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Sequestration dermoid Sebaceous cyst
• Occurs in the line of fusion • Occurs anywhere except palm and sole
• Skin is not adherent (free) • Skin is adherent over summit
• Extends often into deeper plane or cavities through suture line • Subcutaneous plane—do not extend to deeper plane
• Punctum is absent • Punctum is present—70% cases
• Bone resorption and indentation is common • Freely mobile without bone resorption
• With restricted mobility • Superficial swelling, mobile
• Needs proper evaluation with X-ray/CT scan
• Excision is done under general anaesthesia • Excision is done under local anaesthesia
SRB's Manual of Surgery
(Fordyce’s disease is heterotopic sebaceous glands in
mucosa of the lip and oral cavity).
Hair loss over the surface is common due to constant pres-
sure over the roots of the hair follicles.
Unpleasant odour of sebum content is typical.
Complications
Infection and abscess formation.
Surface may get ulcerated leading to formation of a painful,
fungating mass with discharge called as—Cock’s peculiar
tumour—often resembles epithe lioma. It is a misnomer as
it is not a tumour. It is a chronic granuloma on an ulcerated
surface of a sebaceous cyst.
A B
Figs. 1.158A and B: Cock’s peculiar tumour over scalp and ear.
Fig. 1.160: Large sebaceous horn face (Courtesy: Dr Prithvishetty
MS; Father Muller’s Medical College, Mangaluru).
Note:
• Multiple sebaceous cysts may be associated with syndromes like
Gardner’s syndrome.
• Sebaceous cyst in the scrotum is usually multiple, firm and often calcified
without any punctum. It is often treated by partial or total scrotectomy.
Scrotum with multiple sebaceous cysts is strawberry scrotum.
Sebaceous horn results from hardening of slowly discharged
sebum through the punctum. (Horn is one which has greater
length than its base diameter. Cutaneous horn is keratin
deposition).
A
Figs. 1.159A and B: Sebaceous horn: (A) Scalp; (B) Face.
B
Fig. 1.161: Strawberry scrotum—multiple sebaceous
cysts on the scrotum.
Fig. 1.162: Multiple sebaceous cysts back.
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Fig. 1.16 3: Incision for sebaceous cyst is elliptical
which includes punctum.
Treatment
Excision including skin adjacent to punctum using elliptical
incision—dissection method.
Incision and avulsion of cyst wall.
If abscess is formed, then drainage initially and later excision
is done.
If capsule is not removed properly the cyst will recur.
Epidermoid (Epidermal) Cyst
It is a benign cyst often also called as epidermal/keratin/infundibular/follicular infundibular cyst. Most of them originate from the
follicular infundibulum. Epidermal cells from the infundibulum of
the hair follicle proliferates within the dermal space. Exposure to
UV light and human papilloma virus infection may be the causes.
Tiny superficial cysts are called as Milia which are common in
neonates and younger age. Epidermal cyst contains cheese
like material often with typical foul smell. It is common in face,
trunk, neck, extremities and scalp. Plugging and occlusion of the
pilosebaceous unit, high testosterone levels are often observed.
It is often associated with Gardner’s syndrome, Basal cell naevus
syndrome. It is lined by stratified squamous epithelium.
Trichilemmal or pilar cysts are benign cysts lined by stratified squamous epithelium of isthmus of the hair follicle without
granular cell layer. It occurs in 10% of population with 90% in the
scalp and often multiple (70%). Erroneously but very often they
are called as sebaceous cysts. They are common in female and
middle aged. Punctum will not occur in trichilemmal cyst but it can
form horn. It can be autosomal dominant hereditary or acquired.
Note:
Clinically sebaceous cyst as diagnosis is well accepted even now. Pathological nature is difficult to assess and understand often.
77
CHAPTER 1E General Surgery: Swelling
A
B
Figs. 1.164A and B: Elliptical incision and removal of sebaceous cyst.
The worth of your lives comes neither in what we do nor whom we know but by whom we are.
NEUROMA
It is swelling arising in relation to the nerve fibre. It can be false
or true neuroma.
