Benign Bony and Soft Tissue Tumors of the Hand

Benign Bony and Soft Tissue Tumors of the Hand

CURRENT CONCEPTS Benign Bony and Soft Tissue Tumors of the Hand William T. Payne, MD, Greg Merrell, MD ENIGN TUMORS OF the hand are commonly seen in...

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CURRENT CONCEPTS

Benign Bony and Soft Tissue Tumors of the Hand William T. Payne, MD, Greg Merrell, MD

ENIGN TUMORS OF the hand are commonly seen in everyday hand surgery practice. It is important to be familiar with the wide variety of tumors that may present in clinics so that appropriate treatment may be delivered. Unfortunately, many of the treatment recommendations for these lesions are based on retrospective studies and case reports involving small series. Other recommendations are based on experience with similar lesions elsewhere in the body and may not be fully applicable to the hand and upper extremity. A thorough history, physical examination, and baseline plain x-rays are the foundation of accurate diagnosis. Many benign tumors have characteristics that enable the clinician to arrive at a diagnosis without biopsy. Certain lesions with a characteristic appearance and benign features may be managed nonsurgically with observation alone. However, vigilance in monitoring for signs of malignancy is encouraged, even for seemingly benign tumors. Signs of malignancy, such as rapid growth, increasing pain, or other atypical features, mandate a thorough workup, and surgical management should be considered. Generally, if a malignant diagnosis is suspected, the biopsy and definitive surgical excision should be performed by the same surgeon with experience in the management of these lesions.

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From the University of Colorado Denver, Aurora, CO; and Indiana Hand Center, Indianapolis, IN. Received for publication July 11, 2010; accepted in revised form August 16, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Greg Merrell, MD, Indiana Hand Center, 8501 Harcourt Road, Indianapolis, IN 46260; e-mail: [email protected] 0363-5023/10/35A11-0032$36.00/0 doi:10.1016/j.jhsa.2010.08.015

BENIGN BONE TUMORS Osteoid osteoma Osteoid osteoma of the hand and wrist is relatively uncommon. The usual presentation is pain, swelling, and local tenderness. Pain occurs more often at night and is characteristically relieved with aspirin. These lesions may occur in the phalanges, carpals, metacarpals, and distal radius. X-rays will sometimes demonstrate osteoid osteoma as a small radiolucent lesion in the bone. Computed tomography reconstructions will demonstrate the presence of the pathognomonic central nidus of bone (Fig. 1). Nonsurgical management of osteoid osteoma involves the use of aspirin for pain management. Over time, the lesion may “burn out” and pain symptoms can resolve. This process may take several years to occur. Radiofrequency ablation has gained widespread acceptance in the treatment of these lesions elsewhere in the body. Soong et al.1 reviewed radiofrequency ablation in the upper extremities of 25 patients. Although this study did not include lesions distal to the forearm, at minimum 1-year follow-up, 19 treatments were rated completely successful, 4 were partially successful, and 2 treatments failed. The 2 failures were attributed to insufficient treatment duration or temperature secondary to proximity to neurovascular structures. Because radiofrequency ablation requires a safe margin of distance from neurovascular structures to prevent iatrogenic thermal damage, use in the hand is not as widespread. Isolated case reports using radiofrequency ablation in the hand reveal mixed results, leading to safety concerns with use in the small bones of the hand.2,3 Surgical management of these lesions involves exci-

©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1901

Current Concepts

It is important to be familiar with the wide variety of benign tumors that may present in everyday hand surgery practice. The treatment of many of these tumors in the hand is based on studies with small numbers of patients or the treatment of similar lesions elsewhere in the body. The purpose of this review is to summarize the recent literature relevant to benign bony and soft tissue tumors in the hand. (J Hand Surg 2010;35A:1901–1910. © 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Benign, tumor, hand, lesion.

