Cysts & Tumors

Ganglion Cyst

A ganglion cyst is a common, non-cancerous growth, bump or lump that can appear on either the palm side or the back (dorsum) of the hand or wrist. More than half of all hand and wrist masses are diagnosed as ganglion cysts. A ganglion cyst forms when an irritated joint leaks a jelly-like clear fluid into a small pouch. Tendon sheaths or knuckle joints can also leak fluid into pouches; these are known as mucous cysts, and they behave and are treated just as ganglion cysts. Ganglion cysts do not spread and they form in patients of all ages. Ganglion cysts have no known cause, but evidence suggests that they may form in joints or tendons irritated by repeated motion, such as from sewing, racquet sports, heavy video gaming or other mechanical movements.

Symptoms and Diagnosis

In diagnosing a ganglion cyst, Dr. Urbanosky will first conduct a careful patient history and perform a thorough visual inspection, looking for a firm lump or swelling near the wrist or finger joints. Other signs of ganglion cysts can include:

• Shape: Ganglion cysts are typically round or oval in shape.
  
• Size: Ganglion cysts vary in size. Those on the underside of the hand and near the fingers are small, roughly the size of a pencil eraser, while those on the wrist can be several times larger.
  
• Trans-illumination: Some ganglion cysts allow light to pass through them.
  
• Density: Some ganglion cysts, such as those near the fingers, are very firm nodules, while others are soft.
  
• Pain: Some ganglion cysts cause no pain, while others, especially those at the base of the fingers can be very tender to the touch.
  
• Bone spurs: If the ganglion cyst occurs near the end joint of the finger, it is common to also find an arthritic bone spur. [[link to bone spur section]]
  
• X-ray: To assess the surrounding joint health, an X-ray is sometimes required.
  

Treatment

In some cases, ganglion cysts will disappear on their own. In other instances, medical intervention is necessary. For those patients whose ganglion cysts become painful or otherwise interfere with their lives, Dr. Urbanosky will recommend either non-surgical or surgical treatment.

Non-surgical treatment options may include:

• Anti-inflammatory medication
  
• Splints
  
• Aspiration: During this in-office procedure, Dr. Urbanosky decreases the cyst’s size by inserting a needle into the ganglion cyst to remove fluid. Cyst recurrence is common after aspiration.
  

Surgical treatment:

When non-surgical treatments do not relieve pain or the ganglion cyst returns, Dr. Urbanosky may recommend surgical treatment. During surgery, Dr. Urbanosky removes the ganglion cyst in addition to a bit of the joint capsule or tendon sheath as a means of removing the entire cyst. Typically, ganglion cyst surgery yields successful results, although cysts can reappear.


Giant Cell Tumor of Tendon Sheath

Giant cell tumors of tendon sheath are the second most common hand tumor, bump or lump behind ganglion cysts. While ganglion cysts are filled with fluid, giant cell tumors are solid. Two-thirds of these non-cancerous (benign) masses occur on the palm side of the fingers or hands and often are found adjacent to the joint nearest the end of the finger (also called the distal interphalangeal joint or DIP joint). These lesions are slow-growing, are likely to affect the index or long fingers and occur anywhere near a tendon sheath (outer lining layer that supports the tendon) or the synovium (the smooth lining of a joint). As is true for most soft-tissue tumors, the cause of giant cell tumor of tendon sheath remains unknown. The typical giant cell tumor patient ranges in age from 30 to 50 years of age. Women are slightly more prone to developing the nodules.

Symptoms and Diagnosis

When diagnosing giant cell tumors of tendon sheath, Dr. Urbanosky will first take a careful patient history and conduct a thorough visual inspection for a firm mass that is firmly fixed. Other signs of giant cell tumors of tendon sheath include:

• Growth rate: Giant cell tumors are very slow growing.
  
• Tenderness: Giant cell tumors may or may not be painful.
  
• Skin mobility: Skin over giant cell tumors is mobile and moves freely.
  
• Trans-illumination: Unlike ganglion cysts, giant cell tumors of tendon sheath do not allow light to pass through them.
  

Dr. Urbanosky may conduct further diagnostic testing through X-rays or an MRI (magnetic resonance imaging) to gain a more complete understanding of the mass.

Treatment

Removing the tumor through surgery is the most common treatment for giant cell tumors of tendon sheath. Dr. Urbanosky will consider all factors of a patient’s case and a patient’s preferences when making a treatment recommendation. Should Dr. Urbanosky recommend surgery to treat a giant cell tumor, it will be because she views it as the best treatment option with the lowest chance of tumor recurrence. Only the most experienced hand surgeons, such as Dr. Urbanosky, are able to fully remove the giant cell tumor since the mass is frequently ensnared with the tendon sheath or synovial joint. Consequently, meticulous dissection by Dr. Urbanosky is required to get optimal results and minimize the risk of satellite lesions and recurrence. Typical giant cell tumors of the tendon sheath range in size from 0.5 cm to 4 cm.

