An intraosseous ganglion is a relatively uncommon, benign cystic lesion that occurs in young and middle-aged adults. Bilateral and symmetrical lesions of the wrist are rare. Intraosseous ganglia of the carpal bones are uncommon causes of chronic wrist pain. Isolated cases of intraosseous ganglion have been reported most commonly in the lunate and scaphoid. The lunate was most frequently affected, followed by the capitate, scaphoid, and triquetrum bones.
Radiolucent lesions in the carpal bones are not uncommon and are often seen incidentally in asymptomatic patients. The differential diagnosis of a lytic lesion in a carpal bone includes unicameral bone cyst, degenerative cyst, fibrous developmental defect, osteomyelitis, and intraosseous ganglion cyst.
This article describes a case of bilateral lunate intraosseous ganglia. A review of the literature revealed that bilateral and symmetrical intraosseous ganglia of the wrist are rare, with only 3 other reported cases of bilateral lunate lesions.
Intraosseous ganglia of the carpal bones are uncommon causes of chronic wrist pain. Isolated cases of intraosseous ganglion have been reported most commonly in the lunate and scaphoid.1 The lunate was most frequently affected, followed by the capitate, scaphoid, and triquetrum bones.2
Radiolucent lesions in the carpal bones are not uncommon and are often seen incidentally in asymptomatic patients. The differential diagnosis of a lytic lesion in a carpal bone includes unicameral bone cyst, degenerative cyst, fibrous developmental defect, osteomyelitis, and intraosseous ganglion cyst.3
This article describes a case of bilateral lunate intraosseous ganglia. A review of the literature revealed that bilateral and symmetrical intraosseous ganglia of the wrist are rare, with only 3 other reported cases of bilateral lunate lesions.4
A 31-year-old man presented with a 2-year history of activity-related pain in both wrists. He could not work properly as an electrician for the past 3 months because of pain, and he had no pain relief despite activity limitation and analgesic drugs. Physical examination revealed limitation in range of motion in both extension and flexion. The pain was localized in the dorsal aspect of the wrist, and pinch strength was decreased. There was no specific history of trauma.
Radiographic (Figure 1), computed tomography (Figure 2), and magnetic resonance imaging (MRI) (Figure 3) studies of both wrists revealed symmetrical, well demarcated, liquid-filled cystic lesions in the lunate bones, which did not penetrate the surrounding tissue.
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Figure 1: Radiographs of the patient's right (A) and left (B) wrists showing a roundish area in the lunate.
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Figure 2: CT of the right wrist showing the extent of bilateral intraosseous ganglion of the lunate. Both wrists revealed symmetrical, well-demarcated, liquid-filled cystic lesions in the lunate bones, which did not penetrate the surrounding tissue. Figure 3: Coronal T1-weighted scan of the left wrist showing a lesion of intermediate signal intensity.
The lunate was exposed through the volar approach. Volar cortex of the lunate was perforated under the control of fluoroscopy. Fenestration of the lunate bones at both wrists revealed a gelatinous yellow cystic material. There was no communication between the lesions and the surrounding joint spaces. Following complete curettage of the cyst under fluoroscopic control, the remaining cavity was irrigated with saline. Care was taken to avoid perforation of the bone. The cavities in both lunate bones were carefully filled under fluoroscopic control with autogenous bone graft harvested from the iliac bone. Wrist capsules were repaired with absorbable sutures, and following skin closure, a short arm plaster cast was applied to both sides.
Physical therapy was started after 20 days of immobilization. The patient was encouraged to begin working with limited activity in 6 weeks, and heavy labor was permitted after 11 weeks.
Histological appearance of the lesion was similar to that of soft tissue ganglions. Histological study revealed the cystic wall surrounded by flattened, synovial-like fibroconnective cells with no true epithelial line (Figure 4). There were focal mucoid degenerations and myxoid transformation of the connective tissue.
Figure 4: Histological study revealing cystic wall surrounded by flattened, synovial-like fibroconnective cells with no true epithelial line (hematoxylin-eosin 40×10).
At 6-month follow-up, radiographs revealed healing of the bone cysts in both lunate bones, and the patient had painless full range of motion in both wrists.
Intraosseous ganglion is rare. The lunate bone is most frequently affected, followed by the capitate, scaphoid, and triquetrum bones.2 Most of the time, these ganglia were found to be eccentric in the periphery of the bone: most of the ganglia in the lunate were on its scaphoid side and most of the ganglia in the scaphoid were on its lunate side.2 Pablos et al4 reported a case of a 43-year-old nurse with bilateral wrist pain of 2 years duration. She reported no previous traumatic episode. Excisional biopsy with curettage and allograft bone packing was performed, and lesions were healed with no problems at 22-month follow-up.
In a prospective study by Van den Dungen et al,5 fifty-one soft tissue ganglion cysts of the wrist were detected for the possibility of associated intraosseous ganglia, and 29 of the patients were found to have intraosseous ganglia associated with dorsal soft tissue ganglia of the wrist. Sixteen intraosseous ganglia was located in the lunate, 7 in the scaphoid, 5 in the capitate, and 1 in the trapezoid.