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FIGURE 1: A Osteoid osteoma of the distal radius. Note the cortical thickening and the central nidus of bone on this axial image. B Osteoid osteoma of the middle phalanx. Again, cortical thickening is present, but the central nidus is smaller and less welldefined. MRIs courtesy of the Center for Diagnostic Imaging, Inc., Indianapolis, IN.

sion of the central nidus. This is usually curative. At mean follow-up of 4 years, 17 of 18 patients were recurrence-free following either en-bloc resection or curettage of histologically confirmed lesions in the hand and wrist.4 Occasionally, bone grafting may be necessary to address any bony defect that remains. Unicameral bone cyst Simple cysts are rare in the hand. They often are discovered as an incidental finding on x-rays of the hand for other conditions. Treatment options vary and include observation or curettage and bone grafting.

Current Concepts

Aneurysmal bone cyst Aneurysmal bone cysts are benign tumors that are locally aggressive. They have a tendency for recurrence, particularly in younger patients with open physes.5 In the hand, lesions present as a slowly enlarging mass or swelling that is sometimes painful. Most commonly, the lesions are seen in the metacarpals, but they may be present anywhere in the hand. Recent case reports describe this tumor in the index sesamoid and trapezium, both treated with resection of the affected bone.6,7 Radiographs demonstrate a lytic lesion located centrally within the bone. The lesion is commonly metaphyseal or epiphyseal in location, and may be adjacent to the physis in skeletally immature patients. The lesion is expansile and may or may not have a sclerotic margin. In larger lesions, magnetic resonance imaging (MRI) will demonstrate fluid-fluid levels consistent with the diagnosis of aneurysmal bone cyst. Treatment of these lesions is challenging. There is a

high tendency for recurrence, and patients should be so advised. In the hand, only small series have been described, making a definitive recommendation difficult. Curettage and bone grafting is the standard treatment, but recurrence still may occur. A review of 6 cases of aneurysmal bone cysts in the hand showed a good outcome with curettage with or without bone graft. The authors suggest that more aggressive treatments be reserved for articular involvement, full bone invasion, or more than one case of recurrence.8 Adjuvant treatments such as high-speed burring or cryotherapy may be technically difficult to apply in the small bones of the hand.9 Cryotherapy has been described for a recurrent aneurismal bone cyst of the phalanx with success in a single case report, but this has not been studied sufficiently to make a strong recommendation.10 Despite aggressive surgical treatment, amputation is sometimes necessary in order to achieve local control. Giant cell tumor of bone Giant cell tumor of bone is a benign tumor that can metastasize. In the upper extremity, it is commonly encountered in the distal radial metaphysis. It is rarely found in the hand. Patients typically present in the third decade with swelling and pain in the area of the lesion. Radiographically, the lesion is radiolucent, expansile, and located in the metaphysis or epiphysis of the bone. Cortical thinning is often present. Because of the possibility of lung metastasis, a computed tomography scan of the chest should be performed at the time of diagnosis.

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implant, and nonvascularized fibula grafting resulted in eradication of the lesion. The authors favor an aggressive approach to the treatment of these lesions in the digits of the hand, with complete excision versus amputation early to prevent recurrence. Because of the risk of recurrence and also the risk of metastasis, continued postoperative monitoring is necessary after treatment of these lesions. CARTILAGINOUS TUMORS Osteochondroma Osteochondromas are tumors that form with a cartilage cap that allows for continued growth away from the bone. The origin of these tumors is believed to be secondary to defect within the periosteum of carpals. They present as a bony prominence that may cause local pain due to irritation of adjacent structures. Osteochondromas have been implicated in tendon snapping, irritation, and rupture.16,17 They are relatively uncommon in the hand. Although rare in the hand, osteochondromas may be found within the phalanges, metacarpals, or carpals. Isolated case reports cite the scaphoid as the most common location in the carpus. Recently, a multilobed osteochondroma of the hamate was described.18 The radiographic appearance of osteochondromas is that of a bony exostosis. Pathological analysis of the lesions shows the presence of a cartilage cap with benign-appearing cartilage that resembles the normal epiphysis. Management of these lesions involves observation versus surgical excision (Fig. 3). Surgical excision of the lesion is generally curative. Enchondroma Enchondroma represents the most common primary tumor of bone in the hand.19 The lesion is most often discovered when a patient presents with a pathologic fracture that occurs secondary to cortical thinning caused by the lesion (Fig. 4). The radiographic appearance of enchondroma is a central, well-circumscribed, radiolucent lesion with or without punctate calcifications. Pathologic fracture occurs as a result of the cortical thinning seen with this lesion. The histological appearance of enchondromas reveals lamellar bone with hyaline cartilage and matrix calcification.20 Often, lesions of the hand have characteristics of chondrosarcoma, having increased cellular atypia when compared with enchondromas elsewhere in the body. It is therefore important to denote that the specimen is from the hand to assist the pathologist in making the proper diagnosis.