For patients with giant cell tumors and arthritis of the joint nearest the end of the finger (also called the distal interphalangeal joint or DIP joint), Dr. Urbanosky might need to conduct debridement (removal of a dead, damaged or infected tissue) or fusion. In cases, where the tumor involves the skin, the patient might also require secondary skin grafting.

Recurrence rates with giant cell tumors of the tendon sheath range widely, mainly due to the success of the surgeon in removing the entire lesion. Consequently, it’s key that patients deliberately seek expert hand surgeons such as Dr. Urbanosky for their giant cell tumor removal.

Giant cell tumors of the tendon sheath are rarely cancerous (malignant), and some patients do choose to live with the condition rather than treat with surgery. Should any change in appearance of the giant cell tumor occur or change in functionality of the hand occur, patients should seek medical reevaluation.


Inclusion Cyst

Inclusion cysts, also known as epidermal inclusion cysts, are closed balloon-like sacs that attach to the underside of the skin’s surface in the hand or wrist. These common cysts contain fluid or semisolid material and are almost always benign. After a puncture, cut or other trauma occurs, skin cells can become trapped under the skin’s surface as the body continues to produce keratin (a waxy substance) in response to the trauma. The cyst grows as more keratin is produced and more skin cells die. The result is an inclusion cyst, a slow-growing sac filled with a gelataneous substance. Inclusion cysts most commonly affect patients in their 30s or 40s and are twice as common in men than women.

Symptoms and Diagnosis

Typically, patients with inclusion cysts don’t exhibit symptoms other than the swollen cyst, but Dr. Urbanosky will conduct a thorough patient history in addition to closely inspecting the lesion, which should be a firm and round nodule of varying size. Dr. Urbanosky will also look for the following infrequent symptoms when diagnosing this common condition:

• Swelling and tenderness: Infected inclusion cysts can become inflamed and painful.
  
• Discharge: A foul-smelling “cheeselike” discharge may be present.
  
• Central pore: Occasionally, a small, distinct point (known as a punctum) will be present.
  
• Nail changes: In cases where the inclusion cyst extends to the fingertip, the cyst may cause changes in the nail such as pincer nail deformity, build up of fluid (edema) or pain.
  
• Malignancy: In the unlikely event the inclusion cyst is cancerous, patients might exhibit rapid cyst growth and bleeding.
  

A number of events can cause inclusion cysts, including any crushing injury. For example, any surgical procedure, dermal grafts, needle biopsies or slamming of a finger in a car door can lead to inclusion cysts. Some studies also suggest that ultraviolet light exposure and human papilloma virus (HPV) play a role in inclusion cyst development.

Treatment

Dr. Urbanosky will consider all factors of a patient’s case and a patient’s preferences when making a treatment recommendation. Asymptomatic inclusion cysts require no treatment. For inflamed inclusion cysts, injections to the lesion or oral antibiotics may be recommended. Infected cysts can also be drained, but recurrence of the cyst is likely.

The most common treatment for inclusion cysts is surgical excision or removal of the cyst and cyst wall. Should Dr. Urbanosky recommend surgery to treat an inclusion cyst, it will be because she views it as the best treatment option with the lowest chance of tumor recurrence.

Recurrence rates with inclusion cysts are common if the surgeon fails to remove the entire cyst wall. Consequently, it’s key that patients deliberately seek expert hand surgeons such as Dr. Urbanosky for their inclusion cyst removal.

Inclusion cysts are rarely cancerous (malignant), and some patients do choose to live with the condition rather than treat with surgery. Tumors do tend to grow over time and can become bothersome. Should any change in appearance of the inclusion cyst or change in functionality of the hand occur, patients should seek medical reevaluation.


Carpal Bossing

Carpal bossing, also called carpometacarpal bossing, is a moderately common condition in which a bony lump forms on the back of the hand, typically where the long hand bones meet the small wrist bones. While carpal bossing is often confused with a ganglion cyst, it is an entirely different condition. It results from wear and tear at the base of the index and middle fingers and often develops from osteoarthritis as the articular cartilage lining thins and bone spurs develop. Carpal bossing typically presents in those ages 20-40 and is twice as common in women.

Symptoms and Diagnosis

Dr. Urbanosky will take a thorough history and conduct an extensive exam when diagnosing carpal bossing, as they are often misdiagnosed as ganglion cysts. Typical symptoms of carpal bossing include:

• Swelling: Hard swelling on the back (dorsum) of the hand.
  
• Lump: The mass may be much more easily viewed when the wrist is flexed.
  
• Pain and tenderness: Carpal bossing may be painful, but often is not.
  
• Limited range of motion: It is common for patients to experience limited movements in the hand with carpal bossing. In particular, the index and middle fingers can have limited movement.
  
