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A 38-year-old woman complains of a painful finger mass of 4 months duration. A photograph of the mass is provided in Figure A. The decision is made to proceed with surgical excision. Which of the following is an advantage of surgical excision with joint debridement as opposed to aspiration?
Reduced rate of infection of the DIP joint
Less post-procedure pain
Improved DIP range of motion
Decreased risk of mass recurrence
Reduced risk of metastasis from seeding the mass into the joint
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Figure A demonstrates a mucous cyst. This benign mass originates from the DIP joint, and is secondary to arthritis. It may be treated with aspiration or surgical excision. However, recurrence occurs frequently with aspiration. Debridement of any osteophytes from the DIP joint is crucial to preventing recurrence with surgical excision. Rizzo et al retrospectively evaluated the results of 154 mucous cysts treated with either aspiration or surgery. Aspiration resulted in a 40% recurrence rate. There were zero recurrences with surgical excision and joint debridement.
Rizzo M, Beckenbaugh RD
J Hand Surg Am. 2003 May;28(3):519-24. PMID: 12772114 (Link to Abstract)
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A 54-year-old gentleman presents to your office with a mass on top of the distal phalanx that has enlarged over the last nine months. His main complaint is significant tenderness to palpation over the mass. There is no pain with forcible movement of his fingers. A clinical photo is shown in Figure A. A dedicated radiograph of the distal phalanx is shown in Figure B. What treatment option is most appropriate for the best patient outcome?
Fusion of distal interphalangeal joint
Removal of bone spur and cyst
Obtain infectious work-up
This is a classic presentation of a mucous cyst. The most appropriate treatment would be excision of the cyst and removal of the underlying bone spur.
A mucous cyst of the hand is usually a small, soft, benign structure. They are associated with osteoarthritis and develop around bone spurs near a joint. Surgery is typically recommended if there is significant pain at the site of the cyst or with range of motion of the involved joint. Nail bed deformity may occur with disease progression if left untreated.
Rizzo et al. examined a series of 132 patients with mucous cysts, comparing outcomes between injection and surgery. They found that 60% of people with aspiration and steroid injection had complete resolution of the cyst compared to 100% with excision.
Figure A shows a small mucous cyst just proximal to the nailbed. Figure B shows a radiograph of the distal interphalangeal joint. There is extensive joint arthritis with dorsal bone spurs.
Answer A: Pain from a mucous cyst is usually constant, but in some people it may come and go. Rarely the cysts will resolve over time. Typically, the mucous cyst will progress with time and cause nail deformity.
Answer B: Aspiration will lead to a >40% recurrence.
Answer C: Removal of cyst and joint fusion would be indicated if there was pain with with any forcible movement of the joint.
Answer E: Infection is usually not associated with a benign mucous cyst.
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