This young man had seen three staff at our practice and we each diagnosed the lump on his wrist as a ganglion. It was about 1.5cm wide, raised, round and bluish with the firm to cystic consistency of a ganglion. It was over the flexor tendon area of his right wrist. It was causing him some discomfort and the pain radiated along the thenar eminence. He was otherwise well, but recently was attending more frequently with the same problem. He would indicate the line of pain on his palm, saying it felt like there was something there and asked if it may be related to a splinter he had had in his thumb previously. As the lump had not changed, I thought he was just anxious.
To our surprise, the next time he attended, he brought an inch-long splinter, which he had extracted from the lump.
The lump now looked like an infected nodule or abscess. It had started discharging pus and a surprisingly clean, long splinter. A year earlier a splinter had pierced his hand between his thumb and index finger. The splinter had been removed at A&E, but he claimed his hand had ‘never been normal since’.
Ganglions are protrusions from the outer tendon lining which usually arise secondary to tendon injury strain or tear. They vary in consistency from firm-to-cystic to firm, depending on their position and depth. Ganglions may increase in size but may also disappear suddenly if knocked sharply. They are easily diagnosed by their position and the change in consistency or tension of the cyst with tendon movement.
With hindsight, this ‘ganglion’ did not become tense with wrist movement, and the tenderness along the thenar eminence was very specific and followed a clear line.
When the skin is pierced by a foreign object, the body treats it like an infection. This may result in inflammation, or abscess or cyst formation. The abscess would be sterile unless there were pathological bacteria in the splinter. Over time, this self-induced abscess pushes the foreign object out.
What I learned
I thought I listened to my patients, but I did not in this case. Remember the rules of examination: inspection and palpation. Just because this looked like a ganglion, I disregarded the fact that it did not feel like one.
Old injuries, commonly cited by patients as the cause of their grievances, should not be taken lightly.
How I changed my practice
Even if you are diagnosing a common condition, if something does not fit then re-evaluate. In future, I am always going to palpate a suspected ganglion and take note of the findings without bias.
I will also be more open-minded about my patients’ theories of their illness.
Dr Samia Bushra is a GP in Dagenham, east London
Dr Bushra would like to thank Omolola Ojuri, practice nurse, and the patient for kindly consenting to have his hand photographed
Do you have a story to share? Submit your own ‘a case that changed my practice’ article to firstname.lastname@example.org. There is a £100 honorarium for every article.