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Digital mucinous pseudocysts.

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997
DIGITAL MUCINOUS PSEUDOCYSTS
JOHN A. GOLDMAN, LEON GOLDMAN, MURRAY S. JAFFE, and DANIEL F. RICHFIELD
Thirty-one patients with 46 digital mucinous
pseudocysts are reviewed. The pseudocysts are usually
soft, fluctuant, dome-shaped, dimpled, smooth lesions located near and often associated with a linear defect of the
fingernail. Transillumination confirms the diagnosis.
Treatment is conservative, usually consisting of intralesional injections. If surgery is necessary, distal interphalangeal joint injection of methylene blue aids in complete removal by identifying the mesothelial-lined pedicle
leading from the distal joint to the pseudocyst.
patients with digital mucinous pseudocysts and correlates the management for practicing rheumatologists.
Digital mucinous pseudocysts are commonly
seen in rheumatology practice, but the most pertinent
literature is found in nonrheumatology publications.
These lesions are commonly located on the finger near
the nail, where they can be associated with a linear atrophic nail defect (Figure 1). This paper reviews 31
RESULTS
From the Department of Medicine, Emory University School
of Medicine, and Emory University Clinic, Atlanta, Georgia, and the
Departments of Dermatology, Surgery, and Pathology, University of
Cincinnati Medical Center, Cincinnati, Ohio.
John A. Goldman, M.D.: Associate Professor of Medicine,
Division of R heumatology-Immunology, Emory,.University School of
Medicine; Leon Goldman, M.D.: Professor and Chairman, Department of Dermatology, University of Cincinnati Medical Center; Murray S.Jaffe, M.D.: Clinical Associate Professor of Surgery, University
of Cincinnati Medical Center; Daniel F. Richfield, M.D.: Clinical
Associate Professor of Dermatology, and Clinical Associate Professor
of Pathology, University of Cincinnati Medical Center.
Address reprint requests t o John A. Goldman, M.D., Department of Medicine, Emory University Clinic, 1365 Clifton Road, N.E.,
Atlanta, Georgia 30322.
Submitted for publication August 19, 1976; accepted November 10, 1976.
Arthritis and Rheumatism, Vol. 20, No. 4 (May 1977)
MATERIALS AND METHODS
Thirty-one patients were examined from 1964 through
1976, and 46 pseudocysts were documented and treated. Lesions were seen in older patients, especially women, and were
treated with various procedures (Table 1 ). Those removed
surgically were examined with Hematoxylin and Eosin, periodic acid-Schiff (PAS), and Giemsa stains.
Clinical Data
Of the 31 patients, most had osteoarthritis or no
joint complaints (Table 1). Although most of the
pseudocysts were located on a finger near the nail, some
were found proximally on the finger away from the nail,
occasionally directly over a Heberden’s node. Two
patients had lesions on their feet. Although most appeared to have a single cystic prominence on clinical
examination, 5 were multilobulated.
The lesions were usually soft, fluctuant, dimpled,
dome-shaped, and smooth-surfaced. Occasionally a verrucose surface or apparent solid tumor was noted.
Transillumination correctly identified the cystic nature
of the lesions, especially when they were not in characteristic locations or deep in the tissue (Figures 2 and 3).
Transillumination also identified multiple lobes when
present. The third finger was the most frequently involved on each hand (Table 2), and three pseudocysts
998
GOLDMAN ET AL
Fig 1. A murinous pseudocyst is visible adjacent to the nail of the middle
finger. Note the adjacent fingernail deformity.
were seen on the toes. Nail deformity was a good clinical
clue to the appropriate diagnosis.
Most patients had noted the pseudocysts for
years to months (Table 3). They had varying symptoms
including pain and tenderness. Sometimes the nail deformity was the patient’s most distressing symptom.
Some developed their Heberden’s nodes months to years
after first noting their pseudocyst. Only 1 had a history
of trauma to the finger.
Fig 2. Mucinous pseudocysi presenting as a cystic tumor away from the
fingernail. over the lateral portion of the distal interphalangeal joint.
Therapy
Most patients were initially treated with incision
and drainage, followed by application and/or intralesional injection of corticosteroid preparations. The
insoluble suspensions were used (Kenalog, Decadron
LA) after aspiration or removal of the jelly-like contents
of the pseudocyst through a proximal incision. Pressure
was maintained until Cordran tape was applied as
tightly as possible over the lesion. The dressings were
changed daily, and either Cordran tape or a potent
corticosteroid cream with a tight Band-Aid was applied.
This treatment was continued for 2-3 weeks, after which
small Band-Aids were used to prevent trauma to the
area.
