Skeletal Radio1 (1994) 23:201-203

Skeletal Radiology

Ultrasonographic evaluation of wrist ganglia Stefano Bianchi, M.D. 1, Ibrahim F. Abdelwahab, M.D. 2, Alicia Zwass, M.D. 3, Patricio Giacomello, M.D. 1

1 E.O. Ospedali Galliera, Genoa, Italy 2 Mount Sinai Medical Center, New York, New York, USA 3 Department of Radiology, Columbia Presbyterian Medical Center, New York, New York, USA

Abstract. This study was performed to assess the effec- tiveness of ul t rasonography in the diagnosis of wrist gan- glia and in their differentiation from other lesions. Sono- graphic examination of 73 patients with palpable masses was performed; their healthy hands and those of 25 healthy volunteers constituted the reference standard. Ganglia appeared sonographically as anechoic oval, round, or lobulated cystic structures. Ul t rasound proved an accurate tool in their diagnosis, with the general ad- vantages of easy, quick, and inexpensive application.

Key words: Ganglion - Wrist - Ul t rasound studies

Ganglia are the most common soft tissue tumors of the hand and wrist [2, 5]. In many instances they may be diagnosed on the basis of a physical examination. How- ever, in some cases additional workup is required. Ultra- sonography is an inexpensive modali ty allowing proper diagnosis and treatment of the ganglia.

Material and methods

Seventy-three patients (40 males and 33 females), 17-62 years old, with an average age of 41 years, and presenting with palpable soft tissue mass on the wrist clinically suspected to be a ganglion, were examined by ultrasound. As the reference standard, the con- tralateral hands of the 73 patients and both hands of 25 healthy volunteers were examined.

Ultrasonography was performed using a real-time commercially available linear array equipment (Mod. 560, Esoata Biomedica, Genoa, Italy) with a 7.5-MHz transducer. A thin (1-cm) stand-off pad was used to improve the visualization of superficial structures.

In every case both wrists were scanned in longitudinal and transverse planes. During the examination the hand lay supine, prone, or oblique, depending on the area of examination. Dynamic studies were also performed during flexion and extension of the fingers.

Correspondence to: Alicia Zwass, M.D., Department of Radiology, Columbia Presbyterian Medical Center, 630 West 168 Street, New York, NY 10032, USA

Results

In 60 out of 73 patients ul t rasonography showed a well- defined oval (Fig. 1) or lobulated (Fig. 2), anechoic, cys- tic mass consistent with the presence of a ganglion. The ganglia measured f rom 3 m m to 35 m m in diameter.

The ultrasound diagnosis was confirmed by surgery in 20 cases. In 15 cases, ultrasound-guided needle aspira- tion was performed and a clear, viscous fluid characteris- tic of ganglion was obtained. In 25 asymptomat ic pa- tients no immediate t reatment was necessary and follow- ups were recommended if clinically warranted.

The wrist ganglia were located as shown in Table I. As can be seen, dorsal ganglia were predominant ly locat- ed in the central aspect, superficial to the scapholunate ligament. The other dorsal ganglia were equally distrib- uted between the medial aspect, surrounding the exten- sor carpi ulnaris tendon, and the distal aspect, at the base of the second and third metacarpals. Volar ganglia were located between the flexor carpi radialis tendon and the radial artery. The ganglia located on the lateral side of the wrist were in close relation to the radial artery and the lateral aspect of the scaphoid bone at the level of the anatomical snuff box.

In 13 out of 73 patients examined, the mass was not a ganglion; these diagnoses were based on sonography. The lesions in these 13 patients are shown in Table 2 and further described below.

Discussion

Ultrasonography using high-frequency transducers has been found very useful in the evaluation of soft tissue masses [6, 8, 13]. Ganglia are the most common (50%- 70%) of all soft tissue tumors of the hand [2, 5]. They have a characteristic cystic appearance and so can easily be differentiated f rom other masses. The etiology and pathogenesis of ganglia are still obscure. Trauma, syno- vial herniation, myxoid degeneration of periarticular connective tissue, and underlying periscaphoid ligamen-

�9 1994 International Skeletal Society

202 S. Bianchi et al. : Ultrasonographic evaluation of wrist ganglia

Fig. 1. Longitudinal volar sonogram of the wrist. The ganglion shows as a sonolucent mass with distal sound enhancement [G). The high viscosity of the material contained in the lesion explains the slight decrease of good through-transmission. Note the radial artery (D1) between cursors. RAD, radius; SC, scaphoid; TR, tri- quetrum

Fig. 2. Transverse sonogram on the dorsal aspect of the wrist show- ing a lobulated ganglion (D1 and D2 between calipers)

