IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 2, February 201 2. ISSN – [0976-31 98]

Compound palmar ganglion: A tubercular manifestationof flexor tenosynovitis of the wristK Arun Kumar, B Kanthimathi, CS Krishnamurthy, S Sujai

ABSTRACTIntroduction: Compound palmar ganglion oftuberculous origin is uncommon. The clinicalpicture is very typical and is always confirmedby histopathology. The condition is bestmanaged in its early stages before it spreads tothe underlying bones causing destruction. Casereport: Here, we report a 55­year­old male whopresented with pain and progressive swellingover the left wrist and hand. Examinationrevealed positive cross fluctuation, restriction ofmovements and islands of numbness overmedian nerve territory. He was diagnosed tohave chronic flexor tenosynovitis of left wristand was treated with debulkingtenosynovectomy along with anti tuberculartherapy. He responded to treatment achieving

full functional recovery. Conclusion: Compoundpalmar ganglion is considered a severe form ofextra­pulmonary musculoskeletal tuberculosis.Intra­operative finding of melon seed bodies orrice bodies as seen in our case is pathognomonicof tuberculous tenosynovitis. According toliterature, extensive debridement and fullcourse chemotherapy brings about a betterprognosis. Early diagnosis, complete debulkingand appropriate anti­tubercular therapy is therecommended treatment. It can improve thepatient functionally by preventing a subsequentarthrodesis which is a major concern for boththe surgeon and the patient.Keywords: Compound palmar ganglion, Chronicflexor tenosynovitis, Melon seed bodies

********Arun Kumar K, Kanthimathi B, Krishnamurthy CS,Sujai S. Compound palmar ganglion: A tubercularmanifestation of flexor tenosynovitis of the wrist.International Journal of Case Reports and Images2012;3(2):28­31.

*********doi:10.5348/ijcri­2012­02­93­CR­7

INTRODUCTIONChronic flexor tenosynovitis of the wrist, commonlyof tuberculous origin is also called compound palmarganglion. Though the incidence is very less, it is notuncommon in developing countries. The clinical pictureis very typical and is always confirmed byhistopathology. The disease can progress and result in agross destruction of structures around the wrist andhence requires excision without delay.

CASE REPORT OPEN ACCESS

K Arun Kumar1 , B Kanthimathi2, CS Krishnamurthy3, SSujai4

Affi l iations: 1Post Graduate, Division of Orthopaedics,Rajah Muthiah Medical College, Annamalai University,Chidambaram, Tamilnadu, India; 2Professor ofOrthopaedics, Division of Orthopaedics, Rajah MuthiahMedical College, Annamalai University, Chidambaram,Tamilnadu, India; 3Professor of Orthopaedics, Division ofOrthopaedics, Rajah Muthiah Medical College, AnnamalaiUniversity, Chidambaram, Tamilnadu, India; 4PostGraduate, Division of Orthopaedics, Rajah MuthiahMedical College, Annamalai University, Chidambaram,Tamilnadu, India.Corresponding Author: Dr Arun Kumar K, Sakthi Medicarecenter, 1 1 2, Bazaar Street, Chidambaram, Tamil Nadu,India, Pin - 608002; Ph: +91 9840538029; Email :dr.arunkumar.orth@gmail .com

Received: 24 July 2011Accepted: 1 9 October 2011Published: 28 February 201 2

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IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 2, February 201 2. ISSN – [0976-31 98]

The palmar synovial bursa, covered by a densepalmar fascia, is not a common site for tuberculosis. Butonce infected, it can cause inflammation of all tendonsheaths about the hand and wrist resulting in mediannerve compression [1]. It can also lead to destruction ofunderlying bones if left untreated. Early recognition andcomplete surgical excision of the diseased tissue alongwith appropriate anti­tubercular therapy gives a betterprognosis.

