Baker’s Cyst - Case Report

 

Ms. Lakshmi. K

Associate Professor, MES College of Nursing, Palachode (po), Kolathur via, Perinthalmanna, Kerala- 679338

 

 

ABSTRACT:

Baker’s cyst is a pocket of fluid that forms a lump behind the knee. It is also called a popliteal cyst. It is usually the result of a problem with the knee joint, such as arthritis or a cartilage tear. Both the condition can cause the knee to produce too much of synovial fluid, which can leads to a baker’s cyst. It tends to occur in adults from ages 35 to 70 years and above. It is common in women than in men due to inflammatory knee joint diseases such as osteoarthritis, rheumatoid arthritis etc. Popliteal cyst in adults are often secondary to degenerative or inflammatory joint disease or joint injury, they usually communicate with the adjacent knee space, especially in older patients with knee pathology communicating cyst contains synovial fluid. In children, popliteal cysts are usually a primary process, arising directly from the gastrocnemius- semimembranosus bursa, they do not communicate with the joint space. Symptoms may include; visible swelling or protrusion on the back of the knee (which can be painful or painless), constant and prolonged knee pain, and tightness at the back of the knee or simply a feeling of tenderness at the back of the knee. It can be diagnosed on by physical examination, x-ray, ultrasound, Doppler study, MRI, CT and Arthrogram. Treatment may include painkillers, R.I.C.E principles, aspiration of excess fluid with corticosteroid injection directly on the swelling. Arthroscopy surgery is done to repair any knee damage. So it is important for the nurses, nursing students to be aware of those cysts to care the client efficiently and effectively. This case report was to discuss regarding bakers cyst and its management.

 

 

 

 

 

 

INTRODUCTION:

Case Summary:

A 76 years old male admitted to the hospital with the complaints of inability to move the left lower limb, oedema over left leg, tenderness present, redness and pain for since 5 days and he was diagnosed as left popliteal cyst / Baker’s cyst and left lower limb cellulitis. He was also a known case of hypertension, diabetes mellitus and benign prostate hypertrophy on regular medications.

 

On Examination:

·        Temperature: 98.degree Fahrenheit

·        Pulse: 88 beats per minutes

·        Respiration: 20 breadth per minutes

·        Blood pressure: 120/ 80 mmHg

·        Oxygen saturation: 92%

·        CVS: S1 S2 +

·        Per abdomen : soft, No organomegally

 

Investigations:

·        Total leucocytes count: 7560 cell/ cu mm, Hb: 11.9gm/dl; PCV: 33.9%: MCV: 86.0fL; MCH: 30.2pg; MCHC: 35.1%; Platelet: 2.82 lakhs/cc.

·        Urea: 27mg/dl; creatinine: 0.5 mg/dl; Uric acid: 2.0mg%; Na: 122meq/l; k: 4.2mEq/l Mg: 1.9mg/dl.

·        ECG: within normal limits.

·        HIV spot : negative

·        HbsAg : negative

·        Urine routine: 15-20 pus cells/hdf;

·        C/S: insignificant growth of gram positive cocci.

·        Venous Doppler: left popliteal cyst/

·        Baker’s cyst.

 

Treatment Given:

·        Inj. Heparin 5000 units BD IV for 5 days.

·        Inj. Cefuroxime 1.5g IV BD

·        T. Deplatt A 75/75 OD

·        T. Rose day 5mg OD

·        T. Urimax 0.4 mg OD

·        T. Envas 5mg BD

·        Inj. Pan IV 40mg

·        Inj. Human actrapid according to sliding scale

·        Inj. Human mixard30/70 20-0-12/sc

 

Definition of Baker’s cyst:

Baker ‘s cyst  is a fluid filled cyst that causes swelling on the back of the knee caused by the build –up of fluid inside sacs called bursa between the two heads of the gastrocnemius (calf muscle). It is named after the British surgeon who described it, Dr. William Morrant Baker (1838-1896) [4]

 

Alternative names:

Baker’s cyst is also known as popliteal cyst or synovial cyst or a hematoma. [2]

 

Epidemiology:

Most Popliteal cyst is asymptomatic and is detected incidentally by an imaging study performed for other reason. It is common in adults from ages of 35 to 70 years.[6] Baker’s cyst affects more women than men, probably because women develop rheumatoid arthritis and osteoarthritis more often. [4]

 

Common causes of baker’s cyst:

·        Excess synovial fluid production resulting in build-up of fluid in an area on the back of the knee (popliteal bursa) bulges to forms the baker cyst.

·        Arthritis of the knee- more common in older adults with osteoarthritis, rheumatoid arthritis or internal derangement of the knee[3]

·        Gout

·         Septic arthritis

·        Reactive arthritis

·         Haemophilia

·        A micro tear in the knee’s meniscal cartilage

·        Injury to the anterior cruciate ligament of the knee. (ACL injury).

·        Sports- related injury that affects the knee.

 

Symptoms and signs of bakers’ cyst

·        Some patients may have no pain and may not even notice the cyst in the knee.

·        Knee pain

·        Tightness or stiffness behind the knee.

·        Calf pain

·        Accumulation of fluid around the knee.

·        Swelling or lump behind the knee is the main sign.

·        Knee joint may click or buckle.

·        Knee joint may lock.

