Swelling over hand dorsum

1. A CASE OF SWELLING OVER THE
DORSUM OF THE RIGHT HAND
PRESENTER : Dr. C.V. ARUNESHWAR
Prof. Dr. S.P. GAYATHRE MA’AM’S UNIT
S1

2. CASE CAPSULE
CHIEF COMPLAINTS :
56 year old female patient presented with complaints of a swelling over dorsum of the right hand for 2
months and an ulcer over the dorsum of the wrist for 2 months
HISTORY OF PRESENTING ILLNESS :
The patient was apparently normal 2 months back following which she developed a Swelling over the
dorsum of the right hand
- sudden onset
- rapidly progressed to current size,
- Initially was painless, but associated with pain
for the past two days
- associated with inability to extend the
index and middle finger of the right hand.
Complaint of an ulcer over the dorsum of the right wrist for 2 months
- Initially began as a painless swelling that
became painful and ruptured with mucinous
discharge.
- Painful at present, non progressive in nature
- Associated with pus discharge, not associated with
bleeding.

3. • h/o loss of weight + ( Could not be quantified).
• h/o inability to extend the index and middle fingers of the right hand.
• No h/o difficulty in extending the wrist.
• No h/o difficulty in flexing the fingers of the right hand.
• No h/o difficulty in extending the elbow.
• No h/o loss of sensations of the right hand, forearm.
• No h/o fever.
• No h/o loss of appetite.
• No h/o evening rise of temperature.
• No h/o night chills.
• No h/o recent trauma to the hand.
• No h/o swellings elsewhere in the body.
PAST HISTORY :
No prior history of similar complaints, surgeries done,
Patient has difficulty in walking since birth due to inversion of her right foot=.
COMORBIDITY HISTORY:
No known comorbidities.

4. PERSONAL HISTORY ;
Mixed diet, No adverse habits.
Attained menopause.
FAMILY HISTORY ;
No similar family history
CLINICAL EXAMINATION ;
Clinical examination was carried out in a naturally lit environment after obtaining her consent
and adequately exposing the patient from right hand till the axilla.
GENERAL EXAMINATION ;
- PS – 2
- Patient is conscious, oriented, afebrile, fairly hydrated,
- No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or bilateral pitting pedal
edema

5. LOCAL EXAMINATION OF THE RIGHT HAND :
Attitude : Wrist is in slight palmar flexion with partly flexed 2nd, 3rd and 4th fingers with extended
5th finger.
SWELLING :
INSPECTION:
Number : Single
Site : Over the dorsum of the right hand
Size : 4 x 4 x 2 cm
Shape : Roughly hemispherical
Surface : Smooth
Skin over swelling : Slightly stretched, no distended veins, no scars, sinuses or ulcers.
Margin : well defined
Extent : 2cm from the wrist joint proximally to 5 cm from the wrist joint distally
From axis of 2nd metacarpal laterally to the axis of the 4th metacarpal
medially.
Non pulsatile,
Finger drop +
No wrist drop, extension of elbow not affected.
Hypothenar wasting +

7. LOCAL EXAMINATION OF THE RIGHT HAND :
PALPATION:
Not warm, non tender
Inspectory findings confirmed
Firm in consistency, does not pit with pressure.
Non pulsatile
Mobility restricted along line of tendons, mobility present perpendicular to line of tendons.
Not fixed to skin
PERCUSSION : Dull
AUSCULTATION :No bruit
Distal pulses : ++
No proximal adenopathy

8. LOCAL EXAMINATION OF THE RIGHT HAND :
Distal Neurological Exam:
Radial Nerve
Triceps : Extension of arm intact, Triceps jerk intact
Brachioradialis : Extension in midprone forearm intact, brachioradialis reflex +, No wrist drop
Extensor digitorum : Finger drop at MCP Joint of 2nd, 3rd, 4th fingers +
Extensor pollicis longus – intact, Extensor carpi ulnaris : Intact
No sensory loss over radial nerve distribution
Median Nerve
Flexor pollicis longus( Flexion of Distal phalanx) , Abductor pollicis brevis (pen Test)
Flexor digitorum superficialis and profundus (Oschners clasp test,pointing index)
Oppones pollicis were all negative
No sensory loss over median nerve distribution

9. LOCAL EXAMINATION OF THE RIGHT HAND :
Distal Neurological Exam:
Ulnar Nerve:
Flexor carpi ulnaris : No radial deviation of wrist on flexion
Interossei : Card test negative
Adductor pollicis : Book test negative.
No sensory loss over ulnar nerve distribution
DIAGNOSIS:
? MALIGNANT PERIPHERAL NERVE SHEATH TUMOUR OF THE POSTERIOR
INTEROSSEOUS NERVE WITH POSTERIOR INTEROSSEOUS NERVE PALSY OF THE
RIGHT HAND WITH ? RUPTURED GANGLON CYST OVER THE RIGHT WRIST.
DIFFERENTIAL DIAGNOSES ;
Soft tissue Sarcoma
Compound Ganglion