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Lumps, bumps, tingles in the night gp education
- 1. Lumps, Bumps and Tingles in the Night - A case based approach to lumps in the hand and nerve entrapment conditions Ms Avanthi Mandaleson MBBS, BMedsci, FRACS, FAOrthA, Hand Surgeon
- 2. Learning Objectives • Identify common lumps in the hand and wrist • How to manage lumps in the hand/wrist • Understand the treatment options for nerve entrapment conditions
- 3. Common lumps and bumps • Hand • Mucous cyst • Heberdon’s nodes • Garrod’s pads • Epidermal inclusion cyst • Foreign body granuloma • Wrist • Ganglia • Carpometacarpal boss • Benign lesions • Lipoma • Giant cell tumours of tendon sheath • Schwannoma • Neurofibroma • Malignant/Aggressive lesions • Sarcoma • Aneurysmal bone cyst • Giant cell tumour
- 4. Common entrapment neuropathies of the upper limb • Median nerve • Carpal tunnel syndrome • Pronator syndrome • Ulnar nerve • Cubital tunnel syndrome • Guyon’s canal entrapement • Cervical radiculopathy
- 5. Mucous cyst Definition Ganglion cyst arising from DIPJ Presentatio n Swelling over DIPJ or nail fold Ridging of nail plate Age group 50-70 yo Association s DIPJ OA Ix (XR) Treatment options Conservative mx Cyst excision and joint debridement When to Overlying skin
- 6. Tendon sheath ganglion Definition Cyst arising from tendon sheath Presentatio n Fixed firm tender mass at distal palmar crease Frequency 10% hand ganglia Ix U/S Radiology findings Cyst arising from A1 or A2 pulley When to refer Refractory pain causing functional limitations Treatment Surgical excision with part of A1 pulley Nil recurrence
- 7. Heberden’s/Bouchard’s nodes Definition Osteophytes affecting the DIPJ and PIPJ Presentatio n Painful and stiff PIPJ and DIPJ Age group >50 years Ix XR When to refer Pain refractory to activity modification and CSI Treatment options CSI Joint debridement PIPJ/DIPJ fusion PIPJ/DIPJ arthroplasty Fusion rate > 91%
- 8. Garrod’s pads Definition Benign fibrofatty pads - fibromatosis Presentatio n Well circumscribed smooth thickening (painful/painless) over dorsal PIPJ/MCPJ Age group > 30 yo Association s Dupuytren’s disease Ix Nil When to refer Treatment of symptomatic Dupuytren’s contracture Treatment Conservative
- 9. Epidermal inclusion cyst Definition Traumatic implantation of epithelial cells into soft tissue or bone Presentatio n Painless well circumscribed firm swelling commonly on fingertip Ix XR/US Radiology findings XR - Can show well demarcated lytic lesion When to refer XR changes Treatment Excisional biopsy
- 10. Definition Traumatic reactive response to retained foreign body Presentatio n Pain, swelling and intermittent inflammation +/- palpable mass Injury pattern History of trauma - wood most common Ix US/XR Radiology findings Foreign body material When to refer Pain or exclusion of soft tissue tumour Treatment Excisional biopsy Foreign body granuloma
- 11. Definition Mucin-filled cyst Presentatio n 20-40 yo women Painful swelling Incidence 60-70% Dorsal 20% Volar Ix US/MRI Radiology findings Ganglion cyst arising from interosseous capsule/ligament or TFCC tear When to refer Pain and functional limitation Treatment Conservative management - Aspiration and CSI Wrist ganglia
- 12. Carpometacarpal boss Mechanism Osteoarthritic spur arising from the 2nd/3rd CMC joint Presentatio n 30-40 y o women Firm, bony tender mass at base of CMC joint Association s CMCJ OA and instability Ix XR (Carpal boss view - 30’ supination)(CT) Radiology findings Bony spur +/- CMC OA When to refer Pain Conservative MX - CSI Osteophyte excision +/-
- 13. Lipoma Definition Benign fat tumours occurring in s/c tissue or intramuscular Presentatio n Soft, well circumscribed painless mass Association s Nerve entrapment in carpal tunnel, Guyon’s canal Ix MRI Radiology findings Well circumscribed lesion with uniform fat signal - assess proximity to adjacent NV structures When to refer Nerve compression or cosmetic
