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Sonographic findings in examination of digital ganglia: Retrospective study
Clinical Radiology (1993) 48, 45-47
Sonographic Findings in Examination of Digital Ganglia: Retrospective Study S. B I A N C H I , I. F. A B D E L W A H A B * , A. ZWASS~', R. C A L O G E R A , A. B A N D E R A L I , P. B R O V E R O and P. V O T A N O
E.O. Ospedali Galliera, Genova, Italy, *Mount Sinai Medical Center, New York, and tColumbia Presbyterian Medical Center, New York, NY, USA A retrospective sonographic study of soft tissue masses of the hand was undertaken. A spherical fluid-filled structure with a well-defined wall was seen in 13 patients and the cases were diagnosed as ganglia. This diagnosis had been generally suspected clinically in the presence of a firm nonpainful lump. This study indicates that ultrasound is a valuable diagnostic tool for the study of soft-tissue masses of the hand and in the differential diagnosis of other soft tissue lesions, such as pigmented villonodular synovitis or tenosynovitis. Bianchi, S., Abdelwahab, I.F., Zwass, A., Calogera, R., Banderali, A., Brovero, P. & Votano, P. (1993). Clinical Radiology 48, 45-47. Sonographic Findings in Examination of Digital Ganglia: Retrospective Study
Accepted for Publication 21 January 1993
Evaluation of the soft tissue lesions o f the hands has been undertaken using a variety of modalities, such as plain films, computed tomography (CT), magnetic resonance imaging (MRI) and sonography [1-5]. Sonography is particularly useful as it is a quick non-invasive method of providing information regarding the size and nature of the mass, its relationship to the tendons, and the integrity of the tendons involved. It is also able to assess tendon movement in relation to the soft tissue lesion. We have undertaken a review of soft tissue lesions of the hands studied by sonography to assess the appearance and differentiation. P A T I E N T S AND M E T H O D S A group of 23 patients with a palpable soft tissue mass located in the digits was examined by sonography. The patients were 18- to 57-years-old with a mean age of 35. Sonography was performed with a real-time lineararray transducer with a frequency of 7.5 MHz. A thin stand-off pad was used for proper visualization of the skin and subcutaneous tissues. Longitudinal and transverse scans were obtained. Dynamic assessment was also undertaken during the active and passive movements of the fingers.
Neither active nor passive flexion or extension o f the finger caused a change in the appearance of the digital ganglia. In 10 patients, the mass was located on the flexor side, which was at the level of the proximal phalanx in nine and over the metacarpal in the tenth case. The ganglion was related to the extensor tendon in the remaining three patients. The digital ganglia were most commonly related to the fourth ray (8/13), with the remainder almost equally divided between the other fingers. The thumb was not involved. Five patients were symptomatic, complaining of pain when the affected hand was overused. The diagnosis of ganglion was confirmed surgically in seven cases. In two cases, an ultrasound-guided aspiration was performed with no recurrence of the lesion. In four patients, a hypoechoic heterogeneous solid mass (Fig. 3) was present and the diagnosis of giant cell tumour of the tendon sheath was made, which was later confirmed surgically. In five cases, the tendon was enlarged, with a fluid collection around the tendon sheath (Fig. 4). These patients had been previously diagnosed as having psoriatic arthritis. One case of a mucous cyst secondary to osteoarthritis was examined and its sonographic appearance was identical to digital ganglia (Fig. 5). The diagnosis was confirmed with a radiograph.
RESULTS An oval well-defined sonolucent mass, adjacent to the tendon, with distal acoustic enhancement, diagnostic of a ganglion, was observed in 13 patients (Figs 1,2). The size of the mass varied from 3 to 14 mm. No change of structure or effusion of the tendon sheath was evident.
Correspondence to: AticiaZwass, Department of Radiology,Columbia Presbyterian Medical Center, 630 West 168 Street, New York, NY 10032, USA.
DISCUSSION The majority of soft tissue masses of the hands are benign (95%, [6]) and a m o n g them ganglia are the most frequently encountered (50-70%, [7-9]). The diagnosis is commonly suspected clinically by the presence of a firm nonpainful lump that can vary in size. The ganglion is an encapsulated cyst containing a thick, clear, gelatinous fluid. Ganglia most commonly occur over the dorsal and/ or volar aspects of the wrist (60 70%, [7]), while volar retinacular ganglia arising from the proximal anular
46
CLINICAL RADIOLOGY
i
(a) (b) Fig. 1 - Transverse (a) and longitudinal (b) sonograms oftbe volar aspect of the hand at the level of the distal metacarpals (MET) showing the ganglion (G) as an anechoic mass, measuring 7.3 mm by 9.3 mm, with distal acoustic enhancement, and closely related to, but separate from, the flexor tendon (FT).
