Ganglion Cyst & Lipoma – Mr.

Kamarul (very common question in exam)

Short Case

Sequence of Examination: 6 S + 1 C

1. Site
2. Size
3. Shape
4. Surface
5. Skin
6. Surrounding (Edge & Mobility)
7. Consistency

Asked in exam:

If swelling is at the DIP then call it mucin cyst not ganglion.

Volar wrist ganglion: arise from radio-scaphoid joint

Dorsal ganglion: arise from scapholunate joint

Not painful

Has a high recurrence rate so have to do excisional biopsy

Aim:

1. Benign or Malignant?
2. Diagnosis - Lipoma or Ganglion Cyst?
3. Proof by special test
- If Ganglion Cyst, proof by special test
- If Lipoma, proof by special test

Sequence of Examination:

1. Site:
- Volar or Dorsum of the Wrist

- Right side or Left side of the Wrist

2. Size:
- Around 1 – 2 cm
- Any swelling < 5cm or less than size of palm (5 – 8 cm) is considered as Benign swelling.
3. Shape:
- Single & globular in shape, most likely benign swelling.
 - Multi-lobular shape, suspect the malignant swelling.
- Ganglion Cyst: single globular or spherical in shape
- Lipoma: single oblong in shape
4. Surface:
- Comment on smooth, shinny and dilated vein.
- Malignant Tumour: dilated vein
- Benign swelling, no dilated vein EXCEPT Hemangioma (Hemangioma is a benign swelling
with bluish discolouration due to dilated vein)
5. Skin:
- Pinch: pinched and try to separate it from the swelling.
Benign swelling (ganglion cyst & Lipoma) able to separate the skin from swelling.
Malignant tumour (skin stuck to swelling) unable to separate the skin from swelling.
- Skin Changes:
Benign swelling: No Peau’d orange changes
Malignant Tumour: Peau’d orange changes
- Tenderness:
Benign swelling: no tenderness
Malignant Tumour: tenderness

6. Surrounding:
Surrounding of the swelling consists of edge and underneath the swelling.

a. Edge
- How to check the edge of the swelling?
- Put index finger on normal site of skin and slide toward swelling & feel for resistance.
- Move in 4 directions:
Proximal to distal, distal to proximal, left to right side & right to left side.
- Ill-defined swelling: when you move from normal skin toward swelling will be smooth,
cannot feel the border.
e.g. Osteosarcoma, Edwing’s Sarcoma
- Well defined swelling: when you move from normal skin toward swelling will stop your
finger and feel the ridge or border.
e.g. Ganglion Cyst, Lipoma

b. Mobility
- What are the structures underneath or at the bottom of the swelling?
- Tendon, Muscle or Bone.
- Find out whether the swelling is attached to the tendon, muscle or bone by mobility.
- How to check mobility?
- Ask the patient to relax the muscle and you hold the swelling.
- Then, you move the swelling sideways and up & down.
- After that, ask patient to contract.
- Pinch the swelling to differentiate from skin and subcutaneous from tendon.
- If the swelling is at the dorsum aspect of the wrist, how to ask patient to contract?
Ask patient to extend the wrist, you apply resistant and you move the swelling.
- If the swelling is at the volar aspect of the wrist, how to ask patient to contract?
Ask patient to flex the wrist, you apply resistant and you move the swelling.
- If the swelling is at flexor compartment forearm, how to ask patient to contract?
Ask patient to flex the wrist, you apply resistant and you move the swelling.
- If the swelling is at extensor compartment forearm, how to ask patient to contract?
Ask patient to extend the wrist, you apply resistant and you move the swelling.
- If the swelling is at the biceps, how to ask patient to contract?
Ask patient to flex the elbow, you apply resistant and you move the swelling.
- If the swelling is at the triceps, how to ask patient to contract?
Ask patient to extend the elbow, you apply resistant and you move the swelling.
- If the swelling is at the deltoid, how to ask patient to contract?
Ask patient to abduct the shoulder, you apply resistant and you move the swelling.
- If the swelling is at the knee, how to ask patient to contract?
Ask patient to extend the knee, you apply resistant and you move the swelling.
- If the swelling is at the popliteal fossa, how to ask patient to contract?
Ask patient to flex the knee, you apply resistant and you move the swelling.
- The principle is you must know the muscle where the swelling located at so that you
able to contract the muscle underneath the swelling.
- How to know whether the swelling is attached to muscle or tendon or not?
During relaxation, the swelling mobile
During contraction, the swelling become less mobile
This proof that swelling is attached to muscle or tendon.
- How to differentiate whether the swelling is attached to muscle or tendon?
If there is change in mobility and size of swelling during contraction means the swelling
is attached to the muscle.
(If attached to muscle, during contraction, swelling will become less mobile, but the size
can be either smaller or more prominent)
If there is only change in mobility but no change in size of the swelling during
contraction means the swelling is attached to the tendon.
(If attached to tendon, during contraction, swelling will become less mobile, but no
different in size of swelling)
- How to differentiate whether the swelling is at superficial or inside the muscle?
During contraction, the swelling become smaller, it is inside the muscle.
During contraction, the swelling become more prominent, it is at superficial of the
muscle.
- If the swelling not mobile at all during both relaxation and contraction indicate what?
The swelling is attached to bone.
- Where does ganglion cyst arise from?
Volar Ganglion Cyst arise from Radio-scaphoid joint.
Dorsum Ganglion Cyst arise from Scapho-lunate joint.
- How was the mobility status of ganglion cyst during relaxation and contraction?
Since Ganglion Cyst arise from joint, not arise from tendon or muscle.
Therefore, mobility of ganglion cyst is the same during relaxation and contraction.
- What is the name given for ganglion cyst if located at distal interphalangeal joint?
 Mucin Cyst. (if ganglion cyst is located at distal interphalangeal joint, don’t called
ganglion cyst anymore, it is called as Mucin Cyst)