True neuroma is a rare tumor. It usually develops in relation to
sympathetic nervous system. Ganglioneuroma type contains
ganglion cells and nerve fibres; it arises from sympathetic chain;
it presents as mass in the neck, thorax, retroperitoneum or
adrenal medulla. It is benign but attains large size. It is treated
by complete excision. Rare myelinic neuroma type contains
only nerve fibres without ganglion cells which is seen in spinal
cord and pia mater.
False neuroma is common which occurs due to injury to nerve by
trauma or during surgery like amputation; it arises from connective
tissue of the nerve sheath. It contains fibrous tissue with coiled
nerve fibres. It can be end neuroma, commonly seen in a amputation stump as tender, localized, firm, swelling which is adherent to
scar underneath. It causes stump neuralgia; troubles the proper
usage of prosthesis. It can be prevented by cutting the nerve after
pulling down for significant length during amputation so that nerve
end gets adequately retracted proximally. Lateral (side) neuroma
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is seen after traumatic partial nerve injury; presents as tender, firm
swelling along the line of peripheral nerve.
A B
SRB's Manual of Surgery
Figs. 1.165A and B: Types of false neuromas: (A) End neuroma:
(B) Lateral neuroma.
FIBROMA
It is a benign tumour arising from fibrous tissue. It is capsu-
A
Figs. 1.167A and B: Multiple neurofibroma.
SITES
B
x Cranial
x Spinal: Neurofibroma is the most common intradural extramedul-
lary spinal tumour
x Peripheral
B
lated.
Fig. 1.168: Patient with multiple neurofibromatosis underwent
Fig. 1.166: Fibroma hand.
laparotomy showing serosal neurofibroma.
True fibroma can be soft or hard. Soft fibroma contains imma-
ture fibrous tissue and is commonly seen face as soft brown
swelling; hard fibroma contains well-formed fibrous tissue
which is common in palm and sole. It is treated by excision.
Note:
• True fibroma is rare and cannot be diagnosed clinically. It is mostly
combined with mesodermal tissues like nerve sheath (neurofibroma),
fat (fibrolipoma), muscle (fibromyoma).
• An entity called aggressive fibromatosis is known to occur as unen-
capsulated proliferation of fibrous tissue, common in abdominal and
chest wall. It is considered presently as locally malignant. It does not
spread through lymphatics or through blood. But recurrence is common.
• Desmoid tumour is a variant of aggressive fibromatosis, seen in females,
often associated with Gardner’s syndrome (Desmos = tendon, eidos =
appearance). Refer chapter Abdominal Wall and Umbilicus.
• Recurrent fibroid of Paget’s is a rare type of fibrosarcoma occurring
in a scar tissue after many years.
NEUROFIBROMA
It is a benign tumour arising from connective tissue of the
nerve containing ectodermal, neural and mesodermal connective tissue components.
It can be single or multiple. Neurofibromas may be associated
with pheochromocytomas, hyper tension and few syndromes.
A
B
Figs. 1.169A and B: Plexiform neurofibroma in the (A) Face and
neck; and (B) Buttock.
Fig. 1.170: Plexiform neurofibromatosis involving trigeminal
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(5th cranial) nerve.
Types
Nodular neurofibroma:
¾
It presents as single smooth, firm, tender (often) swelling
which moves hori zontally or perpendicular to the direction
of the nerve, not in the direction of the nerve.
¾
There is pain and hyperaesthesia in the distribution of
the nerve.
Plexiform neurofibroma:
¾
It commonly occurs along the distribution of 5th cranial
nerve in the skin of face. It often occurs in the cutaneous
distribution of the peripheral nerve.
¾
It attains enormous size with thickening of the skin which
hangs down wards. It causes erosion into the bone, orbit
and deeper struc ture.
¾
It may also undergo myxoma tous degeneration. It causes
cosmetic problem.
¾
Paraesthesia along the distribution of the trigeminal nerve
(commonly ophthalmic division) is common.
