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Musculoskeletal Imaging |
1 From the Department of Diagnostic Radiology, Faculty of Medicine, Alexandria University, Egypt (K.I.E.N., A.A.F.); and the Departments of Radiology (K.I.E.N., M.E.S., R.B., A.M.) and Orthopedic Surgery (R.W.C., L.A.O.), Thomas Jefferson University Hospital, Jefferson Medical College, 132 S 10th St, 1096 Main Bldg, Philadelphia, PA 19107. Received March 6, 1998; revision requested April 14; final revision received October 13; accepted March 16, 1999. Address reprint requests to M.E.S. (e-mail: mark.schweitzer@mail.tju.edu).
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: Two observers retrospectively reviewed MR images of the wrist obtained in 625 patients at 1.5 T for the presence of ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears that were within 3 mm of the ganglion. When available, surgery and/or pathology records were reviewed.
RESULTS: There were 122 ganglia and 37 internal derangements. Of the 22 ulnar-sided ganglia, 10 (45%) demonstrated associated triangular fibrocartilage complex tears. Of the 97 radial-sided ganglia, 27 (28%) demonstrated ligamentous tears related to the site of the ganglion. The radial-sided tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia; the scapholunate ligament, in isolation, in eight ganglia; and both the triangular fibrocartilage complex and the scapholunate ligament in six ganglia. Only one of the ganglia demonstrated an associated lunotriquetral ligamentous tear. Surgical findings confirmed the ligamentous tears in 25 patients.
CONCLUSION: Wrist ganglia are associated, not infrequently, with internal derangements of the wrist.
Index terms: Ganglion, 434.361 • Wrist, abnormalities, 434.361, 434.483 • Wrist, injuries, 434.419, 434.483 • Wrist, MR, 434.121411, 434.121412, 434.121415, 434.12143
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In the knee joint, a portion of the paraarticular cysts initially thought to be ganglia is presently believed to be meniscal cyst (5). Similarly, it has recently been noted that a subset of paraarticular cysts in the shoulder represents the sequela of labral tears (6). Since ganglia are most common in the wrist, we hypothesized that a subset of cystic lesions related to the wrist may be secondary to internal derangements. Consequently, the aim of this study was to determine if a fraction of the cystic lesions about the wrist are associated with internal derangements of the wrist.
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Wrists were imaged in the coronal and axial planes, with a combination of a T1-weighted spin-echo (400–900/10–30 [repetition time msec/echo time msec]) sequence, an intermediate-weighted spin-echo (4,000/40) sequence, a T2-weighted spin-echo (1,800/70) or fast spin-echo (5,300/140) sequence, and a three-dimensional coronal gradient-echo sequence (45/15 or 30/12, 20° flip angle). Other parameters included a 256 x 128–256 acquisition matrix and a 3–5-mm section thickness with a 1-mm intersection gap. For the gradient-echo sequence, the section thickness was 1.2 mm with no intersection gap. The field of view was 10–12 cm.
The clinical indication for MR imaging was wrist pain in 614 patients. However, 11 of the patients had a clinical presentation of a palpable wrist mass. In nine of these patients, additional T1-weighted images obtained after the intravenous administration of 20 mL of contrast material (Magnevist [gadopentetate dimeglumine]; Berlex Laboratories, Wayne, NJ) were available.
Two patients underwent fluoroscopically guided direct MR arthrography; two additional patients underwent indirect (intravenous) MR arthrography (Fig 1a). The MR images were evaluated by two observers (M.E.S, K.I.E.N.) working in consensus to determine the presence of paraarticular ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears in proximity to the ganglion. A ganglion was considered to be related to the ligamentous tear if it was seen within 3 mm of the ligament. Demonstration of a direct communication was not considered a prerequisite for the diagnosis of synovial herniation through the ligamentous tear.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Of the 22 ganglia on the ulnar side of the wrist, 10 (45%) demonstrated triangular fibrocartilage complex tears that were contiguous with the site of the ganglion. Of the 97 ganglia on the radial side of the wrist, 26 (27%) demonstrated ligamentous tears related to the ganglion; the tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia (46%), combined triangular fibrocartilage complex and scapholunate ligamentous tears in six ganglia (23%), and isolated scapholunate ligamentous tear in eight ganglia (31%) (Figs 1, 2). Only one of the three patients with ganglia related to the lunotriquetral ligament demonstrated perforation of this ligament.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Ultrasonography (US) and MR imaging are both effective in depicting ganglia. The lower cost of US makes it useful as the first imaging modality. US will readily depict even small ganglia, which are identified as well-defined, homogeneously anechoic masses (7,8). MR imaging clearly aids in the localization of the ganglia and in the identification of their relationship to adjacent structures, which include vessels, tendons, and nerves (9).
