Transcript Slide 1
Tumors of the Hand By: Prof. Dr. Hussein Abdel Fattah Bone & cartilage Vessels & nerves Synovial sheath & soft tissues The hand is the site of a great variety of benign lesions and a few malignant lesions but benign ones predominates . Malignant skin tumors squamous cell carcinoma, basal cell carc. & malignant melanoma are not included in this survey Tumor like conditions are mentioned Patients seek advice early because of simplicity of recognition and the disability that attends a small lesion in the hand. Benign lesions in the hand are first noticed as a palpable mass, an enlarged digit, or a mechanical dysfunction . Pain may be the presenting symptom in glomus tumor,osteoid osteoma osteoblastoma Many metabolic and degenerative processes are seen in the hand as radiolucent areas, subchondral degenerative cysts in arthropathies and in gout. Parathyroid adenoma Diagnosis Standard X-ray of the hand of excellent quality and definition are essential C.T. & M.R.I. & Bone scan Clinical photo prior to surgery Angiography in the hand is a useful technique for determining the anatomical extent of the lesion and its relationship to intricate system. Particularly in vascular tumors. Many lesions in the hand are part of systemic processes. Radioactive isotope scan serves as a total skeletal survey. Any area of increased activity must be judged in light of the over all clinical picture. Planning Treatment for Hand Tumours For benign lesions of the digits incisions should be placed in such a way that they do not subsequently interfere with function. Types of Surgical Approach Marginal excision. Curettage & graft. Wide resection and intercalary reconstruction. Wide ray resection. In many instances ray resection may be a cosmetically and functionally superior method of reconstruction than composite tissue grafting. Caution is needed against overenthusiastic reconstruction with potential loss of the remaining function of the hand. Enchondroma: Solitary and Multiple The small bones of the hand and have a marked predilection to proximal and middle phalanx and to metacarpal Cartilagenous tumors ECCHONDROMA ENCHONROMA Common painless unless pathological fracture Enchondroma fifth metacarpal Curettage & graft after path. fracture. Multiple chondromata Curettage & collapse of the wall Preoperative Postoperative Ollier,s disease Multiple chondromata Maffuci syndrome With cavernous haemangimata showing calcified thrombi Big benign enchondroma distal Ulna Bone tumors Osteochndrma Osteoid osteoma Giant cell tumor Osteosarcoma Secondary deposit OSTOID OSTEOMA PAINFUL SMALL LESION HOT IN BONE SCAN BENIGN OSTEOBLASTOMA PAINFULL DENSE TUMOR WITH TENDECY TO RECURRENCE B. OSTEOBLASTOMA REURRENCE AFTER CURETTAGE RADICAL EXCISION & ILIAC BONE GRAFT OSTEOCHONDROMA MULTIPLE HEREDITARY EXOSTOSIS ANEURYSMAL BONE CYST G.C.T. OF SECOND METACARPAL DIFF. DIAGNOSIS PARATHYROID BROWN TUMOR HEALS AFTER EXCISON OF ADENOMA G.C.T. INDEX CURETTAGE & GRAFT POSSIBILTY OF RECURRENCE HIGH RAY RESECTION IS MORE RADICAL G.C.T. DISTAL RADIUS EXCISION & FIBUALR GRAFT In contrast, many sarcomas in the hand and particularly on the dorsum tend to mimic an inflammatory process with diffuse swelling, local heat and erythema rather than appear as a discrete swelling. Fibrous Tissue Tumors Fibroma, localised well differeniated Palmar fscia contracture, hereditary slowly growing nodules over years Fibrous tissue localised fibroma DUPUYTREN,S CONTRACTURE Subcutaneous fibrosis in palmar Facia with with progressive contracure& flexion deformity Rt hand operated 3 months ago Lt. hand operated 10 