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Mass: Mobility, Size, Tenderness, Texture

Exams and Signs

Historical Overview

  • Physicians have been puzzled by tumors since the time of Galen. Galen was among the first to theorize that cancer originated from within the body, as “a deep-seated bodily dysfunction”.1
  • Malignant tumors of the hand are rare and account for ~0.5% of cancer deaths per year.2 However, it is important to be vigilant for malignant masses and to engage in rapid diagnosis and treatment.
  • Benign masses are the most common in the hand and wrist. They may have to be excised because of symptoms or to confirm diagnosis. All surrounding anatomy should be protected from injury during surgical excision of benign tumors.

Description

  • Common soft-tissue masses in the hand and wrist include lipomas, ganglion cysts and the giant cell tumor of the tendon sheath. Less common benign masses in the hand include enchondroma, osteoid osteoma, osteochondroma, osteoblastoma and chondroblastoma.2
  • These masses may appear large and deep beneath the skin. Common malignant masses include chondrosarcoma, myeloma and metastases. Ewing’s sarcoma, usually seen in children, is a rare malignant tumor that is difficult to diagnose.3
    • The ganglion cyst is the most common soft-tissue mass in the hand and wrist.
    • The giant cell tumor of the tendon sheath presents a firm mass that can have an irregular surface and does not transilluminate light, whereas ganglions are smooth and transilluminate.
    • Hand masses generally stay the same size or become larger. Ganglions are an exception because they can rupture and become smaller and then larger again.
    • Lipomas fluctuate with weight gain or loss.
    • Bone tumors are usually not palpable as masses, but are accompanied by pain or pathological fractures.

Pathophysiology

  • Masses can originate from any tissue type, including bone, fibrous, nerve and fat.
  • Ganglion masses may arise from synovial or mesenchymal cells at the synovial-capsular interface as a result of repeated minor injury.4

Instructions

  1. Measure the size of the mass. It could be potentially malignant if it exceeds 5 cm.2
  2. Palpate to check for mobility, tenderness, smoothness of the surface and firm masses.
  3. Ask the patient how rapidly the mass has been growing and how much pain he/she experiences.
  4. Evaluate the mass for the presence of a pulse, which may be due to an arterial aneurysm.2 If a Tinel sign tingling response occurs, it suggests a tumor of neurological origin.
  5. If malignancy is suspected, check the patient for pathologic (>1 cm) epitrochlear or axillary lymph nodes.5

Variations

  • In addition to mobility, size and tenderness, masses should be assessed for relationship to joint, overlying skin changes, drainage and compressibility.5
  • Patients with malignant hand masses often present with a shorter duration of pain, whereas patients with benign masses may describe a longer history of pain.2

Related Signs and Tests

  • Allen’s test
  • Tinel’s sign

Diagnostic Performance Characteristics

  • Often ganglion cysts can be diagnosed by physical examination alone.
  • If more detailed anatomic understanding of a mass is needed before surgery or if malignancy is suspected, X-rays, ultrasound or MRI may be useful in the diagnostic process.
Presentation Photos and Related Diagrams
  • Palpation of Dorsal Wrist Mass
    Palpation of Dorsal Wrist Mass
  • Measuring Dorsal Wrist Mass
    Measuring Dorsal Wrist Mass
Definition of Positive Result
  • A positive result occurs when a mass can be identified by palpation or inspection.
Definition of Negative Result
  • A negative result occurs when there is no definite mass.
Comments and Pearls
  • The risk of recurrence of a ganglion cyst is diminished by excising the cyst, its pedicle and a portion of the capsule.4
  • Ultrasound may be useful to differentiate giant cell tumor of tendon sheath from ganglion cysts.6
Diagnoses Associated with Exams and Signs
Videos
Examination of Right Dorsal Wrist Mass
References
  1. Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. London: Fourth Estate, 2011.
  2. Trumble TE, Budoff JE, Cornwall R. Hand, Elbow & Shoulder: Core Knowledge in Orthopaedics. Philadelpia: Mosby, 2006.
  3. Athanasian EA. Malignant Bone and Soft-Tissue Sarcomas of the Hand. J Hand Surg Am 2004;4(2):60-72.
  4. Minotti P, Taras JS. Ganglion Cysts of the Wrist. J Hand Surg Am 2002;2(2):102-7.
  5. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  6. Payne WT, Merrell G. Benign Bony and Soft Tissue Tumors of the Hand. J Hand Surg Am 2010;35(11):1901-10. PMID: 20961700
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