EXTREMITY MASS

When the clinician tries to recall the causes of a mass in the extremities, he or she should consider the anatomy. As the clinician dissects downward from the skin, he or she encounters the subcutaneous tissue, veins, muscles, ligaments, bursae, arteries, lymph nodes, nerves, bones, and joints. The common lesions causing a mass in each of these should easily come to mind.

1. Skin. Common lesions to consider here are sebaceous cysts, lipomas, and cellulitis. Other skin masses are considered on page 396.
2. Subcutaneous tissue. Rheumatic or rheumatoid nodules, tophi of gout, lipomas, and contusions are common.
3. Veins. Dilated veins (varicoceles) and thrombophlebitis present as mass lesions.
4. Muscles and ligaments. Contusions, nodules in myo- fascitis, ganglions, and partial or complete rupture of muscle (e.g., rupture of the rectus femoris) are typical masses originating in the muscles and ligaments. Myositis ossificans may present with nodular masses.
5. Bursae. The bursae may be involved by gout, trauma, or rheumatic conditions and swell with fluid.
6. Arteries. Aneurysms are the most likely cause of an extremity mass originating from the arteries. Severe arteriosclerosis may cause confusion occasionally.
7. Lymph nodes. Tuberculous adenitis, adenitis secondary to infections in the distal portion of the extremity, and metastatic tumors may cause enlargement of the lymph nodes.
8. Nerves. Traumatic neuromas, neurofibromas, and hypertrophy of the nerve in Dejerine–Sottas disease are typical “masses” arising from the peripheral nerve.
9. Bone. Trauma may lead to fractures and subperiosteal hematomas, callus formation following the fracture, or secondary osteomyelitis, all of which may cause a mass. Primary osteomyelitis, tuberculosis of the bone, syphilis of the bone, rickets, and acromegaly may cause bone masses. Typical tumors affecting the bone are chondromas, exostoses (osteomas), osteogenic sarcomas, fibrosarcomas, and metastatic carcinomas, but there are several others. Paget disease may present as an enlargement of the bone.

Approach to the Diagnosis

If the lesion is suspected to arise in the skin, simple biopsy or excision is the best approach. Deeper masses require careful examination, x-rays of the bones and soft tissue, bone scans, CT scans, ultrasonographic studies, and phlebography, arteriography, or lymphangiography. Surgical exploration of the area may be the only means to accomplish a specific diagnosis.

Approach to the Diagnosis

Because the extremities are not considered vital areas, the primary method of diagnosing the cause of a mass is exploration and biopsy. This is all well and good when the lesion is on the skin or subcutaneous tissue; however, when the mass is in the deeper tissues, it is wise to utilize diagnostic tests to determine what the mass is before exploration. If the mass is suspected to be a varix or aneurysm, ultrasonography can be extremely useful in defining it. If the mass is attached to or thought to originate in bone, x-rays of the area and bone scans are useful. If it is uncertain what tissue the mass originates from, a CT scan can be used to help define it. Before ordering any of the above tests, it is best to consult a general or orthopedic surgeon to help select the most appropriate test for the case at hand.

Other Useful Tests

1. CBC (abscess)
2. Sedimentation rate (cellulitis)
3. Tuberculin test (cold abscess)
4. Serum protein electrophoresis (multiple myeloma)
5. Skeletal surgery (metastatic neoplasm)
6. Arteriogram (aneurysm)
7. Phlebogram (varix)
8. Lymphangiogram (Hodgkin lymphoma, lymph node metastasis)
9. Exploratory surgery

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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