Ganglia have been recognized since antiquity and were described by Hippocrates as a knot of tissue containing mucoid flesh (1). Repeated trauma that results in the degeneration and liquefaction of the periarticular connective tissue has been hypothesized as a possible cause (3). Volkmann, in 1882, considered the ganglion to be a prolapse of synovial tissue, basing his view on the fact that the ganglion occurs in the proximity of joints and tendon sheaths. He hypothesized that the bulging synovial membrane maintains its function of producing synovial fluid, with impaired outflow that results in gradual widening of the synovial pouch (3,10).
There are two groups of paraarticular cystic lesions: ganglia and synovial cysts. Ganglia are thin-walled cysts that contain viscous mucoid fluid and are found usually in the hand and wrist. Synovial cysts are herniations of the synovial lining of a disrupted joint space (3).
A portion of paraarticular cysts, which were initially thought to be ganglia, is currently considered to be synovial cyst associated with internal derangements. This was first noted in the knee, where meniscal cysts, initially believed to be ganglia, are presently believed to represent encapsulated paraarticular fluid collections associated with horizontal meniscal tears. It is believed that the synovial fluid is forced out between the leaves of a complete horizontal meniscal tear and collects at the meniscocapsular border. Medial cysts may be more likely to be symptomatic because of the greater pressure they produce beneath the medial collateral ligament (5,11).
Similarly, paralabral cysts in the shoulder are synovial fluid–filled cysts that are related to the glenoid labrum. There is a strong correlation between paralabral cysts, which have a posterior location, and posterosuperior labral tears. These cysts may communicate with the joint via the posterosuperior glenoid labrum, and they may extend medially into the spinoglenoid notch. The posterosuperior paralabral cyst is thus a common location for a cyst that is seen in association with a posterior capsulolabral injury, including superior labral tears extending anterior to posterior, or SLAP lesions (6,12).
We hypothesized that a subset of the cysts that occur around the wrist, although they are commonly called ganglia, represents the sequela of internal derangements of the wrist joint. We believe these wrist ganglia are more accurately termed synovial cysts and are similar to meniscal cysts in the knee and paralabral cysts in the shoulder.
In our study, 30% (37 of 122) of the paraarticular cysts reviewed were related to ligamentous tears. Surgical findings confirmed this association in 25 of 30 patients. Histopathologic findings, which were available for only four patients, indicated an appearance similar to that of meniscal cysts.
We acknowledge a number of limitations with this study. First, the surgical correlation of the imaging findings was available in only 30 patients, and the histopathologic findings were available in only four patients. Perhaps the most important limitation is that, since this is a retrospective study, only cases with ganglia were evaluated for ligamentous tears. Therefore, we did not determine the true incidence of ganglia in patients with internal derangements of the wrist.
Historically, synovial herniation as a cause of ganglia has been conjectured (10). In addition, it is well known that ganglia in the wrist have a characteristic location close to the scapholunate ligament, which is frequently torn. Arthrography occasionally reveals a one-way communication between the opacified joint fluid and the paraarticular ganglia (13). Constrast-enhanced tenography also may reveal communication between an opacified tendon sheath and the ganglion (14).
On the basis of the results of this study, we conclude that a subset of paraarticular cysts around the wrist may be the sequela of internal derangements. Although many of these perforations may be asymptomatic, a local ganglion may be a secondary sign of an internal derangement of the wrist. We believe this hypothesis is closely related to the pathophysiology of meniscal cysts in the knee and of labral cysts in the shoulder.
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Footnotes |
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References |
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This article has been cited by other articles:
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  G. Wang, J. A. Jacobson, F. Y. Feng, G. Girish, E. M. Caoili, and C. Brandon Sonography of Wrist Ganglion Cysts: Variable and Noncystic Appearances J. Ultrasound Med., October 1, 2007; 26(10): 1323 - 1328. [Abstract] [Full Text] [PDF]
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 P A J McNee and J Teh Imaging of the wrist Imaging, September 1, 2007; 19(3): 208 - 219. [Abstract] [Full Text] [PDF]
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 J TEH and G Whiteley MRI of soft tissue masses of the hand and wrist Br. J. Radiol., January 1, 2007; 80(949): 47 - 63. [Full Text] [PDF]
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 S. E. Anderson, L. S. Steinbach, E. Stauffer, and E. Voegelin MRI for differentiating ganglion and synovitis in the chronic painful wrist. Am. J. Roentgenol., March 1, 2006; 186(3): 812 - 818. [Abstract] [Full Text] [PDF]
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 C. M. LOWDEN, M. ATTIAH, G. GARVIN, J. C. MACDERMID, S. OSMAN, and K. J. FABER The Prevalence of Wrist Ganglia in an Asymptomatic Population: Magnetic Resonance Evaluation J Hand Surg Eur Vol., June 1, 2005; 30(3): 302 - 306. [Abstract] [Full Text] [PDF]
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P S McAlinden and J Teh Imaging of the wrist Imaging, December 1, 2003; 15(4): 180 - 192. [Abstract] [Full Text] [PDF]
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