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CASE REPORT
An Unusual Cause of Pain In The Finger
A.Manohar

Department of Surgery, University Putra Malaysia, Kampus Klinikal, Jalan Masjid 50856, Kuala Lumpur,Wilayah Persekutuan, Malaysia,

Address for Correspondence

A. Manohar, Department of Surgery,
University Putra Malaysia, Kampus Klinikal,
Jalan Masjid 50856, Wilayah Persekutuan, Malaysia.
Phone: 60320501014
Fax: 60320501014.
Email: manohar.arumugam@gmail.com

Abstract

Ganglions are the most common soft tissue tumour of the hand1. Ganglion of the proximal interphalangeal joint however, is rare. Lack of knowledge of this condition caused delayed treatment of this patient. We report here a case of a ganglion of the proximal interphalangeal joint in a 43 year old Malay lady who was initially misdiagnosed.
Key words: ganglion, proximal interphalangeal joint, synovial cyst, swelling

J.Orthopaedics 2006;3(4)e23

Introduction:

Ganglions are the most common soft tissue tumour of the hand. They are most prevalent in women and generally occur between the 2nd and 4th decades of life 2. Ganglions of the wrist are easily recognized whereas ganglions of uncommon joints such as the proximal interphalangeal joint are easily missed as they are rare.

Case Report

A forty-three year old Malay lady presented to the Orthopaedic clinic with a one month history of  pain and swelling over the dorsal aspect of the proximal interphalangeal joint (PIPJ) of the right middle finger following a trivial injury to her finger. The swelling had progressively increased in size after the injury and she was unable to flex the finger fully, however extension of the finger was unaffected.

An X-ray did not reveal any abnormalities and she was diagnosed to have ligament strain. She was treated conservatively with analgesics, but as her problem persisted, she continued to seek other medical opinions before presenting to the Hand Clinic a year later with the same complaint.

Physical examination
There was minimal swelling over the proximal interphalangeal joint, and on palpation of this area, there was tenderness over the ulna aspect of the right middle finger. She was unable to flex the effected finger fully. There was no weakness of the fingers nor was there any loss of sensation.

Radiographic findings.
X-Rays were unremarkable.

Diagnosis
Pre-operatively a diagnosis of glomus tumour of the right middle finger was made. The differential diagnosis considered were ligament sprain, proximal interphalangeal joint (PIPJ) synovial cyst and thrombosis of the palmar digital vein.

Treatment
Excision biopsy was carried out on the right middle finger. An incision was made along the medial side of the right PIPJ of the right middle finger. A mass measuring 0.1cm X 0.3cm which was bluish black in color was found adherent to the surface of the bone. The mass was removed completely, haemostasis was secured and the wound was closed using Ethilon 6/0 sutures. Post operatively, the patient was treated with a one week course of antibiotics (Cloxacillin 500mg QID) and analgesics as needed.

 

 Figure 1   Swelling over ulna aspect of Right middle finger


 

 

Figure 2   Ganglion arising from  PIP joint of Right middle finger

 

Discussion :

Ganglions of the proximal interphalangeal joints are uncommon2,3. Although trauma has been postulated as an inciting factor, the cause of the ganglions is actually unknown.3. Cheng et al3 reported 4 patients with this condition who were more than 65 years of age. Three of these patients were treated by aspiration and one was surgically treated. Busch et al2 reported six similar cases, all of whom were surgically treated. Our patient was only 43 years old. She was treated surgically and her symptoms resolved after excision of the ganglion with no recurrence to date.

Ganglions of the PIPJ usually arise from the joint capsule between the lateral band and the central slip and communicate with the joint by means of a stalk2. The lesion usually presents on the ulnar aspect of the extensor mechanism2, and this was also seen in our patient. Though small, they may interfere with joint motion. Treatment options of this condition include observation, aspiration and surgical excision1. In most cases, observation is acceptable. Indications for more aggressive treatment include pain, interference with activity, nerve compression and imminent ulceration. The recurrence rate after aspiration is 50% for cysts in most locations, whereas recurrence after surgical excision is only 5% if the stalk of the cyst along with the small portion of the capsule is removed1.

Our patient was treated surgically as preoperatively the lesion was rather small and the diagnosis was not clear; furthermore as the margins of the swelling were not well defined aspiration of the lesion was not attempted. The surgical outcome was satisfactory.

The awareness of this rare condition will be helpful in making an early and accurate diagnosis.

Reference :

  1. Thornburg LE (1999). Ganglions of  Hand and Wrist. Journal of American Academy of Orthopaedic Surgery, 7(4): 231-8.

  2. Busch CC, Cable BM, Dabezies EJ (2000). Ganglion of the proximal interphalangeal joint. Orthopaedics  23(8):839-40.

  3. Cheng CA, Rockwell WB (1999). Ganglions of the proximal interphalengeal joint. American Journal of Orthopaedics , 28 (8): 458-60

 

This is a peer reviewed paper 

Please cite as : A.Manohar : An Unusual Cause of Pain In The Finger

J.Orthopaedics 2006;3(4)e23

URL: http://www.jortho.org/2006/3/4/e23

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