"
,[,
5
Fig. 4 - Longitudinal volar sonogram of a sausage digit in a patient with psoriatic arthritis. Observe the inhomogeneous appearance of the flexor tendon (T fless), with fluid collection in the synovial sheath (small arrow). P1, Proximal phalanx; P2, middle phalanx; M, metacarpal bone.
Fig. 2 - Longitudinal volar sonogram at the level of the proximal phalanx (PI). The ganglion is demonstrated as a sonolucent mass with distal sound enhancement (SC). The flexor tendon is falsely hypoechoic due to a slight obliquity of the beam (FT).
! Fig. 3 - Longitudinal sonogram of the digit, showing a mass with the internal echoes. A giant cell tumour of the tendon sheath was confirmed surgically.
l i g a m e n t o f the flexor t e n d o n sheath have a n incidence o f between 1 0 - 1 2 % [7] a n d 26% [9]. A c o m m u n i c a t i n g duct directed to the a r t i c u l a r space, which is seen in u p to 70% o f cases o f wrist ganglia [9-11], has n o t been d o c u m e n t e d in the p a l m a r digital ganglia. This finding is c o n f i r m e d in the p r e s e n t report. This absence o f a c o m m u n i c a t i n g d u c t c o u l d e x p l a i n the lower recurrence rate in this s u b g r o u p o f digital g a n g l i a [12]. T h e differential d i a g n o s i s includes m u c o i d cyst related to o s t e o a r t h r i t i s (OA), g i a n t cell t u m o u r o f the t e n d o n sheath, tenosynovitis, a n d the sausage digit o f p s o r i a t i c arthritis. T h e l a t t e r shows a w i d e s p r e a d i n v o l v e m e n t o f the t e n d i n o u s structures a n d evidence o f systemic arthritis even i f a sausage digit presents as the first m a n i f e s t a t i o n o f seronegative s p o n d y l o a r t h r o p a t h y . I n tenosynovitis, the flexor t e n d o n is usually increased in size a n d i n h o m o g e n e o u s (Fig. 4), whereas the t e n d o n size a n d echogenicity is p r e s e r v e d in cases o f digital ganglia. T h e s o n o g r a p h i c a p p e a r a n c e s o f v i l l o n o d u l a r t e n o s y n o v i t i s o r g i a n t cell t u m o u r o f the t e n d o n sheath (Fig. 3), which are those o f a h e t e r o g e n e o u s h y p o e c h o i c solid mass, s h o u l d be easily differentiated f r o m the n o n - e c h o i c ganglion. A c u t e infectious t e n o s y n o v i t i s shows an increase in size o f the t e n d o n , with fluid collection in the t e n d o n s h e a t h [ 13-16]. T h e differentiation o f a m u c o i d cyst (Fig. 5), c o m p l i c a t i n g O A , requires a plain r a d i o g r a p h as its s o n o g r a p h i c features are similar to those o f a ganglion. In the present series, s o n o g r a p h y p r o v e d a highly effective d i a g n o s t i c tool. Seven patients s u b s e q u e n t l y
SONOGRAPHIC FINDINGS IN EXAMINATION OF DIGITAL GANGLIA
47
and was a satisfactory alternative to surgery in some cases. Digital ganglion is a benign condition with no complication other than a local pain. Although diagnosis of ganglia can be achieved by M R I or CT, in some cases the smaller ganglia (and ganglion size varied from 3 to 14 mm in our series) could fail to be detected in MRI examination because of its small size [1]. Our study demonstrates a spectrum of soft tissue masses of the digits for which sonography is a fast, inexpensive and highly effective diagnostic tool.