¾
Pachy dermatocele—a variant of plexiform neuro fibroma
where neck is involved. There is thickening and oedema
of skin, pigmentation, thromobosed veins with enormous
proliferation of subcutaneous nerve fibers causing folded
pendulous hanging thickened skin with tissues. It is
common along trigeminal (5th cranial) nerve; rarely is it
seen in limbs and scalp skin.
Fig. 1.171: Multiple neurofibromatosis with café-au-lait
spots in the skin.
Generalised neurofibromatosis (von Reckling hausen’s
disease): (1:4000 births)
¾
It is an inherited autosomal dominant disease wherein
there will be multiple neurofibromas in the body—chromosome 17. It is called as type 1 in which more than 50% will
be familial. Type 1, more commonly, called as von Reck-
linghausen’s disease. Type 2 is acoustic neurofibromatosis
(mutation of chromosome 22). All layers of nerve with
Schwann cells and fibroblasts show tumour proliferation.
¾
It may be cranial, spinal or peripheral.
¾
It is associated with pigmented spots (coffee coloured)
in the skin, commonly seen on the back, abdomen, thigh
(café-au-lait spots). More than 5 in number, with each
1.5 cm or more in size is significant. Café-au-lait signifies
common neuroectodermal origin of nerve sheath cells and
melanocytes. It is also seen in McCune–Albright syndrome.
¾
Axillary/groin freckles and Lisch nodules, pigmented iris,
hamartoma may be present.
¾
Neurological disturbance is uncommon.
¾
It may be associated with MEN type IIb (Multiple neurofibromas of eyelids, lips, and face; medul
lary carcinoma
of thyroid; pheochromocytoma, hyperparathyroidism),
primary brain tumours and bone cysts.
Elephantiatic neurofibromatosis:
¾
It is of congenital origin. It involves limbs.
¾
Skin of the limb is greatly thickened, dry and coarse.
Cutaneous neurofibromatosis:
¾
They are small, multiple, firm/hard nodules arising from
terminal ends of dermal nerves. Overlying skin is normal
without any changes. It commonly occurs all over the
body. It can be pedunculated or sessile. It can occur in
scalp to result in a turban tumour.
Features
Mild pain or painless swelling usually in subcutaneous or
cutaneous plane with tingling, numbness and paraesthesia
along the distribution of nerve.
Round/oval/fusiform swelling along the peripheral/cuta-
neous nerves which moves perpendicular to the direction
of the nerve but not along the longitudinal direction of
nerve fibre with smooth surface and firm consistency. It
is nontender or mild tenderness may be present. Skin is
free unless it is of cutaneous type. Cutaneous type is often soft.
Complications
¾
Cystic degeneration; Haemorrhage into the tissues.
¾
Spinal and cranial neurofibromas can cause neurological
deficits.
¾
Erosion into deeper planes, bone, orbit; Muscle atrophy.
¾
Spinal dumbbell tumour can cause compression of spinal
cord and paralysis of the limb.
¾
Sarcomatous changes: Common in generalised type
(5%). When it occurs it shows rapid enlargement, warmness, more vascularity with dilated veins. Secondaries in
lungs can occur through blood spread.
Treatment: Excision under general or regional anaesthesia.
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CHAPTER 1E General Surgery: Swelling
If we are to grow good corn, we must help our neighbours grow good corn.—Steve Goodier.
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INDICATIONS FOR SURGERY
B
x Symptomatic neurofibroma—pain and pressure symptoms
x Cosmetically problematic lesion; Recent increase in size
x Malignant transformation 5%
Note:
• The most common spinal tumour is neurofibroma.
• von Recklinghausen disease of primary hyperparathyroidism is different as
it is due to raised PTH level causing osteitis fibrosa cystica.
• Familial type of neurofibroma may be associated with scoliosis.
• Café-au-lait spots are also seen in McCune Albright syndrome.
