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Intramedullary Nailing of Humeral Shaft Fractures Tapio Flinkkil/ Management of Humeral Shaft Fractures CME/Benign Tumors of Fibrous Tissue And Adipose Tissue of the Hand

Posted on: Thursday, 10 March 2005, 03:00 CST

For further reading on management of humerus fractures, you can go online and review the following articles in full text, complete with figures of fractures, non-unions and surgical procedures:

Intramedullary nailing of humeral shaft fractures Tapio Flinkkil. Division of Orthopaedic and Trauma Surgery, University of Oulu, Department of Surgery, University of Oulu. Academic Dissertation [presented to] the Faculty of Medicine of Oulu University Hospital, on April 23rd, 2004. Copyright 2004. http://herkules.oulu.fi/ isbn951427296X/

Management of Humeral Shaft Fractures CME

Authors: David C. Templeman, MD; Andrew H. Schmidt, MD

http://www.medscape.com/viewprogram/150_pnt

Benign Tumors of Fibrous Tissue And Adipose Tissue of the Hand. Inagari JV, Fallice JJ. Hand Clinics. 2004;20:243-8.

Tumors of the hand are uncommon and most likely benign. Ganglion cysts, the most frequently encountered comprise 50% to 70% of benign tumors of the hand. The authors divide this article neatly into two sections: benign tumors of adipose origin and fibrous tissue origin.

Benign tumors of adipose origin: Lipomas are an adipose tumor more often found in other parts of the body than the hand. They can develop in subcutaneous fat anywhere in the hand and also intramuscularly, especially the thenar and hypothenar muscles. According to Calandruccio and Jobe, they are "probably the most common solid cellular hand tumor". They can also present in deep spaces such as Guyon's canal, the carpal tunnel, or deep palmar space. Lipomas can also occur in bone and even less frequently in nerves. The his tological characteristics are the lipocyte or adipocyte, which is a mature fat cell that is microscopically recognizable by its 'signet ring' appearance. A central lipid droplet with a nucleus on the periphery parallels the appearance of a "gemstone" on a signet ring. Staining with oil Red O provides further definition to the Hpocytic nature of this tumor.

Symptomatology described by the patient is usually noting of a slow growing, painless mass over several years. Palpation of the mass shows a rubbery, flexible consistency that is relatively mobile. But, unlike a ganglion cyst, this does not transluminate, which is an important factor in achieving the correct diagnosis. Pain may become a factor if the tumor is located adjacent to a nerve or may even encircle a digital nerve. This is apparent with direct pressure to the area.

Upon radiographie or CT examination, the typical Lipoma has the "characteristic radiolucancy of mature fat", according to Enneking. MRI imaging is the most helpful study using a T-I weighting.

Treatment strategies vary. In asymptomatic cases with no pain, little or no growth, and no resultant loss of function, observation is acceptable. However, for the symptomatic patient, marginal excision is recommended. The tumor itself is well encapsulated and surrounded by a thin layer of areolar tissue, which allows it to be "shelled out". If it is complicated by its proximity to a nerve, then careful dissection is warranted. Recurrence of excised Lipomas is rare. A malignant degeneration into a liposarcoma is very rare, although it has been reported.

Lipofribromatosis is a rare pediatric tumor and likely a subtype of infantile or juvenile fibromatosis. Fetsch, et al, presented a series of 45 cases in the year 2000. Eighteen of these cases (40%) presented as hand masses and the histology study revealed a greater than 70% fatty tissue in 35 of 45 cases.

These tumors are poorly marginated (unlike Lipomas) and unfortunately have a high recurrence rate after marginal resection. The follow up study of 25 patients revealed that 72% had recurrence. Complete excision is recommended due to this high rate of return. Congenital onset, male gender, tumor location in the hand or foot, incomplete excision, and miotic activity are all factors identified in recurrence. Evidence of metastatic spread has not been reported.

Angiolipoma is "another breed of cat", according to Enneking. These are composed of mature lipocytes mixed with endothelium lined vascular sinuses. They are presented as a 'painful lump' and the symptoms warrant surgical attention. This tumor is poorly encapsulated and thus not as easily removed as a Lipoma and may require excision of adjacent normal tissue and neurovascular structures. Malignant transformation of this tumor has not been reported.

The rare Lipoblastoma is a benign tumor found most often in the extremities of children under the age of seven. This is usually brought to the attention of the physician by the parent, as it is most commonly a painless mass. Histologically, this tumor is subdivided into lobules of adipose cells in various stages of maturation. Fibrous setae separate these lobules. These findings were reported by Collins and Chattan in a study of 25 cases on 24 children and found 11 of the tumors to arise in the extremities and four in the hand. Chung and Enzinger reported similar findings on a group of 35 excised tumors. After local resection of 25 tumors, two recurrences were noted. One was from excision on the neck, and the other was from the popliteal region of the knee, for a 9% return rate. Complete excision is recommended. No metastatic progression was found.

Lipofibroma and lipofibromatous hamartoma are rare tumors associated with peripheral nerves. In the hand, embedded in the median or digital nerves, they have been reported in the ulnar, radial and plantar nerves. It is considered a hamartoma because both fat and fibrous tissues are normal components of nerves. It is a slow growing mass and due to its intimate proximity to neural tissue, pain and weakness are its hallmarks. Surgical intervention may be decompression of the nerve segment or require sacrifice of part or all of the nerve itself. Biopsy is recommended of excised tissue to confirm tissue diagnosis.