REFERENCES
(a)
(b) Fig. 5 Longitudinal (a) and transverse (b) sonograms of the digit, showing an anechoic mass, not distinguishable from a digital ganglion. This is a mucoid cyst complicating osteoarthritis.
underwent surgery and the pathologic studies confirmed the nature, shape and size of the digital ganglia. Sonographically-guided aspiration also proved highly effective
1 Binkovitz LA, Berquist TH, McLeod RA. Masses of the hand and wrist: detection and characterization with MR imaging. American Journal of Roentgenology 1990;154:323-326. 2 Bernardino ME, Jing BS, Thomas JL, Lindell MM, Zornoza J. The extremity soft-tissue lesion: a comparative study of ultrasound, computed tomography, and xerography. Radiology 1981; 139:53-59. 3 Fornage BD, Schernberg FL, Rifkin, MD. Ultrasound examination of the hand. Radiology 1985;155:785-788. 4 Fornage BD, Rifkin MD. Ultrasound examination of tendons. Radiological Clinics o f North America 1988;26:87 107. 5 Fornage BD, Rifkin MD. Ultrasound examination of the hand and foot. Radiological Clinics of North America 1988;26:109 129. 6 McFarland GB Jr. Soft tissue tumors. In: Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill Livingstone, 1988:2301 2322. 7 Angelides AC. Ganglions of the hand and wrist. In: Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill Livingstone, 1988:2281 2299. 8 Butler ED, Hamill JP, Seipel SR, de Lorimier AA. Tumors of the hand. American Journal of Surgery 1960; 100:293-302. 9 Nelson CL, Sawmiller S, Phalen GS. Ganglions of the wrist and hand. Journal of Bone and Joint Surgery 1972;54A: 1459-1464. 10 Andren L, Eiken O. Arthrographic studies of wrist ganglions. Journal of Bone and Joint Surgery 197 t ;53A:209-302. 11 De Flaviis L, Nessi R, Del Bo P, Calori G, Balconi G. Highresolution ultrasonography of wrist ganglia. Journal of Clinical Ultrasound 1987; 15:17-22. 12 Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ. Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. Journal of Hand Surgery 1987;12A: 1041-1043. 13 FornageDB. Soft tissue changes in the hand in rheumatoid arthritis: evaluation with US. Radiology 1989; 173:735-737. 14 Jeffrey RB Jr, Laing FC, Schechter WP, Markison RE, Barton RM. Acute suppurative tenosynovitis of the hand: diagnosis with US. Radiology 1987;162:741-742. 15 Gooding GAW. Tenosynovitis of the wrist: a sonographic demonstration. Journal o f Ultrasound Medicine 1988;7:225-226. 16 Schechter WP, Markison RE, Jeffrey RB, Barton RM, Laing F. Use of sonography in the early detection of suppurative flexor tenosynovitis. Journal of Hand Surgery 1989;14A:307-310.
Sonographic Findings in Examination of Digital Ganglia: Retrospective Study S. B I A N C H I , I. F. A B D E L W A H A B * , A. ZWASS~', R. C A L O G E R A , A. B A N D E R A L I , P. B R O V E R O and P. V O T A N O
E.O. Ospedali Galliera, Genova, Italy, *Mount Sinai Medical Center, New York, and tColumbia Presbyterian Medical Center, New York, NY, USA A retrospective sonographic study of soft tissue masses of the hand was undertaken. A spherical fluid-filled structure with a well-defined wall was seen in 13 patients and the cases were diagnosed as ganglia. This diagnosis had been generally suspected clinically in the presence of a firm nonpainful lump. This study indicates that ultrasound is a valuable diagnostic tool for the study of soft-tissue masses of the hand and in the differential diagnosis of other soft tissue lesions, such as pigmented villonodular synovitis or tenosynovitis. Bianchi, S., Abdelwahab, I.F., Zwass, A., Calogera, R., Banderali, A., Brovero, P. & Votano, P. (1993). Clinical Radiology 48, 45-47. Sonographic Findings in Examination of Digital Ganglia: Retrospective Study
Accepted for Publication 21 January 1993
Evaluation of the soft tissue lesions o f the hands has been undertaken using a variety of modalities, such as plain films, computed tomography (CT), magnetic resonance imaging (MRI) and sonography [1-5]. Sonography is particularly useful as it is a quick non-invasive method of providing information regarding the size and nature of the mass, its relationship to the tendons, and the integrity of the tendons involved. It is also able to assess tendon movement in relation to the soft tissue lesion. We have undertaken a review of soft tissue lesions of the hands studied by sonography to assess the appearance and differentiation. P A T I E N T S AND M E T H O D S A group of 23 patients with a palpable soft tissue mass located in the digits was examined by sonography. The patients were 18- to 57-years-old with a mean age of 35. Sonography was performed with a real-time lineararray transducer with a frequency of 7.5 MHz. A thin stand-off pad was used for proper visualization of the skin and subcutaneous tissues. Longitudinal and transverse scans were obtained. Dynamic assessment was also undertaken during the active and passive movements of the fingers.
