Transcript Case Study * Abnormal Appearing Ganglion in the dorsal wrist

CASE STUDY – ABNORMAL
APPEARING GANGLION IN THE
DORSAL WRIST
Paige Fabre
PATIENT PRESENTATION
34 year old female patient
 Working as cleaner on the mines – FIFO worker
 History

Several months dorsal wrist pain
 Lump appearing on the dorsal aspect of the wrist,
increasing in size while at work, decreasing while at
home
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No previous imaging, investigations or
interventional treatment
ULTRASOUND REQUEST
The examination was requested by the patient’s
GP
 A “wrist ultrasound +/- aspiration and injection”
was requested
 “Lump on dorsal wrist ? Ganglion” was the
clinical indication given for the exam

ULTRASOUND PROTOCOL
No exact protocol is require for a wrist
ultrasounds
 Images taken and areas examined are
determined by the sonographer and reporting
radiologist
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PROTOCOL FOR THE EXAMINATION
As I am still in training, my supervisor suggested
that I examine all compartments of the dorsal
wrist in longitudinal and transverse to gain a
better understanding of the anatomy.
 If these areas were normal then I was to image
them in transverse to demonstrate that these
areas have viewed. An additional image was to be
taken of Compartment 3 as it crosses over
Compartment 2.

ROOM PREPARATION

The room was prepared before the patient
entered.
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A chair was placed on the side of the bed (opposite
the machine) facing the towards the bed.
A bluey was positioned on the table where the patient
was to place their arms.
The ultrasound machine was moved to the foot end of
the bed to allow for more ergonomic scanning.
Appropriate high frequency transducers were
attached to the machine or within close proximity.
A pre-prepared injection trolley was brought into the
room.
ROOM PREPARATION
PATIENT PREPARATION
At admission to the practice the patient read and
completed a consent form for aspiration and
injection of the wrist in preparation for this being
carried out.
 The patient was wearing an elbow length shirt
and was therefore not required to change.
 The patient’s identity was confirmed and they
were invited into the room.
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PATIENT PREPARATION

The examination was discussed with the patient
before any scanning was attempted.
The patient was made aware that I was in training
and that my supervisor would be assisting me with
the scan. The patient was asked if this would be
acceptable, and their consent was gained.
 The patient was also made aware that we would first
perform the diagnostic scan and from that the
radiologist would decide the best course of action for
the procedure.

ULTRASOUND EXAMINATION
The examination was performed on a Toshiba
Aplio 500 using a variable frequency 18mHz
linear transducer.
 Thick ultrasound gel was applied to the area of
examination to allow for light pressure and
sufficient contact.

ULTRASOUND IMAGES OF THE
COMPARTMENTS
COMPARTMENT 1
Image 1: Left dorsal wrist in transverse showing abductor
pollicus longus and extensor pollicus brevis tendons.
COMPARTMENT 2
Image 2: Left dorsal wrist in transverse showing extensor
carpi radialis longus and extensor carpi radialis brevis
tendons.
COMPARTMENT 3
Image 3: Left dorsal wrist in transverse showing extensor
pollicus longus tendon. Also in view the ERCB, Lister’s
tubercle and Compartment 4.
COMPARTMENT 3 LONG
Image 4: Left dorsal wrist showing the extensor pollicus
longus tendon crossing over Compartment 2.
COMPARTMENT 4
Image 5: Left dorsal wrist in transverse showing extensor
digitorum communis and extensor indicis proprius tendons.
COMPARTMENT 4
Image 6: Left dorsal wrist in transverse showing extensor digitorum
communis and extensor indicis proprius tendons. This image is taken
distally to Image 5, demonstrating the distal separation of the tendons.
COMPARTMENT 5
Image 7: Left dorsal wrist in transverse showing extensor
digiti minimi.
COMPARTMENT 6
Image 8: Left dorsal wrist in transverse showing extensor
carpi ulnaris.
EXTENSION OF THE
EXAMINATION
The compartments of the wrist were examined in
both longitudinal and transverse planes. The
compartments were all deemed normal and the
examination was extended to allow for better
visualisation of the lump as described by the patient.
EXTENSION OF THE EXAMINATION

The following images were taken over the lump
as identified by the patient as the region of
interest.
ROI IMAGES
Image 9: Left dorsal wrist in the region of interest. This
image displays the “lump” superior to the scapho-lunate
ligament.
ROI IMAGES
Image 10: Left dorsal wrist in the region of interest.
Callipers are used to measure the height and width of the
predominately hypoechoic area present.
ROI IMAGES
Image 11: Left dorsal wrist in the region of interest.
Callipers are used to measure the length of the
predominately hypoechoic area present.
ROI IMAGES
Image 12: Left dorsal wrist in the region of interest.
Colour Doppler has been used to identify the possibility of
vascularity.
ROI IMAGES
Image 13: Left dorsal wrist in the region of interest. Colour
Doppler used to demonstrate the possibility of vascularity. A
second image was done to highlight the anechoic region.
ROI IMAGES
Image 14: Left dorsal wrist in the region of interest.
Callipers are used to measure what appeared to be a neck
of a possible ganglion extending from the radio-carpal joint.
EXTENSION OF EXAMINATION
In an attempt to better understand the origin of
the possible ganglion/mass dynamic visualisation
was attempted.
 For these additional images a thick gel layer was
applied to the wrist to maintain contact with
light pressure.
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DYNAMIC IMAGES
Image 15: Left dorsal wrist in the region of interest in
flexion.
DYNAMIC IMAGES
Image 16: Left dorsal wrist in the region of interest in
neural.
DYNAMIC IMAGES
Image 17: Left dorsal wrist in the region of interest in
neutral. An arrow is used to indicate a possible point of
origin.
ULTRASOUND FINDINGS
ULTRASOUND FINDINGS
Solitary well defined encapsulated lesion seen in
region of interest
 Predominately hypoechoic to surrounding tissues
but somewhat heterogenous
 Slight increased vascularity
 Possible neck extending to the scapholunate
ligament
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DIFFERENTIAL DIAGNOSIS

