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Bilateral intraosseous ganglia of the scaphoid and lunate bones
B I L A T E R A L I N T R A O S S E O U S G A N G L I A OF T H E SCAPHOID AND LUNATE BONES M. KLIGMAN and M. ROFFMAN
From the Carmel Medical Center and Teehnion-lsrael Institute of Technology, HaiJit, Israel A rare case of simultaneous bilateral intraosseous ganglia of the scaphoid and lunate bones is presented. The cysts were removed and the carpal bones were grafted with cancellous bone, resulting in a satisfactory outcome. Journal of Hand Surgery (British and European Volume, 1997) 22B: 6:820 821
showed bilateral intraosseous lesions of these carpal bones with disruption of the cortex (Fig 2). The left wrist was operated on first through a dorsal approach, exposing lunate and scaphoid bones. Macroscopically, we found expansion of the scapholunate ligament, eroding the carpal bones at their insertion. The other ligaments were intact. A small window was created on the dorsal aspects of the scaphoid and lunate bones, and the intraosseous cysts were excised. The two cysts in the scaphoid and the one in the lunate bone contained gelatinous fluid. The cysts measured 3 x 6 mm on average. The cavities were packed with cancellous bone taken from the distal radius. A palmar splint was worn for 4 weeks, followed by active mobilization. The right wrist was operated on 6 months after the first operation. The approach, macroscopic lesion and postoperative treatment were similar to the left wrist. The histological findings from both wrists confirmed ganglion cysts with degenerative soft tissue covered by epithelial lining. One year after the first operation the patient was painfree without limitation of motion, and had returned to normal activity.
Isolated intraosseous ganglia of the carpal bone are more common than is believed (Eiken and Jonsson, 1980; Iwahara et al, 1983; Magee et al, 1995). Bilateral intraosseous ganglia are infrequent and have been described in the lunate or scaphoid bones (Logan et al, 1992; Mogan et al, 1981; Schajowicz et al, 1979). To the best of our knowledge, there is no report on simultaneous bilateral scaphoid and lunate intraosseous ganglia in the English-language medical literature.
CASE R E P O R T
A 44-year-old woman complained of intermittent bilateral wrist pain for several months. She did not have an occupation which required strenuous or repetitive use of the wrist. She presented with dorsal pain and swelling in both wrists. The pain was made worse by extension and was localized in the perilunate region. Standard three-view radiography of the wrists revealed polycystic lesions of the scaphoid and lunate bones, bilaterally (Fig 1). The bone scan demonstrated increased uptake only at the right scaphoid. Computed tomography
Fig 1 X-ray, anterior-posterior view, showing eccentric intraosseous lesion of scaphoid and lunate bones in (a) left and (b) right wrist.
820
INTRAOSSEOUS GANGLIA
Fig 2
821
C T scan shows i n t r a o s s e o u s lesions of the (a) left a n d (b) right s c a p h o i d a n d lunate w i t h i n t e r r u p t i o n o f cortical surfaces.
DISCUSSION Intraosseous ganglion cysts are rare, and may be primary or penetration types (Eiken and Jonsson, 1980; Schajowicz et al, 1979; Young et al, 1988). X-rays show an eccentric intraosseous radiolucent lesion which should be differentiated from an osteoarthritic cyst, post-traumatic cyst, simple bone cyst, ostoeid osteoma or osteoblastoma. The last two lesions cause pain, whereas the others rarely cause wrist pain. Isolated intraosseous ganglia in carpal bones commonly affect the scaphoid or lunate bones. They may be due to penetration of juxtaosseous material (type 1) or primary intraosseous degeneration (type 2). In the present case of simultaneous bilateral intraosseous ganglion cysts of scaphoid and lunate bones, the operative findings of the scapholunate ligament eroding into adjacent bones and the carpal bone defect demonstrated in the CT scan are consistent with the penetrating type.
References Eiken O, Jonsson K (1980). Carpal bone cysts: a clinical and radiographic study. Scandanavian Journal of Plastic and Reconstructive Surgery, 14:285 290. Iwahara T, Hirayama T, Takeimitu Y (1983). Intraosseous ganglion of the lunate. The Hand, 15:297 299. Logan S E, Gilula L A, Kyriakos M (1992). Bilateral scaphoid ganglion cysts in an adolescent. Journal of Hand Surgery 17A: 490~495. Magee T H, Rowedder A M, Degnan G G (1995). lntraosseus ganglia of the wrist. Radiology 195:517 520. Mogan J V, Newberg A H, Davis P H (1981). Intraosseous ganglion of the lunate. Journal of Hand Surgery, 6: 61-63. Schajowicz F, Sainc M C, Slullitel J A (1979). Juxta-articular bone cysts (intraosseous ganglia). A clinicopathologic study of eighty-eight cases. Journal of Bone and Joint Surgery, 61B: 107 116. Young L, Bartell T, Logan S E (1988). Ganglions of the hand and wrist. Southern Medical Journal, 81:751 760.
