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Healthy male, 40, presented with a "lump" of 1 month duration, approx. 1 cm prox to the 1st met head along the medial border of the 1st met. "lump" has been present for approx. 2-4 weeks, never painful & has not currently changed in size. The "lump" is approx. 1cm diam, not adhered to skin, less obvious when hallux plantarflexed, more obvious when dorsiflexed. The "lump" is very soft & the strange thing for me at least is that with pressure, the lump completely disappears i.e. no longer seen or felt & may take many hours to recur.

My first thought was a ganglion/cyst but is this disappearance with pressure something seen with cysts? I'm gathering the cysts/ganglion fluid is removed with pressure but over time, builds up again.

My first plan was x-ray/ultrasound. Any thoughts/comments appreciated.

 

Ultrasound. Ultrasound. Ultrasound. Sounds like you are on the money though Mark (of course pending any other medical history that might not have been divulged).

 

Will not be able to arrange until next week but isn't it strange that a ganglion/cyst could be drained simply by pressure? But, in writing that, the opposite must occur to create the cyst/ganglion in the first place, so I'm deducing it's possible to drain a cyst with pressure (possibly?).

 

No, it is quite common for ganglions to swell up and down with activity and joint motion.

This is the most likely dx based on your information.

LL

 

Soft mobile swelling, reducible with pressure, on the medial aspect of the 1st metatarsal head; ganglion = cystic, tumor-like, localised lesion in, or associated with, a tendon sheath......what tendon would that be?.....or joint capsule. Flexor hallucis is on the dorsal aspect of the hallux. Sounds more likely to be a bursa to me. Further investigation helpful.

 

Sounds like a cyst if it's really soft. Could be an A/V injury or malformation.

Ultrasound!

Graham

 

Apologies - my reference above to Flexor hallucis should of course be Extensor hallucis, the tendon of which is on the dorsal surface of the hallux.

 

The cyst has not been ultrasounded as yet, but as I believed it was most likely to be a cyst/ganglion, I anaesthetised the area with a small amount of LA & inserted an 18 gauge needle, no fluid was able to be removed, but since doing this a week ago, the "lump" has not returned. So I am reasonably confident it was/is a cyst/ganglion. I will still pursue an ultrasound to confirm.

 

i don't see what an ultrasound is going to tell you that would be different to your thorough clinical examination. Ultrasound will tell you that there is a fluid mass, probably from the extensor sheath. Report will state signs consistent with ganglion. We already know this really. Best thing, wait until it has swollen and excise it (carefully).

George

 

Mark,
You're right to want some imaging to investigate the pathology. Most likely diagnosis from your examination, initial treatment and (thankfully quite thorough) explanation is it's a ganglion. But..... it is not a chronic, slow growing lesion and it's relatively deep (not subcutaneous from your description) and therefore you're right to be prudent and look at further imaging/ investigation at least for piece of mind for you and your patient (and to cover your ass...ets). Also, I'm guessing your history and physical examination has revealed that there are no other factors that may point you towards suspecting this soft tissue lesion is anything other than a ganglion or bursa?
Personally, I don't go for excision as a first port of call for soft tissue lesions such as this. First up, you don't really know what it is. Second, it's not painful. Third, if it is a ganglion, what's the recurrence rate following excision (not great even if you are 'careful' - although I like to think I perform all surgery carefully as that's kinda the point)?
Bob

 

Bob, you are right. I didnt see the not painful part and of course there is always cortisone also. However i was more trying to emphasise that if it looks like a ganglion, feels like a ganglion acts like a ganglion, why get a ultrasound? Surely this will just tell you that there is a fluid filled sac. If your trying to rule out anything sinister, surely an MR would be better.

And yes i would hope most people are "careful" however i was particularly noting that ganglions tend to be little buggers when you nick one and then can't define the margins.

 

George,
It depends on local factors (does the original poster have access to MR? etc...). Ultrasound is user dependant, but MR may reveal a bit more about the constituents of a soft tissue pathology. A good sonographer could tell you how deep the lesion is and determine its margins - whether it tracks to the joint etc... X-rays would also show any potential impact on underlying bone - is it purely a soft tissue lesion or is there invasion into the underlying bone? Chances are it's a ganglion, but when you are justifying you treatment (when you end up in court) and providing reassurance to a patient, evidence and opinion of your other specialist colleagues help.
Blunt dissect onto your ganglions and get a clip on them - if you burst it, you can use your clip to grip the lesion and your assistant to swab the contents and get the rest of it out. Once you start your surgical training, your tutor will show you this as it's better to see and do than to read on here.
"Careful now"
"Down with this sort of thing"

 

Ha, well Bob i shall keep your comments in mind the next time i assist on one. That clip will be hovering!