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 • Most common hand injury • Predisposed to injury • Males > females • Important for tactile, aesthetic function

Types of Injury • 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 • Nailbed lacerations repaired • 6-0 or 7-0 plain gut • Loupe magnification • Stenting of nail

Nailbed Avulsion • Can replace as graft • Leave small segments on nail • Remove larger segments from nail • Split thickness grafts • Full thickness grafts

Phalangeal Tuft Fractures • Often associated with nailbed injury • Displacement uncommon • Support of nail and pulp • Percutaneous K-wire occasionally

Fingertip Amputation • Area • Depth • Location • Orientation • Bone exposure

Fingertip Amputation Orientations

Fingertip Amputation Goals • Achieve wound closure • Maximize sensory return • Preserve length • Maintain joint function • Obtain Satisfactory Appearance

Conservative Treatment Advantages • Good for smaller defects ( < 1 cm 2 ) • Good in children • Durable cover • Sensation maintained • No tender scars

Conservative Treatment Disadvantages • Requires patient compliance • Longer time to wound closure • Not preferred with bone exposure • Hook nail deformity

Skin Grafts Advantages • Quick coverage

Skin Grafts Disadvantages • High rate of difficulties • Instability • Poor sensibility • Hypersensitivity • Donor site morbidity

Lateral V-Y Advancement Kutler (1944)

Lateral V-Y Advancement Kutler (1944) • 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) • 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) • 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 • Uses uninjured digit • Reliable vascularity • Sensibility varies • Requires multiple Procedures • Requires skin grafting • Flexion contractures, cold intolerance

Thenar Flap

Thenar Flap • 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) • 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 – 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 • 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 I.

V.

Dorsal Wrist Ganglion II. Volar Wrist Ganglion III.

Flexor Tendon Sheath Ganglion IV.

Mucous Cysts Carpal Bosses

Dorsal Wrist Ganglion • 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 • 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 • Observation • Rupture • Aspiration • Injection • Surgical Excision

Giant Cell Tumor of Tendon Sheath • Pigmented Villonodular Sinovitis – considered benign • 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 • 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 – Neurilemmomas – Neurofibromas – Neurofibromatosis (von Recklinghausen’s Disease) – Neurofibrosarcomas – Intraneural tumors of nonneural origin

Peripheral Nerve Tumors Neurilemmoma • 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 • 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 • More common in men • Arteriography • Aneurysm resection, ulnar artery ligation • Regional thrombolysis may be considered if embolization present

Ulnar Artery Aneurysm • Features – 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 • 6- 10% of primary bone malignancies • Rare in hand • Young males • Focal mass • Poor prognosis – hand better - excellent local control and good function

Osteosarcoma • 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 – Irradiated bone – Paget’s disease – Fibrous dysplasia of bone – Giant cell tumor – Solitary enchondroma – Multiple enchondromatosis – Multiple osteochondromas

Chondrosarcoma • Rare in the hand • Typically in elderly • Slow growing • Progressively painful tumor near MP joint • Treatment – Amputation / ray resection • Prognosis good

Epithelioid Sarcoma • Most common soft tissue sarcoma in hand • Notoriously insidious • Local recurrence, distant mets common • Treatment – Radical excision • amputation – node dissection + /- adjuvant therapy

Enchondromas • 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 • 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 – 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 • 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 • 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 – 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 • Removal of line • Documentation of circumstances • Photographs • Cool vs. Warm compresses • Elevation • Waiting for demarcation

Management • 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 • Industrial settings • Can be severe if material injected • Wide surgical opening • Lavage and Debridement • Possible fasciotomy

THE END