The combination of clinical presentation, transillumination, ultrasonography, and MRI

are generally sufficient to distinguish between a benign ganglion cyst

and other potentially neoplastic soft tissue masses.

However, the presence of certain clinical features such as

rapid growth,

pain at rest,

functional impairment,

atypical location (eg, proximal or distal to the wrist rather than overlying the wrist)

should prompt consideration for a surgical biopsy

work up

- ultrasound should show well demarcated thick wall

- xray to r/o bone tumor

- MRI for soft tissue tumor

DIFFERENTIAL DIAGNOSIS

Tenosynovial giant cell tumor — A tenosynovial giant cell tumor is a firm, fixed swelling that generally develops on the flexor surfaces of the tendons of the hands. It can be distinguished from ganglion cysts in that it is a fixed, enlarging mass that does not transilluminate (picture 3).

Epidermoid cysts — Epidermoid cysts, also called epidermal cysts or epidermal inclusion cysts, are small, hard, pearl-like cysts or nodules, often with a central punctum, that is freely mobile on palpation. They tend to disappear spontaneously over time. The most common locations are the volar aspect of the distal phalanx of the index or middle finger or are within the interdigital webs. They are rarely larger than 1 centimeter and do not transilluminate. (See "Overview of benign lesions of the skin", section on 'Epidermoid cyst'.)

Lipoma — Lipomas of the hand and wrist may present as a soft, painless slow-growing mobile nodule. Unlike ganglion cysts, lipomas do not transilluminate. (See "Overview of benign lesions of the skin", section on 'Lipoma'.)

Infectious tenosynovitis — Infectious tenosynovitis can occur in any joint, but occurs most frequently in the hands and wrist. Infectious tenosynovitis is characterized by diffuse swelling and tenderness that tracks along the tendon in a longitudinal fashion, and should be suspected in the setting of a preceding puncture or bite wound. Infection of the hand requires immediate surgical consultation for possible exploration and drainage. (See "Infectious tenosynovitis".)

Rheumatoid nodules — Rheumatoid nodules are firm, nontender, flesh-colored, subcutaneous lesions that occur in approximately 20 percent of patients with rheumatoid arthritis. Rheumatoid nodules may be fixed or movable and when present on the hand or wrist, are usually on the extensor surface. (See "Rheumatoid nodules".)

Tendinous xanthoma — These pinkish, yellow papules may be the first evidence of hyperlipidemia. Usually asymptomatic and bilateral, they may occur abruptly (eruptive xanthomas) over pressure points and extensor surfaces or gradually over Achilles, patellar, and digital extensor tendons. Often, the patient pays no attention to them; the clinician may be the first to realize their significance. (See "Hypertriglyceridemia in adults: Management".)

Tophus — Uric acid deposits can produce firm subcutaneous nodules in patients with gout. They typically originate at the joint margin and may be yellow with overlying erythema when close to the surface. Although tophi can occur at any site, they can be observed in the hands and wrist (picture 4). Tophi from chronic tophaceous gout are typically not painful or tender. (See "Clinical manifestations and diagnosis of gout".)

Synovial sarcoma — A synovial sarcoma is a rare cause of a soft tissue mass around a joint. It can arise at any age and anatomic area but tends to favor the distal extremities in young adults. Larger size of the tumor (>5 cm) is associated with a greater risk for metastases and local recurrence. Synovial sarcoma is a translocation-associated soft tissue malignancy. The translocation t(X;18) has been identified in synovial sarcoma only, and its sensitivity and specificity have been both established. In certain difficult cases, the detection of this fusion event (by RT-PCR or cytogenetic studies) has been instrumental to the correct diagnosis [15]. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma".)

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