necrosis
Usefulness limited to thumb
Cross-Finger Flaps
Gurdin (1950)
Cross-Finger Flaps
Gurdin (1950)
• Best for volar oblique amputations
– Suitable for other types
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Uses uninjured digit
Reliable vascularity
Sensibility varies
Requires multiple Procedures
Requires skin grafting
Flexion contractures, cold intolerance
Thenar Flap
Thenar Flap
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Alternative to cross-finger flap
Uses thicker palmar skin
Staged
Proximally or distally based
Donor site closed primarily
Thenar scar can be painful
Flexion contractures
Used mainly in children
Neurovascular Island Flap
Littler (1960)
Neurovascular Island Flap
Littler (1960)
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Attempts to provide sensibility
Used for thumb, index, ulnar fifth finger
Donor site morbidity (ulnar fourth finger)
Extensive surgery
Results vary widely
Pain, paresthesias, cold intolerance in donor and
recipient digits
Fingertip Replantation
• Technically difficult
• Questionable benefit
Tumors of the Hand
Tumors of the Hand
• Overwhelming majority benign
• Most amenable to surgical excision
Tumors of the Hand
Classification
• Benign
• Malignant
Tumors of the Hand
Classification
• Skin
• Soft Tissue
• Bone
• Metastatic Tumors
Skin Tumors
• Squamous cell carcinoma commonest
• Basal cell carcinoma rare
• Malignant Melanoma
Malignant Skin Tumors
Squamous Cell Carcinomas
• Etiology
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ionizing solar radiation
previous irradiation
burn scars
exposure to arsenic compounds
inherited genetic disorders
Malignant Skin Tumors
Squamous Cell Carcinomas
• Dorsum of hand - common location
• Treatment
– wide excision
• SCC of hand more aggressive
– especially if tumor involves web space
Malignant Skin Tumors
Basal Cell Carcinomas
• Rare on fingers
• Gorlin’s Syndrome
– Palmar variants
• Treatment
– local excision
Malignant Skin Tumors
Malignant Melanoma
• Occur on palms or subungually
• Tumor thickness prognostic indicator
• Treatment
– wide excision or amputation
– appropriate level of amputation not determined
Soft Tissue Tumors
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Ganglions
Giant Cell Tumor Of Tendon Sheath
Glomus Tumor
Peripheral Nerve Tumors
Ulnar Artery Aneurysm
Epidermal Inclusion Cysts
Sarcomas
Ganglions
• 70 % of all hand tumors
• Caused by mucoid degeneration of fibrous
connective tissue in joint capsules or
tendon sheaths
• Women > Men (2-3X)
• Presents as mass +/- pain
Types of Ganglia
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Dorsal Wrist Ganglion
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Volar Wrist Ganglion
III. Flexor Tendon Sheath Ganglion
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Mucous Cysts
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Carpal Bosses
Dorsal Wrist Ganglion
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70% of all hand ganglia
Over scapholunate ligament
Possible periscaphoid ligamentous injury
Can impinge on PIN
Dorsal Wrist Ganglion
Volar Wrist Ganglion
• Most frequent site in children under 10 years
• Arises from FCR tendon sheath, radioscaphoid
or scaphotrapezial joints
• Close proximity to radial artery
– can be bilocular
Volar Wrist Ganglion
Flexor Tendon Sheath Ganglion
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Arise in vicinity of MP joint
Lack of mobility with flexion
Often through A1 pulley, or A1 - A2 region
Pathophysiology
– Pressure damage to fibrous sheath
Flexor Tendon Sheath Ganglion
Mucous Cysts
• Arise in association with tendons and joints
– dorsal aspect of fingers
– from extensor tendon or joint capsule
• Occur primarily in older women
• Associated with osteoarthritis
– arthritic joints must be debrided - decreases reoccurance
Mucous Cyst
Carpal Bosses
• Painful masses on dorsal aspect second and third
metacarpal bases
• Bone lipping of the capitate, accessory ossicles
often present
– os styloideum
• Strongly associated with osteoarthritis
Carpal Bosses
Ganglions
Treatment
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Observation