Benign tumors of fibrous tissue origin: Benign tumors of fibrous origin are a spectrum of tissue masses in their own right. These may include: nodular fasciitis, neurofibroma, schwannoma, fibrous histiocytoma, and fibromatosis. Purely fibrous lesions include; Dupuytren's cords and nodules, nodular fasciitis, Desmoid tumors and fibroma of the tendon sheath.

Dupuytren's knuckle pads and palmar nodules can be mistaken for other nodules. This makes the correct diagnostic process more critical. The knuckle pads are often considered the sentinels of the contraction of the palmar fascia. These occur in males between the ages of 25-40 with a family history of the disease. Juvenile onset has also been noted.

Desmoid tumor: (juvenile) aggressive fibromatosis can occur anywhere in the body. Aggressive fibromatosis arises from the connective tissue or muscle with an average onset age in the thirties. Onset age range is one month to 77 years affecting males and females equally. Pain is seldom a factor with this tumor. It is found in the upper extremity and shoulder girdle less than 30% and approximately 5% in the hand. It is actually benign, but can have an aggressive appearance. It has been found in the bone and can cause fracture. This has a high rate of recurrence and has been found to be as much as 73% within three months. Its size can be 1-27 cm, with an average of 5 cm. Tumors of 4 cm in size found in patients younger than 31 years old generally indicate a high recurrence rate.

The microscopic appearance is of a well-differentiated fibroblast interlaced with collagen bundles with varying cellularity. Usually there is no capsule and the fibroblasts infiltrate the surrounding tissue. This picture makes it difficult to differentiate between a Desmoid tumor and a grade I fibrosarcoma. Treatment is that of a wide local excision. Recurrence may be as high as 90% with incomplete excision. Radiation therapy may begin within a few months of surgery.

Fibroma of the tendon sheath comprises about 3% of hand tumors. Most occur during the fourth decade of life but have been reported from ages three to 68. Men are affected more frequently with a ratio of 1.5 to 2:1. There does not appear to be a racial factor. They are slow-growing and painless unless direct contact is made. They may go undetected for years. These do not transluminate well and thus an early diagnosis may be difficult. Fibromas may be as small as 7 mm but have been reported to encompass an entire digit. They are typically 1.5 to 2 cm and arise from the tendon sheath itself. Macroscopically, they are encapsulated, nodular, multinodular or even lobulated. They are usually smooth and firm but may appear granular and irregular. Color also varies from white, gray-white, tan and uniform or heterogeneous. They rarely involve bone, but they have been reported in approximately 1% of cases, as with involvement in the carpal tunnel. Microscopically, a fibrous pseudocapsule surrounds them. A configuration of dense fibrous tissue stroma with intercellular collagen makes up hypercellular areas. Other areas are paucicellular and may have a matrix that is collagenous, myxoid, fibromyxoid or mucinous. Histological features may overlap with nodular fasciitis except that fibromas are well circumscribed and may have blood vessels. Treatment is excision and the largest series reports a 24% recurrence rate. This report however does not equate recurrence to type of resec\tion. Recurrence usually occurred within 4 months. Several cases were referred to in which excision was marginal, but no incidence of recurrence was reported with these.

Nodular fasciitis is most commonly found in the subcutaneous fascia of the upper extremity, but can be found anywhere in the body. It is referred to in the literature by several monikers: parosteal fasciitis, psudosarcomatous fasciitis, subcutaneous fibromatosis, nodular fibrositis, and proliferative fasciitis. The demographics are similar to Fibroma of the tendon sheath. Diagnosed in children as young as six months and adults of 79 years. The more typical age is between 20-50 years with the average in the third decade. Half to two-thirds are male and half of all lesions are in the upper extremity. This affects the hand at a low incidence of 2%. This is a fast growing lesion and is typically present only two months before excision. Size averages 2 cm but may be as large as 4 cm or small as .5 cm. It may have multiple nodules and is usually free and non-tender. Although not directly connected to a trauma, one study reported a 4% incidence. Occasionally there is eosinophilia is present and MRI studies with T-2 weighted images show increase signal activity when compared with muscle on T-I weighted images. Macroscopically they have a similar appearance to other fibrous tumors. However, the cut surface demonstrates an irregular, coarse trabecular pattern, which may be closely associated with fascia or may occur in muscle but is usually found in the subcutaneous tissue. With magnification, it is even more diverse. The hypo and hypercellular areas more extreme and there may be multinucleated cells. It may exhibit bizarre spindle cells and fibrous areas may be found intermixed with fat, muscle and the myoxmatous stroma of the tumor itself. Four histological subtypes are identified: reactive, densely cellular, proliferative and osteoid/ cartilaginous. Treatment is excision and even with its aggressive growth pattern, there were no recurrences reported. Any suspected recurrences were reevaluated and discovered to be a different tumor type, leading the authors to caution reexamination of the pathological specimens.

TIM MCPHERSON, OTR/L, CHT

Copyright Hanley & Belfus, Inc. Jan-Mar 2005

Source: Journal of Hand Therapy

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