Myxoid pseudocysts rarely occur without wear and tear osteoarthritis

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A multitude of treatments have been recommended, including repeated incision and drainage, simple excision, multiple needlings and expression of contents, X-irradiation (5 Gy, 50 kV, Al 1mm, three times at weekly intervals), electrocautery, chemical cautery with nitric acid, trichloroacetic acid or phenol, massages or injection of proteolytic substances, hyaluronidase, steroids (fluoran-drenolone tape, or injections) and sclerosing solutions, cryosurgery, radical excision and even amputation.

The intralesional injection of corticosteroid crystal suspension has been recommended. The cyst is first drained from a proximal point to avoid leakage of the steroid suspension when the patient's hand is lowered. Careful dissection and excision of the lesion gives the highest cure rate. A tiny drop of methylene blue solution, diluted with a local anaesthetic solution and mixed with fresh hydrogen peroxide, is injected into the distal interphalangeal joint at the volar joint crease. The joint will accept only 0.1-0.2 ml of dye. This clearly identifies the pedicle connecting the joint to the cyst, if one is present, and also the cyst itself. This procedure sometimes reveals occult satellite cysts.

Alternatively, the methylene blue may be injected into the cyst to define the tract back to its site of origin. The incision line is drawn on the finger, including a portion of the skin directly over the cyst and continuing proximally in a gentle curve to end dorsally over the joint. The lesion is meticulously dissected from the surrounding soft tissue and the pedicle traced to its origins adjacent to the joint capsule and resected. Dumb-bell extension of cysts to each side of the extensor tendon is easily dissected by hyperextending the joint. Osteophytic spurs adjacent to the joint must be removed with a fine chisel or bone rongeur. Liquid nitrogen cryosurgery has been used with an 86% cure rate. The field treated included the cyst and the adjacent proximal area to the transverse skin creases overlying the terminal joint. Two freeze/thaw cycles were carried out, each freeze time being 30 s after the ice field had formed, the intervening thaw time being at least 4 min; if this method is adopted then longer freeze times must be avoided or permanent matrix damage may occur. If the cyst is first pricked and emptied of its gelatinous contents, then equally good cure rates can be obtained with a single 20 s freeze after initial ice formation. For distal posterior nail fold lesions, excision of the proximal nail fold and associated cyst has been recommended.

Sclerosing agents may also be useful: after puncture and expression of cyst contents 0.20-0.30 ml of a 1 % solution of sodium tetradecyl sulphate is injected; a second or a third injection may be required at monthly intervals.

Figure 5.30

Epidermoid carcinoma—verrucous periungual involvement.

Figure 5.30

Epidermoid carcinoma—verrucous periungual involvement.

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Arthritis Relief and Prevention

Arthritis Relief and Prevention

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