REMEMBER ABOUT NEUROFIBROMA
SRB's Manual of Surgery
B
x Neurofibroma is fusiform swelling which has got horizontal
mobility but not longitudinal mobility (neurilemmoma has got
free mobility in all directions)
x Café-au-lait spots signify common neuroectodermal origin of
nerve sheath and melanocytes
x Kyphoscoliosis may be an association in familial variety
x Phaeochromocytoma with hypertension may be an association
(20%)
x Plexiform neurofibromatosis commonly involves trigeminal
cranial nerve mainly ophthalmic division causing paraesthesia,
can obstruct the vision when it is large, have grossly thickened
pendulous skin hanging down to various levels
x Calcification, saponification, myxomatous changes, sarcomatous
transformation (fungation, rapid recent increase in size, warmness, dilated surface veins, redness with increased vascularity,
fixity, persistent severe pain, immobility, lung spread) and
cosmetic problem are the complications
x Intestinal neurofibroma may precipitate intussusception
NEURILEMMOMA (SCHWANNOMA)
It is arising from Schwann (neurilemmal cells) cells. They are
lobulated, encapsulated, soft, whitish grey in appearance. They
displace the nerve from which they arise and can be removed.
They are common in acoustic nerve (cerebello pontine angle)
but also can occur in a peripheral nerve. Occasionally, they are
multiple. Calcification is common. It is of ectodermal in origin.
Two types: Anthony A—Two rows of spindle cells with central
acellular area (Verocay bodies). Anthony B—Acellular myloid
areas.
Presentation is pain along the distribution of the nerve, hyper-
aesthesia and tenderness and as, soft or firm, lobulated, well
localised mobile swelling.
Treatment: Excision—easier without causing neurological
damage.
Note:
Recurrent schwannoma could be malignant.
GANGLION
It is a cystic swelling occurring in relation to tendon sheath or
synovial sheath or joint capsule. It contains clear gel like fluid.
Common sites: Dorsum of wrist (Near scaphoid-lunate
articulation); Flexor aspect of wrist; Around ankle joint—
occasionally.
A
B
Figs. 1.172A and B: Ganglion over the dorsum of the wrist—typical
location. It can occur over the flexor aspect also. It can be transill
uminant also.
Pathogenesis:
¾
Cystic degeneration of the tendon sheath.
¾
Leakage of synovial fluid through joint capsule.
¾
There are small islets of microspaces in synovial sheath
which often fuse together or one of them gets enlarged
to form ganglion.
Features
¾
Well-localised swelling which is smooth, soft, cystic, or
tensely cystic (Paget’s test is +ve), non tender, transilluminant. It is mobile but mobility is restricted when tendon
is contracted against resistance.
¾
Occasionally it is communicating with joint capsule.
¾
Often pain, tenderness and restricted joint move ment may
be the presentation (but rare).
Differential diagnosis: Lipoma; lymph cyst; sebaceous cyst;
small ganglion often mistaken for sesamoid bone or exostoses;
bursa.
Treatment:
¾
Asymptomatic ganglion is better left alone because of
high recurrence rate.
¾
Excision: Usually done under local anaesthesia (lignocaine plain 2%). Patient should be explained of high
recurrence rate (30%). After excision always it should be
sent for histo pathology. Firm crepe bandage application
for 4 weeks is better in these patients.
¾
Aspiration and sclerosant injection may be useful.
(In olden days people used to rupture the ganglion using
bible book).
-
PAPILLOMA
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It is warty swelling from the skin or often from the mucous
membrane. It has got a central axis of connective tissue, blood
vessels and lymphatics.
True Papilloma
It is a benign tumour with localised overgrowth of all layers of
the skin. It is commonly pedunculated but rarely can be sessile.
It contains sweat glands, sebaceous glands and hair follicles.
A
Figs. 1.173A and B: Pedunculated papilloma with its pedicle.
Pedunculated papilloma is villous with a central axis of
connective tissues, blood vessels and lymphatics.
Papilloma can be cutaneous or mucosal. Cutaneous can
be squamous or basal cell type. Squamous cell papilloma
can be soft which is seen in eyelids in elderly; or can be
congenital which can be sessile or pedunculated; single or
multiple. Squamous papilloma also occurs in oral cavity.
