Ganglions are the most commonly encountered soft-tissue tumor of the hand and wrist, accounting for approximately 50%-70% of all tumors in the distal upper extremity.',2 The presentation of these cystic lesions has been reported to originate at a number of sites including the dorsal and volar aspects of the wrist joint, the flexor tendon sheath (volar retinacular ganglion), and the distal interphalangeal joint (mucous cyst).110
Although documented,1 ganglions occurring at the proximal interphalangeal joint have not been reported in the literature. This article reports on six patients with ganglions at this joint.
MATERIALS AND METHODS
Between January 1996 and September 1997, six patients presented with a lesion over the dorsal aspect of the proximal interphalangeal joint. A retrospective chart analysis was used to determine the location of the lesion, patient age and sex, any associated diseases, and potential etiologies.
Six patients (nine ganglions) were diagnosed as having a slowly enlarging cystic mass over the dorsum of the proximal interphalangeal joint. The average patient age was 54 years (range: 19-72 years), and the patients were predominantly women (4:2). The ganglions measured from 4-7 mm in size and restricted flexion of the proximal interphalangeal joint to a varying degree.
Clinically, these lesions were soft, slightly tender to palpation, and nonadherent to the surrounding skin and soft tissue. The cysts resided exclusively on the index, middle, and ring fingers of either hand. Three patients had two ganglions. Of these, two were bilateral and one was on an adjacent digit. All six patients had been treated previously for ganglions at other locations in the distal upper extremity.
Excision was performed under conscious sedation with a local field and nerve block. A tourniquet was used in each case. A curvilinear incision over the dorsal aspect of the proximal interphalangeal joint was made, thereby creating a radial-based flap. In all instances, the cysts originated in the joint capsule by means of a stalk and extended dorsally between the fibers of the extensor central slip and lateral band on the ulnar aspect of the digit.
The lateral band was mobilized and retracted dorsally to obtain satisfactory exposure of the joint. The stalk, which emanated from the dorsal capsule, was carefully dissected, and a window of capsule was removed. The ganglion cyst then was excised between the central slip and lateral band, followed by repair of the defect by direct suture approximation.
In four ganglions, hypertrophic synovium was removed from the joint. Degenerative thinning of the articular cartilage with synovitis was present in each of the nine ganglions.
Figure 1 : Low-power view of a ganglion cyst from the proximal interphalangeal
Histologic diagnosis in each case was a ganglion cyst, as demonstrated by the classical myxoid cavitary lesion represented in Figures 1 and 2. Postoperatively, patients were encouraged to engage in limited active motion as soon as possible. All patients regained full range of motion and have experienced no recurrences to date.
A ganglion is a small, multiloculated cystic lesion containing mucinous material and is commonly seen in connective tissues involving joint capsules, tendons, or tendon sheaths. These lesions are considered to be the result of myxoid degeneration of connective tissues that leads to the presentation of a cavitated mass. Although ganglions can theoretically arise from any number of possible foci, they are most commonly encountered in the hand and wrist.11
In our patients, no specific cause could be determined, nor was there a relationship with occupation or daily routine. Indeed, the issue of ganglions of the proximal interphalangeal joint is one that has been given little or no attention in the literature.51214 We have no explanation for the consistent presentation of ganglions on the ulnar aspect of the proximal interphalangeal joint between the lateral band and central slip. All joints had degenerative thinning of the articular cartilage with varying amounts of synovitis. Increased fluid pressure dynamics may be a contributing factor, as with mucous cysts of the distal interphalangeal joint.7
Figure 2: High-power view of a ganglion cyst from the proximal interphalangeal joint.
Ganglions of the proximal interphalangeal joint are clinically and histologically similar to those found in more common locations. Surgical excision of the ganglion can provide relief of symptoms without recurrence, as is demonstrated in these cases. Degenerative joint disease with increased joint fluid dynamics and synovitis may indeed have a causal relationship.
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