Subungual Exostosis Presenting as a Pyogenic Granuloma-like Lesion with Reactive Myofibroblastic Proliferation in Two Young Women.

Subungual exostosis (SE) is a well-recognised benign proliferation of the distal phalanx most often seen in young adults and affecting the big toe. Possible triggers include previous trauma and chronic irritation or infection. We describe two atypical cases of SE in two young women presenting with pyogenic granuloma-like lesions clinically. Diagnostic biopsies were performed to confirm the diagnosis and excluded amelanotic melanoma. However, histology unexpectedly revealed reactive myofibroblastic proliferations mimicking nodular fasciitis overlying the SE. Given the atypical clinical presentation, the diagnosis was initially missed or not considered in both patients. They highlight two important points; the first is that SEs may present with pyogenic granuloma-like lesions clinically and that histological analysis is then required to exclude malignancy, particularly amelanotic melanoma. Secondly, that the histology will show a reactive myofibroblastic proliferation and if the sample is relatively superficial and pathologists are not aware of this potential reaction pattern, the underlying diagnosis of SE may be missed.

Occupational Localized Cutaneous Argyria With Pseudo-Ochronosis in a Jeweler.

ABSTRACT: A case of localized argyria in a 36-year-old female jeweler is described who presented with 2 discrete and asymptomatic bluish-black pigmented macules on the pulp of her left middle finger. A skin biopsy from both lesions demonstrated deposition of brown/black pigmented granules along the basement membrane zone of eccrine glands, blood vessels, nerves, and the dermo-epidermal junction fully in keeping with silver deposition. In addition, there was yellow-brown deposition seen within the interstitial dermis mimicking an early form of ochronosis, so called "pseudo-ochronosis." This latter feature is rarely described in cases of argyria. Transmission electron microscopy and energy dispersive x-ray spectroscopy confirmed the presence of electron dense particles up to 150 nm in diameter and the presence of silver, respectively. On further questioning, the patient had a history of localized and chronic exposure to silver, which specifically involved holding and manipulating silver wires and rings over the left middle finger. This case highlights an unusual and rare presentation of localized argyria in a jeweler. In addition, our case showed preferential silver deposition on dermal elastic fibers which has not been previously described in the literature.

A rare case of a digital papillary carcinoma of the hand with secondary conservative management.

A digital papillary carcinoma (DPC) is a cancer of the sweat glands which develops on the digits of the hands and feet. With an incidence of 0.08 per 1 000 000 people/year, it is often initially misdiagnosed as a simple ganglion although it has a significant risk of metastasis. Histological analysis is beneficial in the formal diagnosis of DPCs. In this report, we present a rare case of DPC affecting the palm of the hand, rather than the more commonly reported DPC of the digits. We discuss the management strategy utilized in this case and the various prognostic considerations taken into account when deciding on an amputation versus local excision surgical approach. All cases of DPC require regular follow up imaging for early detection of recurrence or new metastases to maximize prognosis.

Lipomatous tumours of the hand and wrist A series of 25 cases and review of the literature.

UNLABELLED: consequently reports in the international literature are mainly of individual cases and small series. MATERIAL OF STUDY: This is a retrospective review of a series of 25 patients with lipomatous tumours of the hand and wrist treated between 2001 and 2009. All patients underwent clinical and radiological assessment and a marginal excisional biopsy. 23 lipomas, 1 fibrolipomatous hamartoma (FLH) and 1 well differentiated lipoma-like liposarcoma/atypical lipomatous tumour (WDLLL/ALT) were identified. CONCLUSION: Choosing the most appropriate investigations is mandatory for a correct diagnosis and planning. Ultrasound should always be considered as the first line investigation. MRI helps delineating the anatomy of the lesions and their relationships with the surrounding structures in the hand and wrist, enabling more accurate surgical planning. Histological examination of the excised specimen remains the gold standard for the formulation of the definitive diagnosis and should be performed in every case. KEY WORDS: Digits tumours, Fibrolipomatous hamartoma, Hand tumours, Lipoma, Lipoma-like liposarcoma, Wrist tumours.

Ultrasound-guided percutaneous release of the annular pulley in trigger digit.

The purpose of this study was to describe and evaluate a new technique for ultrasound-guided percutaneous release of the annular pulley in trigger digit using a modified hypodermic needle. A total of 35 ultrasound-guided percutaneous releases were performed on 25 patients diagnosed and referred by hand surgeons in our institution over 16 months from October 2006. Inclusion criteria were as follows: adulthood, triggering present for at least 4 months, failure to respond to conservative management or steroid injections, no previous history of pulley release in the affected digit. Under ultrasound guidance, the affected pulley was released using a standard 19-gauge hypodermic needle bent at two points as the cutting device. Follow-up took place at 12 weeks and 6 months with improvement in triggering and clinically graded pain. At follow-up, no complications had occurred and all patients demonstrated improvement in their triggering, with complete resolution in 32 digits (91%), good improvement in 2 digits (6%) and some improvement in 1 digit (3%). This new technique uses a widely available and safe cutting device and is safe and can be used to provide definitive management for trigger finger, allowing the procedure to be performed in a variety of clinical settings.

Atraumatic hand infection in an infant.

We report a rare case of atraumatic infection of the extensor tendon sheaths. Acute medical staff should be aware of the insidious nature of presentation of this condition, as early aggressive treatment is required to prevent tendon rupture. In this instance, an excellent functional outcome was achieved by surgical drainage and early tendon reconstruction.