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The radiographic classification of giant cell tumor was described by Campanacci et al.11 Grade I lesions are well marginated, with intact cortex that may be thinned but not deformed. Grade II lesions are also well defined, but thinned expanded cortex is present. Grade III lesions have fuzzy borders, bulging into soft tissues, and lack a shell of reactive bone. There is debate regarding the most appropriate treatment of lesions in the distal radius. Treatment depends on the stage of disease. At a minimum, curettage of the lesion is necessary. Various options for adjuvant treatment have been suggested, including high-speed burr, cryotherapy, bone grafting, cementation, and en-bloc excision with allograft reconstruction. In general, treatment should aim to remove as much of the pathologic tissue as possible. Attempts should be made to preserve the articular surface of the radius if possible. In a retrospective review, Harness et al.12 showed a statistically significant increased recurrence rate for Campanacci stage 3 patients treated with curettage and cementation versus those treated with resection and allograft (100% vs 17%, respectively). In Campanacci stage 3 lesions, resection with reconstruction may be necessary (Fig. 2). Various options exist in the reconstruction of the defect. Recently, Szabo et al.13 described their results of allograft reconstruction with Sauvé-Kapandji procedure. At average 7-year follow-up, 9 patients had no recurrence of tumor, metastasis, or nonunion. Others have described free fibula grafting and/or total wrist arthrodesis in the treatment of advanced disease. Giant cell tumor of the hand is unique because it is rarely encountered, and treatment guidelines are based on limited data. Experience from small series suggests recalcitrance of the tumor to isolated curettage and bone graft. Aggressive treatment such as wide excision or amputation should be considered when giant cell tumor of bone is encountered in the hand. Shigematsu et al.14 performed a review of all cases of giant cell tumors of the carpus in the literature. The authors identified 29 giant cell tumors of the carpus, with the hamate being the most common location. In this study, recurrence was noted in 24% of patients undergoing intralesional procedures. For cases of carpal giant cell tumor, they suggest complete excision of the lesion. Ropars et al.15 reviewed cases of giant cell tumor of the digital bones of the hand. In this small study of 4 cases, amputation was performed in 3 grade 3 phalangeal lesions and intralesional curettage was performed in 1 grade 2 metacarpal lesion. Recurrence was observed in the metacarpal and resection with Silastic

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FIGURE 2: A 24-year-old woman with a recurrent giant cell tumor. B The tumor was previously treated with curettage and cementation on 2 previous occasions but recurred. C Note the cortical erosion indicative of soft tissue invasion. D, E The patient was treated with resection of the distal radius with allograft reconstruction and Sauvé-Kapandji arthrodesis of the DRUJ using the technique described by Szabo et al.13 F, G Ten months after surgery, good overall alignment is seen with no evidence of recurrence. Wrist range of motion of 5° extension, 40° flexion, 60° supination, and 45° pronation were obtained.

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Treatment of enchondroma depends on the presence or absence of fracture. If a fracture is present, it is generally recommended to manage the fracture as appropriate. Once the fracture has healed, curettage and bone grafting of the lesion may be performed. It is important to remember to use different instruments to harvest autograft to prevent seeding of tumor cells into the graft harvest site. Recently, Yasuda et al.21 described their technique for treatment of enchondroma of the hand with injectable calcium phosphate bone cement. In 10 patients, incorporation of the cement occurred at an average of 4.5 months. No recurrence was seen at a mean follow-up of 41 months. One patient required reoperation for malunion. This patient is the only one who had acute fracture fixation at the same time as injection of the calcium phosphate cement. The authors recommended use of calcium phosphate cement for healed fractures or enchondroma without fracture because osteotomy through the calcium phosphate cement was difficult.

