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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1060_Библиотеки_им_академика_М_И_Перельмана
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Examination of a Swelling/Lump
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A
B C
Figs 3.59A to C: Pedunculated lipoma. Note the ulceration
in one type. It is excised by elliptical incision.
vessels being surrounded by network of small nerves.
It is special type of arteriovenous communication
(Sucquet-Hoyer canals) with smooth muscle cells and
glomus cells surrounding it. These glomus cells are
either epitheloidal or cuboidal cells. Both medullated
and nonmedullated sensory nerves end in these glomus
cells. They are often seen in limbs and common in
nailbeds. They regulate the temperature of the skin.
The tumour under the nailbed which is a common
site is 2-3 mm in size. Tumour consists of a mixture
of blood spaces, nerve tissue; muscle fibres derived
from the wall of the arteriole, with large cuboidal
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glomus cells—angiomyoneuroma. It does not turn
into malignancy.
Clinical features: Severe burning sensation and
pain, out of proportionate to the size of the lesion.
It is compressible and pain is more when the limb
is exposed to sudden changes in temperature. Slightest
pressure causes excruciating pain. It looks like a reddish
blue spot which does not blanch on pressure. On
increasing the pressure in the arm above systolic, pain
disappears. Pyogenic granuloma and subungual
melanoma are differential diagnosis but typical pain
is diagnostic.
Neurofibroma
It is tumour arising from connective tissue (neural—
ectodermal and fibrous—mesodermal) of the nerve. It
can be single or multiple. Neurofibromas may be associated with pheochromocytomas, hypertension and few
syndromes. Sites—Cranial, spinal and peripheral.
Types
a. Nodular neurofibroma presents as single smooth,
firm, tender (often) swelling which moves horizontally (perpendicular to the direction of the
nerve), not along in the direction of the nerve.
Pressure effects of the tumour over the nerve fibres
cause pain, tingling sensation and hyperaesthesia/
paraesthesia along the distribution of the nerve.
Neurofibroma is the commonest intradural extramedullary spinal tumour.
b. Plexiform neurofibroma commonly occurs along
the distribution of 5th cranial nerve in the skin of the
face. It is more common in ophthalmic division of
trigeminal nerve. It often occurs in the cutaneous
distribution of the peripheral nerve. It attains
enormous size with thickening of the skin which
hangs downwards. It causes erosion into the bone,
orbit and deeper structures. It may cause myxomatous degeneration also. It causes cosmetic problem.
Rarely does it occur in upper limb. Development of
sarcoma is very rare in this type. Pachydermatocele
is a variant of plexiform neurofibromatosis observed in the neck (Figs 3.60A and B).
c. Generalised neurofibromatosis (Von Reckling-
hausen’s disease): It is an inherited autosomal
dominant disease (congenital) wherein there will
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Figs 3.60A and B: Plexiform neurofibromatosis.
SRB’s Clinical Surgery
be multiple neurofibromas in the body (1:4000
live births; chromosome 17). It commonly
involves peripheral nerves; often spinal and cranial
nerves. So it is often classified as cranial, spinal or
peripheral. It is commonly associated with
pigmented spots (coffee coloured) in the skin,
often seen on the back, abdomen, thigh (café au
lait spots. It signifies common neuroectodermal
origin of nerve sheath cells and melanocytes)
(more than 5 in number with each more than 1.5
cm in size are significant) (Figs 3.61A and B).
Axillary or groin freckles with Lisch nodules may
be present. Familial neurofibroma may be
associated with scoliosis or MEN II b syndrome
(Multiple Endocrine Neoplasia syndrome type II
b-medullary carcinoma of thyroid; pheochromocytoma; hyperparathyroidism; multiple neurofibromas in eyelids, lips and face) (Figs 3.62 to 3.64).
d. Elephantiatic neurofibromatosis : It is of conge-
nital origin involving limbs. Skin of the limb is
greatly thickened, dry and coarse.
A
Complications: Sarcomatous changes (5%): When
it occurs it shows rapid enlargement, warmness, more
vascularity with dilated veins. Persistent severe pain;
fixity and fungation also can occur. Secondaries in
lungs can occur through blood spread. Haemorrhage
can occur into the tissues. Spinal and cranial neurofibromas can cause neurological deficits. Erosion can
occur into the deeper planes, bone, orbit. Calcifica-
tions, saponification, myxomatous changes and
B
Figs 3.61A and B: Café au lait spots in the back. It is a feature
of von Recklinghausen’s disease of neurofibromatosis. It is
coffee coloured pigment spots in the skin. More than 5 in
number with each more than 1.5 cm in size is significant.