Basal cell papilloma is oily semitransparent brownish
raised seborrhoeic keratotic lesion in skin around trunk
in elderly.
Papilloma may be—single or multiple.
Papilloma may be—pigmented or nonpigmented.
True papilloma may turn into squamous cell carcinoma
occasionally. There will be sudden increase in size, bleeding
or ulceration.
Papilloma can occur in the breast called as duct papilloma
which is the most common cause of bloody discharge from
the nipple.
Papilloma can occur in mucous membrane like in oral
cavity, urinary bladder (transitional papilloma), in the
rectum (columnar), in the larynx, in the gallbladder
(cuboidal).
Differential diagnosis: Amelanotic melanoma, pedunculated
lipoma, carcinoma.
Treatment: True papilloma is excised with its base along with
surrounding 1 cm skin margin.
Complications of papilloma: Bleeding, malignant transfor-
mation, ulceration, mechanical disability like voice change
when it occurs in vocal cord.
B
A B
Fig. 1.174: (A) Papilloma right waist (sessile). Note the warty
surface. (B)
Note:
Papilloma tongue.
• Fibroepithelial papilloma also called as skin tags/achrochordon is very
common benign skin lesion of usually 5 mm diameter in size; common
in adults; common in neck, axilla, thigh and groin. It is a vascularised
keratinised squamous epithelium, can cause local irritation and insignificant bleeding. If it causes cosmetic problem it is removed by laser/
cautery or excision.
• Infective papilloma: Infective papilloma is a warty lesion due to infec-
tion, e.g. condyloma acuminata. Infective warts can be treated by excision or CO
WARTS
They are usually multiple hyperkeratotic skin patches with
finger like projections, common in children and adolescents.
Warts are usually caused by human papilloma virus (HPV
2 and 4).
They are common in finger tips, face, axilla and sole of the
feet. It may be familial but often stimulated by virus.
Repeated rubbing may cause infection. It can spread to other
fingers and other parts of the body. Kiss lesions can occur.
Warts attain their size in few weeks and then persist for many
months to years. They may regress spontaneously also.
Plantar wart (Verruca plantaris) is wart in the sole. Speci-
ality of this is it gets pushed into the sole of the foot due to
walking. It is common in ball and heel of the foot. It is pearly
snow or diathermy coagulation.
2
Fig. 1.175: Multiple warts in the thumb.
81
CHAPTER 1E General Surgery: Swelling
Look well to this day, for yesterday is but a dream and tomorrow is but a vision. But today, well lived, makes every yesterday a
dream of happiness and every tomorrow a vision of hope. —Kalidasa
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white in colour with brownish haemorrhagic flecks. It is often
covered by apparently normal skin because wart is buried
into the skin. It looks like a circular pit. It is grey white finger/
filiform like strands in the centre of the lesion and is soft.
Plantar warts can be multiple. It is painful and very tender
on pressing (more than callosity or corns). A defined clear
lump may not be felt.
Butcher’s wart/pathologist’s wart/verrucas necrogenica is due
to entry of Mycobacterium tuberculosis through broken skin
which are common in milkmaids. It presents as bluish red
warty lesion from which fluid oozes out on pressure between
projections. It is common over dorsum of hand. Lesion is
SRB's Manual of Surgery
surrounded by pustules.
Senile warts and venereal warts are other types. Venereal
warts are same as infective papilloma.
Differential diagnoses are true papilloma, callosities, neurofi-
bromas.
Treatment:
¾
Salicylic acid, podophyllin cream applications are also
used. Laser ablation of warts is commonly advocated.
¾
Excision is done if other methods fail.
GLOMUS TUMOUR
It is also called as glomangioma.
It arises from the cutaneous glomus composed of a tortuous
arteriole which communicates directly into the venule
(Sucquet-Hoyer canal) and these vessels being surrounded
by network of small nerves making this lesion very painful.
This communication is called as Sucquet-Hoyer canal.
