MUCOUS
CYSTS
OF THE FINGERS
By MAXWELL S. MACCOLLUM, M.D. Section of Plastic Surgery,
University of Michigan Medical Center, Ann Arbor, Michigan
THERE has been disagreement about the aetiology of mucous cysts. Johnson et al. (1965) serially sectioned 6 and found no evidence of any connection between the cystic or myxomatous areas and structures beneath the dermis. Bourns and Sonerkin (1962) also denied communication with the joint. Arner et al. (1956) injected contrast medium into the cyst and reported failure of penetration into the joint; histologically they found mucoid change in the dermal collagen. On the other hand, Barnes et al. (1964) stated that the mucous cyst may arise from the extensor tendon or the joint. Eliasson and Frank (1942) aspirated and then injected a cyst with Diodrast and immediately thereafter showed the contrast medium in the distal joint. Although King (1951) suggested that lymphatics may have carried the Diodrast into the joint cavity, Newmeyer et al. (1974) have conclusively demonstrated connection of the cyst and the joint. Methylene blue injected into the distal joint entered the mucous cysts in each of their 20 cases. Ormsby (1913) suggested an arthritic diathesis. Anderson (1947) reported always finding mucous cysts associated with some degree of hypertrophic arthritis of the terminal interphalangeal joints. Eaton et al. (1973) and Newmeyer f?t d. (1974) dS0 reported some degree of osteoarthritis by X-ray in all cases, Barnes et al. (1964) in 75 per cent, and Kleinert et al. (1972) in 64 per cent. Until recently, treatment by excision and skin grafting was generally advocated (Bourns and Sonerkin, 1962; Barnes et al., 1964; Posch, 1966; Constant et al. 1969; Boyes, 1970; Milford, 1971). Earlier, simple excision and or irradiation (Boyes, 1970; Injection with triamcinolone acetonide was also Milford, 1971) had been employed. suggested (Johnson et al. 1965; Boyes, 1970). Kleinert et aZ. (1972) rotated local flaps to cover the defect after excising the cyst and its pedicle with a section of capsule, possibly with a joint debridement and/or synovectomy. They had no recurrences or loss of joint motion in 36 cases. Eaton et aZ. (1973) performed an arthrotomy of the distal joint and excision of an underlying exostosis on the involved side. They utilised a gently curving transverse incision and with large cysts excised an ellipse of skin over the apex to avoid redundancy in closure. There was no loss of distal joint motion and one recurrence in 50 cases. Constant et al. (1969) reported stiffness of the distal interphalangeal joints in 3 out of 12 cases after primary closure and in 4 of 30 cases following skin grafting. Posch (1966) mentioned skin excision, advancing skin from the side of In a recent article Newmeyer et al. the finger to cover the defect, but had recurrences. (1974) used an unsutured proximally based flap, covered with a moist, mildly compressive dressing. They reported no recurrences and a satisfactory cosmetic result in 20 cases. The author is now reporting his treatment of these lesions by skin excision when necessary, complete dorsal joint debridement and synovectomy, with skin flap closure.
ClidCd Material. During the period 1970 to 1973, 18 patients With 22 mucous cysts of the fingers were surgically treated. All had X-ray evidence of hypertrophic or degenerative arthritis of varying degrees in the involved joint. Frequently the other distal joints, and occasionally the middle joints, also had arthritic changes. Generally (15 of 22 joints) the lesions had mild symptoms of soreness, aching and tenderness. Some of the cysts had ruptured either spontaneously or from trauma. Others had been 118
MUCOUS
CYSTS
OF THE
119
FINGERS
One had previously been opened by another physician or by the patient (8 of 22). excised, recurring within a month. Age ranged from 45 to 77 years. The cysts occurred in the dominant hand of IO patients, the non-dominant hand in 6, and bilaterally in 2. One of the patients had 4 different digits involved, as well as a ganglion of the wrist. The thumb was involved 6 times, the index 6, the middle 7, the ring I, and the little finger 2. There were 12 females with 16 mucous cysts and 6 males with 6 cysts. Surgical Treatment. Under block or general anaesthesia and tourniquet control a dorsal, proximally based, tongue shaped flap is elevated with the distal limit of the incision centred over the cyst (Fig. I). If the skin over the cyst is quite thin, it and an approximately equal width of adjacent skin at the end of the flap are excised, the line of excision being angled proximally on the opposite side if the cyst is situated over the base of the nail (Fig. 2).
56
FIG. I.
Routine
skin incision.
FIG. 2.
Incisions
for skin excision.
