Journal List > J Korean Soc Surg Hand > v.20(1) > 1106508

J Korean Soc Surg Hand. 2015 Mar;20(1):39-42. English.
Published online March 31, 2015.  https://doi.org/10.12790/jkssh.2015.20.1.39
Copyright © 2015. The Korean Society for Surgery of the Hand
Sensory Neuropathy of the Common Palmar Digital Nerve Caused by Ganglion Cyst
Jae Hoon Lee, and Young Joo Cho
Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University, School of Medicine, Seoul, Korea.

Correspondence to: Jae Hoon Lee. Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University, School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Korea. TEL: +82-2-440-6153, FAX: +82-2-440-7498, Email: ljhos69@naver.com
Received March 11, 2015; Revised March 11, 2015; Accepted March 20, 2015.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Ganglion cysts that arise from the palm and compress the median nerve are rarely reported. Previous studies have described ganglion cysts compressing the motor branch of the median nerve, but no reports have described sensory neuropathy of the common palmar digital nerve as a result of ganglion cysts. We present a case of sensory neuropathy similar to carpal tunnel syndrome caused by a ganglion cyst that originated from the second carpometacarpal joint.

Keywords: Ganglion cyst; Common digital nerve; Palm; Sensory neuropathy

INTRODUCTION

Ganglion cysts are the most common soft tissue tumors of the hand and wrist1. In rare cases, ganglion cysts arise from the palm and can compress the median or ulnar nerve2, 3, 4, 5, 6. Ganglion cysts arising from the second carpometacarpal joint of the palm that compress the motor branch of the median nerve have been reported6, but were not accompanied by sensory neuropathy. Here, we report a rare case of a ganglion cyst that arose from the second carpometacarpal joint and caused sensory disturbance by compressing the second common palmar digital nerve.

CASE REPORT

A 33-year-old male, right hand dominant, office worker presented with a 2-month history of palpable mass in the palm and decreased sense on the ulnar side of the index finger and the radial side of the middle finger of the right hand. He had no previous history of the hand trauma.

The patient was right-handed and had no history of trauma. On physical examination, a longitudinal mass was palpated between the thenar crease and the proximal palmar crease in the right palm. The tumor was soft and movable without palpable pulsation, and approximately 1×2 cm in size. The patient had focal tenderness and positive Tinel's sign, but was negative on the Phalen and Allen tests. Two-point discrimination measured 10 mm in the ulnar side of the index finger and the radial side of the middle finger. The patient's range of finger and wrist joint motion was normal but he complained of pain in the metacarpophalangeal joint while making a fist, which made grabbing objects difficult. The patient's grip strength and pinching as measured using a Jamar dynamometer (Asimov Engineering Co., Los Angeles, CA, USA) were similar with a left hand. Plain X-ray showed no abnormalities. Magnetic resonance imaging demonstrated a high-signal, homogenous fluid-filled mass connected to the second carpometacarpal joint that enveloped the second common palmar digital nerve in the midpalm (Fig. 1).


Fig. 1
A T2-weighted magnetic resonance imaging of the right hand demonstrated a high-signal, homogenous fluid-filled mass (white arrow) connected to the second carpometacarpal joint (A) that enveloped the second common palmar digital nerve (small white arrow) in the midpalm (B).
Click for larger image

Because these symptoms caused a great inconvenience to the patient, excisional biopsy was scheduled. A longitudinal skin incision was made over the mass. Dissection was carried proximally, a distal portion of the transverse carpal ligament was released to gain better exposure of the mass. A cystic mass adherent to the perineurium of the second common palmar digital nerve was found (Fig. 2). A stalk of the mass originated proximally from the second carpometacarpal joint. Since the superficial palmar arch crossed over the mass, the artery was ligated and excision was performed under a microscope to prevent further nerve injury. Part of the capsule of the carpometacarpal joint, the origin of the stalk, was dissected simultaneously. Histological examination identified the mass as a ganglion cyst. After surgery, the patient continued to improve, and after 4 months, his digital senses had regained normal level. One year after the operation, the patient did not have any inconveniences in his daily activities and there was no evidence of recurrence of the ganglion cyst on ultrasonography.


Fig. 2
Intraoperative photograph of cystic mass (large arrow) attached to the perineum of the second common palmar digital nerve (small arrow).
Click for larger image

DISCUSSION

Ganglion cysts on the volar surface sometimes appear to protrude into the carpal tunnel, compressing the median nerve and causing carpal tunnel syndrome2, 7, 8, 9. In such cases, ganglion cysts may be palpable proximal to the wrist crease or not palpable at all8, 9. Ganglion cysts may also appear in the midpalm, causing compression of motor3, 4, 5 or sensory9 branches of the median nerve, but only in rare cases. The ganglion cysts in these cases arise from the midcarpal joint or the first or second carpometacarpal joints, leading to motor or sensory disturbances in the thenar area3, 4, 5, 6. To date, only one case of a ganglion cyst arising from the second carpometacarpal joint has been reported6. In that case, the ganglion cyst compressed the motor branch of the median nerve, leading to muscle weakness. There was also a case report that described a ganglion cyst arising from the scaphotrapeziotrapezoid joint and located between the flexor tendons without compressing the nerve10. In our case, a ganglion cyst originated from the second carpometacarpal joint and protruded distally, attaching to the common palmar digital nerve. The ganglion cyst in our case was symptomatic, causing sensory neuropathy in particular. To our knowledge, no previous report has described such a case.

Ultrasonography and magnetic resonance imaging are considered useful for preoperative examination of ganglion cysts5. In our case, we confirmed the size and shape of the ganglion cyst and observed that a stalk of the ganglion cyst originated from the second carpometacarpal joint. During surgery, a ganglion cyst enveloping the common palmar digital nerve was observed. Since neurolysis was not feasible under the Roupe, we performed excision under an operating microscope.

Ganglion cysts in the midpalm may cause compressive sensory neuropathy of the common palmar digital nerve. In our opinion, microscope may be helpful in identifying accurate origin of a complex ganglion and its relationship to the digital nerve and in facilitating safety dissection.

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