• Overlying ganglion or bursitis
  
• Exterior tendon slipping over the bony outcropping (popping)
  
• Changes to the back of the hand due to osteoarthritic causes.
  

With carpal bossing, Dr. Urbanosky often finds diagnosis is obvious after examining the patient, but in some instances, X-rays, scans, blood tests and EMG (electromyography) to test the electrical activity of the muscles may be necessary.

Treatment

Most people only seek treatment for their carpal bossing if they have pain. Dr. Urbanosky first tries to treat pain through non-surgical methods. If those prove ineffective, she may recommend surgery after considering the patient’s individual case and needs.

Non-surgical treatment options for carpal bossing include:

• Activity modification or rest can be effective.
  
• Pain killers, particularly anti-inflammatory analgesics such as ibuprofen, can be effective. These can be taken orally or massaged into skin through a gel.
  
• Splinting the wrist
  
• Steroid injection. Success from injection varies by patient. Some gain relief for the remainder of their lives while others only see a few weeks of benefit. If several injections lead to little relief, Dr. Urbanosky may recommend an alternative treatment.
  

Surgical options:

For carpal bossing patients who fail to respond to non-surgical treatment options, Dr. Urbanosky may suggest a procedure called excision of carpal boss. In this procedure, Dr. Urbanosky makes a small incision across the back of the hand and removes the carpal boss mass. Nearly 90 percent of patients report excellent results with less pain and swelling after excision of carpal boss. As with surgery to treat ganglion cysts, [[link to ganglion cyst]] successful treatment requires expert excision of the carpal boss as well as any osteoarthritic spurring. Patients need to be mindful to seek the care of an expert hand surgeon such as Dr. Urbanosky for this type of treatment.



Enchondroma

Enchondroma tumors are the most common bony tumor of the hand. They can also appear in the upper arm and thigh. Enchondroma is a noncancerous (benign) cartilage tumor that grows on the inside of the bone. Enchondroma tumors typically begin in childhood but stop growing. They are often discovered in patients ages 10 to 20 when X-rays are taken for another reason.

In rare cases, multiple enchondroma tumors can appear as part of a syndrome. These are called Maffucci’s syndrome and Ollier’s disease. While it is rare for a single enchondroma tumor to become cancerous (malignant), it is more common with Maffucci’s syndrome and Ollier’s disease. For those enchondroma tumors that become cancerous, they typically become a chondrosarcoma, a rare form of bone cancer. Distinguishing between enchondroma and low-grade chondrosarcoma is challenging and patients must take care to seek out a hand expert such as Dr. Urbanosky for this type critical diagnosis.

Symptoms and Diagnosis

In diagnosing enchondroma tumors, Dr. Urbanosky takes great care to take a thorough history and perform an exhaustive exam. Common symptoms of enchondroma tumors include:

• Pain: Enchondromas are typically painless. If the patient is experiencing pain, Dr. Urbanosky will delve further into its cause. Pain at night or rest can signal malignancy, but must be distinguished from other more common causes of pain, such as injury.
  
• Bone deformity: These tumors can deform the bones of the hands or feet, severely when they appear in multiples as in Ollier’s disease and Maffucci’s syndrome.
  
• Enlarged finger or broken bone (pathologic fracture)
  

The diagnosis of an enchondroma is critical in making sure the tumor is not a more aggressive or cancerous tumor. Dr. Urbanosky may employ many different diagnostic tools to ensure the diagnosis is accurate. Those tools may include:
X-ray, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan.

Treatment

This is a complicated condition. Many enchondromas require no treatment at all. In cases where the tumor shows no sign of growing, Dr. Urbanosky will watch the enchondroma with X-rays. Many surgeons believe asymptomatic enchondroma tumors do not need removing. When needed, treatment for enchondroma can vary. This sometimes causes debate, even among orthopaedic oncology surgeons due to the difficulty in determining the aggressiveness of the lesion. Dr. Urbanosky will carefully consider your particular situation and needs before recommending treatment.

When Dr. Urbanosky sees that an enchrondroma needs treating surgically, it is typically through a procedure that requires scraping out and filling the cavity with bone graft or other filling substance. Instance or recurrence of the enchrondoma is possible, but not likely.
In cases of more aggressive or malignant tumors (chondrosarcomas), Dr. Urbanosky will refer to an oncologic orthopedics sub-specialist.
There is significant ongoing research on enchondromas and chondrosarcomas. Patients should take care to see a surgeon such as Dr. Urbanosky who goes to great lengths to remain current on the latest research and treatment options for these difficult-to-diagnose conditions.

If you think that you may have a cyst or tumor of the hand or wrist, contact Dr. Leah Urbanosky for a consultation:  (815) 462-3474.

Wrist Conditions
Wrist Fractures & Sprains
Scaphoid/Navicular Fractures
Carpal Tunnel Syndrome
Cysts & Tumors