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55 years old female, index, progressive apparition

a finger mass, isolated lesion, no pain

?

Can you describe this lesion and tell us
what is your diagnostic ?

Clinical element for diagnosis

Soft-tissue tumor (≈

0,5 cm diameter)

Around the DIP, most often between
the joint line and the proximal nail
wall

Independent from the skin but
thinning of the it

Fixed to the underlying structures

Usually slightly lateralized

Other clinical presentations

Epidemiology

1rst description by Hyde in 1882

Mean age between 50-70 (from 20 to > 100 years)

Mostly female: Sex ratio 2-2,5 / 1 (70% of females)

90% at the DIP (10% at the toes)

Most frequent on the index and middle finge

This is also a
mucous cyst

Anderson (1947) 1st reported
that mucous cyst could induce
nail plate deformities

20-40% of cases

Due to pressure of the cyst of
the nail matrix

What is the distance between the
distal fibers of the extensor
tendon and the proximal part of
the nail matrix ?

Qu
esti
ons

?

?

What is the actual length of
insertion of the extensor tendon
at P3 level ?
1 mm
1,2-1,4 mm
1,6-1,8 mm
>2 mm

What is the distance between the
distal fibers of the extensor
tendon and the proximal part of
the nail matrix ?
1,4 mm

A

s
n

r
e
w

What is the actual length of
insertion of the extensor tendon
at P3 level ?
1,2-1,4 mm

?
Mucous cyst: what else could it be ?

Differential
diagnosis

Heberden’s node

Cyst

Heberden’s node, that can also
be associated lesion

William Heberden

Personal physician of the Queen (of England)
1rst description of angor (angina) in 1768
✤ « The physician should be guided….by his
observations ».
✤ Took notes at the bed of the patient, in
Latin … notebook
Stecher 1940 : made the link between
Heberden’s nodes and arthrosis
William
Heberden
(August 171017 may 1801)

Is there a relation between finger
arthrosis and mucous cyst ?

Frequency of osteophytes.

72% (Kleinert)

74% (Chaise)

84% (Roulet)

93% (Fritz)

How frequent are they ?

Mucous cyst are classified with
synovial tumors
These lesions represent about
70% of all soft-tissue tumors of
the hand

Wrist ganglia

Mucous cyst

Synovial cyst of flexor sheath

1714 hand tumors at the Institut de la Main
Synovial Cyst 1024
Mucous cyst
192
Giant cell tumor 173
Glomus tumor
79
Chondromas
73
Schwannomas
44
Epidermoid cyst 41
Fibromas
23

Divers 3%
Nerf 3%
Lipome 4%
Glomique 5%
Vasculaire 5%
SNVP 10%

K.mucoïde
11%

K.synovial
59%

Physiopathology: what would you
explain to patients ?

Physiopathology:
not well understood

Theory of the synovial
hernia (Kleinert 1972,
Newmeyer 1975, Eaton 1973)

Frequent communications
with the joint, sometimes a
small conduit is visible,…

But no lining cells are
present in the cyst, …

Physiopathology

Theory of the fibroblastic metaplasia
is preferred (Ledderhose 1893,
Ritschel 1895, Carp & Stout 1928,
Johnson 1965, Angélides 1976) .

Secondary to various trauma
(osteophytes, articular
hyperpressure), capsular fibroblasts
secrete mucines in the peri-articular
tissues

Clinical diagnosis can sometimes be
more difficult

Mucous cyst with proximal
growth without skin thinning

Mucous cyst over the proximal
nail matrix with evolution by
episodes realizing this deformity

The mucous cyst is not visible and
there is only a nail plate dystrophy.
Diagnosis can be made by puncture

In case of development under
the nail matrix, only nail
dystrophy is present

association of a mucous cyst over AND under the nail matrix !

What is the recurrence rate of
digital mucous cyst after aspiration ?
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%

?