Neither active nor passive flexion or extension o f the finger caused a change in the appearance of the digital ganglia. In 10 patients, the mass was located on the flexor side, which was at the level of the proximal phalanx in nine and over the metacarpal in the tenth case. The ganglion was related to the extensor tendon in the remaining three patients. The digital ganglia were most commonly related to the fourth ray (8/13), with the remainder almost equally divided between the other fingers. The thumb was not involved. Five patients were symptomatic, complaining of pain when the affected hand was overused. The diagnosis of ganglion was confirmed surgically in seven cases. In two cases, an ultrasound-guided aspiration was performed with no recurrence of the lesion. In four patients, a hypoechoic heterogeneous solid mass (Fig. 3) was present and the diagnosis of giant cell tumour of the tendon sheath was made, which was later confirmed surgically. In five cases, the tendon was enlarged, with a fluid collection around the tendon sheath (Fig. 4). These patients had been previously diagnosed as having psoriatic arthritis. One case of a mucous cyst secondary to osteoarthritis was examined and its sonographic appearance was identical to digital ganglia (Fig. 5). The diagnosis was confirmed with a radiograph.
RESULTS An oval well-defined sonolucent mass, adjacent to the tendon, with distal acoustic enhancement, diagnostic of a ganglion, was observed in 13 patients (Figs 1,2). The size of the mass varied from 3 to 14 mm. No change of structure or effusion of the tendon sheath was evident.
Correspondence to: AticiaZwass, Department of Radiology,Columbia Presbyterian Medical Center, 630 West 168 Street, New York, NY 10032, USA.
DISCUSSION The majority of soft tissue masses of the hands are benign (95%, [6]) and a m o n g them ganglia are the most frequently encountered (50-70%, [7-9]). The diagnosis is commonly suspected clinically by the presence of a firm nonpainful lump that can vary in size. The ganglion is an encapsulated cyst containing a thick, clear, gelatinous fluid. Ganglia most commonly occur over the dorsal and/ or volar aspects of the wrist (60 70%, [7]), while volar retinacular ganglia arising from the proximal anular
46
CLINICAL RADIOLOGY
i
(a) (b) Fig. 1 - Transverse (a) and longitudinal (b) sonograms oftbe volar aspect of the hand at the level of the distal metacarpals (MET) showing the ganglion (G) as an anechoic mass, measuring 7.3 mm by 9.3 mm, with distal acoustic enhancement, and closely related to, but separate from, the flexor tendon (FT).
"
,[,
5
Fig. 4 - Longitudinal volar sonogram of a sausage digit in a patient with psoriatic arthritis. Observe the inhomogeneous appearance of the flexor tendon (T fless), with fluid collection in the synovial sheath (small arrow). P1, Proximal phalanx; P2, middle phalanx; M, metacarpal bone.
Fig. 2 - Longitudinal volar sonogram at the level of the proximal phalanx (PI). The ganglion is demonstrated as a sonolucent mass with distal sound enhancement (SC). The flexor tendon is falsely hypoechoic due to a slight obliquity of the beam (FT).
! Fig. 3 - Longitudinal sonogram of the digit, showing a mass with the internal echoes. A giant cell tumour of the tendon sheath was confirmed surgically.
