Metastatic Bone Disease: Forearm, Hand

Fig. 28.1
Preoperative (a) and postoperative (b) radiographs of a 61-year-old man with metastatic lung carcinoma to the proximal ulna with minimally displaced pathologic fracture . Treatment consisted of curettage with adjuvants followed by plate stabilization augmented with cementation

In the setting of oligometastatic disease , occasionally radical excision is warranted. Reconstructive modalities are limited in this location, and often necessitate the use of bulk allograft, free vascularized fibula, or custom endoprostheses. These techniques apply only on a case-by-case basis and should be reserved for those with reasonably good anticipated longevity due to the increased healing requirements and protracted recovery.

Amputation is sometimes a better alternative than limb-salvage. If amputation is pursued, it should be at a level that has the best likelihood to heal without reoperation, while preserving as much function as possible, bearing in mind that nearly all of these patients will choose not to become prosthetic wearers. For distal forearm metastases requiring amputation, a trans-radial amputation can heal predictably. For proximal forearm metastases, a long trans-humeral amputation is preferred to a through elbow amputation.

Surgical Management in the Carpus and Hand

In an extensive review of the literature, the median survival of patients with metastasis to the hand was 6 months [2]. Acrometastasis is generally a finding of late-stage, disseminated metastatic carcinoma [4]. This should be borne in mind when undergoing surgical decision-making to avoid extensive periods of recovery, or disability associated with postoperative protocol. When metastasis presents in the hand, and is symptomatic enough to justify surgical treatment, ablative surgery is usually preferred (Fig. 28.2). Particularly with involvement of the phalanges, interphalangeal amputation can effectively relieve pain, heal predictably, and preserve function. With proximal phalangeal or metacarpal involvement, a ray amputation can usually be accomplished with good preservation of function as well. Ray amputation is preferred to metacarpophalangeal amputation for both functional and cosmetic reasons. For metastasis involving the thumb, interphalangeal amputation has been shown to have a better functional outcome than metacarpophalangeal amputation [5].


Fig. 28.2
Radiograph of a 74-year-old man with metastatic lung carcinoma to the distal phalanx of the thumb. He was treated with interphalangeal amputation

Metastasis to the carpus is rare, but is reported, and it has been reported to be the initial presentation of malignancy [6]. In most cases surgical treatment will be limited to excision alone, or amputation . Arthrodesis should only be considered if a radical excision is to be performed and there is no plan for adjuvant radiation therapy, as radiation can have an inhibitory effect on fusion.

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Jun 4, 2017 | Posted by in ORTHOPEDIC | Comments Off on Metastatic Bone Disease: Forearm, Hand

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