Mucous cysts of the DIPJ
Mucous cyst DIPJ
• Ganglion cyst of the DIPJ • Usually occurs between the fifth and seventh
decades• Associated with osteophytes or spurring of
the DIPJ• Osteoarthritis in other joints
Ganglion/Mucous cyst• Single or multiloculated cyst which appears smooth, white &
translucent• Wall is made up of compressed collagen fibres and is sparsely
lined with flattened cells without evidence of an epithelial or synovial lining
• Mucin-filled “clefts” from the capsular attachment of the main cyst interconnect with the adjacent underlying joint via tortuous continuous ducts
• Stroma may show tightly packed collagen fibres or sparsely cellular areas with broken fibres and mucin-filled intercellular & extracellular lakes
• No inflammatory reaction or mitotic activity has been noted
Ganglion/Mucous cyst
• Contents of cyst characterized by a highly viscous, clear, sticky, jelly-like mucin made up of glucosamine, albumin, globulin, & high concentrations of hyaluronic acid
• Aetiology & pathogenesis remain obscure• Most widely accepted theory - mucoid degeneration
associated with degeneration of joint capsule or tendon sheath
• Injury & mechanical irritation may stimulate production of hyaluronic acid to form mucin, which may penetrate joint ligaments and capsules and then coalesce to form cyst
Clinical signs
• Longitudinal grooving of the nail - earliest sign without a visible mass, caused by pressure on the nail matrix
Clinical signs
• Enlarged cyst with attenuated overlying skin
Clinical signs
• Cyst (3-5mm) usually lies to one side of the extensor tendon and between the dorsal distal joint crease & the eponychium
Clinical signs
• Often has Heberden’s nodes and radiographic evidence of osteoarthritic changes in the joint
Treatment
• Primarily surgical• Numerous alternative treatment reported in
the past with moderate success:– Intralesional injection - eg. Sodium morrhuate,
triamcinolone– Occlusive flurandrenolone tape
Surgical Management
• Excision of the cyst alone• Wide excision of the cyst along with
surrounding adjacent structures - eg.the overlying skin, osteophyte debridements
• Debridement of the DIPJ osteophytes only, without excision of the cyst itself or overlying skin
Operative technique
• L-shaped / H-shaped / curved incision
• Elliptical excision of attenuated or involved skin
Operative technique
• Cyst mobilized, traced to the joint capsule & excised with the joint capsule
• All tissue excised between the extensor tendon & the adjacent collateral ligaments
• Insertion of the extensor tendon and the nail matrix must be protected
Operative technique
• Excison of osteophytes
• Skin closure may require rotation / advancement dorsal skin flap or a full-thickness graft
Alternative approach• Transverse incision
centred over DIPJ• Base of mucous cyst
identified & excised while leaving the distal & superficial portion of the cyst intact
• Excision of osteophtyes & joint capsule with direct skin closure
• Allow several weeks for involution of the remaining cyst
Complications
Residual nail deformitiesStiffnessSkin necrosisRecurrence:
- inadequate excision- ganglion extension to the other side of extensor tendon- persistent underlying arthritic process
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