Received:21 February 1997 Accepted after revision: 19 May 1997 M. Kligman MD, Department of Orthopaedic Surgery,Carmel Medical Center, Michael Street, Haifa 34362, Israel. © 1997The British Societyfor Surgery of the Hand
From the Carmel Medical Center and Teehnion-lsrael Institute of Technology, HaiJit, Israel A rare case of simultaneous bilateral intraosseous ganglia of the scaphoid and lunate bones is presented. The cysts were removed and the carpal bones were grafted with cancellous bone, resulting in a satisfactory outcome. Journal of Hand Surgery (British and European Volume, 1997) 22B: 6:820 821
showed bilateral intraosseous lesions of these carpal bones with disruption of the cortex (Fig 2). The left wrist was operated on first through a dorsal approach, exposing lunate and scaphoid bones. Macroscopically, we found expansion of the scapholunate ligament, eroding the carpal bones at their insertion. The other ligaments were intact. A small window was created on the dorsal aspects of the scaphoid and lunate bones, and the intraosseous cysts were excised. The two cysts in the scaphoid and the one in the lunate bone contained gelatinous fluid. The cysts measured 3 x 6 mm on average. The cavities were packed with cancellous bone taken from the distal radius. A palmar splint was worn for 4 weeks, followed by active mobilization. The right wrist was operated on 6 months after the first operation. The approach, macroscopic lesion and postoperative treatment were similar to the left wrist. The histological findings from both wrists confirmed ganglion cysts with degenerative soft tissue covered by epithelial lining. One year after the first operation the patient was painfree without limitation of motion, and had returned to normal activity.
Isolated intraosseous ganglia of the carpal bone are more common than is believed (Eiken and Jonsson, 1980; Iwahara et al, 1983; Magee et al, 1995). Bilateral intraosseous ganglia are infrequent and have been described in the lunate or scaphoid bones (Logan et al, 1992; Mogan et al, 1981; Schajowicz et al, 1979). To the best of our knowledge, there is no report on simultaneous bilateral scaphoid and lunate intraosseous ganglia in the English-language medical literature.
CASE R E P O R T
A 44-year-old woman complained of intermittent bilateral wrist pain for several months. She did not have an occupation which required strenuous or repetitive use of the wrist. She presented with dorsal pain and swelling in both wrists. The pain was made worse by extension and was localized in the perilunate region. Standard three-view radiography of the wrists revealed polycystic lesions of the scaphoid and lunate bones, bilaterally (Fig 1). The bone scan demonstrated increased uptake only at the right scaphoid. Computed tomography
Fig 1 X-ray, anterior-posterior view, showing eccentric intraosseous lesion of scaphoid and lunate bones in (a) left and (b) right wrist.
820
INTRAOSSEOUS GANGLIA
Fig 2
821
C T scan shows i n t r a o s s e o u s lesions of the (a) left a n d (b) right s c a p h o i d a n d lunate w i t h i n t e r r u p t i o n o f cortical surfaces.
DISCUSSION Intraosseous ganglion cysts are rare, and may be primary or penetration types (Eiken and Jonsson, 1980; Schajowicz et al, 1979; Young et al, 1988). X-rays show an eccentric intraosseous radiolucent lesion which should be differentiated from an osteoarthritic cyst, post-traumatic cyst, simple bone cyst, ostoeid osteoma or osteoblastoma. The last two lesions cause pain, whereas the others rarely cause wrist pain. Isolated intraosseous ganglia in carpal bones commonly affect the scaphoid or lunate bones. They may be due to penetration of juxtaosseous material (type 1) or primary intraosseous degeneration (type 2). In the present case of simultaneous bilateral intraosseous ganglion cysts of scaphoid and lunate bones, the operative findings of the scapholunate ligament eroding into adjacent bones and the carpal bone defect demonstrated in the CT scan are consistent with the penetrating type.
References Eiken O, Jonsson K (1980). Carpal bone cysts: a clinical and radiographic study. Scandanavian Journal of Plastic and Reconstructive Surgery, 14:285 290. Iwahara T, Hirayama T, Takeimitu Y (1983). Intraosseous ganglion of the lunate. The Hand, 15:297 299. Logan S E, Gilula L A, Kyriakos M (1992). Bilateral scaphoid ganglion cysts in an adolescent. Journal of Hand Surgery 17A: 490~495. Magee T H, Rowedder A M, Degnan G G (1995). lntraosseus ganglia of the wrist. Radiology 195:517 520. Mogan J V, Newberg A H, Davis P H (1981). Intraosseous ganglion of the lunate. Journal of Hand Surgery, 6: 61-63. Schajowicz F, Sainc M C, Slullitel J A (1979). Juxta-articular bone cysts (intraosseous ganglia). A clinicopathologic study of eighty-eight cases. Journal of Bone and Joint Surgery, 61B: 107 116. Young L, Bartell T, Logan S E (1988). Ganglions of the hand and wrist. Southern Medical Journal, 81:751 760.
Received:21 February 1997 Accepted after revision: 19 May 1997 M. Kligman MD, Department of Orthopaedic Surgery,Carmel Medical Center, Michael Street, Haifa 34362, Israel. © 1997The British Societyfor Surgery of the Hand