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Common benign masses of the hands and wrists
Caring for Your
Hands
M
Common benign masses are categorized
generally as cystic masses, bony masses,
or soft tissue masses. Cystic masses form
around joints or tendons and are filled with
the fluid that lubricates these structures.
Most bony masses are arthritic masses associated with joints. Soft tissue masses are less
common, but may occur due to tissue con10 ORTHOPAEDIC EXCELLENCE
Mucous cysts are ganglion cysts composed
of fluid from the finger joints closest to the
finger nails. These cysts tend to arise on the
back of the fingers close to the base of the
fingernail. They may cause marked thinning
of the skin and occasionally will burst spontaneously and drain a clear mucoid substance.
Some may cause a linear ridge within the nail
due to pressure from the mass on the tissue
that makes the fingernail. Arthritic joints are
more susceptible to these masses; X-rays often
reveal bone spurs near the masses.
Retinacular cysts are fluid-filled masses
that arise from the sheath enclosing the tendons on the palm side of the hand. One feels
them as pea-sized (or smaller) firm masses
at or adjacent to the skin crease on the palm
side of the hand where the fingers meet the
palm. They are immobile and are quite tender with applied pressure.
By Ryan Karlstad, MD
asses on the hands and wrists are
a frequent source of anxiety for
patients and represent a common
reason for consultations with hand surgeons.
The masses may grow rapidly in size, become
painful, and limit function. Fortunately, the
vast majority of hand and wrist masses are
benign and cause more annoyance than harm.
However, malignant masses should be treated
aggressively. They may be characterized by
resting pain, overlying skin changes, loss of
motion, or sensory loss. A physician should
address any mass with these properties.
the wrist, usually on the thumb side. Dorsal
wrist ganglions may be more visible with
wrist flexion, and both can be painful with
pressure or rigorous use of the hands and
wrists or at the extremes of wrist motion.
Like all cysts, they may fluctuate in size. The
overlying skin retains a normal appearance.
Ganglions associated with tendons most
commonly are seen on the back of the hand.
They move (as the tendons do) with flexion
and extension of the fingers.
tracture or trauma. Some examples of common benign masses of the hand and wrist
are described below. This list is by no means
exhaustive, but it does represent some of the
most frequently seen masses in a normal
hand surgical practice.
Cystic Masses
Ganglion cysts are the most common soft
tumors of the hand, accounting for up to 70
percent of all hand and wrist masses. They
are fluid-filled masses that arise around
joints or tendons. Ganglion cysts contain
fluid that lubricates these structures that has
expanded through a weak area in the tissue
that normally encapsulates the fluid.
Dorsal wrist ganglions most frequently occur
on the back of the wrist. Volar (or palmar)
wrist ganglions (the second most common
site of occurrence) arise on the palm side of
Depending on their nature and symptoms,
cystic masses can be treated with observation and oral anti-inflammatory medications,
aspiration and/or injection of steroid, or
surgical excision. Cyst aspiration is a simple
office procedure, but the recurrence may be
high because the mass may simply refill with
fluid. The outdated practice of hitting ganglions (historically known informally as “Bible
bumps”) with a book or other heavy objects
is not advised. Surgical excision has a low
rate of recurrence (less than 10 percent) but
is a more invasive procedure done in an
operating room or minor procedure room.
Bony Masses
Arthritic bone spurs occur as a natural
result of degenerative changes that occur
with use of the hands throughout life. The
joints closest to the fingernails are most
affected (these bumps are known as Haberden’s nodes), but frequently are seen
around the middle joints of the fingers as
well (aka Bouchard’s nodes). The spurs are
rarely painful at rest but can be a source of
tenderness. They may be associated with
degenerative cysts (see mucous cysts above)
and joint stiffness. Treatment generally involves relieving joint pain and stillness rather
than mass excision. However, excision of the
masses can be performed if these bones are
especially prominent and prone to injury.
Soft Tissue Masses
Dupuytren’s nodules are firm soft tissue
nodules in the palm that result from a focal
contracture of the leathery tissue lying just
beneath the skin. They might be associated
with areas of skin “pitting.” A patient with
Dupuytren’s is typically male with northern or central European ancestry. The palmar
“Common benign masses are categorized generally as cystic
masses, bony masses, or soft tissue masses.”
– Ryan Karlstad, MD
Metacarpal boss (a word for “bony protuberance”) is a bony mass on the back of the
hand where the hand intersects with the
wrist. The mass occurs in line with the index
and/or middle fingers. It may appear more
prominent with wrist flexion. They are usually asymptomatic but may cause a painful
irritation of the overlying tendons. No treatment is generally necessary for asymptomatic
metacarpal bosses, but those associated with
tendon irritation are likely to respond to steroid injections or surgical excision.
skin at the base of the ring and small fingers is generally involved, and sometimes
the web space between the thumb and
index finger may also be involved. The
nodules may coalesce into a band to cause
a contracture that prevents full extension
of the affected fingers. The masses may be
mildly tender, but most are painless. Their
natural history is unpredictable — some
may progress rapidly while others remain
static for years. Treatment for Dupuytren’s
is generally symptomatic unless tenderness
over the mass or contracture limits function. Surgical excision can be complicated
by recurrence or disease progression in
other digits. Postoperative therapy (including splinting) is generally necessary in advanced cases.
Masses often cause concern, especially
when painful. Most can be diagnosed by
appearance and location alone. Some require biopsy for diagnosis. Consult your
physician if you notice overlying skin
changes, rapid change in mass size, resting
pain, numbness, or loss of function. OE
Ryan R. Karlstad, MD, graduated
from Johns Hopkins School of Medicine,
completed internship and orthopaedic
surgery residency at the Mayo Clinc,
then took fellowship training in hand
surgery at UCLA Medical Center. Dr. Karlstad
is board-certified in Orthopaedic Surgery by the
American Board of Orthopaedic Surgery with a
Certificate of Added Qualification in Hand Surgery.
He is a member of the American Academy of
Orthopedic Surgery, American Society for Surgery of
the Hand, and American Medical Association.
ORTHOPAEDIC EXCELLENCE 11