Soft Tissue Swellings Flashcards
What is a lipoma?
neoplastic proliferation of fat
What is the aetiology of lipomas?
Usually occurs in the subcutaneous fat, can occur in muscle
What is the typical presentation of lipomas
- Features suggestive of a benign soft tissue neoplasm include smaller size, fluctuation in size (malignant tumours don’t regress in size), cystic lesions, well‐defined lesions, fluid filled lesions and soft/fatty lesions
- Lipomas have a characteristic consistency, with no overlying skin changes
- Other features of lipomas: can be large (several cms), can be discreet or less well defined, slow growing and painless/ non-tender
What is the management of a lipoma?
- Based on symptoms
- Can be left alone
- Surgical excision if causing symptoms
What is a giant cell tumour of the tendon sheath?
Benign nodular tumour found on the tendon sheath of the hands and feet
What is the pathophysiology of a giant cell tumour of the tendon sheath?
- Benign regenerative hyperplasia with inflammatory process
- Can be localised (common) or diffuse (uncommon, associated with pigmented villonodular synovitis)
What is the presentation of a giant cell tumour of the tendon sheath?
- Firm, discreet swelling, usually on volar aspect of digits
- Can occur in toes
- May or may not be tender
What are the investigations for a giant cell tumour of the tendon sheath?
Imaging - x-ray, ultrasound, MRI
What does this image show?
Giant cell tumour of the tendon sheath
What is the management of a giant cell tumour of the tendon sheath?
- Leave alone if no functional issue
- Surgical excision - usually marginal excision (not complete) as tumour is adherent to tendon sheath
- Incidence of recurrence
What is a mucous cyst?
Outpouching of synovial fluid from DIP caused by early OA
What is the aetiology of a mucous cyst?
- Higher incidence in females
- 40-60 years
What is the presentation of a mucous cyst?
- Raised swelling of DIP/PIP joint or just distal to the joint (between joint crease and nail plate)
- Painful
- Always on the radial/ulnar side of the midline
- Can fluctuate in size
- Initially quite small but can increase in size and cause thinning of the skin
- If the skin becomes very thin it can rupture and produce discharge
- If it becomes particularly large it can deform the nail and cause a ridge
What is seen in this image?
Mucous Cyst
What is the management of a mucous cyst?
- May be left alone - majority of cysts will completely disappear over time
- In patients with particularly deep/cracked nail ridges, or those who are constantly discharging, consider excision
- Often needs advancement/rotation flap if larger
What is a ganglion cyst?
Outpouchings of the synovium lining of joints and filled with synovial fluid
What is the aetiology of a ganglion cyst?
The weakness can be developmental (e.g. juvenile Baker’s cyst) or as a result of underlying joint damage/arthritis with build up of pressure within the joint (adult Baker’s cyst, mucous cyst of DIP joint, wrist ganglion)
What is the pathophysiology of a ganglion cyst?
- Not a true cyst as they have no epithelial lining
- Histologically - space with myxoid material
What is the presentation of a ganglion cyst?
- Occur around a synovial joint or a synovial tendon sheath - commonly arise around the wrist, can also occur in feet and knees
- Well-defined round swellings
- <10mm - several cm
- May be quite firm and readily transilluminate
- They are usually painless/non-tender but may feel tight
- Skin mobile, fixed to underlying structures
What is seen in this image?
Ganglion cyst
What is the management of a ganglion cyst?
- Usually resolve with time but excision may be required for localized discomfort or cosmesis
- Needle aspiration may be attempted but recurrence is common
- The historic treatment of striking the wrist with a heavy book (‘bible technique’) to burst the swelling is not advised
What is a sebaceous cyst?
Slow growing, painless, mobile discreet swellings formed by blockage of the sebaceous gland
What is the aetiology of a sebaceous cyst?
Originate at hair follicles and fill with caseous material (keratin)
What is the presentation of a sebaceous cyst?
- Commonly occur on face, trunk and neck but can also occur on limbs
- Can become infected
What is seen in this image?
Sebaceous cyst
What is the management of a sebaceous cyst?
May require excision and/or biopsy
What is an abscess?
Discreet collection of pus
What is the aetiology of an abscess?
Abscesses on a limb can occur from cellulitis, bursitis, penetrating wound or infected sebaceous cysts
What is the presentation of an abscess?
- Defined and fluctuant swelling
- Erythema, pain
- History of trauma (e.g. bite, IVDU) or cellulitis
What is the management of an abscess?
- Surgical excision and drainage
- Rest, elevation, analgesia, splint
- Antibiotics
What is nodular fasciitis?
Benign proliferation of fibroblastic and myofibroblastic cells
What is the histology of nodular fasciitis?
Very cellular, lots of mitoses figures, plump cells; stellate and spindle, tissue culture appearance, haemorrhage, mature towards periphery
What is the presentation of nodular fasciitis?
- Young adults, upper extremity
- History of prior trauma at the site in 25% of cases
- Rapidly growing
- Superficial or deep
- Usually <5cm
- Usually circumscribed
What is the management of nodular fasciitis?
None - reassurance, self-liming course
What is myositis Ossificans?
Abnormal calcification of a muscle haematoma following trauma
What is the presentation of myositis ossificans?
- Initial soft swelling,
- hardness develops over several weeks
What is the investigations of choice for myositis ossificans?
X-ray and MRI - peripheral mineralisation
What is the management of myositis ossificans?
- Observation, intervene only if symptoms demand
- Must wait until maturity of ossification (6-12 months), otherwise risk of recurrence
What is bursitis?
Inflammation of the synovium-lined sacs that protect bony prominences and joints
What is the aetiology of bursitis?
- Can become inflamed after repeated pressure or trauma - may present as a soft tissue swelling
- Pre‐patellar bursitis
- Olecranon bursitis
- Bunions (bursitis over the medial 1st metatarsal head in hallux valgus)
- Can become secondarily infected and form an abscess (usually bacterial infection from a small wound on the limb)
What is the management of bursitis?
- With inflammatory bursitis the fluid component of the swelling usually subsides but a thickened bursal sac may be left
- Recurrence may occur and excision may be required but problems can occur with scarring
