Nerve and Tendon-Origin Masses in Ankara, Turkey

Nerve- and tendon-origin masses are usually benign and slow-growing formations that develop from nerve or tendon structures in the hand and wrist region. One of the most common is schwannoma, a nerve sheath tumor. These masses may cause pain, numbness, or weakness.

Among tendon-origin masses, the giant cell tumor of the tendon sheath stands out. This tumor is commonly seen in the fingers and grows slowly. Nerve-origin lesions can affect nerve function and lead to motor or sensory symptoms. Early diagnosis prevents loss of function.

In the diagnostic process, physical examination, ultrasound, and magnetic resonance imaging (MRI) are important. Especially in masses related to nerves, a neurological examination should be performed and electrophysiological tests should be used if necessary. A biopsy may be required to confirm the diagnosis.

Treatment is usually surgical, and care is taken to preserve nerve or tendon structures. Microscopic dissection techniques are used during the operation. Postoperative physiotherapy is important for full functional recovery. Although the risk of recurrence is low, follow-up is recommended.

What Are Nerve- and Tendon-Origin Masses?

Nerve- and tendon-origin masses are generally benign soft tissue formations that develop from peripheral nerves or tendon tissues. The most common are schwannoma, neurofibroma, and giant cell tumors of the tendon sheath. These masses can cause pain, numbness, or limited movement. Diagnosis is made through physical examination and magnetic resonance imaging, and definitive diagnosis is often determined by pathological examination. Treatment is planned according to the type of mass and symptoms.

Why do masses seen in the extremities fall within the specialty of plastic surgery?

The distal parts of our body, namely the extremities, are an incredible engineering marvel. In a very narrow space, just beneath the skin, bones, the tendons that move them, the nerves that carry the command, and the vessels that supply the area intertwine. A millimetric error here can cause loss of sensation at the fingertip or inability to perform a movement.

Plastic surgery is fundamentally built on the principle of “respect for tissue.” When approaching a mass, we evaluate not only that mass but also the surrounding healthy tissue, the vascular network, and the nerve conduction pathways as a whole. Especially in conditions such as nerve sheath tumors or tendon adhesions, it is necessary to work under microscopic magnification. This precision both preserves function and speeds up the healing process. In addition, since our extremities are the limbs most visible in social life, hiding incisions along the natural skin lines and using aesthetic suturing techniques make the role of plastic surgery in this field indispensable.

How are nerve sheath tumors distinguished and what types are there?

Peripheral nerves are like electrical cables that carry commands from the brain to the muscles and transmit sensations from the skin to the brain. Around these cables there are protective sheaths and supporting cells. Nerve-origin masses usually arise from these supporting structures. Our patients generally present with swelling in their hands or arms that creates an electric shock sensation when pressed or causes numbness. The overwhelming majority of these masses are benign, but their biological behavior differs.

The benign tumor types we most commonly encounter in this group are:

• Schwannoma
• Neurofibroma

Schwannomas originate from nerve sheath cells (Schwann cells) and usually grow within a capsule attached to but separate from the nerve itself. You can think of this like the insulating plastic part of an electrical cable swelling without touching the copper wires inside. This structural feature is a major advantage surgically, because with microscopic techniques the tumor can be “peeled out” without damaging the nerve fibers (that is, the copper wires).

In neurofibromas, the situation is somewhat more complex. Here, the tumor has entered between the nerve fibers and become integrated with them. In other words, the wires inside the cable and the insulating material are mixed together. In this case, removing the tumor may sometimes require sacrificing a portion of the nerve fibers. This distinction directly affects preoperative planning and the discussion to be held with the patient.

How can malignant masses and sarcoma risk be recognized?

Although most extremity masses are benign, there are also tumors with malignant potential. Malignant Peripheral Nerve Sheath Tumors (MPNST) or soft tissue sarcomas, although rare, can have an aggressive course. Therefore, every mass should be taken seriously and examined in detail. The appearance or palpation of a mass alone does not tell us everything, but some “red flags” prompt us to be more careful.

Some findings that suggest a possibility of malignancy or require further evaluation are:

• Rapid growth
• Night pain
• Firm consistency
• Fixation/adhesion
• Large size
• Skin changes

Especially for masses larger than 5 centimeters, deeply located (beneath the muscles), and showing progressive enlargement, advanced evaluation with MRI should be performed and a biopsy should be planned. Benign masses are usually mobile and slide under the skin; however, malignant masses tend to feel more fixed and firm because they adhere to surrounding tissues.

Could a burning sensation on the sole of the foot be a symptom of Morton’s Neuroma?

Foot health is an element that directly affects our overall quality of life. Especially common in female patients, pains in the forefoot while walking—such as the sensation of stepping on a pebble or electric shock-like pain radiating to the toes—may be a sign of Morton’s Neuroma. Although it includes the word “neuroma” in its name, this is not actually a true tumor; it is thickening and degeneration of the nerve due to chronic compression.

This condition is usually seen in the nerve between the 3rd and 4th metatarsal bones. Wearing narrow-toed and high-heeled shoes for a long time compresses the nerve in this region between bones and ligaments. Over time, the nerve tissue thickens in response to this pressure and forms a scar tissue around it.

If non-surgical methods (insoles, shoe changes, injections) do not provide benefit in patients diagnosed with Morton’s neuroma, surgical treatment comes to the forefront. In plastic surgery practice, the approach to this region is generally made from the top of the foot (dorsal approach). The skin of the sole is very special and, since it bears load, a scar formed there may cause pain while walking later on. Therefore, by making the incision from the top of the foot, we both reach the nerve safely and enable the patient to bear weight earlier and painlessly after surgery.

