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Bone Soft Tissue still uncertain, but some evidence indicates underlying peri-scaphoid ligamentous instability. 151 Volar wrist ganglia—Volar wrist ganglia arise from the flexor carpi radialis tendon sheath or the radioscaphoid, scapholunate, or scaphoid-trapeziumtrapezoid joint. Ultrasonography can delineate the origin preoperatively. The ganglion is in close proximity to the radial artery, which can cause it to be bilocular. Flexor tendon sheath ganglia—Flexor tendon sheath ganglia arise from the volar flexor tendon sheaths in the vicinity of the metacarpophalangeal joint. They often present through the A1 or A2 pulleys or in the interval between them. Flexor tendon sheath ganglia are thought to be a direct result of pressure damage to the fibrous sheath and require excision only if symptomatic, taking a small cuff of pulley as required. 152 Mucous cysts—Ganglia arising in association with tendons and joints on the dorsal aspect of fingers can originate from the extensor tendon itself or, more commonly, from the joint capsule. 153–155 They occur primarily in older women who have osteoarthritic changes of the underlying joint, usually the distal interphalangeal joint. When an underlying arthritic joint is the cause of the ganglion, the joint must undergo débridement or the ganglion will recur. Mucous cysts can produce a deformity of the nail plate Table 2 Grading of Bone and Soft-tissue Tumors of the Hand134 SRPS Volume 10, Issue 25, 2009 Benign (G0) Low-grade Sarcomas (G1) High-grade Sarcomas (G2) Enchondroma Osteochondroma Fibrous dysplasia Osteoid osteoma Bone cysts Hemangioma Osteoblastoma Ganglion Giant cell tumor (tendon sheath) Lipoma Neurolemmoma Chondromatosis Glomus tumor Giant-cell tumor Desmoplastic fi broma Chondrosarcoma (low-grade) Parosteal osteosarcoma Desmoid Liposarcoma (low-grade) Fibrosarcoma (low-grade) Kaposi’s sarcoma Osteosarcoma Ewing’s sarcoma Lymphoma Chondrosarcoma Angiosarcoma Myeloma Synovioma Malignant fi brous histiocytoma Liposarcoma (high-grade) Rhabdomyosarcoma Epithelioid sarcoma Clear cell sarcoma Angiosarcoma Hemangiopericytoma Malignant schwannoma from pressure on the nail bed. Brown et al. 156 reported their experience with 26 nail deformities secondary to mucous cysts of the distal interphalangeal joint managed by excision of the cyst and débridement of associated osteophytes. No recurrences occurred during the follow-up period, and residual nail deformity in eight patients was negligible. Pathologic anatomy—A ganglion typically has a uni- or multilocular main cyst that communicates with smaller intra-articular cysts through a tortuous, continuous, one-way valvular system of ducts. 140 Microscopic examination of the ganglion wall typically reveals compressed collagen fibers with no evidence of cells of epithelial or synovial origin. 157,158 The cyst contains viscous mucoid material consisting of glucosamine, albumin, globulin, and hyaluronic acid. Management—Rosson and Walker 159 reviewed the natural history of ganglia in children and noted that 22 of 29 lesions resolved spontaneously. A conservative approach to ganglia is therefore advocated for young patients. 159,160 The management of wrist ganglia in adults is controversial. The literature supports a spontaneous regression rate of 38% to 58%, 161 whereas treatment of all types is associated with recurrence rates from less than 1% 143 to 50% 162 (average 24%). Incomplete excision of the cyst stalk 13
SRPS Volume 10, Issue 25, 2009 complex probably accounts for the high recurrence rate. 163 Prevention of recurrence depends on identification and excision of the involved segment of joint capsule and deep attachments of the cyst pedicle to the scapholunate ligament but only minimal resection of the ligament itself to prevent future scapholunate dissociation (Fig. 10). 164 Clay and Clement 150 noted only 3.2% recurrence when using that protocol. More radical procedures pose a greater risk of subsequent stiffness, hypertrophic scar, wound infection, and nerve damage. Figure 10. Ganglion with pedicle attached to scapholunate ligament. (Reprinted with permission from Minotti and Taras. 164 ) Filan and Herbert 165 think that symptomatic dorsal wrist ganglia are the result of scaphoid instability that, if present at the preoperative clinical examination, is treated by a dorsal capsulorrhaphy of the wrist combined with ganglion excision. Of seven patients who underwent surgery for recurrent ganglia in whom capsulorrhaphy was performed, none had experienced recurrence of ganglia at 12 months. The treatment of wrist ganglia is indicated only in the event of significant discomfort or deformity. Although surgery is the mainstay of treatment, various nonoperative techniques have been advocated. Aspiration 166,167 or injection of enzymes, 168 sclerosing agents, or cortisone have been suggested, but all are associated with a significant recurrence rate. Arthroscopic resection of the ganglion might be associated with a lower recurrence rate. 169–171 It can also 14 identify the exact origin of the ganglion and other intra-articular pathological conditions. Giant Cell Tumors of Tendon Sheath Giant cell tumors are the second most frequent type of hand tumor. They typically occur in the fingers of 20to 40-year-old patients and are slightly more common in women. Giant cell tumors of the tendon sheath are also known as pigmented villonodular synovitis when they arise from the volar joint recess. 172,173 No evidence has shown that repeated hemorrhage, friction, or cholesterol imbalance contributes significantly to the development of giant cell tumors, and only approximately one-third of patients provide histories of previous trauma or surgery to the region. Pain and tenderness are not prominent features, but prolonged unchecked tumor growth interferes with mechanical function of the hand. The clinical presentation of a giant cell tumor of the tendon sheath is that of a lobulated, mottled, yellow subcutaneous mass. Although the diagnosis usually is evident clinically, magnetic resonance imaging (MRI) has been described as an adjunct in the preoperative assessment of extensive tumors. 174 The characteristic lobulation is seen microscopically, and a relatively noncellular, collagenous connective tissue often divides and partially envelops the lesion. 175 Histological examination reveals the basic polyhedral cells of a fibrous xanthoma. In the more cellular areas, mitotic figures are seen, but never in large numbers. Also present are spindle cells, multinucleated giant cells, foam cells, and reticulin. 175,176 The tumor can erode bone by pressure 177 and/or infiltrate the overlying dermis. 178 Frank bony invasion has been documented. 179 Treatment is complete local excision, ensuring total clearance of the volar joint recess. Recurrences unfortunately are common, especially in the fingers, and are the result of inadequate resection, for which repeat excision is recommended. 180 Extensive recurrences often necessitate arthrodesis of the affected joint in that resection of violated ligaments and joint capsule might be required. Very occasionally, amputation is necessary. Despite infiltrative growth patterns, rapid recurrence, and a frequently confusing histological appearance, giant cell tumors are considered benign. 181
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