The cyst can frequently be exposed without rupture and followed into the joint. Extension of the cyst proximally along or under the extensor tendon has been observed. In I patient it extended to the level of the proximal interphalangeal joint. The dorsal and dorso-lateral aspect of the distal interphalangeal joint is debrided, exostoses contoured, lifting up the extensor insertion and carefully removing excess bone there if necessary, thickened capsular tissues removed, and a synovectomy performed. Occasionally smaller cysts are found on the involved and/or opposite side of the joint. In addition to those grossly seen, the pathologist in 3 instances reported The operative field is irrigated, bleeding points “several cysts ” in the specimens. controlled, and closure accompanied with interrupted and continuous 6/o nylon. When skin has been excised the flap is advanced distally. This is easily done, although it may require more proximal extensions of the lateral incisions to just distal to the middle joint. The finger is dressed with Vaseline gauze, plain gauze and Tubegauz. At IO days the dressing and sutures are removed and the patient started on gradual use.
120
BRITISH JOURNAL
OF PLASTIC SURGERY
Results of Treatment. All wounds healed primarily. There have been no recurrences. Cosmetic improvement of the region of the joint was achieved in many of the cases. Seven of the 22 joints had a decreased range of motion, averaging 20'. This was not related to the severity of the arthritis found on the pre-operative X-rays. One patient regained normal motion post-operatively, but a year later developed pain, loss of motion, and X-ray evidence of increased degenerative changes. Patients complained of minor tenderness or soreness in 5 of the 22 operated joints. These had also been symptomatic before operation. CONCLUSION
This approach offers an easy method of skin cover, especially when treating thinned out skin over a cyst, improvement in the joint contour, investigation of both sides of the joint, and removal of any other cyst(s) which may exist. The chief disadvantage is loss of motion in approximately 30 per cent of the joints, averaging 20~. Clinically and functionally this was of little consequence in a distal joint; however, if the joint cannot be fully extended, it may be unsightly. I wish to express my thanks to William C. Crabb, M.D., for his encouragement and helpful criticism in preparing this paper. REFERENCES C. R. (1947). Longitudinal grooving of the nails caused by synovial lesions. Arches of Dermatology and Syphilology, 55, 828. ARNER, O., LINDBLOM, A. and ROMANUS, R. (1956). Mucous cysts of the fingers. Acta Chirurgica Scandinavica, III, 314. BARNES,W. E., LARSEN, R. D. and POSCH, J. L. (1964). Review of the ganglia of the hand and wrist with an analysis of surgical treatment. Plastic and Reconstructive Surgery, 34, 570. BOURNS,H. K. and SONERKIN,N. G. (1962). Mucoid lesion (mucoid cysts) of the fingers and toes. Clinical features and pathogenesis. British Journal of Surgery, 50? 860. BOYES,J. H. (1970). In “Bunnell’s Surgery of the Hand”, 5th Edition, p. 675. Philadelphia: J. B. Lippincott Co. CONSTANT, E., ROGER, J. R., POLLARD, R. J., LARSEN, R. D. and POSCH, J. L. (1969). Mucous cysts of the lingers. Plastic and Reconstructive Surgery, 43, 241. EATON, R. G., DOBRANSKI,A. I. and LITTLER, J. W. (1973). Marginal osteophyte excision in treatment of mucous cysts. Journal of Bone and Joint Surgery, SSA, 570. ELIASON,A. and FRANK, S. B. (1942). Pathogenesis of synovial lesions of the skin. Archives of DermatoloPv and Svahilolo~v. ~6. 691. JOHNSON,W. C.,--GRAH&; J. H.-and ~%E~WIG,E. B. (1965). Cutaneous myxoid cyst. A clinopathological and histochemical study. The Journal of the American Medical Association, xgr, 15. KING, E. S. J. (1951). Mucous cysts of the fingers. Australian and New ZealandJournal of Surgery; 21, 121. KLEINERT, H. E., KUTZ, J. E., FISHMAN, J. H. and MCGRAW, L. H. (1972). Etiology and treatment of the so-called mucous cyst of the finger. Journal of Bone andJoint Surgery, 54-4, 1455. MILFORD, L. (1971). “The Hand”, p. 248. St. Louis: C. V. Mosby Co. NEWMEYER, W. L., KILGORE, E. S. and GRAHAM, W. P. III (1974).Mucous cysts: the dorsal distal interphalangeal joint ganglion. Plastic and Reconstructive Surgery, ~3~ 313. ORMSBY, 0. S. (1913). Synovial lesions of the skin. Journal of Cutaneous Diseases, 31, 943. POSCH, J. L. (1966). Soft tissue tumors of the hand, in “Hand Surgery”, edited by Flynn, J. E., pp. 1012, 1016. Baltimore: Williams and Wilkins Co. ANDERSON,
CYSTS
OF THE FINGERS
By MAXWELL S. MACCOLLUM, M.D. Section of Plastic Surgery,
