Most cysts, tumors, and other lesions on the hand and wrist can be diagnosed in your office. A trio of experts provides step-by-step guidance.
This is the first of a two-part series. Part 2 will appear in the April issue.
Primary-care clinicians are frequently the first medical professionals to examine patients with bumps and abnormal wounds around the hand and wrist. The clinician can often initiate treatment by diagnosing ganglion cysts, referring wounds that are healing slowly or poorly, or advising observation. In many cases, referral to the hand-surgery service for definitive excision, biopsy, and additional treatment is necessary. On rare occasions, oncologists, radiation therapists, and vascular surgeons may be consulted for adjuvant treatment.
Figure 1. A radiovolar ganglion cyst with radial artery passing over its central point. Attempted needle aspiration often punctures the artery.
Treatment decisions in all cases should be based on the “golden rule” of hand surgery—“function over cosmesis.” Patients may insist on intervention for minor lesions and need to be reminded that there are risks, including unsightly scarring, to every surgical procedure.This article, the first of two installments, will focus on the most obvious benign and malignant bumps of the hand and wrist.
Ganglion cysts are among the most common of the hand and wrist cystic masses. Although subdermal, they are usually visually apparent, and their location and consistency on palpation result in accurate diagnosis in nearly every patient. Originally described as mucoid degenerations, it is now believed that these cysts can result from chronic irritation and stretching of joint capsules and other supporting tissues. The dorsal wrist ganglion is the most frequently seen (60%-70% of all ganglion cysts) followed by volar wrist ganglions and cysts of the flexor and extensor tendon sheaths. Ganglion cysts of all types are more common in women than in men by a ratio of 3-to-1 and have been reported in children.
Ganglion cysts can occur after varying degrees of trauma, including contusions or twisting and stretching injuries, but it is not unusual to have the patient report an insidious onset. Complaints of pain range from none or minimal to severe and incapacitating, and it is not uncommon for the patient to report changes in lesion size prior to seeking examination.
Physical examination typically reveals a soft mass with a cystic consistency to palpation that may transilluminate with a penlight. Lesions of the flexor tendon tenosynovial sheath are usually found on the volar aspect of the metacarpophalangeal joint region and are pebblelike and firm to palpation.
Occasionally, a palpable radial artery pulse will accompany radiovolar ganglion cysts. Standard x-ray evaluation may yield evidence of degenerative joint disease, especially in the proximal carpal row and distal interphalangeal joint, but it is usually otherwise negative. Ultrasound and MRI may be helpful in diagnosing occult ganglions.
Conservative treatment of gangion cysts in the hand and wrist can be initiated by the primary-care clinician and ranges from reassurance and benign neglect to splinting, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspiration of the lesion. Aspiration is best accomplished by administering local anesthetic directly over the lesion and then puncturing it with an 18G needle. While multiple punctures of the cyst wall have been advocated in conjunction with aspiration, others have found no discernible difference between single vs. multiple perforations.
In addition to simple aspiration, substances such as hydrocortisone and hyaluronidase have been injected to reduce inflammation, with varying results. Patients should be advised that injections can cause hypopigmentation of the skin, nerve injury, subcutaneous fat necrosis, and infection. Aspirated carpal ganglions will recur at rates ranging from 22%-89%. It is important to remember that aspirations should not be attempted with radiovolar ganglions because of the possibility of injury to the radial artery (Figure 1). Following aspiration, immobilization may be utilized for comfort but does not significantly reduce the recurrence rate.
In a case of failed conservative treatment or the presence of a radiovolar ganglion, surgical intervention is appropriate. Under anesthesia, the skin is incised and the cyst removed, taking care to remove the small tentacle or “tail” within the joint to reduce the recurrence rate. Successful arthroscopic resection of dorsal wrist ganglions has been reported.
Complications of surgery include injury to branches of the radial artery, branches of the sensory cutaneous nerves, scar adhesion, wrist stiffness, and recurrence.
Figure 2. Mucous cyst. Directly below the mucinous material is a bony osteophyte.
Mucous cysts are a type of ganglion cyst that represents mucoid degeneration of a Heberden’s node located in the distal interphalangeal joint of the digits or the interphalangeal joint of the thumb. An underlying osteophyte is present and there may be radiologic evidence of joint-space narrowing and cystic changes of the joint. In rare cases, fingernail deformities such as ridging herald an occult lesion, but the cyst is readily apparent in most instances. Mucous cysts appear on the dorsum of the joint and have a clear transparent membrane containing mucus (Figure 2).
Since the lesions can degenerate and become infected, with a risk of osteomyelitis, the appropriate treatment is excision of the cyst and the attendant osteophyte. Operative complications include stiffness, persistent pain, infection, injury to the nail matrix, and the need for rotational skin flaps or full-thickness skin grafting to cover large defects. Nail-plate deformities caused by local compression of the cyst on the germinal matrix typically improve or resolve after cyst excision.
