Derm Dx: Firm Nodule on the Hand - Clinical Advisor

Derm Dx: Firm Nodule on the Hand

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A 25-year-old white woman presents for evaluation of a growth on the dorsal surface of her left hand. The lesion has been present for approximately 5 years. She denies localized pain, paresthesia, or loss of hand coordination. The growth was drained of fluid 2 years ago but has since recurred. Examination reveals a firm nodule fixed to underlying tissue.

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Ganglion cyst is a benign soft tissue tumor that usually presents on the hand or wrist. Lesions occur most commonly in individuals aged 20 to 40 years and affect women more than men. A history of trauma is documented in...

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Ganglion cyst is a benign soft tissue tumor that usually presents on the hand or wrist. Lesions occur most commonly in individuals aged 20 to 40 years and affect women more than men. A history of trauma is documented in approximately 10% of patients. Larger cysts may lead to weakness, pain, and loss of function.1 Ganglion cysts contain a gelatinous, mucinous fluid and are thought to be the result of a herniation in dense connective tissues such as tendon sheaths, bursae, joint capsules, ligaments, and menisci. The cysts have stalks or pedicles that communicate with the underlying joint.

Patients will typically present with a firm 1- to 2-cm hand or wrist nodule. Lesions may be slightly movable and are tethered in place by the attachment to the underlying joint capsule or tendon sheath.2 Symptoms may include pain with activity or palpation, decreased range of motion, and decreased grip strength. Some volar ganglia may cause paresthesia from compression of the median and/or ulnar nerves.3

A time-honored treatment for ganglion cyst is continuous digital pressure or pressure with a book, which gives the ganglion cyst the nickname “Bible cyst.”4 However, this treatment method demonstrates high recurrence rates with inconsistent and unreliable results. Other options for treatment include watchful waiting and nonoperative aspiration with steroid injection. Surgical excision is the treatment of choice for definitive removal.2 

Lauren Ax, MSPAC, PA-C, is a PA professional from Arcadia University, and Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.

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References

  1. De Keyser F. Ganglion cysts of the wrist and hand. UpToDate website. https://www.uptodate.com/contents/ganglion-cysts-of-the-wrist-and-hand?search=Ganglion%20cysts%20of%20the%20wrist%20and%20hand&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8. Updated October 6, 2017. Accessed January 10, 2019.
  2. Gude W, Morelli V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008;1(3-4):205-211.
  3. Burke FD, Melikyan EY, Bradley MJ, Dias JJ. Primary care referral protocol for wrist ganglia. Postgrad Med J.  2003;79(932):329-331.
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