Compound Plamar Ganglion

8/19/2019 Compound Plamar Ganglion

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DEPARTMENT OF ORTHOPAEDICS

KASTURBA MEDICAL COLLEGE MANGALORE

Moderators: Presented by:

Dr!S"rendra U Ka#at$ Dr!Pra%een Pat&'

Dr Hars$%ard$an Date: ()*+,*(++-

COMPOUND PALMAR GANGLION

Is a progressive swelling and inflammation of the tendon sheath that distends the

sheath proximal & distal to flexor retinaculum with limitation of excursion of the

involved tendons is classically called “Compound Palmar Ganglion”.

Et&o'o.y

In most cases it is caused by infection with the tubercle bacillus. ometimes other

organisms are responsible. ! similar condition may complicate rheumatoid arthritis

without demonstrable bacterial infection.

Pat$o'o.y

Commonly flexor tendon sheaths in the lower foreman & hand are affected.

"xtensor sheath are less commonly involved. #he walls of the tendon sheath may

be thin & almost translucent or thic$ and fibrotic.

#he affected sheaths are greatly thic$ened & show the changes of chronic

inflammation.

#he lining membrane is replaced by tubercular granulation tissue.

#he swelling may contain serous fluid% masses of fibrinous material% melon seed

bodies or caseous material.elon'seed bodies resemble grains of boiled sago.

#hey are composed of collection of fibrin %cellular debris% and occasional tubercle

bacilli.

#he visceral as well as the parietal layer of the sheath is affected so that the

tendons itself becomes involved% granulation tissues spreading longitudinally

among the fibres which become separated into bundles.



In fluid type #he bursa becomes distended with clear fluid containing melon'seed

bodies & its lining membrane is thic$ened & granular.

In dry type #he lining membrane becomes replaced by tubercular granulation tissue

which proliferates to encompass & invade the tendons.

C'&n&/a' 0eat"res

Is a hour glass swelling

Gradual onset of swelling with mild aching pain% in the region of the affected

tendon sheaths.

#he pain is seldom severe% accompanies with the stiffness of the finger.

Characteristically it affects the lowest five or six centimeters of the front of the

forearm & the proximal part of the palm% sometimes the flexor sheaths of the

fingers & thumb are swollen% giving the digits a fusiform appearance.

In many cases fluctuation can be elicited with some crepitus between the forearm

swelling & the swelling in the palm with the flexor retinaculum in between.

!t first range of movements of the fingers & thumb is impaired slightly.

(ater there is moderate restriction of flexion & extension of digits% with

corresponding loss of functions.

D&a.nos&s

Persistent swelling of gradual onset in the line of tendon sheaths in the lower

forearm & hand always suggests chronic tenosynovitis. )luctuation between

the forearm swelling & the palmar swelling provides strong corroborative

evidence.



If an active tuberculosis lesion is found in the body elsewhere it is reasonable

to infer that the tenosynovitis is also due to tuberculosis.

Co#1'&/at&ons

#he ad*acent bones% *oint or tendons may get involved% with obvious wasting of

ad*acent muscles.

+upture of tendons especially sublimes.

,ischarging sinuses & involvement of radial & ulnar busae.

edian nerve compression in the carpal tunnel.

Treat#ent

It depends on the severity of the lesions.

Conservative

-perative

Conser%at&%e 2

In mild cases where the function of fingers & thumb is not impaired%

conservative treatment is advised.

Immobiliation of the wrist & forearm with plaster of paris for three months%

fingers being left free.

In tuberculosis cases% a course of anti'tubercular drugs is given.

O1erat&%e

' In severe cases% under antibiotic cover% a meticulous excision of all infected

synovium is carried out% the affected part of the hand is immobilied% during the

period of wound healing.

' /ere curvilinear incision% starts in the lower forearm% s$irts the thenar crease &

continues distally in the direction of the head of the fourth metacarpal.



' If the radial bussa involved% additional midlateral incision is re0uired for the

thumb.

' 1runner2s 3ig'3ag approach provides excellent visualiation of the whole lesion

& facilitates the retention of pulleys from the fibrous flexor sheath.

' In case of sublimus tendon rupture% it is excised & the stump is restored to the

profundus by transferring the distal stump to the ad*acent tendon with intact

motor.

' #he combination of surgery & antibiotics should eradicate the disease% long term

follow up examination are needed to ensure that other lesions have not

subse0uently progressed.

REFERENCES4

5. -utline of -rthopaedics% 6th "d% 7ohn Crawford% !dams.

8. urgery of hand% 7.1.(ippincott% 9th "d 5:;9.

<. 1aily & (ove2s hort practice of surgery% 5;th edition.

9. #he Infected /and% ,avid & 1ailey 5:;< 5st "d.

=. #uberculosis in the wrist and hand% +obert. /.C.+obins.

;. 717% )eburary 5:=6% vol <:1%:5'5>5.

6. Green “s -perative /and urgery% 9th "d %5>6<'5>6?% 5;;5'5;;:%8>88'8>8=

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Compound Plamar Ganglion