Examination of a Swelling/Lump
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A
73
B
Figs 3.62A and B: Multiple neurofibromas (von
Recklinghausen’s disease).
Fig. 3.63: Multiple neurofibromas with intestinal
neurofibroma. It may precipitate intussusception.
Fig. 3.64: Neurofibrosarcoma in a female with multiple
neurofibromatosis.
pressur e symptoms are other complications. Intestinal
neurofibroma may precipitate intussusception.
Neurilemmoma (Schwannoma)
It is arising from ectodermal Schwann (neurilemmal
cells) cells. They are benign, lobulated, encapsulated,
soft, and whitish in appearance. They displace the nerve
from which they arise and can be removed. Anthony
A type contains two rows of spindle cells with central
acellular Verocay bodies. Anthony B type contains
acellular amyloid areas. They are common in acoustic
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nerve but do can occur in a peripheral nerve.
Occasionally they are multiple. Present as freely
mobile swelling; with pain along the distribution of
the nerve, hyperaesthesia, and tenderness. Recurrent
schwannoma could be malignant (Malignant
schwannoma are very aggressive).
adrenal medulla. It is relatively benign symptomless
and often attains large size.
Neuroblastoma—It is poorly differentiated, aggressive, embryonic type of tumour. It is seen in infants
and children. It spreads through blood but can go for
spontaneous remission occasionally.
Neuroma
Two types of neuromas are found—False neuroma
and true neuroma.
False neuroma: It occurs due to injury to the nerve
either after trauma or amputation which presents as
tender swelling. It arises from the connective tissue
of nerve sheath. It contains fibrous tissue with coiled
nerve fibres. It can be end neuroma commonly seen
in amputation stump as a tender localised firm swelling
often adherent to the stump scar. It can cause neuralgia
in the stump. It prevents proper usage of the prosthesis.
So during amputation, nerve should be pulled down
and cut so as to make cut end to retract more proximally
which prevents it to form neuroma. It can be lateral
(side) neuroma which is observed after partial nerve
injury usually after trauma. It presents as a tender,
firm swelling along the line of the peripheral nerve
(Fig. 3.65).
True neuroma: It is rare tumour. It occurs in
connection with sympathetic system.
Types:
Ganglioneuroma—It contains ganglion cells and nerve
fibres. It occurs in connection with sympathetic chain.
So it is observed in neck, thorax, retroperitoneum,
Myelinic neuroma: It contains only nerve fibres. Here
ganglion cells are absent. It occurs in spinal cord or
pia mater.
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 are: Dorsum of the wrist (near
scaphoid-lunate articulation); flexor aspect of wrist
around ankle joint—occasionally.
Pathogenesis: Possibilities thought of are—cystic
degeneration of the tendon sheath; leakage of synovial
fluid through joint capsule; presence of small islets
of microspaces in synovial sheath which often fuse
together or one of them gets enlarged to form ganglion.
Clinical features—Well-localised, smooth, soft,
cystic, or tensely cystic (Paget’s test is positive),
nontender, transilluminant, swelling which is mobile
but mobility is restricted when tendon is contracted
against resistance (Figs 3.66A to D). Occasionally
it communicates with joint capsule. Often pain,
tenderness and restricted joint movement may be the
presentation (but rare).
Fig. 3.65: Types of false neuroma—end and lateral.
Differential diagnosis—Lipoma; lymph cyst; sebaceous cyst; neurofibroma. Patient should be explained
of high recurrence rate (30%) after excision.
Papilloma
It is warty swelling from the skin or often from the
mucous membrane (Fig. 3.67). It has got a central
axis of connective tissue, blood vessels and lymphatics.
True papilloma—It is a benign tumour with localised
overgrowth of the all layers of the skin. It contains
sweat glands, sebaceous glands and hair follicles. It
is commonly pedunculated but rarely can be sessile.