Tumour consists of a mixture of blood spaces, nonmedullated
nerve tissue, muscle fibres derived from the wall of the arteriole, with large cuboidal glomus cells—angio
They are often seen in limbs and common in nail-beds near
the finger tips, as purple red swelling.
It is 2–3 mm in size.
It does not turn into malignancy.
myoneuroma.
Even the slightest pressure will give rise to severe pain.
Dilated vessels compress over nerves.
It is compressible and pain is more when the limb is exposed
to sudden changes in tempera ture (cold stimulus).
On increasing the pressure in the arm above systolic, pain
disappears.
It looks like a reddish blue spot which does not blanch on
percussion.
Subungual type may not be visible but only to cause episodic
digital severe pain.
It is usually single, but rarely multiplicity is observed as
familial.
Differential diagnosis
¾
Pyogenic granuloma—bleeds on touch.
¾
Subungual melanoma—painless pigmented lesion.
Treatment: Excision cures the condition.
BURSAE
Bursa is a sac like cavity containing fluid within, which
in normal location prevents friction between tendon and
bone.
Bursa secretes synovia like clear fluid in a cavity lined by
flat endothelium. It reduces the friction at the site between
tendon and bone. Normally fluid content is little to cause a
swelling. Minor trauma or infection causes sudden increase in
fluid secretion of the bursa making it to enlarge and clinically
palpable as pathological bursitis. Bursa is common around
knee, elbow, heel and hip.
Long-standing bursitis leads into thickening of its wall often with
calcification making it feel hard with indurated surface. Lining of
bursa may become rough or fluid may contain loose fibrinous
particles to create grating sensation (crepitus) on the surface.
Often overlying skin becomes thick, cracked and horny due
to repeated friction and inflammation.
Bursa may get adherent to deeper tissue as well as overlying
skin to make it immobile. Bursa is usually well-localised,
smooth, fluctuant, nontender swelling. Often it can be bilateral—in knee or elbow.
Bursitis can become painful, tender and often with restricted
movement once it gets infected.
Joint related should be examined. Bursa may be communi-
cating with the adjacent joint.
Gout or rheumatoid arthritis can cause bursa. For example,
olecranon bursa can develop in gout patient.
Bursa should be differentiated from cold abscess, soft tissue
Fig. 1.176: Glomus tumour in finger tip—subungual region.
tumour, aneurysm, synovial tumour (sarcoma) at different
locations.
Features
Severe burning sensation and pain, out of proportionate to
the size. The most common site is nail-bed.
Complications of bursa: Infection of bursa can occur due
to trauma to overlying skin or through blood; can cause
mechanical disturbances and discomfort.
MANAGEMENT OF BURSAE
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B
x US of the anatomical site, X-ray of the part or MRI are very useful.
x Avoiding friction and other aggravating factors may control many
bursae.
x Aspiration and steroid injection may be useful.
x Bursa which is felt indurated with thick wall or calcified or infected
or attained large size or which interferes with joint movement or
daily activities needs surgical excision. Subcutaneous bursa can
be excised under local anaesthesia; large or deeper bursa requires
general anaesthesia for excision.
Different Types
It can be anatomical or adventitious.
Anatomical
Anatomical bursae are located normally in a particular
anatomical site with a purpose of reducing friction. They are
commonly deep and adjacent to a bone or joint.
They become pathological and clinically significant when it
presents with bursitis.
They are soft, cystic, well localised, nontransilluminating
swelling at known anatomical site.
¾
Subhyoid bursa: An horizontally oval swelling situated below
the hyoid bone and in front of the thyrohyoid membrane.
¾
Subacromial bursa: In front and lateral to humeral head
in relation to supraspinatus tendon between acromion
and greater tuberosity of humerus.
¾
Bicipitoradial bursa.
¾
Olecranon bursa (Student’s elbow, Miner’s elbow): It
is subcutaneous bursa in relation to olecranon which
becomes distended due to prolonged periods of leaning
over elbow. Gout may involve this bursa.
83
CHAPTER 1E General Surgery: Swelling
A B
Figs. 1.178A and B: (A) Prepatellar bursa (Housemaid’s knee);
(B) Infrapatellar bursa (Clergyman’s knee).