Intralesional injections and/or application of
corticosteroids were more successful than other local
treatments (Table 4). The presence of Heberden’s nodes
did not effect the outcome. Four patients with Heberden’s nodes responded to intralesional injection, 4 did
not, and with 5 there is no follow-up. Five patients
underwent simple surgical excision of the pseudocysts,
all with recurrence. Two patients with recurrences had
surgery with interphalangeal joint injection of methylene blue, which aids as a marker for complete resection. These two cases have not had further recurrences.
Table 1. Characteristics of 31 Patients with Mucinous Pseudocysts
Age
Sex ( M / F )
Osteoarthritis and
Heberden’s Nodes
N o Joint
Complaints
RA
Arthralgias
or Tendonitis
34-8 1
(mean 61)
13/18
13
12
3
3
DIGITAL PSEUDOCYSTS
Table 2 . Location of 46 Pseudocysts on the Distal Digits of the Hands
and Feet
Right hand
Digits
Pseudocysts
I
2
6
3
I1
1
6
3
4
5
Totals
27
Left hand
1
4
5
3
2
I
3
1
2
1
3
2
2
3
16
Left foot
3
46
cysts sometimes not noted clinically. After the cystic
area is identified, it is dissected off the underlying extensor tendon by sharp dissection. The methylene blue
assists in identifying the stalk during the operation, and
thus allows its complete removal with the pseudocyst. A
synovectomy of the distal interphalangeal joint is performed if necessary, and boney spurs along the joint are
removed with a rongeur.
Pathologic Findings
Fig 3. Transillutninarion using ajberopric probe directed adiacent to the
border OJ rhe cystic tunior in Figure 2 . The light is directed into the
dorsutti of the disral inrerphalangeal joinl. Nore the transmission of the
lighr rhrough the pseudocyst.
Surgical Therapy
To Prevent m ~ r r e n c after
e
SWWY, it is important to identify the Pedicle connecting the Joint to the
pseudocyst, and to dissect the entire pseudocyst as well
as this stalk which communicates with the joint. According to the technique demonstrated by Newmeyer ( l ) , the
appropriate distal joint of the finger with the mucinous
pseudocyst is injected with a mixture of methylene blue,
saline, or local anesthetic and hydrogen peroxide solution (Figure 4). After this injection, the pseudocystic
area turns dark blue (Figure 5). A flap-type incision is
then made at the base of the fingernail and dissected
back (Figure 6 ) . The interphalangeal injection of the
methylene blue solution occasionally reveals multiple
Histopathologic findings explain why these lesions are termed Dseudocysts. There was no evidence of
a cystic lining of these lesions at their upper pole. A
synovial lining was not found. Although cavities or cystic spaces were present, the circumference of the space
showed that compressed connective tissue formed the
wall. Fibroblasts lay about the periphery of the lesions.
The matrix in general was myxomatous, contained
hyaluronic acid, and had a light basophilic-staining appearance. Only along the short stalk or pedicle leading
into the joint space did we find evidence of a mesothe-
Table 3. Duration of Mucinous Pseudocysts
Years
Months
Weeks
Sudden onset
Unable to delineate
13
10
2
1
5
-
1000
GOLDMAN ET AL
Fig 6. The skin y a p is dissected backward to reveal the multiple lobes of
Fig 4. A mixture o / methylene blue, saline, and hydrogen peroxide is
injected into the distal interphalangeal joint of the finger in Figure 1.
lial-like lining (Figure 7), which has not been reported
by previous investigators. This lining, however, was not
present in the extensive upper cystic area. The identification of the stalk helped to explain the extrusion of
hyaluronic acid into the tissue of the finger and the
subsequent development as a mass simulating a cyst.
The stalk or pedicle connected the distal interphalangeal
joint to the pseudocyst.
DISCUSSION
There are numerous references in the literature to
mucinous pseudocysts, usually under the inaccurate title
Fig 5 . The methylene blue is visible in the mucinous pseudocyst. The nail
dejormiry is more apparent in this uiew.
the mucinous pseudocyst. From this point the dissection is continued, and
the stalk is located and traced back to its origin at the distal interphalangeal joint. Note the extensive network underneath the skin.
of mucous cysts or myxoid cysts of the finger (2-4). The
many other, sometimes erroneous names include synovial cysts, myxomatous degeneration cysts, periarticular
fibroma, nail cysts, cystic nodules of the finger, dorsal
cysts, and cystic nodules. These are not true cysts and do
not appear to be synoviomas. Even the Clinical Slide
Collection on the Rheumatic Diseases published by The
Arthritis Foundation identifies a digital mucinous
pseudocyst on slide No. 182 as a synovial cyst ( 5 ) .