- 14. Giant cell tumour tendon sheath Definition Benign soft tissue tumour Presentatio n Firm , nodular, non-tender, slow growing swelling on palmar surface of fingers/hand Incidence 2nd most common tumour in the hand - after ganglions Ix XR/MRI Radiology findings Soft tissue shadow, pressure erosion of bone When to refer Concern of malignant tumour
- 15. Schwannoma Definition Benign nerve tumour Presentation Painless mass over flexor surface forearm or hand in 40- 60 yo. Uncommon - neurological deficit Incidence Most common benign nerve tumour of upper limb Ix MRI Radiology findings Similar features to neurofibroma and malignant nerve sheath tumours When to refer Exclude malignancy Treatment Marginal excision - shelled out from surrounding nerve 4% risk of post-operative nerve deficit but majority improve
- 16. Neurofibroma Definition Benign nerve tumours arising within nerve fascicle Presentation Painless mass Neurological deficit Associations Neurofibromatosis - potential for malignant transformation Ix MRI or PET When to refer Enlarging lesions or progressive deficit Treatment Conservative <2cm - monitoring Transection of entering and exiting fascicles Outcomes Higher risk of nerve deficit
- 17. Aneurysmal Bone CystDefinition Benign aggressive rapidly growing bone lesion Presentatio n 20 yo, painful progressive swelling Incidence 5% all benign bone tumours but only 3-5% occur in hand Ix XR/MRI Radiology findings Expansile lytic lesion with fluid, fluid levels on MRI When to refer Early referral to exclude malignancy Treatment Intra-lesional excision and bone grafting
- 18. Giant cell tumour Definition Local aggressive benign bone tumour - potential for metastasis Presentatio n 40 yo. Pain and swelling. Pathological fracture Incidence 5% benign bone tumours Ix XR/MRI Radiology findings Expansile destructive lytic lesions with soft tissue extension When to refer Early referral to exclude malignancy Treatment Local and systemic staging Chemotherapy - metastatic disease Intralesional excision - high
- 19. Median nerve entrapmentSites of entrapment Pronator syndrome Carpal tunnel syndrome Presentatio n CTS - Radial 3 1/2 digits numbness, night sx Pronator synd - As above + palm numbness, no night sx proximal forearm pain Anatomical site 2 heads pronator teres/ lacerates fibrosis/FDS Transverse carpal ligament Ix NCS - CTS When to refer Recalcitrant symptoms - Failed CSI and bracing. Thenar wasting /weak opposition Treatment Neural glide exercises Open/endoscopic carpal tunnel release
- 20. Ulnar nerve entrapment Sites of entrapment Cubital tunnel Guyon’s canal Presentatio n Cubital tunnel - Ulnar 1 1/2 digits inc dorsal hand Guyon’s canal - Ulnar 1 1/2 Differential C8 radiculopathy - Medial forearm numbness Thenar wasting Ix NCS When to refer Recalcitrant symptoms > 6 months Motor weakness/muscle wasting/clawing Treatment Posture correction - night time splint Neurolysis (+/- nerve transposition) Anti-claw procedures inc
- 21. Summary • Pattern recognition for hand lumps and bumps • Low threshold for XR • US - Benign lesions • MRI - aggressive lesions • Entrapment neuropathies - clinical presentation • Conservative treatment options - Physiotherapy neural glide • Surgical referral timing - Save nerves before weakness
- 22. How to refer? Avanthi Mandaleson Hand Surgeon T: 9456 9077 F: 9456 9177 Mob: 0487 208 655 avanthimandaleson@icloud.com Private Consulting: Heidelberg Surgical Level 7, 10 Martin Street Heidelberg Knox Orthopaedic Group Mountain Highway Wantirna TAC/Workcover welcome Hand therapy and Radiology on site Service aims to provide review and treatment plan within 48hrs for urgent cases Public: Department of Orthopaedic Surgery Austin Health Division of Hand Surgery Orthopaedic Department Dandenong Hospital, Monash Health