Tumours of hand bones and fingers can be of wide description such as lumps, nodules. They are usually not cancerous, but they are usually unsightly. Patient usually comes with complaint of swelling with unaesthetic appearance or could have sensory or motor symptoms due to compression of the underlying nerves. Due to complex movements of hand and fingers, treatment of tumours of hand is very important more so in some professions like musician, typist, military services.

Tumours of the hand can arise from the skin, fat, tendons (structures which moves the fingers), bone, muscles, nerves and the blood vessels.

Of all the hand tumours, few tumours are very common-

1. Cysts
2. Lipoma
3. Ganglion
4. Glomus Tumor
5. Giant cell tumour of the tendon sheath
6. Neurofibroma
7. Sarcomas or soft tissue tumours
8. Bone tumour

Cysts

Cysts are very common tumours of the hand.

The most common cysts found in the hand are sebaceous cyst or inclusion cyst.

Both the cysts are harmless, do not create any problem apart from difficulty in doing daily tasks because of their bulky nature and aesthetic concern.

They should be excised completely otherwise recurrences are common.

Lipoma

Lipoma is the tumor of fat cells located just below the skin of the hand. They are often confused with the Cysts. They are non-painful but can be if the underlying nerve is compressed. They also do not create any problem apart from difficulty in doing daily work because of their bulky nature and aesthetic concern.

Lipoma on the hand should be excised but if on forearm and arm, can be left.

If multiple lipomas are present on arm and forearm region, they can be left as such and only big ones which cause cosmetic concerns are removed.

Ganglion

Ganglion is the most common soft tissue tumor of the hands. They are filled with mucus and are cystic in nature and often develops from capsule of the joint or tendon sheath.

Ganglions are most commonly found on the back of the hand at the wrist joint. They can also be found at the front of the hand at the wrist joint.

Ganglions usually grow slowly and do not cause any pain until large enough but they interfere with the movements of the wrist. They can be quite painful at extreme movements of the wrist joint while working.

Ganglions are readily diagnosed by clinical examination. They are present as a small bumpy swelling on the back or front of wrist.

The diagnosis and deeper communication or origin (whether joint or tendon sheath) can be confirmed by ultrasonography or MRI Even mildly painful Ganglion cysts should be removed when they are diagnosed to prevent the complication of spontaneous rupture which can lead to spread of mucinous material along the tendon sheath in the forearm.

Complete excision by surgery is the best form of treatment for ganglion which should be done under Brachial block or General Anaesthesia.

No form of aspiration of the cyst or puncture of the cyst with the needle or steroid injection should be given in the cyst as it can lead to further complications.

Recurrence is common.

Glomus Tumor

Glomus tumours are very commonly found in women in their middle age years.

These tumours are non-cancerous, very small and vascular (made up of blood vessels and highly sensitive nerve endings)

They are found beneath the nail plate and nail bed of the fingers.

They are very painful and often go undiagnosed by most of the clinicians. Patient always complaints of severe pain in the affected finger and hand. Glomus tumor often presents with a classical triad of symptoms - severe pain, point tenderness and cold sensitivity. Few can have bluish discoloration of the nail or deformity of the nail along with the above symptoms.

X rays and imaging studies are mostly normal. Glomus tumours are most commonly diagnosed with MRI scan of the affected finger.

Surgical excision is the treatment of choice and usually give relief to most of the patients.

The surgery is usually done under brachial block anesthesia or general anaesthesia. The nail plate is removed, nail bed is slit longitudinally and the tumor is removed. The nail bed is sutured with absorbable sutures.

Giant cell tumor of the Tendon sheath

Giant cell tumour of the tendon sheath are also very common tumours of the hand. They are also non-cancerous and are present along the joints, ligaments and tendon sheaths.

They are firm, nodular and non-painful.

They can grow to much larger dimension, and these usually present with symptoms of nerve compression or unaesthetic appearance.

The diagnosis is usually confirmed with MRI scan and Fine Needle Aspiration Cytology (FNAC).

Complete excision of this tumor is must while preserving the nerve and artery of the fingers.

