Introduction
Tumors of hand bones and fingers are usually not cancerous, but they are usually unsightly.
Due to the complex movements of the hand and fingers, treatment of tumors of the hand is very important more so in some professions like musician, typist, and military services.
Where does the tumors arise from in the hand?
Tumors of the hand can arise from the skin, fat, tendons (structures which move the fingers), bone, muscles, nerves, and blood vessels.
What are the common Hand tumors?
Of all the hand tumours, few tumours are very common-
- Cysts
- Lipoma
- Ganglion
- Glomus Tumor
- Giant cell tumour of the tendon sheath
- Neurofibroma
- Sarcomas or soft tissue tumours
- Bone tumour
Cysts
Cysts are very common tumors of the hand.
The most common cysts found in the hand are sebaceous cysts or inclusion cysts.
Both the cysts are harmless, and 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.
- Non-painful but can be if the underlying nerve is compressed.
- They also do not create any problems apart from difficulty in doing daily work because of their bulky nature and aesthetic concerns.
Lipoma on the hand should be excised but if on the forearm and arm, can be left.
If multiple lipomas are present on the arm and forearm region, they can be left as such and only big ones that cause cosmetic concerns are removed.
Ganglion
Ganglion is the most common soft tissue tumor of the hand.
They are filled with mucus and are cystic in nature and often develop from the capsule of the joint or tendon sheath.
Where is ganglion found on the hand?
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.
What are the symptoms of ganglion?
- 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 the wrist.
The diagnosis and deeper communication or origin (whether joint or tendon sheath) can be confirmed by ultrasonography or MRI
What is the treatment of Ganglion?
Even mildly painful Ganglion cysts should be removed when they are diagnosed to prevent the complication of spontaneous rupture which can lead to the 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.
What should not be done in treatment for ganglion?
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.
Do Ganglions recur?
Recurrence is common.
Glomus Tumor
Glomus tumors are very commonly found in women in their middle age years.
These tumors are non-cancerous,
very small and vascular (made up of blood vessels and highly sensitive nerve endings)
Where is a glomus tumor found on the hand?
They are found beneath the nail plate and nail bed of the fingers.
What are the symptoms of a Glomus tumor?
They are very painful and often go undiagnosed by most of the clinicians. The patient always complains 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.
How is a glomus tumor diagnosed?
X-rays and imaging studies are mostly normal. Glomus tumors are most commonly diagnosed with an MRI scan of the affected finger.
How is glomus tumor treated?
Surgical excision is the treatment of choice and usually gives relief to most of the patients.
The surgery is usually done under brachial block anesthesia or general anesthesia.
The nail plate is removed, the nail bed is slit longitudinally, and the tumor is removed. The nail bed is sutured with absorbable sutures.
Giant cell tumor(GCT) of Tendon sheath
Giant cell tumor (GCT) of the tendon sheath is also very common tumors 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.
How is GCT present?
They can grow to much larger dimensions, and these usually present with symptoms of nerve compression or unaesthetic appearance.
How is the diagnosis of GCT made? What is the treatment of GCT?
The diagnosis is usually confirmed with an MRI scan and Fine Needle Aspiration Cytology (FNAC).
Complete excision of this tumor is a must while preserving the nerve and artery of the fingers.
Schwannoma & Neurofibroma
What is schwannoma or a neurofibroma?
Both of them are nerve tumors, commonly found in the hand.
Schwannoma is a tumor of the outer covering of the nerves.
Neurofibroma is the tumor of nerve fibers within the nerve.
Schwannoma is the most common benign nerve tumor of the upper limb. They are well-circumscribed, well-defined, slow-growing masses developed along the course of one of the major nerves of the arm (median, ulnar, or radial). Very rarely, you get a 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.
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 deficits. They can be painful too if compressed.
What is the treatment of Schwannoma or neurofibroma?
The diagnosis is usually confirmed with an MRI scan and Fine Needle Aspiration Cytology (FNAC).
In a 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
Soft tissue sarcomas are better known as cancer of the soft tissue. The most common soft tissue sarcomas of the hand are-
- malignant fibrous histiocytoma,
- epithelioid sarcoma and
- synovial sarcoma which is usually diagnosed on biopsy or FNAC.
What are the symptoms of soft tissue sarcomas?
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.
What are investigations done for soft tissue sarcomas?
- Radiograph of hand to see bone erosion.
- HR Ultrasonography of swelling in a few cases
- NCV/ EMG (if there is any nerve compression)
- MRI / CT scan of hand
- Chest X-ray, CT scan of the chest and axilla to see whether it has spread to lungs and lymph nodes or not.
What is the treatment of soft tissue sarcomas?
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.
Is the treatment complete after surgery in soft tissue sarcoma?
No. Biopsy determines the next step in management.
It tells whether the tumor is benign or malignant or which subtype of soft tissue sarcoma is present.
If benign then no other intervention is needed but monitoring and follow-up are needed to assess the recurrence of the tumor.
If malignant, a secondary procedure or adjunct therapy in the form of chemotherapy or radiotherapy may be required.
Bone tumors of hand
Bone tumors of the 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 tumors 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.
What are investigations done for bone tumors of the hand?
- Radiograph of the hand to see whether the mass is rising from the bone or not
- MRI / CT scan of the hand easy gold standard investigating technique to look for the extent of the tumor and its soft tissue extension.
What is the treatment of bone tumors of the hand?
Bone tumors 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.
Amputation of the finger or hand is advised to save the life of the patient where-
- reconstruction is not possible or fruitful in malignant or cancerous bone tumors,
- to limit the possible spread of the tumor to various parts of the body
Is the treatment complete after surgery for bone tumors of the hand?
The final report of Biopsy will determine the next step in management.
It tells whether the tumor is benign or malignant or which subtype of bone tumor.
If benign then no other intervention is needed but monitoring and follow-up are needed to assess the recurrence of the tumor
If malignant, a secondary procedure or adjunct therapy in the form of chemotherapy or radiotherapy may be required.
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