Date of Presentation
5-4-2023 12:00 AM
College
School of Osteopathic Medicine
Poster Abstract
A ganglion cyst is a benign fluid-filled sac that develops idiopathically on the dorsal aspect of the wrist by the joint capsule or tendon sheath. It is diagnosed clinically, with MRI and ultrasound used for confirmation. Treatment includes immobilization, aspiration, hydrossection, steroid or hyaluronidase injection, and surgery. Although uncommon, Dorsal Ganglion Cysts (DGC) can lead to Dorsal Wrist Impingement (DWI) syndrome. This syndrome is caused by a thickening of the wrist capsule from overuse, injury, or repetitive procedures. This thickness leads to capsule pinching commonly by the extensor carpi radialis brevis (ECRB) tendon during wrist extension and tenderness by the lunate. In recalcitrant cases, MRI may show recurring ganglion cysts or maybe “normal.” Therefore, the diagnosis is clinical, and imaging is used to rule out secondary causes. Treatment includes rest, immobilization, occupational therapy, NSAIDS, cortisone injection, and surgery. Currently, very few studies describe the connection between these complications. Thus, we present a rare case of a 23-year-old female with recurrent DGC with an associated DWI syndrome. This patient initially reported idiopathic Left dorsal wrist pain at the tendon sheath. Her original X-ray was unrevealing, but MRI showed two ganglion cysts. Left tendon sheath hydrossection, left wrist corticosteroid injections, and left wrist ganglion cyst excision were progressively performed. Occupational therapy, oral Meloxicam, and Voltaren gel treatments were also incorporated. Resolution of cysts was confirmed on imaging and overall improvement in range of motion and strength was noted. However, there was minimal pain relief. The pain was reproduced with end-range wrist extension and dorsal wrist palpation. A follow-up EMG ordered to rule out neuropathic causes was unrevealing. However, a repeat X-ray revealed mild soft tissue swelling dorsal to the wrist and a repeat MRI revealed ganglion cysts at the dorsal aspect of the lunate and ERB tendons. These overall findings were suggestive of re-accumulation of dorsal ganglion cysts with a component of dorsal impingement syndrome. The patient was referred to orthopedic surgery for evaluation and possible revision surgery. To our knowledge, this rare case demonstrated that removing a DGC may be associated with developing DWI Syndrome. The diagnosis of this syndrome may be evaded due to negative findings on X-ray, MRI and EMG. However, trauma such as repeated hand surgery or recurring ganglion cyst may clinically cause the wrist pain to worsen despite improvement in range of motion and strength. Patients with surgical excision of wrist cysts should be especially taken into account since excision heightens risk of recurrence and can irritate the tendon sheet. Interdisciplinary efforts by PM&R, OT, and surgical team may help with pain management. We recommend that future studies consider creating a guideline for this condition.
Keywords
Ganglion Cysts, Wrist Joint, Pain, Connective Tissue Diseases
Disciplines
Dermatology | Medicine and Health Sciences | Skin and Connective Tissue Diseases | Surgery
Document Type
Poster
Dorsal Wrist Impingement Syndrome Pain After Ganglion Cyst Removal – A Case Report
A ganglion cyst is a benign fluid-filled sac that develops idiopathically on the dorsal aspect of the wrist by the joint capsule or tendon sheath. It is diagnosed clinically, with MRI and ultrasound used for confirmation. Treatment includes immobilization, aspiration, hydrossection, steroid or hyaluronidase injection, and surgery. Although uncommon, Dorsal Ganglion Cysts (DGC) can lead to Dorsal Wrist Impingement (DWI) syndrome. This syndrome is caused by a thickening of the wrist capsule from overuse, injury, or repetitive procedures. This thickness leads to capsule pinching commonly by the extensor carpi radialis brevis (ECRB) tendon during wrist extension and tenderness by the lunate. In recalcitrant cases, MRI may show recurring ganglion cysts or maybe “normal.” Therefore, the diagnosis is clinical, and imaging is used to rule out secondary causes. Treatment includes rest, immobilization, occupational therapy, NSAIDS, cortisone injection, and surgery. Currently, very few studies describe the connection between these complications. Thus, we present a rare case of a 23-year-old female with recurrent DGC with an associated DWI syndrome. This patient initially reported idiopathic Left dorsal wrist pain at the tendon sheath. Her original X-ray was unrevealing, but MRI showed two ganglion cysts. Left tendon sheath hydrossection, left wrist corticosteroid injections, and left wrist ganglion cyst excision were progressively performed. Occupational therapy, oral Meloxicam, and Voltaren gel treatments were also incorporated. Resolution of cysts was confirmed on imaging and overall improvement in range of motion and strength was noted. However, there was minimal pain relief. The pain was reproduced with end-range wrist extension and dorsal wrist palpation. A follow-up EMG ordered to rule out neuropathic causes was unrevealing. However, a repeat X-ray revealed mild soft tissue swelling dorsal to the wrist and a repeat MRI revealed ganglion cysts at the dorsal aspect of the lunate and ERB tendons. These overall findings were suggestive of re-accumulation of dorsal ganglion cysts with a component of dorsal impingement syndrome. The patient was referred to orthopedic surgery for evaluation and possible revision surgery. To our knowledge, this rare case demonstrated that removing a DGC may be associated with developing DWI Syndrome. The diagnosis of this syndrome may be evaded due to negative findings on X-ray, MRI and EMG. However, trauma such as repeated hand surgery or recurring ganglion cyst may clinically cause the wrist pain to worsen despite improvement in range of motion and strength. Patients with surgical excision of wrist cysts should be especially taken into account since excision heightens risk of recurrence and can irritate the tendon sheet. Interdisciplinary efforts by PM&R, OT, and surgical team may help with pain management. We recommend that future studies consider creating a guideline for this condition.