Schwannoma and Neurofibroma of the Upper Limb

Schwannoma is the tumor of the outer covering of the nerves.

Neurofibroma is the tumor of nerve fibres within the nerve.

Schwannoma is the most common benign nerve tumour of the upper limb. They are well circumscribed, well defined, slow growing mass developed along the course of one of the major nerves of the arm (median, ulnar or radial). Very rarely, you get neurological deficit of the involved nerve.

On clinical examination, if the mass is pressed it can cause radiation pain in the area of distribution of the nerve. The diagnosis is usually confirmed with MRI scan and Fine Needle Aspiration Cytology (FNAC).

Surgical treatment is the treatment of choice and excision is done with preservation of the nerve.

Neurofibroma is a slow growing tumor of the nerve fascicles within the substance of the nerve. They can develop in any of the nerves of the arm and can present with neurological deficit also. They can be painful too if compressed.

The diagnosis is usually confirmed with MRI scan and Fine Needle Aspiration Cytology (FNAC).

In few cases, multiple neurofibroma are seen in contrast to schwannoma which is mostly single.

Surgical treatment is the treatment of choice and excision is done with nerve reconstruction and nerve grafting.

Soft tissue Sarcomas of hand and Upperlimb

Soft tissue sarcomas are better known as cancers of the soft tissue. The most common soft tissue sarcomas of the hand are malignant fibrous histiocytoma, epithelioid sarcoma and synovial sarcoma which are usually diagnosed on biopsy or FNAC.

They usually present as rapidly growing growth or mass over the hand or fingers with areas of hardness or ulceration, mass in an atypical location with enlarged lymph nodes in the axilla.

Investigations

1. Radiograph of hand to see bone erosion.
2. HR Ultrasonography of swelling in few cases
3. NCV/ EMG (if there is any nerve compression)
4. MRI / CT scan of hand
5. Chest Xray, CT scan of the chest and axilla to see whether it has spread to lungs and lymph nodes or not.

Treatment

Soft tissue sarcomas are usually treated with wide local excision of the swelling with biopsy of swelling. The defect created by the excision of the sarcoma is reconstructed with an appropriate reconstructive technique as discussed in limb salvage surgery.

Biopsy determine the next step in management.

It tells whether the tumour is benign or malignant or which subtype of soft tissue sarcoma is present.

If benign then no other intervention needed but monitoring and follow up is needed to assess the recurrence of tumour.

If malignant, secondary procedure or adjunct therapy in form of chemotherapy or radiotherapy may be required.

Bone tumors of hand

Bone tumors of hand are not very common and could be benign or cancerous. The most common bone tumors of the hand are enchondroma, chondroma, osteochondroma, exostoses, osteoid osteoma, giant cell tumours of the bone, aneurysmal bone cyst, Ewing's sarcoma and osteosarcoma. They are usually diagnosed on biopsy or FNAC.

They usually present as rapidly growing growth or mass over the hand or fingers with areas of hardness or ulceration, with or without enlarged lymph nodes in the axilla.

Investigations

1. Radiograph of hand to see whether the mass is rising from the bone or not
2. HR Ultrasonography of swelling to be done in few cases
3. MRI / CT scan of hand easy gold standard investigating technique to look for the extent off the tumor and its soft tissue extension
4. FNAC is done to know its subtype.
5. Chest Xray, CT scan of the chest and axilla to see whether it has spread to lungs and lymph nodes or not.

Treatment

Bone tumours of the hand are usually treated with wide local excision of the tumor with preservation of vital important structures. The defect created by the excision of the tumor is reconstructed with an appropriate reconstructive technique as discussed in limb salvage surgery.

In few cases where reconstruction is not possible or fruitful in malignant or cancerous bone tumors, then amputation of the finger or hand is advised to save the life of the patient and to limit the possible spread of the tumor to various parts of the body.

Biopsy determine the next step in management.

It tells whether the tumour is benign or malignant or which subtype of bone tumor.

If benign then no other intervention needed but monitoring and follow up is needed to assess the recurrence of tumour.

If malignant, secondary procedure or adjunct therapy in form of chemotherapy or radiotherapy may be required.