Tumors and Tumor-like Lesions of the Pediatric Hand and Wrist: Clinical Presentation and Risk Factors for Malignancy.
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BACKGROUND: Malignant tumors of the pediatric hand and wrist are rare. We hypothesize that pain, large size, and palm/wrist location are risk factors for malignancy in children. METHODS: A retrospective review was conducted of patients younger than 18.9 years of age presenting to our institution with hand and wrist tumors or tumor-like lesions over a 15-year period. Patients with skin lesions, commonly encountered subcutaneous masses (lipomas, ganglion cysts, and sebaceous cysts), multiple hereditary exostoses, and Ollier disease were excluded. Data collection included demographics, clinical presentation, imaging features, and surgical management. Risk factors for malignancy were determined using receiver operating characteristic and descriptive statistical analysis. RESULTS: Three hundred twenty-seven tumors and tumor-like lesions were identified in 312 patients, with a mean age of 10.1 ± 4.6 years. Three hundred fifteen (96.3%) lesions were benign, and 12 (3.7%) lesions were malignant. The most common benign bone tumors were osteochondromas (75/160, 46.9%) and enchondromas (50/160, 31.3%), while the most common benign soft-tissue masses were vascular malformations (39/155, 25.2%) and giant cell tumors of the tendon sheath (30/155, 19.3%). The most common location was the digit. All malignant tumors (3 bone, 9 soft tissue) were in either the palm or wrist. Epithelioid sarcoma (4/9) and synovial sarcoma (2/9) were the most common soft-tissue malignancies, and osteosarcoma (3/3) was the only identified malignant bone tumor. Overall, the most common presenting complaints were swelling (63%) and pain (19.9%). Bivariate analysis found size >11.4 mm and palm/wrist location as risk factors for malignancy. Based on ROC analysis, age and pain ratings were poor predictors of malignancy. Among bone tumors, an aggressive zone of transition, periosteal reaction, and cortical destruction were significant radiographic risk factors for malignancy. CONCLUSIONS: The most common tumors and tumor-like conditions of the pediatric hand and wrist include osteochondromas, enchondromas, vascular malformations, and giant cell tumors of the tendon sheath. Larger tumors (>11.4 mm) and lesions found in the palm/wrist are more likely to represent malignancies and should be approached with caution. LEVEL OF EVIDENCE: Level III-therapeutic.