·        A syndrome of pseudothrombophlebitis may occur as a result of cyst dissection into the calf or actual rupture of the cyst leads to diffuse swelling of the calf, pain and sometimes erthyma and oedema of the ankle. [3]

 

Diagnosis of baker’s cyst:

·        On physical examination- it is best palpated with the knee partially flexed and is best viewed posteriorly with the patient standing and knees fully extended to visualise popliteal swelling. [7]

·        X – ray abnormal popliteal fossa

·        Ultrasound for small popliteal cyst with aneurysm

·        Ultrasound guided popliteal cyst aspiration.

·        MRI and CT scans of ruptured dissecting popliteal cyst.

·        Doppler, ultrasound, arthrogram is required to establish correct diagnosis. Since deep vein thrombosis and bakers cyst may co-exist.[1]

 

Differential diagnosis [5]

·        Deep vein thrombosis

·        Tumours

·        Popliteal aneurysms

·        Other cystic masses.

 

Prevention of a baker’s cyst [8]

Knee joint trauma during exercise and sporting activities is common and chances of developing Baker’s cyst .It can be prevented or reduced by

·        Gently go through the range of motions needed for during sport to warm up the knee joint and surrounding soft tissues.

·        Stretch your muscles before beginning your activity.

·        Choose appropriate and supportive footwear.

·        Always cool down after exercise using gentle, slow stretching.

·        If there is any knee injury, stop doing activities. Apply an ice pack to the area to ease any swelling and then consult the doctor.

 

Treatment of baker’s cyst:

A baker’s cyst will commonly resolve on its own and no treatment is required.

 

General measures:

Follow the R.I.C.E principles [4]

 

R- Resting knee needs to rest.

 

I- Icepacks useful in reducing inflammation. Make sure there is no direct contact with ice on skin.

 

C- Compression bandages and use of crutches help to support the knee.

 

E- Elevate the leg when possible, especially at night.

 

Take non- steroidal anti- inflammatory drugs, such as ibuprofen and naproxen to reduce swelling and pain in the affected knee.

 

Baker cysts often resolve with aspiration (removal) of excess knee fluid in conjunction with cortisone injection. [7]

 

The OSMO Patch is especially designed to draw fluid from the body and reduce swelling and associated pain in conditions such as a baker’s cyst. [5]

 

Treating a ruptured cystl:

A Baker's cyst can often rupture (burst), resulting in fluid leaking down into your calf. This causes a sharp pain in the calf which becomes red, swollen and tight. The fluid will gradually be reabsorbed into the body within a few weeks. The recommended treatment for a ruptured cyst is rest and elevation (keeping the affected calf raised). Prescription painkillers - usually a combination of paracetamol and codeine – can also be used to control any pain. [8]

 

Surgery to repair knee damage [5]

In some cases, it may be possible to drain (aspirate) a bakers cyst. However, it may not be   possible to aspirate long- term (chronic cyst) because they are made of jelly. Surgically removing a bakers’ cyst isn’t easy because unlike other types of cyst, they don’t have lining. Surgery may be needed to repair the knee joint if it’s significantly damaged as a result of an injury or a condition such as osteoarthritis and rheumatoid arthritis. A type of keyhole surgery called arthroscopy is usually used.

 

Recovery time after treatment of a Baker cyst:

Recovery time depends on the form of treatment rendered. With medications or injections into the knee, recovery can be rapid, within days to weeks. If surgical repair is done, recovery generally takes one to three months. [7]

 

Exercise programs:

Exercise programs should be planned in consultation with the doctor, physiotherapist, and exercise physiologist. Some of the preferred exercises are swimming, walking, chair exercises, low impact aerobics, strength training, dancing etc. [5]

 

CONCLUSION:

Baker’s cysts are a common occurrence in adults and children.  The common causes are excess synovial fluid production, inflammatory knee joint disease, knee injuries etc.  The symptoms usually occurs tightness or stiffness behind the knee, swelling behind the knee, slight pain behind the knee and into the upper calf. The diagnoses can be done by Ultrasound, X-ray, Magnetic resonance imaging (MRI) and Doppler study. A Baker's cyst will commonly resolve on its own, and no treatment is required. Sometimes needs symptomatic treatment such painkillers, rest, icepack application, use of compression bandages and elevation of affected legs at night. Arthroscopy surgery is done in case of knee joint diseases. My client had a ruptured baker’s cyst and inj heparin is given s/c as prophylaxis treatment for deep vein thrombosis. Arthroscopy surgery is advised but client not willing to undergo surgery. He was on symptomatic treatment.

 

 

 

REFERENCES:

1.     Davidson’s “principles and practice of medicine” 20^th edition, Churchill Livingstone’s Elsevier publication, 2006: 1099, 1103.

2.     Harrison’s “principles of internal medicine” 17^th edition volume -II 2008: 1652-53, 2087, and 2154.

3.     Goldman ausiello “Cecil medicine” 23^rd edition, volume –II   Elsevier publication 2007: 2003.

4.     Www. Medi news today.com

5.     www.osmopatch.com

6.     www.updates July 2016.

7.     www.medicine.net.

8.     www.mayoclinic .com

 

 

 

 

 

Received on 05.06.2017       Modified on 18.09.2017

Accepted on 21.10.2017       ©A&V Publications All right reserved