University of Michigan Medical Center, Ann Arbor, Michigan
THERE has been disagreement about the aetiology of mucous cysts. Johnson et al. (1965) serially sectioned 6 and found no evidence of any connection between the cystic or myxomatous areas and structures beneath the dermis. Bourns and Sonerkin (1962) also denied communication with the joint. Arner et al. (1956) injected contrast medium into the cyst and reported failure of penetration into the joint; histologically they found mucoid change in the dermal collagen. On the other hand, Barnes et al. (1964) stated that the mucous cyst may arise from the extensor tendon or the joint. Eliasson and Frank (1942) aspirated and then injected a cyst with Diodrast and immediately thereafter showed the contrast medium in the distal joint. Although King (1951) suggested that lymphatics may have carried the Diodrast into the joint cavity, Newmeyer et al. (1974) have conclusively demonstrated connection of the cyst and the joint. Methylene blue injected into the distal joint entered the mucous cysts in each of their 20 cases. Ormsby (1913) suggested an arthritic diathesis. Anderson (1947) reported always finding mucous cysts associated with some degree of hypertrophic arthritis of the terminal interphalangeal joints. Eaton et al. (1973) and Newmeyer f?t d. (1974) dS0 reported some degree of osteoarthritis by X-ray in all cases, Barnes et al. (1964) in 75 per cent, and Kleinert et al. (1972) in 64 per cent. Until recently, treatment by excision and skin grafting was generally advocated (Bourns and Sonerkin, 1962; Barnes et al., 1964; Posch, 1966; Constant et al. 1969; Boyes, 1970; Milford, 1971). Earlier, simple excision and or irradiation (Boyes, 1970; Injection with triamcinolone acetonide was also Milford, 1971) had been employed. suggested (Johnson et al. 1965; Boyes, 1970). Kleinert et aZ. (1972) rotated local flaps to cover the defect after excising the cyst and its pedicle with a section of capsule, possibly with a joint debridement and/or synovectomy. They had no recurrences or loss of joint motion in 36 cases. Eaton et aZ. (1973) performed an arthrotomy of the distal joint and excision of an underlying exostosis on the involved side. They utilised a gently curving transverse incision and with large cysts excised an ellipse of skin over the apex to avoid redundancy in closure. There was no loss of distal joint motion and one recurrence in 50 cases. Constant et al. (1969) reported stiffness of the distal interphalangeal joints in 3 out of 12 cases after primary closure and in 4 of 30 cases following skin grafting. Posch (1966) mentioned skin excision, advancing skin from the side of In a recent article Newmeyer et al. the finger to cover the defect, but had recurrences. (1974) used an unsutured proximally based flap, covered with a moist, mildly compressive dressing. They reported no recurrences and a satisfactory cosmetic result in 20 cases. The author is now reporting his treatment of these lesions by skin excision when necessary, complete dorsal joint debridement and synovectomy, with skin flap closure.
ClidCd Material. During the period 1970 to 1973, 18 patients With 22 mucous cysts of the fingers were surgically treated. All had X-ray evidence of hypertrophic or degenerative arthritis of varying degrees in the involved joint. Frequently the other distal joints, and occasionally the middle joints, also had arthritic changes. Generally (15 of 22 joints) the lesions had mild symptoms of soreness, aching and tenderness. Some of the cysts had ruptured either spontaneously or from trauma. Others had been 118
MUCOUS
CYSTS
OF THE
119
FINGERS
One had previously been opened by another physician or by the patient (8 of 22). excised, recurring within a month. Age ranged from 45 to 77 years. The cysts occurred in the dominant hand of IO patients, the non-dominant hand in 6, and bilaterally in 2. One of the patients had 4 different digits involved, as well as a ganglion of the wrist. The thumb was involved 6 times, the index 6, the middle 7, the ring I, and the little finger 2. There were 12 females with 16 mucous cysts and 6 males with 6 cysts. Surgical Treatment. Under block or general anaesthesia and tourniquet control a dorsal, proximally based, tongue shaped flap is elevated with the distal limit of the incision centred over the cyst (Fig. I). If the skin over the cyst is quite thin, it and an approximately equal width of adjacent skin at the end of the flap are excised, the line of excision being angled proximally on the opposite side if the cyst is situated over the base of the nail (Fig. 2).
56
FIG. I.
Routine
skin incision.
FIG. 2.
Incisions
for skin excision.