Fig. 3.Longitudinal dorsal sonogram demonstrating a ganglion consisting of a superficial (2) and a deeper (1) component separated by the ligament (DI between the cursors). The high viscosity of the material contained in the lesion explains the slight decrease

of good through-transmission. MET, metacarpal bone; C, capi- tate; L, lunate; R, radius

Fig. 4. Longitudinal (right) and transverse (left) scans at the level of the first compartment demonstrating a thick dorsal retinaculum of the abductor pollicis longus tendon and the extensor pollicis brevis tendon. Note the small synovial effusion. This appearance is consistent with a diagnosis of De Quervain's disease

Fig. 5. Dorsal longitudinal sonogram showing no soft tissue abnor- malities. The bony protuberance represents a palpable lesion, which was confirmed by plain roentgenograms (os styloideum). OS, os styloideum; S, scaphoid; R radius; H, head

Table 1. Location of wrist ganglia (60 cases)

Site Number of cases %

Dorsal: central 39 65 medial 3 5 distal 3 5

Volar 12 20 Lateral 3 5

Table 2. Conditions diagnosed other than ganglia (13 cases)

Site Diagnosis Number of cases

Lateral De Quervain's disease 2 Dorsal Carpal boss 4

Incomplete tendon rupture 1 Volar Vascular disease 2

Carpal tunnel syndrome 2 Tenosynovitis 2

tous ins tab i l i ty have been sugges ted as some o f the causes [2, 16].

G a n g l i a arise f rom the synov ium o f a j o i n t or t endon sheath o r f rom the t endon itself. The wall o f a gangl ion is m a d e up o f compres sed co l lagen f ibers and is l ined

wi th f la t tened cells w i thou t evidence o f an epi the l ia l or synovia l l ining [2]. G a n g l i a con ta in a h ighly viscous, clear, s t icky mater ia l . A c o m m u n i c a t i n g duct to the j o i n t space is seen in up to 70% o f cases o f wris t gangl ia [1, 6, 11]. This duc t m a y opac i fy du r ing wris t a r t h r o g r a -

S. Bianchi et al. : Ultrasonographic evaluation of wrist ganglia 203

phy [1], and may also be identified by magnetic reso- nance imaging [7] and ul t rasonography [6]. Failure to remove this duct during surgery contributes to local re- currences.

We noted that the wrist ganglia in our study arise at the specific sites described by many authors [2, 9, 15]. Thus, dorsal ganglia most commonly arise over the scapholunate ligament (60% 70% of ganglia of hand and wrist [2]). Volar wrist ganglia (13%-20% of all the lesions [9]) generally arise f rom the radioscaphoid or scapholunate joint (65% arise f rom these two joints [9]), less commonly f rom the scaphotrapezoid and metacar- potrapezoid joints.

A ganglion is a firm, smooth round mass with a diam- eter ranging f rom 4 m m to 40 m m [13]. Ganglia are fre- quently associated with discomfort, aches, or weakness. They may be associated with a compressive neuropathy; for example, compression of the ulnar nerve by a gangli- on in Guyon ' s canal ]15], or the median nerve in the carpal tunnel [10]. On ultrasound examination the gan- glion is revealed as a well-defined cystic lesion. Old le- sions may contain irregular internal echoes and a thicker wall [6]. Ganglia may be multiple (Fig. 3) or present as a cluster [6]. Ul t rasonography may also demonstrate small occult painful ganglia that cannot be detected by physical examination [12]. The differential diagnosis in- cludes: tenosynovitis, including De Quervain 's disease (Fig. 4), soft tissue tumors, vascular lesions such as an aneurysm, muscle abnormalities in the form of a tear or hypertrophy, and bone abnormalities such as carpal boss (Fig. 5).

Magnetic resonance imaging and computed tomogra- phy also may play a role in the evaluation of soft tissue masses of the wrist. Magnetic resonance imaging is a superb modali ty for delineation of the anatomic loca- tion, extension, and intrinsic structure [7] of the lesion; however, it is less easily available and more costly than ultrasonography. Computed tomography plays much less of a part because of the limited soft tissue contrast it provides [4]. Wrist ar thrography is less commonly per- formed because of its invasiveness and use of ionizing radiation.

Conclusion

Ultrasonography using high-resolution equipment is a quick and effective method for evaluating soft tissue

masses of the wrist. This examination can easily establish the nature of the lesion and may suggest a diagnosis other than a ganglion. Ul t rasonography also delineates the relationship of the lesion with the underlying bony and soft tissue structures. It is useful in the puncture and aspiration of ganglia.

References

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