Pedunculated papilloma is villous with a central axis
Examination of a Swelling/Lump
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75
C
D
Figs 3.66A to D: Ganglion over the wrist. Its mobility should be checked both with wrist relaxed as well as with wrist
extending against resistance. Skin should be held/pinched to confirm that ganglion is not fixed to skin.
of connective tissues, blood vessels and lymphatics
(Figs 3.68 and 3.69). Infective papilloma is a warty
lesion due to infection. For example, Condyloma
acuminata. 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. Mechanical disability
B
like voice change is observed when it occurs in vocal
cord.
Differential diagnosis: Amelanotic melanoma, pedunculated lipoma, carcinoma. Papilloma can occur in
the breast called as duct papilloma which is the
commonest cause of bloody discharge from the nipple.
Papilloma can occur in mucous membrane like in oral
cavity, urinary bladder (transitional papilloma), in the
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Fig. 3.67: Papilloma tongue. Note: Papilloma can also occur
in mucous membrane like in oral cavity, urinary and gallbladder, rectum.
Fig. 3.69: Papilloma which is pedunculated. Note its base.
rectum (columnar), in the larynx, in the gallbladder
(cuboidal) (Figs 3.67 and 3.70).
Fibroma
It is a benign tumour arising from fibrous tissue. It
is capsulated.
Fig. 3.68: Pedunculated papilloma with its pedicle.
Classification of true fibroma:
1. Soft fibroma: Contains immature fibrous tissue.
Common in face, presents as soft brown swelling.
2. Hard fibrom a: Contains well-formed fibrous tissue.
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
Fig. 3.70: It is often called as condyloma. It is dry, raised
lesion in the anal canal. Condyloma lata is seen in secondary
syphilis. Condyloma acuminata is of viral origin.
Examination of a Swelling/Lump
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aggressive fibromatosis is known to occur as
unencapsulated proliferation of fibrous tissue, common
in abdominal and, chest wall. It is presently considered
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). Recurrent Fibroid of Paget’s is a rare
type of fibrosarcoma occurring in a scar tissue after
many years.
Bursae
Bursa is a sac like cavity containing fluid within, which
in normal location prevents friction between tendon
and bone. It is smooth, soft/firm (tensely cystic),
fluctuant, cystic. Skin may be free or often adherent
due to chronic inflammation. Sometimes tenderness
can occur in bursae due to acute inflammation or
abscess formation. Usually it is mobile but inflammation may restrict the mobility. It should be
differentiated from sebaceous cyst, soft tissue tumour,
lipoma, neurofibroma. Minor injuries and pressure
leads into bursitis, which will present as a swelling
at the site. Inflammation of this bursa due to friction
causes bursitis, which commonly presents as swelling,
pain, and restricted movements.
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Fig. 3.71: Bursa near elbow joint.
Fig. 3.72: Bursa over elbow joint.
Different types: It can be anatomical or adventitious.
Anatomical
Subhyoid bursa: A horizontally oval swelling situated
below the hyoid bone and in front of the thyrohyoid
membrane.
Subacromial bursa: In front and lateral to humeral
head in relation to supraspinatus tendon between
acromion and greater tuberosity of humerus. Bicipito
radial bursa. Olecranon bursa (Student’s elbow,
Miner’s elbow) (Figs 3.71 to 3.73 and 3.75) .
Psoas bursa: A tensely cystic swelling beneath and
below the inguinal ligament on 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).
Prepatellar bursitis (Housemaid’s knee): It occurs in
front of lower part of patella and upper part of patellar
Fig. 3.73: Adventitious bursa over lateral
aspect of foot—a common site.
tendon due to constant pressure (like kneeling) (Fig.
3.74).
Infrapatellar bursitis (Cler gyman’ s knee): It is inflammation of bursa occurring in relation to lower half
of the patellar tendon (Fig. 3.74).
Semimembranosus bursa; Bursa anserina: Located
under the tendons of Guy ropes (sartorius, gracilis
and semitendinosus tendons) (Goose’s foot).
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Fig. 3.74: Prepatellar (Housemaid’s knee) and
infrapatellar bursae (Clergyman’s knee).
SRB’s Clinical Surgery
Fig. 3.76: Common site of adventitious
bursa (Bunion).
Semimembranosus Bursa
It is a cystic swelling in the upper medial aspect of
the popliteal fossa under the semimembranosus
tendon. It is said that friction under the tendon causing
bursitis.