Ganglion or Mass
GANGLIONS IN THE WRIST
GANGLION
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Definition

Mucin filled soft tissue cyst (Pal and Wallman 2014,
500) (Ahuja 2007, 13:114) (Tsou and Khoo 2012,450)

May either be from the synovial lining of the joint or
the tendon sheath (Pal and Wallman 2014, 500)

Represent 80% of all soft tissue tumours in the hand
and wrist (Ahuja 2007, 13:116)
AETIOLOGY
Mucoid degeneration
 Synovial herniation
 Trauma to the joint capsule
 Trauma to the ligaments
 Repetitive actions
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(Pal and Wallman 2014, 500)(Tsou and Khoo 2012,450)
PATIENT PRESENTATION

Lump on the wrist
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Usually on the dorsal surface
Usually painless however some patients exhibit pain
on dorsiflexion
Changing in size with time and activity
May be slow growing or spontaneously appear
Patients at risk
Women are more affected than men
 Teenagers through to those in their middle adult
hood more affected
 Patients with laxity in their ligaments
 Previous history of trauma or injury to the wrist
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(Pal and Wallman 2014, 500)(Ahuja 2007, 13:116)
DIFFERENTIAL DIAGNOSIS
Tenosynovitis
 Giant Cell Tumour
 Vascular Anomaly
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(Ahuja 2007, 13: 116)
ULTRASOUND APPEARANCE OF GANGLION
Hypoechoic fluid filled sac
 Stalk may be seen extending to the joint from
which it arises
 Non compressible
 Non vascular unless there has been a recent
leakage. Surrounding tissues may be oedematous
and with a slight increase in vascularity
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(Ahuja 2007, 13:114)
ALTERNATIVE IMAGING MODALITIES
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Ultrasound is the preferred method of imaging
however MRI may also be useful in identifying
non symptomatic ganglia
INTERVENTIONAL TECHNIQUES
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Non Invasive
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Aspiration and injection
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60% chance of reoccurrence (Pal and Wallman 2014, 502)
Rest
 Bible/ Manual rupture (not recommended)
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Invasive
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Surgery to excise either open or arthroscopic
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Most affective however longer healing time
(Pal and Wallman 2014, 502) (Ahuja 2007, 13:116)
GANGLION IN THE PRESENCE OF A SLL
TEAR
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A ganglion extending from the scaphoid lunate
joint space is often indicative of a scapholunate
ligament tear (Harish et.al. 2009, 118)
It is believed that this was the case in this
patient.
ASPIRATION AND INJECTION
After a discussion with the radiologist and the
patient it was decided that aspiration of the
ganglion was to go ahead followed by an injection
of Xylocaine, Ropivacaine and Celestone.
PROCEDURE PREPARATION
A sterile trolley was assembled.
 The following was included
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Sterile dressing back
2 x 3ml luerlock syringes
Extension tube
Drawing-up needle
21G needle
Sterile gloves were made available for the
radiologist.
PROCEDURE
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A clean environment was established.
The patient’s wrist was positioned in slight
flexion. This was achieved with a gel bottle being
placed beneath the wrist covered with bluey.
PROCEDURE
The skin was prepped with an alcohol solution as
per practice protocol.
 Appropriate volumes of the drugs to be
administered were decanted.
 Local anaesthetic was first injected into the site
and allowed to take effect.
 An attempt to aspirate the suspected ganglion
was made.
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ASPIRATION
Image 18: Area of suspected ganglion. An aspiration of
several areas was attempted with nil fluid extracted.
PROCEDURE
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As no fluid was extracted, an injection of
Ropivacaine and Celestone was administered
ASPIRATION
Image 19: Area of suspected ganglion. Injection of
medication.
POST PROCEDURE
POST PROCEDURE
The patient appeared to tolerate the procedure
well.
 They were informed to rest the wrist for 24-48
hours and were given post procedure care
instructions as per practice protocol.
 A “pain chart” was also given to the patient to
record the effectiveness of the procedure.
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REFERENCES
Ahuja, Anil T. 2007. Diagnostic Imaging: Ultrasound. Salt Lake City: Amyirsys.
Harish, Srinivasan, John O'Neill, Karen Finlay, Erik Jurriaans, and Lawrence
Friedman. 2009. Current Problems in Diagnostic Radiology 38(3): 111-125.
DOI 10.1067/j.cpradiol.2008.02.001
Jacobson, Jon A. 2007. Fundementals of Musculoskeletal Ultrasound. Philadelphia:
Saunders Elsevier.
Pal, Julie, Jackie Wallman. 2014.Fundamentals of Hand Therapy. 2nd ed. Online. DOI
10.1016/B978-0-323-09104-6.00036-5
Tsou, Ian Y.Y., and Jenn Nee Khoo. 2012. “Ultrasound of the wrist and hand”.
Ultrasound Clinics 7(4): 439-455. DOI 10.1016/j.cult.2012.08.001