Fig. 1.179: Prepatellar (Housemaid’s knee) and infrapatellar
bursae (Clergyman’s knee).
Fig. 1.177: Location of olecranon bursa (Student’s elbow).
¾
Prepatellar bursa (Housemaid’s knee/miner’s beat knee): It
lies subcutaneously in front of lower half of patella and upper
half of patellar tendon (upper part) undergoes inflammation
in people who do much kneeling. Joint is normal here.
¾
Subcutaneous infrapatellar bursa occurs between skin
and lower part of the tibial tuberosity and ligamentum
patellae. It is called as Clergyman’s knee. (‘Clergyman’ is
Christian priest who kneels down during prayer).
¾
Suprapatellar bursitis is deep to patella and vastus inter-
medius, in front of lower end of femur. It communicates
with knee joint.
There is only one pretty child in the world, and every mother has it.— Chinese proverb.
¾
Psoas bursa: A tensely cystic swelling situated beneath
and below the inguinal ligament, in the lateral aspect
of the femoral triangle. But it will not extend above the
inguinal ligament into the iliac region (unlike in psoas
abscess which extends above and is cross fluctuant).
Psoas bursa lies between the psoas tendon and lesser
trochanter. When it is enlarged, it causes diffuse swelling
over outer part of femoral triangle lateral to femoral
vessels. When hip is moved swelling becomes painful.
It also should be differentiated from femoral hernia.
¾
Brodie’s bursa lies deep to medial head of gastrocnemius.
¾
Semimembranosus bursa.
¾
Bursa anserina—under the tendons of Guy ropes (sarto-
rius, gracilis and semitendinosus tendons—Goose’s foot).
¾
Retrocalcaneum bursa—between calcaneum and tendo-
Achilis.
Adventitious Bursa
Adventitious bursa occurs in an unusual place/site due to friction/
pressure between two layers of tissue. Once it becomes chronic
it may get adherent to overlying skin or tissue underneath.
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¾
Billing gate hump appears over 7th cervical spine deep
to overlying skin in people carrying weight over it. Billing
gate is a large fish market in London.
Condition should be differentiated from soft tissue tumour,
sebaceous cyst, ganglion (depending on the location of
bursa).
Management:
¾
X-ray of the part and FNAC of swelling should be done.
¾
Later it is excised usually under local anaesthesia.
SEMIMEMBRANOSUS BURSA
SRB's Manual of Surgery
Fig. 1.180: Bursa near elbow joint.
It may get infected, wall gets calcified, and fluid may become
thick. It is well-localised, cystic usually nontender swelling.
It becomes painful and tender if infected.
Lining of bursa may become rough or fluid may contain
loose fibrinous particles to create grating sensation/crepitus
on the surface.
It is a cystic swelling in the upper medial aspect of the
popilteal fossa under the semimembranosus tendon. It is
said to be due to friction under the tendon causing bursitis.
It is located between semimembranosus tendon and femoral
condyle above the knee joint line.
It is common in young adult; in both sexes. It is most
common swelling of the popliteal fossa.
It is nontender, cystic/tensely cystic (firm) swelling located
above and on medial aspect of the popliteal fossa, fluctuant,
noncompressible, often transilluminating, often with a fluid
thrill. When it enlarges it comes out of semimembranosus
tendon to become subcutaneous.
Content of bursa does not communicate with knee joint. So
fluid cannot be reduced into the joint cavity; but often appears
flaccid on flexion of knee or by firm pressure probably due to
Fig. 1.181: Adventitious bursa over lateral aspect of foot—
a common site.
displacement of fluid into deeper recesses of the bursa. The
swelling becomes tense when knee is extended.
Knee joint is normal.
Differential diagnosis:
Management
¾
Ultrasound of popilteal fossa shows the cystic swelling
Baker’s cyst, popliteal aneurysm.
under semimembranosus tendon. X-ray knee joint is normal.
¾
Excision is done under general anaesthesia using tourniquet in prone position. Complete excision of the sac
is needed to prevent recurrence.