Dupuytren’s contracture (DC) is a fibroproliferative disorder of the palmar aponeurosis, the layer of tissue directly beneath and attached to the skin of the palm. The palmar aponeurosis prevents the palm from moving when the hand is engaged in gripping and torquing activities. Histopathologically, it is the result of fibroblast and myofibroblastic hyperplasia secondary to the secretion of type III collagen and is microscopically similar in appearance to fibrosarcoma.
The etiology appears to be genetic, with a prevalence of 18%-30% in Northern European and Scandinavian men aged 65 years or older. The inheritance pattern follows an autosomal dominant model. It is more common in men than women by a ratio of 6-to-1 and remains a disease primarily confined to the Caucasian race (although it has been described in patients with African and Occidental heritages as well as in the pediatric population). DC is also associated with plantar fibromyomatosis (Ledderhose’s disease) and Peyronie’s disease (contracture of the penis).
Figure 3. Typical Dupuytren’s contractive with palmar cord and flexion contracture of the metacarpophalangeal joint.
The pretendinous bands and nodular palmar thickenings typically begin in the fourth and fifth rays of the hand (Figure 3). Risk factors include the use of alcohol and tobacco, as well as insulin-dependent diabetes (a previous association with epilepsy has not borne out). Repetitive trauma has been associated with the onset of DC, but it remains noncompensible when it comes to workers’ compensation.
Treatment begins with simple observation. Early reports on the use of clostridial collagenase injections are promising but have not yet been approved for use in the general population. Hyperbaric oxygen therapy has also been reported as a method of conservative management, and patients taking tamoxifen were noted to have improvement in their Dupuytren’s lesions. Occupational therapy does not appear to have a role in the early management of DC, although patients report that stretching exercises have improved mobility.
Surgical intervention designed to remove the nodules and thickened pretendinous bands and to correct joint contractures is the mainstay of treatment.
The timing of the surgery depends on the patient’s ability to use his hand for activities of daily living. In mild cases that are well-localized, the necessary palmar fasciectomy can be completed in one procedure. If the disease is extensive and involves the majority of the palm, however, multiple fasciectomies are more beneficial in terms of postoperative complications. Occupational therapy designed to provide a nighttime extension splint, management of open wounds, and recovery of motion is important for a good outcome. Surgery has been shown to improve the appearance of the deformity as well as the function of the hand. The five-year recurrence rate has been estimated at approximately 50% and is usually based on the growth of new lesions in the hand as opposed to disease showing up in previously treated areas.
Hemangiomas typically appear within the first month of life and undergo a rapid phase of growth at a rate much greater than the child’s development. Toward the end of the first year, the lesions undergo a slow involution with varying degrees of resolution. Clinically, hemangiomas may be superficial, appearing as reddish discolorations (strawberry nevus) or completely subdermal, causing only a soft-tissue deformity. A palpable nontender to tender mass that ranges in consistency from “wormlike” to firm (usually without a palpable thrill or audible bruit) is a common finding. Patients may complain of numbness secondary to involvement of the adjacent nerves or loss of motion due to involvement of tendons and joints but do not typically report color and temperature changes.
Standard radiographs should be obtained to evaluate for possible lysis of the bone due to compression by the tumor mass, as well as calcification within the mass itself. The evaluation for vascular lesions in the upper extremity also includes arteriography, magnetic resonance angiography (MRA), and three-dimensional CT angiography. Clinicians will find these radiographic modalities useful in identifying the location of the lesion as well as the involvement of the adjacent structures. This helps in operative planning and advising the patient and/or parents of the possible long-term sequelae of attempting to remove the mass.
Figure 4. Pediatric hemangioma of the hand. Note convoluted “wormlike” nature of the mass.
Treatment options include observation, steroid or laser therapy (for superficial hemangiomas), and surgical interventions (for deep hemangiomas). For superficial hemangiomas, simple observation may be all that is required. Otherwise, oral prednisone in doses of 2-4 mg/kg/day for four to six weeks may result in lesion involution. Pulsed-dye argon (yellow) laser therapy and neodymium:yttrium-aluminum-garnet laser therapy have also been shown to be effective. Interferon-alfa-2a has been used to treat life-threatening hemangiomas and complications of steroid therapy. In lesions that are painful, rapidly growing, and causing loss of function, surgical treatment is recommended. This should be a multidisciplinary approach involving an interventional radiologist as well as a surgeon. The interventional radiologist embolizes the lesion while the surgeon attempts to resect and debulk the mass (Figure 4). The masses are frequently difficult to excise in toto, and injury to adjacent structures, such as muscles, tendons, joints, and nerves, must be avoided in order to recover maximum function.
Arterial aneurysms and thromboses
Trauma is the leading cause of injury to the vessels of the hand and digits. The ulnar artery is most frequently involved, usually as a result of gunshot wounds and stabbings as well as what is called “hypothenar hammer syndrome.”
Hypothenar hammer syndrome is caused by repetitive striking of the ulnar side of the hand. The hook of the hamate strikes the superficial palmar branch of the ulnar artery, leading to complete or partial arterial occlusion, thrombosis, and subsequent digital ischemia. Aneurysmal dilatation of the artery can result from blunt-force trauma as well as open injury to the vessel.