CASE REPORTA 55­year­old male butcher, presented withcomplaints of an increasing swelling over the volaraspect of his left hand and wrist. The condition wasassociated with pain which was worse at night,disturbing sleep. He had loss of appetite and loss ofweight for six months prior to admission. Evening riseof temperature was more marked for the past onemonth. There was no similar history in the family andno history of contact with any tuberculous patient.Examination revealed two swellings proximal anddistal to the flexor retinaculum with a positive crossfluctuation (figure 1). Entire sensory territory of themedian nerve was numb. Movements of wrist andfingers were limited along with loss of power in thefingers. Radiographs of the wrist and hand were normalwithout any involvement of the underlying bones. Thechest was normal clinically and radiographically. Bloodparameters were within normal limits except anelevated ESR which was 40 and 84 at 1/2 and one hourrespectively. There was no evidence ofimmunodeficiency. There were no other detectable fociof infection.Excision and biopsy was planned and carried outwithout delay. With a usual approach to the volar wristand hand, the skin and fascia was incised and retracted.Careful dissection and release of the flexor retinaculumrevealed a single continuous fluctuant mass which wasfilled with fibrinous material and straw colored fluid(figure 2). Fluid sample was taken for PCR. Theganglion also contained melon seed bodies (figure 3), allof which were evacuated completely. Inflamed tendonsheaths were excised after protection of the mediannerve. A thorough wash was given and the wound wasclosed. Histopathology of the specimen revealedinflammatory lesions with large granulomas ofepitheloid cells and multiple giant cells with centralcaseous necrosis (figure 4). PCR was positive formycobacterium tuberculosis.According to WHO guidelines, patient was startedwith two months of isoniazid (H), rifampicin (R),pyrazinamide (Z), ethambutol (E) in the intensive phasefollowed by 4 months continuation phase of HR thrice aweek [2]. Finger mobilization was started in the firstweek postoperatively which was well tolerated by thepatient. Later, mobilization of the wrist was started.Subsequent review of the patient showed a completerecovery of numbness and regaining of power in theoperated hand. By eight weeks, the patient had returned

to normal activity with full function of the affected side.There were no contractures and the scar remainedhealthy.One year later, having completed anti tuberculartherapy, patient is comfortable with using his left hand.There are no signs of recurrence and no other foci ofinfection.

Figure 2: Single fluctuant mass.

Figure 1: Clinical picture showing compound palmar ganglion.

DISCUSSIONTuberculosis is still widely present in manydeveloping countries, especially more so inimmunocompromised individuals. Though tuberculosisaffects various organ systems in the body, involvementof hand and wrist is quite rare. Hence the diagnosis andconfirmation of this clinical entity is delayed because ofthe rarity of the condition. Mycobacterium tuberculosisis the most common causative organism for such anextensive lesion over the wrist and hand and is alwaysconfirmed by culture. Operative finding of melon seedbodies are highly suggestive of tuberculoustenosynovitis [3].

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IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 2, February 201 2. ISSN – [0976-31 98]

Figure 3: Fibrinous material and Melon seed bodies.

Figure 4: Histopathology showing large granuloma ofepitheloid cells.

Early diagnosis, complete debulking and appropriateanti­tubercular therapy is needed to overcome thiscondition. With lack of pulmonary symptoms,diagnosing this condition is quite difficult. Patientsusually present after six months to one year of beingdiseased when the condition had already progressed toan extent. In that situation, a debulkingtenosynovectomy and chemotherapy is a must for abetter prognosis. Moreover, it is the recommendedtreatment of choice favoured in various reports in theliterature [4 ­ 7].Interfering with the disease before it involves theunderlying bones is the main goal of treatment. Earlysurgery can improve the patient functionally bypreventing a subsequent arthrodesis which is a majorconcern for both the surgeon and the patient. Early postoperative mobilization helps to regain a powerful handgrip and also prevents stiffness and adhesions.The one year follow up of our case reveals no signs ofrecurrence and the patient had returned to his bestfunctional status.

CONCLUSIONThus, we conclude insisting that the possibility oftuberculosis in a chronic flexor tenosynovitis of the wristshould always be kept in mind. The delay between theonset of symptoms and the diagnosis should beminimized so that a timely interference could beplanned which would do much good for the patient.

*********Author ContributionsK Arun Kumar – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedB Kanthimathi – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedCS Krishnamurthy – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedS Sujai – Substantial contributions to conception anddesign, Acquisition of data, Analysis and interpretationof data, Drafting the article, Revising it critically forimportant intellectual content, Final approval of theversion to be publishedGuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© K Arun Kumar et al. 2012; This article is distributedunder the terms of Creative Commons attribution 3.0License which permits unrestricted use, distribution andreproduction in any means provided the original authorsand original publisher are properly credited. (Please seewww.ijcasereportsandimages.com /copyright­policy.phpfor more information.)

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