l i g a m e n t o f the flexor t e n d o n sheath have a n incidence o f between 1 0 - 1 2 % [7] a n d 26% [9]. A c o m m u n i c a t i n g duct directed to the a r t i c u l a r space, which is seen in u p to 70% o f cases o f wrist ganglia [9-11], has n o t been d o c u m e n t e d in the p a l m a r digital ganglia. This finding is c o n f i r m e d in the p r e s e n t report. This absence o f a c o m m u n i c a t i n g d u c t c o u l d e x p l a i n the lower recurrence rate in this s u b g r o u p o f digital g a n g l i a [12]. T h e differential d i a g n o s i s includes m u c o i d cyst related to o s t e o a r t h r i t i s (OA), g i a n t cell t u m o u r o f the t e n d o n sheath, tenosynovitis, a n d the sausage digit o f p s o r i a t i c arthritis. T h e l a t t e r shows a w i d e s p r e a d i n v o l v e m e n t o f the t e n d i n o u s structures a n d evidence o f systemic arthritis even i f a sausage digit presents as the first m a n i f e s t a t i o n o f seronegative s p o n d y l o a r t h r o p a t h y . I n tenosynovitis, the flexor t e n d o n is usually increased in size a n d i n h o m o g e n e o u s (Fig. 4), whereas the t e n d o n size a n d echogenicity is p r e s e r v e d in cases o f digital ganglia. T h e s o n o g r a p h i c a p p e a r a n c e s o f v i l l o n o d u l a r t e n o s y n o v i t i s o r g i a n t cell t u m o u r o f the t e n d o n sheath (Fig. 3), which are those o f a h e t e r o g e n e o u s h y p o e c h o i c solid mass, s h o u l d be easily differentiated f r o m the n o n - e c h o i c ganglion. A c u t e infectious t e n o s y n o v i t i s shows an increase in size o f the t e n d o n , with fluid collection in the t e n d o n s h e a t h [ 13-16]. T h e differentiation o f a m u c o i d cyst (Fig. 5), c o m p l i c a t i n g O A , requires a plain r a d i o g r a p h as its s o n o g r a p h i c features are similar to those o f a ganglion. In the present series, s o n o g r a p h y p r o v e d a highly effective d i a g n o s t i c tool. Seven patients s u b s e q u e n t l y
SONOGRAPHIC FINDINGS IN EXAMINATION OF DIGITAL GANGLIA
47
and was a satisfactory alternative to surgery in some cases. Digital ganglion is a benign condition with no complication other than a local pain. Although diagnosis of ganglia can be achieved by M R I or CT, in some cases the smaller ganglia (and ganglion size varied from 3 to 14 mm in our series) could fail to be detected in MRI examination because of its small size [1]. Our study demonstrates a spectrum of soft tissue masses of the digits for which sonography is a fast, inexpensive and highly effective diagnostic tool.
REFERENCES
(a)
(b) Fig. 5 Longitudinal (a) and transverse (b) sonograms of the digit, showing an anechoic mass, not distinguishable from a digital ganglion. This is a mucoid cyst complicating osteoarthritis.
underwent surgery and the pathologic studies confirmed the nature, shape and size of the digital ganglia. Sonographically-guided aspiration also proved highly effective
1 Binkovitz LA, Berquist TH, McLeod RA. Masses of the hand and wrist: detection and characterization with MR imaging. American Journal of Roentgenology 1990;154:323-326. 2 Bernardino ME, Jing BS, Thomas JL, Lindell MM, Zornoza J. The extremity soft-tissue lesion: a comparative study of ultrasound, computed tomography, and xerography. Radiology 1981; 139:53-59. 3 Fornage BD, Schernberg FL, Rifkin, MD. Ultrasound examination of the hand. Radiology 1985;155:785-788. 4 Fornage BD, Rifkin MD. Ultrasound examination of tendons. Radiological Clinics o f North America 1988;26:87 107. 5 Fornage BD, Rifkin MD. Ultrasound examination of the hand and foot. Radiological Clinics of North America 1988;26:109 129. 6 McFarland GB Jr. Soft tissue tumors. In: Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill Livingstone, 1988:2301 2322. 7 Angelides AC. Ganglions of the hand and wrist. In: Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill Livingstone, 1988:2281 2299. 8 Butler ED, Hamill JP, Seipel SR, de Lorimier AA. Tumors of the hand. American Journal of Surgery 1960; 100:293-302. 9 Nelson CL, Sawmiller S, Phalen GS. Ganglions of the wrist and hand. Journal of Bone and Joint Surgery 1972;54A: 1459-1464. 10 Andren L, Eiken O. Arthrographic studies of wrist ganglions. Journal of Bone and Joint Surgery 197 t ;53A:209-302. 11 De Flaviis L, Nessi R, Del Bo P, Calori G, Balconi G. Highresolution ultrasonography of wrist ganglia. Journal of Clinical Ultrasound 1987; 15:17-22. 12 Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ. Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. Journal of Hand Surgery 1987;12A: 1041-1043. 13 FornageDB. Soft tissue changes in the hand in rheumatoid arthritis: evaluation with US. Radiology 1989; 173:735-737. 14 Jeffrey RB Jr, Laing FC, Schechter WP, Markison RE, Barton RM. Acute suppurative tenosynovitis of the hand: diagnosis with US. Radiology 1987;162:741-742. 15 Gooding GAW. Tenosynovitis of the wrist: a sonographic demonstration. Journal o f Ultrasound Medicine 1988;7:225-226. 16 Schechter WP, Markison RE, Jeffrey RB, Barton RM, Laing F. Use of sonography in the early detection of suppurative flexor tenosynovitis. Journal of Hand Surgery 1989;14A:307-310.