Tristram D. Montales, MD
Clinical Associate Professor
University of the Philippines – Manila, College of Medicine
Department of Orthopedics, Division of Hand & Reconstructive Microsurgery
This module will cover common soft tissue masses or tumors in the hand. The vast number of masses that occur within the soft tissues of the hand are benign. Masses in the hand may arise from any of the following structures:
Bone and cartilage
Muscle
Nerve
Skin and its adnexa
Subcutaneous tissue
Synovium and tendon
Vessel
A detailed history and physical examination are the essential starting points when a patient presents with a mass in the hand. If a classic history can be obtained for a common tumor, then physical examination alone can confirm the diagnosis. It is important to ask when the mass was first noticed. Was there any history of trauma? Has the mass changed in size, shape, color, or consistency? Is the mass growing? If so, how fast?
Examination of any mass should take note of the following:
Site
- Location of the lesion
Size
- should be recorded and photographed
Shape
- Defined or irregular margins
Color
- Presence or absence of pigmentation
Consistency
- Fluctuance, soft and yielding vs hard/firm and unyielding
Mobility
- Fixed to surrounding structures or mobile
Ulcers
- Edge, floor and base of ulcer characteristics
Radiographic imaging will provide the following information regarding the tumor:
Lesions arising from bone
Effect of soft tissue lesion on bone
Presence of calcification on soft tissue mass
Ganglions and Mucous Cysts
Ganglion cysts are the most common soft tissue tumors of the hand. These mucin-filled cysts are usually attached to the adjacent underlying joint capsule (Fig.1), tendon, or tendon sheath. Ganglions can appear quite suddenly or develop over a period of several months. They may subside with rest, enlarge with activity, and rupture or disappear spontaneously. While their cause is unknown, the cysts may form in the presence of joint or tendon irritation, arthritis, mechanical changes, or injury. Osteoarthritic changes are commonly seen with cysts at the DIP or carpometacarpal joints.
Fig. 1 Ganglion cyst attached to underlying joint (assh.org/handcare)
Other conditions that cause diffuse swelling over the dorsum of the wrist, such as extensor tenosynovitis, lipomas, and other hand tumors, also must be considered in the differential diagnosis. The history, physical examination, techniques of transillumination (Fig. 2), and aspiration should allow a conclusive diagnosis in most instances.
Fig. 2 Transillumination test. (quizlet.com)
The contents of the cyst are characterized by a highly viscous, clear, sticky, jelly-like mucin made up of glucosamine, albumin, globulin, and high concentrations of hyaluronic acid. The contents of the cyst are more viscous than normal joint fluid.
Treatment for a ganglion cyst can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless. Ganglion cysts frequently disappear spontaneously. Nonoperative treatment may include:
Observation and reassurance
Digital pressure
Injection of hyaluronidase or sclerosing solutions
Aspiration with or without cortisone injection
If the cyst becomes painful, limits activity, or is otherwise unacceptable, several treatment options are available, including:
Open Excision – careful identification of the pedicle and excision of its attachment decreases the likelihood of recurrence
Arthroscopic
Although recurrences are infrequent with proper excision, >50% may recur if incompletely excised.
Wrist Ganglion
Dorsal wrist ganglion account for 60-70% of all wrist ganglions. Volar wrist ganglion, the second most common (18-20%) is usually found radial to the FCR tendon and may occlude the radial artery due to its proximity (Fig. 3) . Usually originate in the scapholunate joint.
Fig. 3. Volar wrist ganglion
Mucous Cyst
Found in the dorsal DIP joint. Causes groove or split in the nail (Fig. 4). May erode and cause chronic or recurrent infection. A local flap is needed to cover the defect created after excision.
Fig. 4. Nail groove due to mucous cyst (http://sonjacerovac.com/)
Giant Cell Tumor of the Tendon Sheath
Also known as pigmented villonodular synovitis. This is the second most common hand tumor. Etiology is not clear but it is always found in the presence of synovial tissue, most commonly in the flexor tendon sheath. Usually present late, when the mass is big enough to be palpable. On palpation, it has the consistency of soft rubber will irregular boundaries.
May produce radiologic changes due to pressure on the underlying bone. MRI typically shows a well-defined mass adjacent to or enveloping a tendon. Characteristically, the mass is hypointense on T1 weighted images, approximately equal to skeletal muscle. On T2 weighted images there is usually low signal due to chronic hemorrhage with hemosiderin deposition.
During excision, seen as a characteristic yellow and brown mottled tumor that surrounds normal structures rather than displacing them (Fig. 5). Recurrence is common if excision is not meticulous.
Fig. 5 Intra-op gross appearance of giant cell tumor of tendon sheath (from personal files of Dr. Montales)
Factors that predict a higher recurrence include:
Multiple primary lesions or satellite lesions
Thumb involvement
Presence of bony erosion
Epidermal inclusion cyst
Often due to minor wound that drives skin cells below the skin surface. Smooth, spherical tumor that is attached to skin but mobile over underlying tissue. Found almost exclusively in the palmar surface & commonly in the fingertips. The tumor grow over an interval of months to years to produce a painless swelling.
Fig. 6 Epidermal inclusion cyst of the finger (https://www.assh.org/handcare)
Pyogenic Granuloma
Pyogenic granuloma is usually manifested as a solitary reddish nodular tumor of the skin or mucosa (Fig. 7). It is also known as lobular capillary hemangioma and is a benign vascular tumor. Although the exact etiology is unknown, many believe that it is caused by trauma and subsequent infection. Spontaneous resolution is unusual. Careful excision under magnification, including a margin of normal tissue, has proved to be most effective. In the subungual location, pyogenic granuloma may be the result of a nail plate puncture wound, whether traumatic or iatrogenic. Repeated silver nitrate application to the lesion has resulted in resolution; however, nail growth abnormalities may occur and be long-standing.
Fig. 7 Pyogenic granuloma (Green’s Operative Hand Surgery 7th Ed.)
Glomus Tumor
This is a benign tumor that contains the cells of the normal glomus apparatus, which is an arteriovenous anastomosis in the dermis used to control skin circulation. It presents with a triad of symptoms comprised of paroxysmal pain, pinpoint tenderness and cold sensitivity. It is most commonly located underneath the nail. Tenderness is extreme and very well localized. A localized bluish discoloration in the nail bed (Fig. 8), with or without nail plate ridges, strongly suggests the diagnosis.
Fig. 8 Bluish discoloration of the nail plate is seen on the right proximal corner of the nail. (Glomus Tumors, E McDermott, The Journal of Hand Surgery / Vol. 31A No. 8 October 2006)
Cold sensitivity may be provoked by immersion in an ice bath or by spraying the lesion with ethyl chloride, which causes well-localized pain. Glomus tumors appear as dark, well-delineated lesions on T1-weighted and bright on T2-weighted MRI. Treatment of symptomatic lesions is surgical excision. Lesions in the nail bed are exposed after removal of the nail.
References:
1) Lister’s The Hand
2) Green’s Operative Hand Surgery 7th Ed
4) https://musculoskeletalkey.com/soft-tissue-tumors-of-the-forearm-and-hand