Rupture
Aspiration
Injection
Surgical Excision
Giant Cell Tumor of Tendon Sheath
• Pigmented Villonodular Sinovitis
– considered benign
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Second commonest hand tumor
20 to 40 year olds
slightly more common in men
Lobulated mottled-yellow subcutaneous mass
Giant Cell Tumor of Tendon Sheath
• Polyhedral cells of a fibrous xanthoma,
multinucleated giant cells, foam cells, reticulin
• Can erode bone, skin by pressure
• Complete local excision recommended
• Recurrence common
Glomus Tumor
• Benign hamartomas of glomus apparatus
– usually <1cm. In diameter
• Pain, pinpoint tenderness, cold sensitivity
– diagnostic triad
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Subungual
Angiography, MRI, and Transillumination
Excision recommended, recurrence common
Remove nail and repair bed
Peripheral Nerve Tumors
• Rare in hand
• All lesions arise from Schwann cells
– Produce myelin and collagen
• Difficult to diagnose and treat
Peripheral Nerve Tumors
• Types
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Neurilemmomas
Neurofibromas
Neurofibromatosis (von Recklinghausen’s Disease)
Neurofibrosarcomas
Intraneural tumors of nonneural origin
Peripheral Nerve Tumors
Neurilemmoma
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Most common neural cell tumor
Dumbbell shaped
Extrinsic to nerve proper
Treatment
– Enucleation to preserve nerve fibres
• Recurrences rare
• Malignant degeneration not a feature
Peripheral Nerve Tumors
Neurofibromas
• Can proliferate within the nerve fibres
– produce functional abnormalities
• Excision more difficult
• Schwann cells associated with mast cells,
lymphocytes, mucoid material, and xanthoma cells
• Can cause gigantism of the affected part
Peripheral Nerve Tumors
Neurofibromatosis
• Autosomal dominant
• Multiple peripheral and central neurofibromas
– acoustic neuromas, meningiomas, optic gliomas
• Diagnosis
– café au lait spots, greater than 6
• Sarcomatous degeneration reported
– 10% - 15% of lesions
Peripheral Nerve Tumors
Neurofibrosarcomas
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Neurosarcomas or Malignant Schwannomas
2-3% of malignant hand tumors
Usually associated with neurofibromatosis
Local extension and metastasis are common
Mortality - 90%
Treatment
– Wide excision or amputation
Peripheral Nerve Tumors
Intraneural Tumors of Nonneural Origin
• Types
– lipofibromatous hamartomas
• seen if first decade of life
• associated with median nerve
• treatment - carpal tunnel release after excision of tumor
– hemangiomas
– ganglion cysts
– lipomas
Ulnar Artery Aneurysm
• Hypothenar hammer syndrome
– post traumatic
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More common in men
Arteriography
Aneurysm resection, ulnar artery ligation
Regional thrombolysis may be considered if
embolization present
Ulnar Artery Aneurysm
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Pulsatile mass
Digital ischemic changes
+/- distal emboli
Tinel’s sign often present
Epidermal Inclusion Cyst
• Palmar surface
• Traumatic etiology - penetrating hand injuries
• Cyst wall consists of squamous epithelium with
laminated keratin
• Contents are protein, cholesterol, fat, fatty acids
• Can become infected
• Cyst wall removal recommended
Sarcomas
Malignant neoplasm arising in tissue of
mesenchymal origin
Sarcomas
• Combination therapy
– wide excision, radiotherapy, and chemotherapy
• Amputation reserved for recurrences
• Metastasis tend to occur at distant sites
Ewing’s Sarcoma
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6- 10% of primary bone malignancies
Rare in hand
Young males
Focal mass
Poor prognosis
– hand better - excellent local control and good function
Osteosarcoma
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Rare in hand ( .18% of osteosarcomas)
Increasing pain from rapidly growing mass
Arise de novo or from other lesions
Wide excision and adjuvant therapy
Osteosarcoma
• More frequent in
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Irradiated bone
Paget’s disease
Fibrous dysplasia of bone
Giant cell tumor
Solitary enchondroma
