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resolved within 2 years. For this reason, observation is recommended initially for ganglion cysts in children.17-20 Giant-Cell Tumors of the Tendon Sheath Giant-cell tumors of the tendon sheath (GCTTS) are the next most common soft tissue tumors of the upper extremity, after ganglions. These benign tumors are known by a number of different names, including fibrous xanthoma, localized nodular tenosynovitis, and benign synovioma.4 They are commonly classified into nodular and diffuse varieties, with the diffuse type being closely related to pigmented villonodular synovitis (PVNS). There is a slight female predominance (3 to 2), and they most commonly occur in the fifth and sixth decades of life.21 Clinically, they manifest as a painless soft tissue mass, oftentimes having been present for many years. They can be found on either the dorsal or volar side of the hand or digit. Most commonly they are found on the volar aspect of the digit, at the level of the proximal phalanx (Fig. 24-9). As with ganglion cysts, they can uncommonly cause a local mass effect, compressing neurovascular structures to cause numbness or sensitivity distal to the lesion. Ward and coworkers22 reported one case of GCTTS manifesting as acute carpal tunnel syndrome. Similarly, longstanding tumors can cause erosion of adjacent bone, which can be appreciated on plain radiographs. Histologic examination reveals that these lesions are very similar to PVNS. Foam cells with small nuclei and lipid-laden granules within the cytoplasm are characteristic. These cells are accompanied by brown deposits of hemosiderin.23 Treatment for GCTTS is surgical excision (Fig. 24-10). Meticulous technique is imperative in order to completely excise the mass. Identification of the neurovascular bundles in the digit proximal to the lesion is imperative prior to excision. For this reason, extensile incisions are utilized. The authors have operated on cases in which the digital nerve was found to be volar to the lesion and the artery either midsubstance or dorsal. Recurrence rates for these tumors is high—up to 50%4—but can be diminished with good technique. Gholve and colleagues24 examined the treatment of a pediatric population with GCTTS treated with surgical excision, and at 2-year follow-up there were no episodes of recurrence. They attributed their success to “meticulous dissection and excision” under loupe magnification. Surgical dissection may require evaluation of joint involvement, as GCTTS may extend intra-articularly and require arthrotomy for complete excision. Lipomas Lipomas are common soft tissue tumors composed of mature adipocytes. They are characterized by their soft consistency; however, in the hand they can take on a number of varied appearances. They are typically painless and often are not noticed until they reach a significant size. These tumors can arise from any place in which there is adipose tissue. Some hypothesize that they can be related to prior blunt trauma.25 They vary in size from quite large in the arm, to smaller lesions within the hand and finger. In the hand, they can be found in intramuscular locations within the intrinsic muscles.26,27 Babins and Lubahn28 and Vekris and associates29 reported palmar lipomas that caused compression of the median nerve, producing symptoms of carpal tunnel syndrome. Azuma and collaborators30 and Ersozlu and colleagues31 reported the cases of a subcutaneous lipoma of the resolved within 2 years. For this reason, observation is recommended initially for ganglion cysts in children.17-20 Giant-Cell Tumors of the Tendon Sheath Giant-cell tumors of the tendon sheath (GCTTS) are the next most common soft tissue tumors of the upper extremity, after ganglions. These benign tumors are known by a number of different names, including fibrous xanthoma, localized nodular tenosynovitis, and benign synovioma.4 They are commonly classified into nodular and diffuse varieties, with the diffuse type being closely related to pigmented villonodular synovitis (PVNS). There is a slight female predominance (3 to 2), and they most commonly occur in the fifth and sixth decades of life.21 Clinically, they manifest as a painless soft tissue mass, oftentimes having been present for many years. They can be found on either the dorsal or volar side of the hand or digit. Most commonly they are found on the volar aspect of the digit, at the level of the proximal phalanx (Fig. 24-9). As with ganglion cysts, they can uncommonly cause a local mass effect, compressing neurovascular structures to cause numbness or sensitivity distal to the lesion. Ward and coworkers22 reported one case of GCTTS manifesting as acute carpal tunnel syndrome. Similarly, longstanding tumors can cause erosion of adjacent bone, which can be appreciated on plain radiographs. Histologic examination reveals that these lesions are very similar to