What is the recurrence rate of
digital mucous cyst after aspiration ?
A. 20%

B. 40%
C. 60%
D. 80%
E. 100%

Rizzo reported a 40% and Dodge a 36% recurrence rate
Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the
fingers; a review of 134 cases with minimum 2-year follow-up
evaluation. J Hand Surg Am. 2003;28(3):519- 524.
Dodge L, Brown RL, Niebauer JJ, McCarroll R. The treatment of
mucous cysts: Long- term follow-up in sixty-two cases. J Hand
Surg Am. 1984;9(6):901-904.

Which surgical treatment will you
choose ?

Cyst excision

Cyst excision with ligation of the pedicle

Excision of the osteophytes

En-bloc excision of the cyst and the
overlying skin with coverage by a
flap

DIP arthrodesis = Radical treatment

En-bloc excision of the cyst and
the overlying skin with
coverage by a skin graft

Cyst simple Excision ?

NO: > 20% of recurrences - to be abandoned

Year

Nbr cases

Type of surgical treatment

% Reccurence

CONSTANT

1969

42

Excision
Excision with skin graft

25%
3%

DODGE

1984

62

Excision simple

28 %

CRAWFORD

1990

37

Excision simple
Excision + rotation flap

25 %
8%

Cyst Excision with ligation of the
pedicle

Proposed by De Berker, English dermatologist with a
large experience

6% recurrence (fingers), 40% (toes)

(But he also realizes something which is close to a
local flap)

Should we excise the cyst ?

Gingrass: Not always - 18 complete healing of nail
deformity over 20 cases, without recurrence at 3 years
while they had a 36% of persistent nail deformity
when they tried to remove the cyst

Roulet : Yes, always

Gingrass MK, Brown RE, Zook EG. Treatment of fingernail deformities secondary to ganglions of the distal interphalangeal
joint. J Hand Surg 1995;20A:502–505.
Roulet S, Marteau E, Bacle G, Laulan J. Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection:
Results in 68 cases at a mean 6.63 years’ follow-up. Chirurgie de la main 2015; 34:197–200

Osteophytes removal ?

Most authors consider that
« articular debridement » is a very
important step

Capsulectomy, osteophytes
removal, articular lavage,…

Some authors only do that with a
1,5% recurrence rate (Roulet)

Roulet S, Marteau E, Bacle G, Laulan J. Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection:
Results in 68 cases at a mean 6.63 years’ follow-up. Chirurgie de la main 2015; 34:197–200

What about skin coverage ?

Secondary healing or simple skin sutures does not
prevent healing

Many authors consider that a « plastic technique of
coverage » is mandatory to reduce the recurrence rate

Others consider it useless (Rizzo)

Rizzo M, Beckenbaugh RD. Treatment of Mucous Cysts of the Fingers: Review of 134 Cases With Minimum
2-Year Follow-Up Evaluation. J Hand Surg 2003;28A:519–524

Year

Nbre cases

Type of surgical treatment

% Recurrence

CONSTANT

1969

42

Excision simple
Excision with skin graft

25%
3%

KLEINERT

1972

36

Excision with local flap

0 %

DODGE

1984

62

Excision simple

28 %

CRAWFORD

1990

37

Excision simple
Excision with local flap

25 %
8%

CHAISE

1994

100

Excision with skin graft

2 %

YOUNG

1999

6

Excision with bilobed flap

0

de BERCKER

2001

47

Excision + flap + ligation of the pedicle

6 %

BLANC

2004

27

Excision with bilobed flap

3,7 %

Complications

N = 86 mucous cyst excised

Extension lag : 17%

Persistant nail deformity :
40%

Infection : 3%

Recurence : 3%

Conclusion

Frequent lesion

Most frequently needs a surgical treatment

Good results can usually be obtained, but…
Primum non nocere
Hippocrate: Traité des Épidémies (I, 5) 410 bc defined the goal of
medicine : « to have, facing diseases, two goals: be useful or at least
do not harm » (« ἀσκέειν, *ερὶ τὰ νουσή2ατα, δύο, ὠφελέειν, ἢ 2ὴ
βλά*τειν »).