years ago at age of 53 Age 63 now Fibrous Tissue Tumors Diffuse Fibromatosis Diffuse Fibromatosis is a soft tissue tumour of neurolemmal sheath ,muscular fibrous sheath that has a nasty habit of many local recurrences if not completely excised. These tumors can be very painful and disfiguring. They show tendency to malignant destructive recurrence. M.R.I. coronal section M.R.I. AXIAL CUTS Ray resection of the medial two RAYS to save good function of the hand AFTER THREE YEARS FIBROMATOSIS OF SECOND RAY FOR RESECTION Recurrent malignant Triton tumor Diffuse fibromatosis M.R.I.showing extensive infiltration in the sole of the foot Symes amputation was mandatory after four previous excisions Synovial Tumors Pigmented villonodular synovitis A REACTIVE LESION OF TENDON SHEATH USUALLY ON THE PALMAR ASPECT OF DIGIT SLOWLY GROWING 20% SHOWS BONE EROSION, 2O% LOCAL RECURENCE Pigmented villonodular synovitis in the index MARGINAL EXCISION Longstanding tumor with pressure bone atrophy P.V.N.S. THUMB Flap incision Tendons nerves, vessels intact PVNS in the SECOND toe Chondromatosis Synovii Unique case in the radial and ulner synovial bursa in the distal forearm and palm of the hand SLOWLY DEVELOPING HARD NODULES WITH SLIGHT PAIN & CREPITUS ON MOVING THE FINGERS Excision of chondromatous masses Nerve tumors Neurofibroma Glomus tumor Elephantiasis nurofibromatosis Nerve sheath tumor in dorsal digital nerve of little finger Dorsal digital nerve neurofibroma painful excision Nerve sheath tumor fo median nerve presenting as C.T.S. simple decompression Unique case Multiple neurofibromatosis tender sheath tumor for excision preserving the nerve trunk Tumor Like Conditions Simple ganglion Inclusion dermoid Megalodactylia Vascualar anomalies Lymphatic obstruction anomalous Gouty arhropathy,tophi Rheumatoid tenosynovitis T.B. tenosynovitis & spina ventosa Simple dorsal Palmer ganglion Muscinous filled cyst adjacent to joint caopsule or tendon sheath, with an outer fibrous wall and inner synovial lyning filled with clear colorless gelatenous fluid Implantation Dermoid Skin epithelial cells implanted through a small skin puncture Megalodactylia In the Hands and Feet Hyperplastic, giant overgrowth of one or more digit usually the middle, index, or thumb, including the phalanges. Some are due to bony overgrowth with normal appearing soft tissue parts, others from excess fat, lymphatic and fibrous tissue. Large neurofibromata with trophic effect on the overgrowth may be associated with angiomata and lymphomata Megalodactylia Elephantiasis neurofibromatosis Ring finger Child two years Middle and ring fingers Second and third Toes Megalodactylia ray-resection Short sh metacarpalo r t Megalodactylia ring finger ray resection Elephantisis neurofibromatosis good function leave alone MEGALODATYL second & third ray MEGALODATYLIA RESECTED BIG TOE , SECOND & THIRD RAYS MEDIAL LATERAL Three months postoperative Vascular Tumors Haemangioma Arterial aneurysm Arteriovenous aneurysm Lymphatic obstruion ANGIOGRAM FOR ANEURYSM ULNER ARTERY TRAUMATIC ARTERIAL ANEURYSM Artriovenous fistula in forearm veins were arterialized, with distal ischemia loss of distal end of the index Cavernous Haemangioma Congenital lymphatic obstruction with elephantiasis Congenital Lymphatic Obstruction Adult lymphoedema Neonatal Chronic Gouty Tophi Eroding I.P. Joints Gouty Tophi in Hands and Feet Rheumatoid Tenosynovitis Melon Seed Bodies Rheumatoid Tenosynovitis around Extensor Tendons Tuberculous Dactylitis age 2 yrs T.B. TENOSYNOVITIS in tendon sheath of flexor group Early Leprotic Late Nerve Palsy THANK YOU