7. Consistency:
- Ganglion Cyst: Cystic
- Lipoma: Soft

Special Test
Special Test to proof Ganglion Cyst or Lipoma
(any benign swellings are needed to perform transillumination test & fluctuation test)

1. Transillumination test
- In exam you need bring a black manila card, roll it and put it on the swelling.
- Then, put your pen torch and torch it from the other site.
- Eye must be looking through the manila card and see whether can see any light coming
out through manila card or not.
- If the swelling is a ganglion cyst: can see the light because the content is fluid (fluid can
transilluminate the light)
- If the swelling is a lipoma: cannot see the light because the content is fat (fat cannot
transilluminate the light)

2. Fluctuation Test
- Put 2 fingers on top of the swelling
- Press one site of the swelling, the other finger will go up.
- In Ganglion Cyst, fluctuation test is positive because the content is fluid. (epidermoid
cyst, abscess)
- In Lipoma, fluctuation test is negative because the content is fat.

3. Slip Test (Pseudo-fluctuation Test)

- Put one finger on top of the swelling and another finger at the edge of the swelling.
- Then, press the finger on the edge of the swelling and the Lipoma will move
- Once, the lipoma moved, another finger which is on top of the swelling will go up.
- It looks similar like fluctuation test but faking it because you press at the edge of the
swelling not directly on the swelling.
- That’s why is called Pseudo-fluctuation Test

After complete the examination, examiner will ask the candidate a few questions:
Question 1: What are this swelling is? Benign or Malignant?
Answer: Benign

Question 2: If benign swelling? What type of swelling is this? Lipoma or Ganglion Cyst?
Answer: Ganglion Cyst

Question 3: If it is Ganglion Cyst, what are special test you can performed to show us it is a Ganglion
Cyst?
Answer: Transillumination Test, Fluctuation Test
Additional Test to check for Ganglion Cyst

Allen’s Test : if patient comes with a radial artery or ulnar artery cut, in surgery we have to know
which artery is the dominamt cause need to ligate, most commonly, radial artery is the dominant.

(Allen’s Test can only be done if the swelling is at the Volar aspect, very near to the radial artery. If
the swelling is at the dorsum, you don’t have to do)

How to do Allen’s Test?

- ask patient to open and closed hand until hand become white.
- Then, you hold the wrist (one finger at the radial site and another finger at the ulnar side)
- Then, ask patient to open his or her palm will show white colour.
- Then, release the radial artery and see whether the return of the peripheral blood perfusion is fast
or slow.
- Then, repeat again the same step.
- Now, release the ulnar artery and see the reperfusion rate of the palm is it the same as reperfusion
as radial side or different?
- If reperfusion rate at the radial site is slower mean the swelling is compressing the radial artery.
Then, you need to do an MRI scan.
- If reperfusion rate is equal on the radial site and ulnar site mean the swelling not compress on the
radial artery. Then, no need to do MRI scan.

Investigation
Laboratory Investigation:
(depend on the age)
1. Routine Blood Investigation
2. ESR, CRP (NO NEED because the both ganglion cyst & lipoma are benign)
3. Tumour markers (NO NEED unless you think the swelling is malignant)
Radiological Investigation:
1. X-ray (No Need)
2. Ultrasound (Yes. To confirm the content. If the content is fluid, you can see from the
ultrasound but the content is not fluid, you cannot see.)
3. CT scan (No Need)
4. MRI scan (No Need. Unless if the swelling is very near to the radial artery.) for lipoma mri is
diagnostic. If swelling is more than 5cm must rule out cancer with biopsy, must do mri first
then biopsy. Bcause to avoid hitting any neurovascular supply. After biopsy, there will be a
hematoma so can be misterpreted as cancer in the mri.

Treatment:
Non-operative (Non-surgical):
a. Medication (No Need)
b. Immobilization (No Need)
c. Physiotherapy (No Need)
 d. Injection
- Ganglion Cyst: aspiration of fluid & inject of corticosteroid
However, why patient no advice for aspiration & injection?
Because the problem with aspiration & injection will have very high recurrence rate.
Which one will have higher recurrence rate? Volar or Dorsum?
Dorsum (60% recurrence rate), Volar (40% recurrence rate)
That’s why ganglion cyst definitive treatment is Surgery, not aspiration.
- Lipoma (No Need)

Operative (Surgical):
a. Surgery
Excision Biopsy
(Excise, send specimen to the lab for histopathology study & get the result)
Lipoma
- If capsulated Lipoma (incision & remove it)
Ganglion Cyst
- Ganglion Cyst has head and neck
- Neck is within Wrist joint (either radio-scaphoid or scapho-lunate joint)
- Thus, when remove ganglion cyst must remove together with the neck, cannot just
remove the head only because it will get recurrence.
- Therefore, after remove the head of the ganglion cyst, you need to ligate the neck, so
that, it will not get recurrence.