Fig. 3.75: Location of olecranon bursa (Student’s
elbow).
Retrocalcaneum bursitis—occurs between calcaneum
and tendoAchilles.
Adventitious bursa occurs in an unusual site like in
hallux valgus (bunion) over first metatarsal, over lateral
malleolus (tailor’s bursa), between clavicle and skin
near shoulder (porter’s bursa), between gluteus
maximus muscle and ischial tuberosity (weaver’s
bursa), between tendoachilles and skin (retroachilles
bursitis) or over gluteal tuberosity (Fig. 3.76). It occurs
due to friction or pressure.
Clinical features: It is common in young individuals.
It is soft, smooth, cystic, often transilluminant and
nontender, noncompressible swelling located in upper
and medial aspect of the popliteal fossa. On flexion
of knee the swelling disappears and on extension it
becomes more prominent. Swelling does not communicate into the knee joint cavity . Here knee joint is normal
(Figs 3.77 and 3.78A and B).
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.
Clinical features: It is common in middle-aged
individuals. It is smooth, soft and cystic, often tender
swelling located below and on midline of the popliteal
fossa (Fig. 3.79). On flexion swelling increases and
on extension swelling decreases in size. Pain and
tenderness are present in knee joint with effusion
showing positive patellar tap. The knee joint
movements are painful and restricted.
Examination of a Swelling/Lump
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Fig. 3.77: Semimembranosus
bursa—typical location.
A
B
Fig. 3.78: Semimembranosus bursa—typical location.
On flexion it disappears.
Fig. 3.79: Morrant-Baker’s cyst—typical location.
Lymph Cyst (Lymphatic Cyst)
It is an acquired type of distension cyst wherein
lymphatics form a localised swelling with a capsule
around it. This localised cystic swelling contains
lymph. It is commonly due to trauma. T rauma causes
disruption of subcutaneous lymphatics causing
accumulation of lymph in a localised area with a
capsule. It usually occurs in subcutaneous plane, which
is well-defined, smooth, soft, nontender, mobile, noncompressible, fluctuant (positive Paget’s test), and
brilliantly transilluminant (Fig. 3.80). It is usually not
adherent to the overlying skin. Common sites are in
limbs and neck. It can get infected and form an abscess.
Differential diagnosis: Cold abscess, dermoid cyst.
Calcinosis Cutis
It is a type of calcification (dystrophic) in or under
the skin. It usually presents as a circumscribed lesion
in the skin. It is commonly seen in females and common
site is in the waist (Fig. 3.81). It is usually bilateral.
It is said to be due to friction causing degeneration
of skin and immediate deeper structure with increased
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Fig. 3.80: Lymph cyst, which is transilluminant.
It is an acquired condition.
SRB’s Clinical Surgery
Callosity is thickened, grayish brown hyperkera-
totic patch of skin commonly of hands and feet over
an area of excessive wear and tear in relation to
occupation. It protrudes outwards. When top layer
is removed, shiny , translucent, homogenous dead skin
layer can be exposed. It is not a painful condition.
It can be left alone (Fig. 3.82).
Fig. 3.82: Callosity foot. It is outward protruding grayish
brown hyperkeratotic patch of skin in the foot/hand. It is not
a painful condition.
Corn is a localised, smaller, deeper lesion with
palpable tender nodule having a yellow white core of
cornified dead skin in the centre. It is common in soles,
tips of toes. Often corns are multiple and bilateral (Fig.
3.83). It is often due to friction like using ill-fitting
footwear. Corns are painful and tender. Corn can be
commonly hard in the sole or rarely soft corn do can
Fig. 3.81: Calcinosis cutis near waist is a common site.
It is common in females.
local alkalinity of the tissue causing precipitation of
the calcium leading to solid, hard, swelling in the skin.
Cut section shows hard, yellowish material. It may
mimic calcified lipoma or neurofibroma.
Callosity and Corn
They are thickened, hyperkeratotic skin due to pressure
and repetitive minor trauma. They are common in old
people due to old age skeletal changes causing
maldistributed weight bearing.
Fig. 3.83: Corn foot. It is localised, painful, tender, deep
lesion with a deep core that contains degenerated dead
keratotic cells and cholesterol.
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