What is the treatment for a cyst on the distal interphalangeal (DIP) joint?

Treatment of Cysts on the Distal Interphalangeal (DIP) Joint

Corticosteroid injection via a volar, transtendon, intra-articular approach is the recommended first-line treatment for symptomatic DIP joint ganglion cysts, with surgical intervention reserved for cases that fail conservative management or have specific indications.

Diagnosis and Classification

Before initiating treatment, proper identification of the cyst type is essential:

• DIP joint cysts are typically mucous cysts (also called digital myxoid cysts)
• They arise from the DIP joint capsule and are associated with osteoarthritis
• Often present as small, firm nodules on the dorsal aspect of the DIP joint
• May cause nail deformities in approximately 29% of cases 1

Treatment Algorithm

First-Line Treatment:

1. Corticosteroid injection
   • Volar, transtendon, intra-articular injection technique
   • Provides resolution in approximately 52.2% of cases
   • Safe and effective with minimal complications 2
   • Advantages: minimally invasive, can be performed in-office, avoids surgical risks

Second-Line Treatment (if injection fails):

1. Surgical intervention options:

   • Total dorsal capsulectomy

     • Resection of dorsal half of DIP joint capsule without cyst excision
     • High success rate with no recurrences reported in studies
     • Resolves nail deformities in most cases (average 5 months)
     • Preserves joint motion 3

   • Osteophyte excision with joint debridement

     • Removes underlying cause (osteophytes) and cleans dorsal joint capsule
     • Reduces recurrence rates
     • Improves pain scores (VAS score reduction from 4.93 to 4.07)
     • Preserves or improves range of motion in most patients 4

   • Dorsally based flap technique without osteophytectomy

     • Very low recurrence rate (1.4%)
     • Minimal impact on joint motion
     • No reported infections or wound complications 5

Complications to Monitor

When discussing treatment options with patients, inform them about potential complications:

• Post-surgical complications:
  • Loss of extension (17% of cases, ranging from 5-20°) 1
  • Infection risk (superficial and deep infections possible)
  • Nail deformities (7% new deformities post-surgery)
  • Recurrence (3% with traditional excision) 1
  • Other: persistent swelling, pain, numbness, stiffness, and joint deviation

Monitoring and Follow-up

• Follow-up evaluation at 2-4 weeks post-treatment to assess resolution
• Monitor for 6-12 months to detect any recurrence
• Assess for improvement in nail deformities if present initially
• Evaluate range of motion and pain levels

Special Considerations

• Patients with osteoarthritis of the DIP joint have higher likelihood of developing these cysts
• Middle-aged and elderly patients are most commonly affected
• The dominant hand is involved in approximately 56.5% of cases 2
• Nail deformities may resolve after successful treatment in up to 60% of cases 1

The treatment approach should be guided by symptom severity, functional limitations, and patient preferences, with corticosteroid injection being the preferred initial intervention due to its favorable risk-benefit profile and ability to avoid the complications associated with surgery.