A recent study by Gaulke et al.19 reviewed 21 patients who underwent surgical treatment. Twenty of the 21 patients had cancellous bone grafting for solitary enchondroma of the hand. At mean 9-year follow-up, normal-appearing bone was identified radiographically in 11 cases and recurrence in 3 cases. Seven patients had indeterminate radiographs that could not rule out recurrent enchondroma. Periodical radiological re-examination is recommended by the authors to assess for recurrence. It is important to educate patients preoperatively that tumor recurrence may be seen, necessitating further surgery. Periosteal chondroma (juxtacortical chondroma) Periosteal chondromas are rare in the hand. These lesions often present as a painless mass, and radiographs typically show a surface lesion of the bone with scalloping of the cortex. The lesion is not continuous with the cortex of the underlying bone. There is a calcified appearance within the scalloped area. An MRI shows

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FIGURE 3: A, B X-rays of osteochondroma of the proximal phalanx. The lesion was causing discomfort and was excised. C Image of the lesion in situ following Bruner approach to the mass. D Gross image of the lesion after excision.

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FIGURE 4: A, B Enchondroma of the phalanx presenting as a pathological fracture. Note the cortical thinning associated with the lesion.

Current Concepts

features of an extramedullary cartilaginous tumor with low T1 and high T2 signal.22,23 The histopathologic appearance of periosteal chondromas is that of lobulated hyaline cartilage. They are more cellular than enchondromas, and occasional calcification may be observed.24 –26 Treatment guidelines for this tumor in the hand are based on small series and case write-ups. Takada et al.26 reviewed the literature regarding this tumor and reported on a series of 5 patients. In 5 patients, one had recurrence. This patient did not have excision of the underlying cortical bone. The authors recommend resection of the underlying cortex to prevent recurrence of the lesion.

to be separate from the medullary canal of the bone. The lesion has similar MRI characteristics to periosteal chondroma, with low T1 signal and high T2 signal.27 Flint and McKay28 recently compared the distinguishing characteristics of BPOP and periosteal chondroma. A BPOP is characterized by a lesion with cartilage cap. Bizarre-appearing chondrocytes and hypercellularity are present. A zone of endochondral ossification is present in the cap.28 Surgical excision is the generally recommended treatment for this lesion (Fig. 5); BPOP is associated with a high risk of recurrence. Michelsen et al.29 recommend excision of the underlying periosteum to decrease risk of recurrence.

Benign parosteal osteochondromatous proliferation (Nora’s tumor) Benign parosteal osteochondromatous proliferation (BPOP) is a benign lesion that is found in the hands and feet. It can often appear with a presentation similar to periosteal chondroma. The lesion is often associated with a traumatic injury to the hand. A BPOP is a surface lesion found on the surface of long bones of the hand. Unlike periosteal chondromas, cortical scalloping is usually absent on plain radiographs. Magnetic resonance imaging shows the lesion

Chondromyxoid fibroma Chondromyxoid fibroma is a tumor of long bones that is rarely encountered in the hand. Clinically, patients present with pain. Radiographs will demonstrate a radiolucent eccentric metaphyseal lesion. Because these tumors are rare in the hand, treatment recommendations are based on small numbers of cases. In general, curettage and bone grafting are the appropriate treatment.30 Recently, a case of proliferative chondromyxoid fibroma occupying the entire metacarpal was described. The authors of the report describe treatment of the

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FIGURE 5: A Patient presented with a large mass in the digit. B Excision of the large mass using a Bruner approach yielded a BPOP lesion.