The cyst can frequently be exposed without rupture and followed into the joint. Extension of the cyst proximally along or under the extensor tendon has been observed. In I patient it extended to the level of the proximal interphalangeal joint. The dorsal and dorso-lateral aspect of the distal interphalangeal joint is debrided, exostoses contoured, lifting up the extensor insertion and carefully removing excess bone there if necessary, thickened capsular tissues removed, and a synovectomy performed. Occasionally smaller cysts are found on the involved and/or opposite side of the joint. In addition to those grossly seen, the pathologist in 3 instances reported The operative field is irrigated, bleeding points “several cysts ” in the specimens. controlled, and closure accompanied with interrupted and continuous 6/o nylon. When skin has been excised the flap is advanced distally. This is easily done, although it may require more proximal extensions of the lateral incisions to just distal to the middle joint. The finger is dressed with Vaseline gauze, plain gauze and Tubegauz. At IO days the dressing and sutures are removed and the patient started on gradual use.
120
BRITISH JOURNAL
OF PLASTIC SURGERY
Results of Treatment. All wounds healed primarily. There have been no recurrences. Cosmetic improvement of the region of the joint was achieved in many of the cases. Seven of the 22 joints had a decreased range of motion, averaging 20'. This was not related to the severity of the arthritis found on the pre-operative X-rays. One patient regained normal motion post-operatively, but a year later developed pain, loss of motion, and X-ray evidence of increased degenerative changes. Patients complained of minor tenderness or soreness in 5 of the 22 operated joints. These had also been symptomatic before operation. CONCLUSION
This approach offers an easy method of skin cover, especially when treating thinned out skin over a cyst, improvement in the joint contour, investigation of both sides of the joint, and removal of any other cyst(s) which may exist. The chief disadvantage is loss of motion in approximately 30 per cent of the joints, averaging 20~. Clinically and functionally this was of little consequence in a distal joint; however, if the joint cannot be fully extended, it may be unsightly. I wish to express my thanks to William C. Crabb, M.D., for his encouragement and helpful criticism in preparing this paper. REFERENCES C. R. (1947). Longitudinal grooving of the nails caused by synovial lesions. Arches of Dermatology and Syphilology, 55, 828. ARNER, O., LINDBLOM, A. and ROMANUS, R. (1956). Mucous cysts of the fingers. Acta Chirurgica Scandinavica, III, 314. BARNES,W. E., LARSEN, R. D. and POSCH, J. L. (1964). Review of the ganglia of the hand and wrist with an analysis of surgical treatment. Plastic and Reconstructive Surgery, 34, 570. BOURNS,H. K. and SONERKIN,N. G. (1962). Mucoid lesion (mucoid cysts) of the fingers and toes. Clinical features and pathogenesis. British Journal of Surgery, 50? 860. BOYES,J. H. (1970). In “Bunnell’s Surgery of the Hand”, 5th Edition, p. 675. Philadelphia: J. B. Lippincott Co. CONSTANT, E., ROGER, J. R., POLLARD, R. J., LARSEN, R. D. and POSCH, J. L. (1969). Mucous cysts of the lingers. Plastic and Reconstructive Surgery, 43, 241. EATON, R. G., DOBRANSKI,A. I. and LITTLER, J. W. (1973). Marginal osteophyte excision in treatment of mucous cysts. Journal of Bone and Joint Surgery, SSA, 570. ELIASON,A. and FRANK, S. B. (1942). Pathogenesis of synovial lesions of the skin. Archives of DermatoloPv and Svahilolo~v. ~6. 691. JOHNSON,W. C.,--GRAH&; J. H.-and ~%E~WIG,E. B. (1965). Cutaneous myxoid cyst. A clinopathological and histochemical study. The Journal of the American Medical Association, xgr, 15. KING, E. S. J. (1951). Mucous cysts of the fingers. Australian and New ZealandJournal of Surgery; 21, 121. KLEINERT, H. E., KUTZ, J. E., FISHMAN, J. H. and MCGRAW, L. H. (1972). Etiology and treatment of the so-called mucous cyst of the finger. Journal of Bone andJoint Surgery, 54-4, 1455. MILFORD, L. (1971). “The Hand”, p. 248. St. Louis: C. V. Mosby Co. NEWMEYER, W. L., KILGORE, E. S. and GRAHAM, W. P. III (1974).Mucous cysts: the dorsal distal interphalangeal joint ganglion. Plastic and Reconstructive Surgery, ~3~ 313. ORMSBY, 0. S. (1913). Synovial lesions of the skin. Journal of Cutaneous Diseases, 31, 943. POSCH, J. L. (1966). Soft tissue tumors of the hand, in “Hand Surgery”, edited by Flynn, J. E., pp. 1012, 1016. Baltimore: Williams and Wilkins Co. ANDERSON,