The pathogenesis remains obscure. Theories include synovial herniation, neoplasia, metaplasia of mesenchymal precursor cells, proliferation of synovial rest cells, and traumatic mucoid degeneration of connective tissue.1,6 There is no endothelial or synovial lining. A thin sclerotic margin of bone often surrounds the ganglion. Some authors have suggested that this represents an attempt by the host bone to repair the defect within the lunate.6
Radiographs usually reveal an eccentrically placed radiolucent lesion with a thin sclerotic margin contained within, and not expanding, the lunate. Radiolucent lesions in the carpal bones are not uncommon and are often seen incidentally in asymptomatic patients. The differential diagnosis of a lytic lesion in a carpal bone includes unicameral bone cyst, degenerative cyst, fibrous developmental defect, osteomyelitis, and intraosseous ganglion cyst.3 Computed tomography can be used to further define the location and extent of the lesion and aid in surgical planning.7 Computed tomography and MRI help clarify the extent of the abnormality and allow for more accurate preoperative planning. In some lesions, an intra-articular extension can be visible in relation to the defect on the surface of the lunate by MRI.1,7,8 Magnetic resonance images, as in our case, show intermediate signal intensity on T1-weighted images and high-signal intensity on T2-weighted images.9
Appropriate clinical management of an isolated symptomatic cystic carpal lesion begins with a trial of conservative therapy. Aspirin or nonsteroidal anti-inflammatory drugs and splinting are advised. Repeat plain radiographs are important to monitor for changes. Operative indications are: (1) failure of conservative modalities to provide adequate relief of symptoms; (2) suspicious radiographic changes; and (3) progression of the lesion.10
When a suspected ganglion is identified by any imaging study and is felt to account for the symptoms, surgery may be considered. The most definitive therapy is curettage. Excision with bone grafting may be performed only if the cavity is large. Segmental excision may be performed with large lessions in nonweight-bearing areas. The recurrence rate after any treatment is low.3
No true fracture was reported due to intraosseous ganglia, but cortical perforation is noted intraoperatively in the case report by Uzel et al.11
Recurrences are rare. Calcium phosphate bone cement is a useful material for repairing bone defect after curettage of an intraosseous ganglion or bone cyst of a carpal bone. Bain et al7 reported that treatment by traditional open curettage and bone grafting can lead to ongoing pain and stiffness of the wrist. They suggest an arthroscopically assisted minimally invasive technique of debridement and grafting of the lunate intraosseous ganglion. They published an arthroscopically assisted (minimally invasive) technique of lunate ganglion excision with bone grafting with the aim of reducing the morbidity seen with open techniques.7 Between open and arthroscopically assisted techniques, we performed the most familiar open technique, and since the lesion was closer to the volar cortex of the lunate, we used the volar approach.
- Tham S, Ireland DC. Intraosseous ganglion cyst of the lunate: diagnosis and management. J Hand Surg Br. 1992; 17(4):429-432.
- Schrank C, Meirer R, Stäbler A, Nerlich A, Reiser M, Putz R. Morphology and topography of intraosseous ganglion cysts in the carpus: an anatomic, histopathologic, and magnetic resonance imaging correlation study. J Hand Surg Am. 2003; 28(1):52-61.
- Mogan JV, Newberg AH, Davis PH. Intraosseous ganglion of the lunate. J Hand Surg Am. 1981; 6(1):61-63.
- Pablos JM, Valdés JC, Gavilán F. Bilateral lunate intraosseous ganglia. Skeletal Radiol. 1998; 27(12):708-710.
- Van den Dungen S, Marchesi S, Ezzedine R, Bindou D, Lorea P. Relationship between dorsal ganglion cysts of the wrist and intraosseous ganglion cysts of the carpal bones. Acta Orthop Belg. 2005; 71(5):535-539.
- Waizenegger M. Intraosseous ganglia of carpal bones. J Hand Surg Br. 1993; 18(3):350-355.
- Bain GI, Turner PC, Ashwood N. Arthroscopically assisted treatment of intraosseous ganglions of the lunate. Tech Hand Up Extrem Surg. 2008; 12(4):202-207.
- Barth E, Hagen R. Juxta-articular bone cyst. Acta Orthop Scand. 1982; 53(2):215-217.
- Feldman F, Singson RD, Staron RB. Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiol. 1989; 18(5):353-358.
- Noel SH, Engber WD. Intraosseous carpal ganglions. Iowa Orthop J. 1987; (7):52-54.
- Uzel M, Cetinus E, Bilgic E, Bakaris S. Intraosseous ganglion of the lunate: a case report. Joint Bone Spine. 2003; 70(5):393-395.
Drs Kural, Sungur, and Cetinus are from Haseki Training Hospital Orthopedic and Traumatology Clinic, Istanbul, Turkey.
Drs Kural, Sungur, and Cetinus have no relevant financial relationships to disclose.
Correspondence should be addressed to: Cemal Kural, MD, Haseki Training Hospital Orthopedic and Traumatology Clinic, Atakoy 9, Kisim A2 Bloc D:92, 34156 Bakirkoy-Istanbul, Turkey (firstname.lastname@example.org).