lesion with curettage and cancellous allograft implantation. At one year, no recurrence was witnessed.31 FAT/CONNECTIVE TISSUE Lipoma Lipomas are benign tumors of fatty tissue. In the hand, they may appear anywhere, can occasionally become quite large (Fig. 6A), and have been described as a rare cause of carpal tunnel syndrome.32 They present as a

painless mass that is slow growing. They are most often noted in the subcutaneous tissue of the arm. On plain radiographs, lipomas may demonstrate the so-called Bufalini sign. This is a relatively radiolucent area within tissue and signifies rarefaction of the tissue via fatty tumor presence. An MRI characteristically shows a well-circumscribed mass that mirrors the appearance of the normal mature fat on both T1 and T2 images. Pathologic appearance of lipomas is consistent

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FIGURE 6: A Patient presented with a large mass in the first web space. B Exposure of large lipoma. C Gross photo of large lipoma. Note the encapsulated appearance of the lesion, which was easily dissected from the first web space.

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FIGURE 7: A Close-up image of schwannoma along the course of a digital nerve. Note the draping of fascicles over the lesion. B After dissection of the fascicles away from the lesion, it is excised. C, D The MRIs of a different case show characteristic location and signal characteristics. MRIs courtesy of Proscan Imaging, Inc., Indianapolis, IN.

with mature fat macroscopically and microscopically (Fig. 6B). Treatment of lipomas in the upper extremity involves observation or surgical excision. Marginal excision is appropriate for these lesions, and recurrence is rare. Typically, the lesion is easily dissected from surrounding tissues.

Current Concepts

Giant cell tumor of tendon sheath Giant cell tumor of tendon sheath has been referred to by a litany of historic names over the years. It is very common in the hand and wrist. The tumor presents as a soft tissue mass beneath the skin. It is usually not tender to palpation. Radiographs will demonstrate no specific findings. Ultrasound is shown to be useful in distinguishing giant cell tumor of tendon sheath from ganglion cysts.33 Giant cell tumor of tendon sheath has a histological appearance similar to that of pigmented villonodular synovitis. Treatment of giant cell tumors involves surgical excision. Recurrence rates tend to be high, with variable rates reported by different authors. A recent prospective study of 213 cases showed 27 recurrences (13%) at a minimum 3-year follow-up. Of those recurrent tumors,

those involving the extensor tendon, flexor tendon, or joint capsule had the highest risk of recurrence.34 Close monitoring and/or adjuvant treatment is recommended for tumors involving these structures by the authors. NERVE Schwannoma Schwannoma represents a benign proliferation of schwann cells. These lesions often present as soft tissue masses along the course of a peripheral nerve. Radiographs will be normal. Pathological specimens will demonstrate the classic Antoni A and Antoni B histological appearance. The Antoni A pattern is an organized pattern of tumor cells in a stacked arrangement or storiform pattern. Antoni B patterns are interspersed between Antoni A areas and are generally disorganized or myxoid in appearance. Treatment of Schwannoma involves observation or surgical excision. Generally, these lesions will easily “shell out” away from the nerve with minimal dissection (Fig. 7). By definition they do not intertwine with the nerve fascicles, in stark contrast to neurofibromas,

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FIGURE 8: A glomus tumor presented beneath the nail of this 51-year-old female patient. She had been experiencing cold intolerance for several years. B X-ray images show no obvious findings. C Transungual approach to the lesion, which was easily shelled out from beneath the nail bed.

Neurofibroma Neurofibromas are commonly seen in association with neurofibromatosis. They can involve any peripheral nerves and may be multifocal. Radiographs generally are normal or show soft tissue density. An MRI may be useful in demonstrating deep lesions. Surgical treatment of neurofibromatosis depends on the location. These tumors are frequently extensively intertwined in the surrounding nerve fascicles, making surgical excision difficult if not impossible without damaging the nerve. Cutaneous lesions may be excised, and sacrifice of the peripheral nerve may be necessary. Deeper lesions, and in particular those involving motor nerves, may need to be treated differently. Options for lesions in important nerve structures include excision with nerve grafting. VASCULAR Glomus tumor The glomus tumor is a benign proliferation of cells from a glomus body. The glomus body is involved in regulation of vascular flow for temperature control at the fingertip and elsewhere in the body. Classically, glomus tumors present as a subungual mass in the fingertip.35 Patients describe hypersensitivity to cold temperatures. Occasionally, bluish discoloration may be present beneath the nail. Radiographs typically are normal or may demonstrate scalloping of the dorsal bone of the distal phalanx where the tumor lies. An MRI can show the tumors, but its routine use has been questioned by at least one study.36