Fig. 1.182: Common site of adventitious bursa (Bunion).
Examples
¾
Bunion is adventitious bursa in patient with hallux valgus
occurring between head of first metatarsal and skin.
¾
Tailor’s bursa occurs between lateral malleolus and skin.
¾
Porter’s bursa occurs between skin over shoulder and
clavicle.
¾
Weaver’s bursa occurs between gluteus maximus, ischial
tuberosity and skin.
¾
Retro-Achillis bursitis occurs between skin and Achilles
tendon.
¾
Subcalcaneal bursitis occurs between calcaneum and heel
in long distance runners.
A B
Figs. 1.183A and B: (A) Semimembranosus bursa typical location;
(B) Morrant Baker’s cyst—typical location.
A
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B
Figs. 1.184A and B: Semimembranosus bursa—typical location. On
flexion it only becomes flaccid but does not disappear.
MORRANT BAKER’S CYST
It is a cystic swelling containing gel like fluid in the lower midline
of the popliteal fossa. It occurs due to herniation of the synovial
membrane of the knee joint as a result of chronic arthritis.
It is pulsion/pressure diverticulum of the synovial membrane
towards surface under the gastrocnemius through an opening
in the joint capsule. It is below the joint line.
It is common in middle-aged individuals.
It is smooth, soft and cystic, nontransilluminant, often tender
swelling located below (the joint line) and in midline of the
popliteal fossa.
On flexion swelling disappears and on extension swelling
increases in size.
Pain and tenderness are present in knee joint with effusion
showing positive patellar tap.
The knee joint movements are painful and restricted.
Baker’s cyst may rupture sometimes causing severe sudden
pain and swelling in the calf mimicking deep vein thrombosis.
Management: X-ray of joint shows arthritic changes; MRI is
needed; Arthritis is treated and Baker’s cyst is excised under
general anaesthesia or spinal anaesthesia in prone position.
LYMPHANGIOMA
It is congenital localised clusters of dilated lymph sacs in the
skin and subcutaneous tissue that has failed to join the normal
lymph system during development period.
Types
Capillary Lymphangioma
It is simple type which can be present at birth but noticeable
skin vesicles often develop in few years.
It is common at the junction of body to limbs-like near
shoulder, axilla, groin or buttock.
Skin vesicles contain clear watery or yellow fluid. Bleeding
within the vesicle may turn it into brown or black. Its features
includes multiple, indistinct white/brown/black coloured vesicles of 0.5–4 mm size at typical locations in children involving
around 5–20 cm area of skin in the particular location.
If it is less than 5 cm in size it is called as lymphangioma
circumscriptum.
Fig. 1.186: Lymphangioma circumscripta (Courtesy: Dr
Balasaraswathy, DVD, DNB, Consultant Dermatologist, Mangaluru)
If it is more than 5 cm in size it is called as lymphangioma
diffusum.
If it is with reticulated ridges, it is called as lymphoedema ab igne.
Area is soft, spongy, often fluctuant with fluid thrill and
translucency. It is not compressible. Vesicles will not fade
on pressure.
Often lesion may get infected to make it painful and tender.
Condition will not block the lymph drainage in normal
lymphatics and skin oedema is absent.
Regional lymph nodes are not enlarged.
85
CHAPTER 1E General Surgery: Swelling
A B
Figs. 1.185A and B: Baker’s cyst. It is below the joint line.
Differential diagnosis: Semimembranosus bursa; Throm-
bosed popliteal aneurysm (often bilateral).
Cavernous Lymphangioma
It is soft, lobulated, fluctuant, brilliantly transilluminant
larger lymphatic swelling with often multiple communicating
lymphatic cysts.
It often extends into deeper plane like muscle. It is common
in face, mouth, lips (macrocheilia), tongue (macroglossia).
Cystic Hygroma
It is collection of clustered sequestered lymph sacs (occurring
during developmental period in utero) presenting in newborn as
The mother’s heart is child’s schoolroom.—Henry Ward Beecher.
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