Typically, the patient reports a history of repeated use of the hypothenar eminence of the dominant hand in hammerlike fashion. It is considered an occupationally related disorder with an estimated prevalence of 14% in laborers who are systematically screened for an arterial lesion. It has also been reported as the result of injuries from multiple sports, including golf, tennis, baseball, football, and hockey.
Patients may complain of color and temperature changes, as well as painful pulsatile masses in the hand, and can usually relate the onset of symptomatology to a traumatic event.
Physical examination may reveal swelling and tenderness around the radial edge of the hypothenar eminence and in the region of Guyon’s canal. A palpable thrill or pulse over the ulnar artery in the canal, digital color and temperature changes, and skin and nail-bed lesions (including petechiae and flame hemorrhages resulting from thrombus embolization) may be seen. Digital color, temperature, and sensory changes may be dramatic in appearance if the patient does not have good collateral flow from the ulnar artery-dominant superficial palmar arch or the radial artery-dominant deep palmar arch or if there is extensive thrombosis throughout the arches.
Figure 5. The lower arrow indicates a probable thrombus in the ulnar artery secondary to an aneurysm. The upper arrows indicate decreased blood flow, likely due to embolization from the thrombus.
Radiologic evaluation should include standard radiographs of the hand to evaluate for vessel calcification and tortuosity coupled with a more sophisticated radiologic study to evaluate the artery itself. Standard arteriography or MRA provides detailed information regarding the location, extent of injury, and degree of occlusion in most cases. Partial occlusion of the vessel has the appearance of a corkscrew configuration and is highly suggestive of impaired blood flow. Digital subtraction angiography may show complete occlusion without retrograde filling due to intraluminal thrombus formation (Figure 5). Ultrasound has been shown to be beneficial in instances of complete occlusion where angiography was inconclusive.
Hypothenar hammer syndrome has been treated successfully via thrombolysis as well as IV prostaglandin and heparin, but the condition is most amenable to surgical intervention. The goal of surgery is to remove the thrombosed aneurysmal portion of the ulnar artery and to restore flow either by direct end-to-end anastamosis, interpositional vein graft, or use of an autologous arterial graft, such as that taken from the inferior epigastric artery. Postoperatively, patients are advised to avoid using their hand in hammerlike fashion and encouraged to avoid nicotine and caffeine to help maintain the patency of the vascular reconstruction.
Figure 6. Melanoma of the nail. Nail deformity and brownish discoloration are present.
The incidence of melanoma is doubling every 8-10 years. The two most common melanomas encountered on the hands are the acrolentiginous melanoma lesion, usually found on the palm or underneath the nail bed (Figure 6), and lentigo maligna, also known has the “Hutchinson freckle,” a flat irregular brown-to-black lesion noted on the skin in sun-exposed areas. Patients may report the insidious development of enlarging pigmented lesions with irregular borders. They are usually nonpainful and unaccompanied by signs of inflammation.
The diagnostic workup should include a thorough upper-extremity examination with particular attention paid to the epitrochlear and axillary lymph nodes. Liver function tests and CT scans of the head, neck, chest, and abdomen should also be performed to complete the metastatic workup. Initially, incisional biopsy in the thickest portion of the lesion is preferred. Surgical incision should include margins of 1 cm of normal skin for each millimeter of tumor thickness. Postsurgical follow-up comprises visits every three months for the first two years followed by visits every six months for the next two years. Prognosis is affected by tumor thickness, involvement of the lymph nodes, and presence of metastatic disease.
Squamous cell carcinoma
Squamous cell carcinoma is the most frequent skin malignancy of the hand seen in clinical practice. It usually appears as an innocuous, indolent, slowly ulcerating lesion of the skin. If neglected, it can progress to large, striking deformities (Figure 7). The patient frequently has a significant history of sun exposure and premalignant lesions known as “actinic keratoses.”
Figure 7. Squamous cell carcinoma of the thumb.
The squamous cell carcinoma diagnostic workup and physical examination are similar to that of malignant melanoma in that attention must be paid to the possibility of metastases. The results of the diagnostic workup dictate the surgical management, which can range from excision of the lesion to amputation of part or all of the extremity. A multidisciplinary approach incorporating oncology and radiation therapy may be required. Prognosis for a metastatic lesion is poor, with a five-year survival rate of 39%.
In evaluating patients presenting with a hand or wrist mass, the primary-care clinician can frequently determine the specific pathology using key historical information. Such information includes insidious onset vs. trauma and the presence of pain (especially at night or following exposure to cold or sensory or motor changes) along with physical examination findings, including location, consistency, and appearance. Diagnostic studies (e.g., standard radiographs, arteriography, and CT scans) will be helpful in making the diagnosis. Appropriate intervention, including observation or referral to a hand surgeon, can then be initiated.
The second installment, featuring less obvious benign and malignant bumps, will appear in the April issue. For a list of references used in this article, contact the editor via e-mail ([email protected]) or telephone (646.638.6077).