One of the most common soft tissue swellings of the hand and wrist, tendon sheath cysts are cystic masses that occur in the joint or tendon sheath and contain fluid. Although tendon sheath cysts are benign lesions, they can cause pain, weakness and loss of function, and many patients seek medical attention for aesthetic reasons or because of concerns that they may be malignant.
Tendon sheath cysts can occur in individuals of all ages, with the most common occurring between the ages of 10-40 and slightly more common in women. The most common location is dorsal to the wrist (70% of cases), and most dorsal wrist tendon sheath cysts can be found to originate from the radial lunate ligament by tracing them along the “stalk”. These cysts may be unicompartmental or multicompartmental in nature. The second most common site of tendon sheath cysts in the hand is the palmar aspect of the wrist (20% of cases), located in the small polygonal osteoarthrosis of the navicular bone.
Examination
On physical examination, tendon sheath cysts may present as significant swelling or may present only as arthralgia (especially wrist pain). The cyst is usually tough, smooth, round, elastic, and sometimes painful to the touch. Patients may notice a change in the size of the cyst over Time. Occasionally, cysts can compress and cause nerve entrapment, resulting in loss of sensation and/or movement.
If the cyst is easily palpable, an outpatient fluoroscopy can easily differentiate a tendon sheath cyst from a solid tumor: a positive fluoroscopy for a tendon sheath cyst and a negative fluoroscopy for a solid tumor.
Ultrasonography can be used to help diagnose tenosynovial cysts. Most tendon sheath cysts are well-defined, thick-walled, and echogenically enhanced. Solid-appearing tendon sheath cysts, although uncommon, may be cool and resemble benign tumors.
In patients with occult wrist pain, magnetic resonance imaging can distinguish most tendon sheath cysts from other types of masses.
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Ultrasound (click for larger image)
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MRI examination
Differential diagnosis
Tenosynovial cysts of the wrist are distinguished from the following diseases ?
- Giant cell tumor of the tendon sheath – A giant cell tumor of the tendon sheath is a tough, fixed mass that usually occurs on the surface of the flexor tendons of the hand. It is a fixed, enlarged mass that is opaque.
Lipoma – Lipomas of the hand and wrist may present as slow-growing, painless, mobile, soft nodules that are radiopaque.
- Infectious tenosynovitis – Infectious tenosynovitis can occur in any joint, but most often in the hand and wrist. It is characterized by diffuse swelling and pressure pain along the tendon longitudinally. Movement of the fingers usually induces pain, usually with prick or bite.
Rheumatoid nodules – Rheumatoid nodules are tough, non-tender, flesh-colored subcutaneous lesions seen in approximately 20% of patients with rheumatoid arthritis. Rheumatoid nodules may be fixed or mobile and are usually located on the surface of the extensor muscles when present on the hand or wrist.
- Gout stones – In patients with gout, uric acid deposits can cause hard, subcutaneous nodules. They usually originate at the edges of the joints, and those close to the skin surface may be yellow in color with erythema on the skin surface. Although gout stones can occur in any location, they can be observed in the hands and wrists.
Treatment
- for patients who are asymptomatic or do not want any intervention, we recommend reassurance and observation. more than 50% of patients may experience spontaneous regression of tendon sheath cysts without intervention.
- For symptomatic patients, aspiration of the tendon sheath cyst may be performed. However, patients should be informed that more than half of the tendon sheath cysts treated with aspiration will recur within approximately 1 year.
With personal observation follow-up, even those that recur will improve (become smaller) after aspiration. With aspiration alone, without fixation and without injection of drugs (glucocorticoids), aspiration of tendon sheath cysts does not cause complications.
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Before and after aspiration
- For patients with persistent or recurrent symptoms after initial conservative treatment, surgical treatment is recommended. Surgical removal of a tenosynovial cyst requires both the cyst and its stalk to be removed and, if it is connected to the joint, the tip to be ligated.
Surgery is usually quite effective, but if it is not done correctly, the tendon sheath cyst may recur after surgery. Approximately 10% of cases recur after surgery. Potential complications of surgery include infection, decreased joint mobility, tendon damage, neurovascular damage, and unsightly scarring.
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