The exact mechanism for this cystlike formation
is unknown. Many authors did not believe that there
was a communication with the joint. Arner et a1 unsuccessfully tried to identify a communication by injecting
contrast media into the cyst alone ( 2 ) . Kleinert et al
noted a stalk in all of their patients (6), and Newmeyer
et af identified the communication in all of their patients
by injecting methylene blue, saline or lidocaine, and
hydrogen peroxide into the distal interphalangeal joints
( I ). Trauma was associated with 1 of our cases and did
not appear to be constant finding in other series. Some
authors noted a very strong relationship to osteoarthritis and osteophyte formation. In Newmeyer’s
series, all the patients had hypertrophic osteoarthritis
changes with or without osteophytes ( I ). Kleinert found
that 64% of his patients had osteoarthritis of the distal
interphalangeal joint of the involved finger (6). Other
authors have not cited this frequency of association
with osteoarthritis.
Pseudocysts were commonly seen on the fingers.
Because of their closeness to the nail, they were often
associated with linear nail defects. The pressure of the
pseudocyst on the nailplate appeared to- cause the nail
DIGITAL PSEUDOCYSTS
1001
Table 4. Therapy of Mucinous Pseudocysts
Type of
Treatment
No. of
Pseudocysts
Successful
Outcome
Unsuccessful
Outcome
lntralesional injection and/or
application of
corticosteroid
41
13
18
10
Massage, local
heat or none
5
0
4
1
Simple surgical
excision
5
0
5
Methylene-blueassisted surgical excision
2
2
0
deformity. We saw the nail configuration return to normal when the pseudocyst was no longer present. I n this
series they were found proximally over the distal interphalangeal joint away from the nail, and also in the toes.
They have not been reported to be associated to other
joints of the fingers and toes. Transillumination has
been suggested as an aid in the differential diagnosis,
especially of proximal lesions or deep firm lesions (7).
Without transillumination, some of the pseudocysts
would not be diagnosed clinically.
Usually after rupture, this type of pseudocyst
recurred or rarely healed spontaneously. Spontaneous
remission, which has been reported in the literature,
occurred in 1 of our patients (4). More frequently, cysts
have recurred after intralesional injections, and after
incomplete surgical excision that did not also remove the
pedicle to the joint space. Injection of methylene blue
into the joint space allows improved dissection of these
pseudocysts. Some authors advocate the injection of
hyaluronidase rather than local steroids (8). It appears
that the best approach clinically is initial conservative
therapy and intralesional injections. Surgical excision
should be considered if these methods are not successful.
The etiology of the pseudocyst is still unclear. No
experimental studies have induced the development of
new lesions, and electron microscopic studies have not
yet been performed. The gelatinous material is felt to be
hyaluronic acid, and the communication with the joint
space can explain its presence. The mesothelial lining of
the pedicle or stalk does not continue into the tissue
mass-thus the name pseudocyst rather than cyst.
Whether these lesions can precede the presence of os-
No
FOIIOW-UP
teophytes, or occur because of the presence of osteophytes, remains to be seen. Some authors feel that the
osteophytes must be surgically removed to prevent recurrence (1,6). As we have documented, some of our
patients with clinical Heberden’s nodes responded to
local injections without recurrence of the pseudocyst.
Thus even when these osteophytes persisted, we did not
see further lesions. If surgery is performed, the stalk
should be resected, because it serves as a nidus for
recurrence if allowed to remain. This resection is important because recurrence of this lesion, no matter
what the type of therapy, is the most common problem
that all authors have noted.
kig 7. Mesothelial lining along the stalk leading from the distal interphalangeal joint space to the mucinous pseudocyst ( X SO).
GOLDMAN ET AL
1002
ACKNOWLEDGMENT
The authors thank Ms. Jennie Crook for typing the
manuscript.
REFERENCES
Newmeyer WL, Kilgore ES Jr, Graham W P 111: Mucous
cysts: the dorsal distal interphalangeal joint ganglion. Plast
Reconstr Surg 53:313-315,1974
Arner 0, Lindholm A, Romnaus R: Mucous cysts of the
fingers: report of 26 cases. Acta Chir Scand 11 1:314-321,
1956
Johnson WC, Graham J H , Helwig EB: Cutaneous myxoid
cyst: a clinicopathological and histochemical study. JAMA
191:15-20. 1965
Constant E, Royer J R , Pollard RJ, et al: Mucous cysts of
the fingers. Plast Reconstr Surg 42:241-246, 1969
Visual Aids Subcommittee of the Professional Education
Committee of the Arthritis Foundation: Clinical Slide Collection on the Rheumatic Diseases. New York, The Arthritis Foundation, 1972, slide 182
Kleinert HE, Kutz JE, Fishman J H , et al: Etiology and
treatment of the so-called mucous cyst of the finger. J Bone
Joint Surg 57A:1455-1458, 1972
Goldman L, Kitzmiller KW: Transillumination for diagnosis of mucinous pseudocyst of the finger. Arch Derrnatol
109:576, 1974
Labouche F, Lanchec C: Note on local treatment of mucoid cysts of the fingers. Bull SOCFr Dermatol Syphiligr
76:90-92, 1968
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