Multiple enchondromatosis
Multiple osteochondromas
Chondrosarcoma
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Rare in the hand
Typically in elderly
Slow growing
Progressively painful tumor near MP joint
Treatment
– Amputation / ray resection
• Prognosis good
Epithelioid Sarcoma
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Most common soft tissue sarcoma in hand
Notoriously insidious
Local recurrence, distant mets common
Treatment
– Radical excision
• amputation
– node dissection + /- adjuvant therapy
Enchondromas
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Remain within substance of bone, cartilage
Congenital cartilaginous rests
Proximal, middle phalanges
Well demarcated oval swellings
Radiolucent diametaphyseal lesions
Curettage +/- bone grafting
Multiple Enchondromas
• Ollier’s dyschondroplasia
– disseminated involvement
• Maffucci’s syndrome
– multiple enchondromas associated with hemangiomas
Osteochondromas
• Most common cartilaginous neoplasm in body
– not hand
• Young patients
• Radiographically
– Bony protuberances from metaphyseal cortex
• 1 % risk malignant transformation
Chondroblastomas
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Rare
Young patients
Epiphysis of tubular bones
Sclerotic rim on X-ray
Malignant transformation unusual
Treatment
– curettage, +/- bone grafting
Bone Cysts
• Unicameral Bone Cyst
– Common in children
– Diaphyseal
• abuts, but does not cross the epiphysis
– Treatment
• curettage and cancellous bone grafting
Bone Cysts
• Aneurysmal Bone Cyst
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Second decade
males = females
Eccentric in metaphysis or diaphysis
Expansile and lucent
Treatment
• resection or curettage with bone grafting
Osteoid Osteoma
• Benign osteoblastic tumor
• Histology
– Richly vascularized osteoblastic osteoid tissue
• Uncommon in hand
– distal phalynx most common site
• Usually young males
Osteoid Osteoma
• Localized painful area over tubular bone
• Pain worse at night, relieved by aspirin
• Radiographically
– Small central lucency, sclerotic surroundings
• Treatment
– complete excision
– pack cavity with cancellous bone
Osteoblastomas
• Similar to osteoid osteomas
• Benign with bone destruction
• Entire bone removed for cure
Giant Cell Tumor of Bone
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Uncommon anywhere in the body
Ages 30 to 50
Solitary lesion
Dull constant pain
Epiphyseal end of bone affected
Translucent, thin cortex
Sarcomatous degeneration 10%
Wide resection
Metastatic Tumors
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Very uncommon
Associated with primary lung, kidney
Distal phalanges
Amputation recommended if life expectancy
compatible
Injection Injuries
Injection Injury
• Extravasation
– Medications
– Intravenous agents
• Industrial hydraulic devices
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Paints
Lubricants
Adhesives
Organic solvents
Extravasation
• Inflammatory reaction
– Tissue death, slough, ulceration
• Most cases recognized promptly
– Temporary erythema
• Major injury
– Surgical debridement
– Amputation
Drugs
• Osmotically active agents
– Potassium, Calcium, Urea, PPN
• Ischemia- inducing agents
– Catecholamines, vasopressors
• Direct cellular toxicity
– Antineoplastics, bicarbonate, digoxin, diazepam
Management
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Removal of line
Documentation of circumstances
Photographs
Cool vs. Warm compresses
Elevation
Waiting for demarcation
Management
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Many recognized late
Close observation
May require serial debridement
Watch for compartment syndrome
Management
• Hyaluronidase
– reduces tissue injury
• allows rapid diffusion of irritants
– Advocated for
• 10% dextrose, calcium, potassium, aminophylline, naficillin,
radiocontrast media, and parenteral nutrition
• Experimentally beneficial for vinca alkaloids
High Pressure Injection
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Industrial settings
Can be severe if material injected
Wide surgical opening
Lavage and Debridement
Possible fasciotomy
THE END