Enchondroma of hand
What is Enchondroma of hand?
Enchondroma is a non-cancerous (benign) tumor of bone and develops most commonly in small bones of the hand. However, it can also grow in long bones of the body such as femur (thigh bone), tibia (shin bone) and humerus (arm bone). It usually grows as a solitary tumour, but it may grow as multiple tumors. It could be associated with Ollier’s disease or Maffucci syndrome. Its exact cause is not known. It is assumed that it happens due to cells transforming to cartilage from bone.
It affects both men and women equally in the age group 20- 50 years. It is most common bone tumor in the hand (60%). It affects femur (20%), humerus (10%) and tibia (10%). It accounts for 3-10 % all tumors of bone and 12-24% of all benign tumor of bone. When endochondroma becomes cancerous, it turns into a malignant cartilage tumor named as chondrosarcoma. However, it happens very rarely.
What are the symptoms of Enchondroma of hand?
Enchondromas are usually painless and don’t exhibit any symptoms. In most patients it’s an incidental finding when x-rays are done for other reasons (injury, arthritis) in hand. In some patients they grow, leading to thinning of bone that could lead to deformity and swelling. As this tumour could weaken the bone, some patients present with fracture (pathological) following minor injury.
How is it diagnosed?
It is diagnosed by your medical history, history of injury, physical examination and an X-ray. X-ray helps to determine the exact position of the lesion. CT scan/MRI scan is performed in selected patients to assess the lesion, joint surface and plan for surgery. Unlike most bone tumour, biopsy is not routinely performed for hand enchondroma, however in doubtful and symptomatic patient’s surgical curettage and bone grafting is performed.
What happens if nothing is done?
Most of the cases are skillfully neglected (monitored at regular intervals), however there is a risk that the tumor may grow, weaken the bone and cause fracture. Besides it is extremely uncommon for the tumor to turn to a malignant cancer.
How is it treated?
Management of Enchondroma depends on the location of lesion, size, joint involvement, pathological fracture and its stability. Majority of the lesions could be treated with skillful neglect and regular monitoring. Besides majority of the undisplaced/minimally displaced pathological fractures could be treated conservatively by closed reduction, immobilization by splint, application of ice packs, painkillers and hand therapy.
Surgery is indicated in
- Pathological fractures – unstable, joint involvement
- Large lesions
- Recurrent fractures
- Suspicion of Low-grade chondrosarcoma
- Patient preference
What are the non-operative treatments?
- Skillful neglect- your surgeon may suggest regular monitoring of the tumor to assess if it grows or not. If the tumor remains without symptoms, then there is no need for its removal. He will keep watch on the tumor by periodic x-rays or other tests.
What does the operation involve?
The main purpose of surgery is to remove the tumour, restore normal bone, stabilisation and early mobilization.
You are operated as a day case procedure under anesthesia; a cut is made on the affected part of the hand where the tumor is present. The operation can be done by two procedures-
- You are admitted to the hospital and the operation is usually performed as a day case.
- The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation, but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
- A tourniquet is tied around your upper arm or the base of finger to reduce blood loss during surgery.
- Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation. A cut is made over the affected skin,
Curettage- it is a surgical procedure in which the tumor is removed out of the bone by scrapping. The scrapings are sent for histopathology to confirm the diagnosis.
Grafting- after curettage, your surgeon will fill the gap with a bone graft in order to stabilize the bone. In this procedure, a healthy bone piece extracted from other part of the body (wrist or hip) is grafted on the affected part. To improve stability in some patients the surgeon fixes the bone with plate, pins or screws.
The skin is closed with an absorbable suture. The operation takes 1 hour and most patients are discharged on the same day.
The operation takes 1-2 hours to end. Most patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Your hand is rested in a half cast for 2 weeks to protect it from injury and allow proper healing.
- You should keep your arm elevated (above the level of your heart) most of the times as it prevents swelling. Besides keep moving your fingers, elbow and shoulder.
- Before discharge, your physiotherapist will teach you gentle exercises of the hand, wrist, elbow and shoulder that you can start soon after the operation from the first day.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and hand therapy.
- Following ORIF with plates and screw, usually the plaster is changed to splint and hand therapy commenced
- If the fracture is fixed with pins, that has to stay for 4 weeks and removed in the clinic after check x-rays
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You will be guided by your surgeon and hand therapists based on radiographic (X-ray) and clinical union of the fracture. In majority of the cases, you could start a gentle range of movement (ROM) exercises at 2 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around six weeks. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of the lesion, quality of bone and method of fixation.
Are there any risks?
- Stiffness in the finger
- Recurrence (2-15%)
- Persistent pain
- Pathological fractures
- Hardware complications- screw penetration into the joint, tendon irritation
- Injury to digital nerve and blood vessels
- Tendon injury
- Complex regional pain syndrome
- Transformation into malignant chondrosarcoma
What are the results of the operation?
Most patients regain full function and strength of the injured hand with fewer major complications (<1%). It is more predictable under the experiences of the author.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take 2- 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and you should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of the lesion and the treatment modality. Your physician will be able to advise you.
- Enchondroma affecting base of middle finger (Proximal phalanx) causing pathological fracture.
- Following curettage, bone graft and stabilization with plates and screws. Patient regained full function after surgery.