Upper Limb: Tumours

Question 1

What is the most common soft tissue tumor of the hand?

Answer 1

Ganglions are the most common soft tissue tumor of the hand, accounting for 50-70% of all masses.

Question 2

What is the gender ratio for ganglions?

Answer 2

The gender ratio for ganglions is approximately 3:1, with females being more affected than males.

Question 3

What age group is most commonly affected by ganglions?

Answer 3

70% of ganglion cases occur between the ages of 20 and 40.

Question 4

What is the recurrence rate of ganglions after excision?

Answer 4

Ganglions have a 50% recurrence rate if incompletely excised and a 20% recurrence rate if completely excised.

Question 5

What is the most common type of dorsal wrist ganglion?

Answer 5

The most common volar wrist ganglion is the Scapho-Lunate ganglion,

Question 6

What is the composition of a ganglion cyst?

Answer 6

Ganglion cysts contain a clear viscous gel, glucosamine, albumin, globulin, and hyaluronic acid.

Question 7

What are the possible aetiologies of ganglions?

Answer 7

The aetiology of ganglions is disputed, with theories including mucoid degeneration and production of hyaluronic acid due to minor trauma.

Question 8

What are the common locations for ganglions?

Answer 8

Common locations for ganglions include the dorsal wrist, volar wrist, flexor sheath, mucous cysts at DIPJ, and less commonly at PIPJ, extensors, Guyon’s canal, carpal tunnel, and within bone.

Question 9

What are the signs and symptoms of ganglions?

Answer 9

Many ganglions are asymptomatic, but some may cause a dull ache or weakness in the hand or wrist due to carpal involvement or compression.

Question 10

What is the differential diagnosis for ganglions?

Answer 10

Differential diagnoses include Carpometacarpal Boss, which is a hard OA spur, and Extensor digitorum manus brevis, an abnormal accessory muscle.

Question 11

What is the treatment for dorsal wrist ganglions?

Answer 11

Treatment options include observation, sclerosant therapy, aspiration, intralesional steroid injection, and pressure.

Question 12

What is the surgical approach for a dorsal wrist ganglion excision?

Answer 12

Surgery involves a transverse incision over the SLL, retracting EPL and EDC, mobilizing the pedicle, incising the capsule, and excising the ganglion tangentially off the SLL.

Question 13

What is the typical origin of volar wrist ganglions?

Answer 13

Volar wrist ganglions typically originate from the STT joint (Scaphotrapezial-trapezoid).

Question 14

What is the treatment for volar wrist ganglions?

Answer 14

Surgery is usually recommended for volar wrist ganglions due to the risk of harming the radial artery.

Question 15

What are mucous cysts and their characteristics?

Answer 15

Mucous cysts arise from the DIPJ, typically in individuals aged 50-70, and may cause a longitudinal groove in the nail due to pressure on the germinal matrix.

Question 16

What is the treatment for mucous cysts?

Answer 16

Treatment involves an L-shaped or curved incision over the cyst, mobilizing it, and excising it with part of the joint capsule.

Question 17

What is a Giant Cell Tumor of tendon sheath?

Answer 17

A Giant Cell Tumor is a relatively common soft tissue tumor of the hand that arises from the synovium and is benign but locally invasive. Grey and multi-loculated. treated by local excision (high recurrence rate)

Question 18

What are the characteristics of a Glomus Tumor?

Answer 18

Glomus tumors are painful, tender, and can cause cold insensitivity; they are often found under nails and in finger pulps. A gloms is an AV anastomosis involved in thermoregulation.

Question 19

What is the most common benign bone tumor?

Answer 19

Enchondroma is the most common benign bone tumor, often presenting as a pathologic fracture in young adults.

Question 20

What is Osteoid Osteoma?

Answer 20

Osteoid Osteoma is a benign bone-forming tumor that causes night pain relieved by aspirin, typically found in young individuals.

Question 21

What is Nodular Fasciitis?

Answer 21

Nodular Fasciitis is a self-limiting benign fibroblastic lesion that presents as a firm lump, often in the forearm or hand.

Question 22

What are the malignant tumours of the hands?

Answer 22

(excluding cutaneous malignancy)

o Chondrosarcoma - usually secondary to multiple enchondromatosis
o Osteosarcoma - most common?
o Ewing’s - Pyrexia, pain, raised ESR. Onion skin on x-ray
o Metastases - only 1% of tumours metastasise to hand.

Question 23

What are some of the benign intraneural tumours of the brachial plexus?

Answer 23

1. nerve sheath tumour (majority)
   - sensory sy, normal neurologocial exam
   - round regular mass on MRI

a. schwannoma:
- 80-90% preserve nerve
- fascicular level resection

b. Neurofibroma:
- 70-80% preserve nerve
- often more central compared to schwannoma
- NF2: plexiform schwannoma
- NF1 - plexiform neurofibroma - some are unresectable, dont operate on every tumour

Question 24

Describe any malignant nerve tumours you are aware of

Answer 24

1. malignant peripheral nerve sheath tumour (MPNST)
   - sporadic
   - NF1 (5-10%)
   - post radiation
   - present with pain, neurological deficit, and rapid growth with irregular features o MRI
   - Mgt: diagnosis, staging, percutaneous biopsy + neoadjuvent treatment then surgery (Wide resection -> limb sparing vs ampuation). multimodal approach
   - 50% 5yr survival
2. neurolymphoma - usually picked up on PET scan
3. Breast Ca