Compound palmar Compound palmar ganglionganglion

Moderators:Moderators:Dr.Surendra U KamathDr.Surendra U KamathDr HarshvardhanDr Harshvardhan

Presented by: -Presented by: -Dr.Praveen PatilDr.Praveen Patil

Compound Palmar GanglionCompound Palmar Ganglion

Is a progressive swelling and Is a progressive swelling and inflammation of the tendon sheath that inflammation of the tendon sheath that distends the sheath proximal & distal to distends the sheath proximal & distal to

flexor retinaculum with limitation of flexor retinaculum with limitation of excursion of the involved tendons excursion of the involved tendons

EtiologyEtiology

Infection with the tubercle bacillusInfection with the tubercle bacillus

Rheumatoid arthritisRheumatoid arthritis

PathologyPathology Commonly flexor tendon sheaths in the Commonly flexor tendon sheaths in the

lower foreman & hand are affected.lower foreman & hand are affected. Extensor sheath are less commonly Extensor sheath are less commonly

involved. involved.

The affected sheaths are greatly thickened The affected sheaths are greatly thickened & show the changes of chronic & show the changes of chronic inflammation. inflammation.

The lining membrane is replaced by The lining membrane is replaced by tuberculosis granulation tissue.tuberculosis granulation tissue.

The swelling may contain serous fluid, The swelling may contain serous fluid, masses of fibrinous material, melon seed masses of fibrinous material, melon seed bodies or caseous material. bodies or caseous material.

The visceral as well as the parietal layer of The visceral as well as the parietal layer of the sheath is affected so that the tendons the sheath is affected so that the tendons itself becomes involved, granulation itself becomes involved, granulation tissues spreading longitudinally among the tissues spreading longitudinally among the fibres which become separated into fibres which become separated into bundles. bundles.

Clinical featuresClinical features Is a hour glass swelling Is a hour glass swelling

Gradual onset of swelling with mild aching Gradual onset of swelling with mild aching pain, in the region of the affected tendon pain, in the region of the affected tendon sheaths.sheaths.

The pain is seldom severe, accompanies The pain is seldom severe, accompanies

with the stiffness of the finger. with the stiffness of the finger. Fusiform appearance. Fusiform appearance.

In many cases fluctuation can be elicited In many cases fluctuation can be elicited with some crepitus between the forearm with some crepitus between the forearm swelling & the swelling in the palm with the swelling & the swelling in the palm with the flexor retinaculum in between.flexor retinaculum in between.

At first range of movements of the fingers At first range of movements of the fingers

& thumb is impaired only slightly. & thumb is impaired only slightly.

CROSS FLUCTUATION

DiagnosisDiagnosis Symptoms & signsSymptoms & signs

If an active tuberculosis lesion is found in the If an active tuberculosis lesion is found in the body elsewhere it is reasonable to infer that body elsewhere it is reasonable to infer that the tenosynovitis is also due to tuberculosis the tenosynovitis is also due to tuberculosis

ComplicationsComplications The adjacent bones, joint or tendons may The adjacent bones, joint or tendons may

get involved, with obvious wasting of get involved, with obvious wasting of adjacent muscles. adjacent muscles.

Rupture of tendons especially sublimes. Rupture of tendons especially sublimes. Discharging sinuses & involvement of Discharging sinuses & involvement of

radial & ulnar bursae. radial & ulnar bursae. Median nerve compression in the carpal Median nerve compression in the carpal

tunnel. tunnel.

TreatmentTreatment

Depends on the severity of the lesions.Depends on the severity of the lesions.

Conservative Conservative OperativeOperative

ConservativeConservative In mild cases where the function of fingers & In mild cases where the function of fingers &

thumb is not impaired, conservative treatment thumb is not impaired, conservative treatment is advised. is advised.

Immobilization of the wrist & forearm with Immobilization of the wrist & forearm with plaster of paris for three months, fingers being plaster of paris for three months, fingers being left free. left free.

In tuberculosis cases, a course of anti-In tuberculosis cases, a course of anti-tubercular drugs is given tubercular drugs is given

OperativeOperative

Here curvilinear incision, starts in the Here curvilinear incision, starts in the lower forearm, skirts the thenar crease & lower forearm, skirts the thenar crease & continues distally in the direction of the continues distally in the direction of the head of the fourth metacarpal. head of the fourth metacarpal.

If the radial bursa involved, additional If the radial bursa involved, additional midlateral incision is required for the thumb. midlateral incision is required for the thumb.

Zig-Zag approachZig-Zag approach

provides excellent visualization of the whole lesion & provides excellent visualization of the whole lesion & facilitates the retention of pulleys from the fibrous facilitates the retention of pulleys from the fibrous flexor sheath. flexor sheath.

In case of sublimus tendon rupture,In case of sublimus tendon rupture,

it is excised & the stump is restored to the it is excised & the stump is restored to the profundus by transferring the distal stump to profundus by transferring the distal stump to the adjacent tendon with intact motor.the adjacent tendon with intact motor.

The combination of surgery & antibiotics The combination of surgery & antibiotics should eradicate the disease, long term should eradicate the disease, long term follow up examination are needed to follow up examination are needed to ensure that other lesions have not ensure that other lesions have not subsequently progressed.subsequently progressed.