Unusual Vascular Anomalies in Pediatric Hand and Plastic Surgery

INTRODUCTION: Rare pediatric vascular tumors and malformations can be diagnostically and therapeutically challenging. They may present atypically, mimic more common conditions, or be life-threatening. Understanding of the various conditions, early recognition, and multidisciplinary management are essential for successful treatment. METHODS: A retrospective review was performed of selected pediatric vascular anomaly cases managed at a tertiary referral center between March 2023 and August 2025. Cases were chosen based on diagnostic complexity, rarity, and the requirement for multidisciplinary and/or targeted systemic therapy. CASE PRESENTATION SUMMARY: Five cases are presented: kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon, congenital hemangioma, generalized lymphatic anomaly, and PIK3CA-related overgrowth spectrum disorder presenting with multifocal osteolytic lesions and fractures. Diagnoses were established through radiologic, histopathologic, and targeted genetic and molecular testing. Management combined wound care and reconstruction with systemic therapies. Propranolol was used as first-line therapy in infantile hemangioma, corticosteroids and sirolimus were used in vascular tumors with hematological complications, and alpelisib was utilized in PIK3CA-related disease. Outcomes were variable but demonstrated significant symptomatic and functional improvement with good overall tolerance of systemic therapy. CONCLUSION: These cases highlight the heterogeneity of pediatric vascular anomalies and their potential to mimic nonvascular pathology. Hand and plastic surgeons play a key role in recognition, biopsy, wound care and reconstruction, and rehabilitation within multidisciplinary teams. Novel targeted systemic therapies, such as sirolimus and alpelisib, alongside more traditional agents, including propranolol and corticosteroids, are central where surgery alone is inadequate. Awareness of these rare vascular anomalies is essential for timely diagnosis and treatment.