Surgical excision is the treatment of choice for patients presenting with glomus tumor (Fig. 8). A transungual approach is described that allows for complete excision of the tumor. In 17 patients undergoing a transungual approach, Lee et al.37 reported no recurrence and no nail deformity at an average 10-month follow-up. Recurrence of glomus tumor has been studied. Gandhi et al.38 reviewed recurrence in a series of 12 surgically treated cases. A total of 5 cases of recurrence were present. All tumors presented in new separate locations. Based on this, the authors recommend thorough examination for satellite lesions at surgery to prevent local recurrence. A wide variety of tumors may present within the hand and upper extremity. It is important to be familiar with the presentation, diagnosis, and treatment of each. Some of these lesions are very common, whereas others are rarely observed. Unfortunately, there are limited data to guide treatment of the less common benign tumors. Despite this, understanding the characteristics of different benign tumors will allow the hand surgeon to manage patients in such a way that symptoms and recurrence will be minimized and function will be maximized. REFERENCES 1. Soong M, Jupiter J, Rosenthal D. Radiofrequency ablation of osteoid osteoma in the upper extremity. J Hand Surg 2006;31A:279 –283. 2. Ramos L, Santos JA, Santos G, Guiral J. Radiofrequency ablation in osteoid osteoma of the finger. J Hand Surg 2005;30A:798 – 802. 3. Harrod CC, Boykin RE, Jupiter JB. Pain and swelling after radiofrequency treatment of proximal phalanx osteoid osteoma: case report. J Hand Surg 2010;35A:990 –994. 4. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg 2002;27B:440 – 443. 5. Gibbs CP Jr, Hefele MC, Peabody TD, Montag AG, Aithal V, Simon

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and therefore the nerve may be spared with surgical excision. Recurrence of these tumors is rare.

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MA. Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg 1999;81B:1671–1678. Havulinna J, Parkkinen J, Laitinen M. Aneurysmal bone cyst of the index sesamoid. J Hand Surg 2005;30B:1091–1093. Tuzuner T, Subasi M, Alper M. The trapezium: a new location for an aneurysmal bone cyst. J Hand Surg 2006;31B:347–348. Epub 2006 Jan 27. Ropars M, Kaila R, Briggs T, Cannon S. Aneurysmal bone cysts of the metacarpals and phalanges of the hand. A 6 case series and literature review. Chir Main 2007;26:214 –217. Athanasian EA. Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clin 2004;20:269 –281, vi. Athanasian EA, McCormack RR. Recurrent aneurysmal bone cyst of the proximal phalanx treated with cryosurgery: a case report. J Hand Surg 1999;24A:405– 412. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J. Bone Joint Surg 1987;69A:106 –114. Harness NG, Mankin HJ. Giant-cell tumor of the distal forearm. J Hand Surg 2004;29A:188 –193. Szabo RM, Anderson KA, Chen JL. Functional outcome of en bloc excision and osteoarticular allograft replacement with the SauveKapandji procedure for Campanacci grade 3 giant-cell tumor of the distal radius. J Hand Surg 2006;31A:1340 –1348. Shigematsu K, Kobata Y, Yajima H, Kawamura K, Maegawa N, Takakura Y. Giant-cell tumors of the carpus. J Hand Surg 2006;31A: 1214 –1219. Ropars M, Kaila R, Cannon SR, Briggs TW. Primary giant cell tumours of the digital bones of the hand. J Hand Surg 2007;32E: 160 –164. Shah NR, Wilczynski M, Gelberman R. Osteochondroma of the capitate causing rupture of the extensor digiti minimi: case report. J Hand Surg 2009;34A:46 – 48. Takagi T, Matsumura T, Shiraishi T. Lunate osteochondroma: a case report. J Hand Surg 2005;30A:693– 695. Koti M, Honakeri SP, Thomas A. A multilobed osteochondroma of the hamate: case report. J Hand Surg 2009;34A:1515–1517. Gaulke R, Suppelna G. Solitary enchondroma at the hand. Long-term follow-up study after operative treatment. J Hand Surg 2004;29B: 64 – 66. O’Connor MI, Bancroft LW. Benign and malignant cartilage tumors of the hand. Hand Clin 2004;20:317–323, vi. Yasuda M, Masada K, Takeuchi E. Treatment of enchondroma of the hand with injectable calcium phosphate bone cement. J Hand Surg 2006;31A:98 –102. Varma DG, Kumar R, Carrasco CH, Guo SQ, Richli WR. MR imaging of periosteal chondroma. J Comput Assist Tomogr 1991; 15:1008 –1010.