Are swellings seen in the fingers giant cell tumors?

One of the most common soft tissue masses we see in the hands and fingers after simple cysts is Tenosynovial Giant Cell Tumors. Although the name sounds frightening (“giant cell” merely describes the cell structure seen under the microscope), these masses are benign. However, being “benign” does not mean they are harmless; they are quite stubborn and prone to recurrence:

They usually appear as slowly growing, firm, painless lumps on the palmar side or sides of the fingers. When opened during surgery, a yellow-brown, multi-lobulated structure resembling a small bunch of grapes is encountered. These tumors originate from tendon sheaths or joint lining.

The most critical point in surgical treatment is cleaning the tumor without damaging the tunnel systems called “pulleys” that attach tendons to bones. If the tumor is not completely removed, the risk of recurrence is high. However, if these tunnels that provide the finger’s movement mechanism are damaged during cleaning, finger movements may be impaired. Achieving this balance requires meticulous dissection under magnification (with loupes or a microscope).

Does the book-hitting method work for wrist cysts?

Ganglion cysts are the most common masses seen around the wrist. Although they are popularly called “nerve cysts,” they actually have no relation to nerves. They are bubbles herniating from the joint capsule or tendon sheath, filled with joint fluid of a jelly-like consistency. They usually occur due to strain or structural weakness.

A very wrong belief passed down over time is to burst these cysts by hitting them with a heavy object (it was called a “Bible cyst” because thick encyclopedias or the Bible were used in the past). This method is definitely not recommended and is quite harmful. Bursting the cyst uncontrollably provides only temporary flattening. Since the sac (cyst wall) remains inside and the root (stalk) is not repaired, the cyst refills in a short time. Moreover, this hard blow can seriously damage the delicate bones, vessels, and nerves in the wrist.

The situations considered when deciding on surgical treatment for ganglion cysts are:

• Severe pain
• Restricted movement
• Aesthetic concern
• Rapid growth
• Weakness in the hand

In surgical treatment, the aim is not only to remove the visible balloon but to find the stalk that connects that balloon to the joint and ligate it at its root. Otherwise, more than half of cysts that are only aspirated with a needle or insufficiently removed will recur.

Why are MRI and EMG necessary in the diagnostic process?

For a surgeon, surprises are usually undesirable. Therefore, before surgery we want to know “what we will encounter inside” down to the finest detail. Although physical examination in hand and extremity masses gives us an idea about the mass’s firmness, mobility, and location, we need technological eyes for the status of deep structures:

Magnetic Resonance Imaging (MRI) is the gold standard for soft tissue tumors. It shows us the exact dimensions, borders, and whether the mass is cystic or solid. More importantly, it maps the mass’s relationship with the main vascular and nerve bundles. In this way, the surgeon knows which vital structure is in which layer before making an incision.

Electromyography (EMG) is a test that measures the electrical conduction of nerves. Especially in nerve-origin tumors or in situations where a mass compresses a nerve (entrapment neuropathies), it enables us to understand how much the nerve has been damaged. Sometimes, even if the mass is small, the pressure on the nerve can be significant, or the opposite may be true. EMG guides us regarding the timing and content of surgery (whether only decompression is needed or nerve repair is required).

How are nerve repair and microsurgical techniques applied?

In some cases, especially in masses that infiltrate nerve fibers such as neurofibromas or in traumatic masses, it may be necessary to remove the damaged portion of the nerve as well while excising the tumor. At the point where nerve integrity is disrupted, microsurgery comes into play. Nerves cannot reconnect by themselves in mid-air; the severed ends need to be brought face to face.

If the removed segment is small and the nerve ends can be approximated without tension, an “end-to-end repair” is performed. Using sutures much thinner than a strand of hair, the nerve sheath is stitched under the microscope. However, if a large gap remains, forcibly joining the ends impairs nerve conduction. In this case, the method called a “nerve graft” is used. A segment taken from another part of the body (usually sensory nerves such as the sural nerve at the back of the leg, which does not cause significant functional loss when harvested) is transplanted as a “patch” or “bridge” to the missing area.

Nerve healing is a process that requires patience. Along the repaired nerve line, fibers progress at a rate of about 1 millimeter per day. In other words, it may take months for a nerve repaired at the wrist to reach the fingertip and restore sensation or movement there.

How are surgical scars and aesthetic outcomes improved?

In plastic surgery, there is technically no such concept as “scarless surgery”; wherever the scalpel touches, a biological healing process and a scar (cicatrix) form accordingly. However, our expertise is to ensure that this scar becomes “invisible” or “acceptable.” In extremity surgery, a scar is not only an aesthetic issue but also a functional one. A poor scar that crosses a joint can prevent the finger from extending (contracture).

Some of the methods we use to improve scar quality and aesthetic outcomes are:

• Zigzag incisions
• Aesthetic sutures
• Atraumatic technique
• Silicone gels
• Compression garments

In the postoperative period, we use silicone-containing creams and tapes to prevent the scar from becoming raised. If a person’s wound healing is genetically poor and raised scars called “keloids” develop, steroid injections or laser treatments come to the fore at this stage. In the late period, the quality of the skin can be improved and the scar can be made less noticeable by injecting fat beneath depressed scars.