PVNS. Foam cells with small nuclei and lipid-laden granules within the cytoplasm are characteristic. These cells are accompanied by brown deposits of hemosiderin.23 Treatment for GCTTS is surgical excision (Fig. 24-10). Meticulous technique is imperative in order to completely excise the mass. Identification of the neurovascular bundles in the digit proximal to the lesion is imperative prior to excision. For this reason, extensile incisions are utilized. The authors have operated on cases in which the digital nerve was found to be volar to the lesion and the artery either midsubstance or dorsal. Recurrence rates for these tumors is high—up to 50%4—but can be diminished with good technique. Gholve and colleagues24 examined the treatment of a pediatric population with GCTTS treated with surgical excision, and at 2-year follow-up there were no episodes of recurrence. They attributed their success to “meticulous dissection and excision” under loupe magnification. Surgical dissection may require evaluation of joint involvement, as GCTTS may extend intra-articularly and require arthrotomy for complete excision. Lipomas Lipomas are common soft tissue tumors composed of mature adipocytes. They are characterized by their soft consistency; however, in the hand they can take on a number of varied appearances. They are typically painless and often are not noticed until they reach a significant size. These tumors can arise from any place in which there is adipose tissue. Some hypothesize that they can be related to prior blunt trauma.25 They vary in size from quite large in the arm, to smaller lesions within the hand and finger. In the hand, they can be found in intramuscular locations within the intrinsic muscles.26,27 Babins and Lubahn28 and Vekris and associates29 reported palmar lipomas that caused compression of the median nerve, producing symptoms of carpal tunnel syndrome. Azuma and collaborators30 and Ersozlu and colleagues31 reported the cases of a subcutaneous lipoma of the nail plate, and then repairing the nail bed after excision. Maxwell and coworkers36 noted that up to one quarter of patients have multiple lesions, and that wounds should be thoroughly explored at the time of surgery for additional tumors. He also noted that if symptoms persist for more than 3 months after initial excision, the wound should be reexplored to look for additional lesions. Pyogenic granuloma is another lesion characterized by abundant capillary proliferation. In contrast to the other vascular lesions, most believe that this lesion is secondary to trauma, with a subsequent superimposed infectious component. Clinically, these lesions appear as beefy red, friable masses that bleed (Fig. 24-12). These lesions do not tend to resolve spontaneously. Treatments with electrocautery, silver nitrate, and lasers have all been attempted with some success. The mainstay of treatment remains careful excision including a small cuff of normal tissue along with primary closure of the wound. Inclusion Cysts Inclusion cysts are common in the hand. They are thought to be the result of penetrating trauma. The traumatic event causes epithelial skin components to become lodged within the subcutaneous layer. Another theory is that embryonic cells that have been dormant are stimulated by trauma.37 The cells then proliferate in the subcutaneous layer and produce keratin, thus forming a tumor. Because this process can take many years to occur, the history of a definite traumatic event cannot always be elicited. These cysts are commonly found in manual laborers who subject their hands to light trauma more frequently. Usually, they are found on the volar surface of either the palm or the digits. Although they are most often solitary lesions, multiple lesions in the same hand have been reported.3 In addition to the subcutaneous tissues, these cysts can also be found within the flexor tendons or bony elements.38 The treatment for symptomatic inclusion cysts is surgical excision. These masses usually have a discrete wall filled with a foul-smelling, cheesy material. Histologically, the cell wall is composed of epithelial cells, and the cheesy material is composed of keratin. Excision should have the goal of removing the entire wall of the cyst, in addition to the cyst’s contents. Some recommend that an ellipse of skin be taken around the cyst to ensure complete excision. Goebel and associates3 emphasized the importance of everting the skin edges when closing the wound to decrease the chance of recurrence. When these lesions are found within a bone, the bone should be curetted back to a bleeding cancellous bed. In extreme cases bone erosion may be so severe as to require en bloc resection with reconstruction. Figure 24-13 demonstrates the authors’ case in which most of the distal phalanx was eroded by inclusion cyst. Reconstruction was performed with iliac crest bone grafting and nail plate preservation,