23. Woertler K, Blasius S, Brinkschmidt C, Hillmann A, Link TM, Heindel W. Periosteal chondroma: MR characteristics. J Comput Assist Tomogr 2001;25:425– 430. 24. Bauer TW, Dorfman HD, Latham JT Jr. Periosteal chondroma. A clinicopathologic study of 23 cases. Am J Surg Pathol 1982;6:631– 637. 25. Baumhoer D, Jundt G. Tumours of the hand: a review on histology of bone malignancies. J Hand Surg 2010;35E:354 –361. 26. Takada A, Nishida J, Akasaka T, Shiraishi H, Furumachi K, Tajima K, et al. Juxtacortical chondroma of the hand: treatment by resection of the tumour and the adjacent bone cortex. J Hand Surg 2005;30B: 401– 405. 27. Orui H, Ishikawa A, Tsuchiya T, Ogino T. Magnetic resonance imaging characteristics of bizarre parosteal osteochondromatous proliferation of the hand: a case report. J Hand Surg 2002;27A:1104 – 1108. 28. Flint JH, McKay PL. Bizarre parosteal osteochondromatous proliferation and periosteal chondroma: a comparative report and review of the literature. J Hand Surg 2007;32A:893– 898. 29. Michelsen H, Abramovici L, Steiner G, Posner MA. Bizarre parosteal osteochondromatous proliferation (Nora’s lesion) in the hand. J Hand Surg 2004;29A:520 –525. 30. Strauch RJ, Kleinman WB. Chondromyxoid fibroma of a metacarpal: a case report and review of the literature. J Hand Surg 1996; 21A:293–295. 31. Nalbantoglu U, Aktas S, Peker KR. Chondromyxoid fibroma involving the entire metacarpal: a case report. J Hand Surg 2005;30A: 1083–1086. 32. Babins DM, Lubahn JD. Palmar lipomas associated with compression of the median nerve. J Bone Joint Surg 1994;76A:1360 –1362. 33. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR Am J Roentgenol 2004;183:337–339. 34. Williams J, Hodari A, Janevski P, Siddiqui A. Recurrence of giant cell tumors in the hand: a prospective study. J Hand Surg 2010;35A: 451– 456. 35. McDermott EM, Weiss AP. Glomus tumors. J Hand Surg 2006;31A: 1397–1400. 36. Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Subhi F, ElShayeb AF. Magnetic resonance imaging in the diagnosis of glomus tumours of the hand. J Hand Surg 2005;30B:535–540. 37. Lee IJ, Park DH, Park MC, Pae NS. Subungual glomus tumours of the hand: diagnosis and outcome of the transungual approach. J Hand Surg 2009;34E:685– 688. 38. Gandhi J, Yang SS, Hurd J. The anatomic location of digital glomus tumor recurrences. J Hand Surg 2010;35A:986 –989.

ERRATUM

In the article by Marcoccio I, Vigasio A, which appeared in the September 2010 issue of the Journal (“Muscle-in-Vein Nerve Guide for Secondary Reconstruction in Digital Nerve Lesions,” Vol. 35A, No. 9, pp. 1418 –1426), the authors’ names printed incorrectly. Their correct names are Ignazio Marcoccio and Adolfo Vigasio. Current Concepts JHS 䉬 Vol A, November 