INTRAOSSEOUS GANGLION CYST OF SCAPHOID: A CASE REPORT

Nasir Muzaffar, Nissar Shah, Sulaiman Seth, Sheikh Ajaz

Case Report from the Hospital for Bone and Joint Surgery, Barzalla,
Srinagar, Kashmir, India
Address correspondence to:
Dr Nasir Muzaffar
Bone and Joint Surgery Hospital, Barzalla, Srinagar,
Kashmir, J&K, India

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in connection with the submitted article. No financial aid was received for
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ABSTRACT
Intraosseous ganglion cysts are rare causes of hand and wrist pain. Differential diagnosis of
painful cystic radiolucent carpal lesions includes osteoid osteoma and osteoblastoma. Isolated
cases of ganglion cysts occurring in the lunate, scaphoid, pisiform, hamate, triquetrum,
capitate, metacarpal, and phalanx have been reported. A case of intra-articular intraosseous
ganglion cyst of the scaphoid is presented. A 32-year-old right-handed man presented with a 2
year history of progressive left-wrist pain. No history of trauma was reported. Conservative
treatment with anti-inflammatory medications before referral was unsuccessful. This case
was treated with curettage and bone grafting having excellent results with visual and analog
pain scores reduced from 68 to 11 and range of motion was 90 extension to 80flexion and
full grip strength.
Keywords: Intraosseous ganglion; scaphoid; curettage; bone grafting
INTRODUCTION
Intraosseous ganglion is a cystic lesion that contains gelatinous material, most often occurs in
middle-aged patients, and is regarded as similar to soft-tissue ganglion. The etiology is
unknown, but association with degenerative joint disease has been considered. An
intraosseous ganglion has been defined as abenign cystic and often multiloculated lesion
made up of fibrous tissue, with extensive mucoid changes, located in the subchondral bone
adjacent to a joint.(1) Intraosseous ganglions, although share same pathology as the soft
tissue ganglions are rare entities, further rare in carpals. Cases of intraosseous ganglions are

reported in literature mostly in lower limbs and lunate among carpals,with scaphoid being
rare site of the involvement. We describe a symptomatic case which was successfully treated by
intralesional curettage, and autogenous bone grafting.
CASE REPORT
A 32-year-old male, mechanic by occupation presented with a 2 years history of left wrist
pain. The patient complained of a dull aching pain worsened by usual activity of the left
upper extremity and relieved by rest. The various conservative management options such as
splinting and NSAIDS did not fully relieve his symptoms. There was no history of any
definite trauma. On examination marked tenderness was present in region of the volar
scaphoid proximal pole as well as overlying the dorsal radial styloid and snuff box. There
was no swelling or palpable mass around the wrist. The grip strength was symmetrically
normal. The range of motion of the wrist was normal and comparable to the contralateral
wrist. The conventional radiographs revealed a well defined radiolucent lesion radiographs
within the scaphoid without collapse of the bone (Fig 1). CT confirmed a cystic lesion with
normal appearance of other parts of the scaphoid (Fig 2). His hematological investigations
including hemogram, ESR, RA factor, uric acid, serum calcium, phosphate, alkaline
phosphatase, were within normal limits. The patient was operated using a volar approach
under fluoroscopic guidance and the scaphoid was exposed (Fig 3). The cyst was evacuated
enbloc.(Fig 4) Then the cavity was packed using cancellous bone from the distal of the
radius. The joint capsule and wound was closed and the wrist was immobilized in glass
holding position for 5 weeks after that gradual mobilization started and full range of motion
achieved at 7 weeks. Patient returned to full employment at 8 weeks. The patient was totally
free from earlier symptoms, with full grip strength, 3 months after operation. Over 6 months
period trabeculations were being noted within the grafted scaphoid. (Fig 5) The pathology
report described a cystic lesion with a delicate wall of fibro-connective tissue cells without

true epithelial lining. Gross and microscopic findings were characteristics of an intraosseous
ganglion cyst

DISCUSSION
Intraosseous ganglion may have developed either within the bone near but not directly
communicating with a joint or from adjacent joint tissues with secondary penetration into
bone.(2) The first type is more commonly reported.(3,4,5)

Intraosseous ganglion was

described by Fisk in 1949(6) as a periosteal ganglion-like lesion developing a cystic bony

defect through intraosseous penetration. In 1966 Crabbe (7) named it the intraosseous
ganglion cyst. Various Synonymous terms include synovial bone cyst, ganglionic cystic
defect of bone and subchondral bone cyst. The differential diagnosis of a lytic painful lesion
consists of chondroblastoma, enchondroma, fibrous dysplasia, osteoblastoma, osteoid
osteoma, giant cell tumor, chondromyxoid fibroma, unicameral bone cyst, osteoarthritis,
rheumatoid arthritis and intraosseous ganglion cyst. Intraosseous ganglion has been reported
most commonly in the epiphyses of long tubular bone.(8) Most frequently, they develop in
the subchondral bone of the lower limb, primarily the hip, knee, and ankle, with the femoral
head and the medial malleolus being the two most common locations. Schajowicz et al
reported 88 cases (9), 16 involving the carpal bones, including scaphoid, lunate, triquetrum,
and capitate. Lesions in scaphoid are reported very rarely. The radiographs show a welldefined osteolytic lesion. The pathologic finding is similar to its soft tissue ganglion in all
respects, with a smooth translucent wall composed of compressed collagen fibrins devoid of
synovial lining. This type of cyst contains a highly viscous clear mucin consisiting of high
concentration of hyaluronic acid in combination with glutamine, albumin and glucosamine
Intraosseous ganglion cysts may be most easily confused pathologically with the juxta-articular

cysts of osteoarthritis.(10) The earlier age of occurrence and the absence of other stigmas of osteoarthritis are helpful in differentiating them. Curettage of the cyst and packing with cancellous
bone graft were performed in most reported cases.(4) Various theories have been published about
the origin of the Interosseus ganglion, but the main etiology is still not clear. There are two
types of intraosseous ganglia: one originating by penetration of an extra-osseous ganglion
into the underlying bone, the other one is an idiopathic type.(11)The mechanism for the
penetrating type is the erosion of an extraosseous ganglion through the bone.(12) The
primary or idiopathic type has no apparent extraosseous communication. The idiopathic type
of ganglion cyst appears to originate from modified mesenchymal or synovial cells at the
capsule-synovial interface due to repeated minor injury, which explains high prevalence of
ganglion cyst in the scapho-lunate site where the motion and force is concentrated. The
repeated minor injuries and mechanical stress cause intramedullary vascular disturbance
leading to aseptic bone necrosis. This is followed by proliferation of fibroblasts and
histocytes and production of hyaluronic acid with mucoid degeneration leading to the
formation of the cyst. Mainstay of treatment for the interosseous ganglion is mainly by
curettage of lesion & bone graft (4). We also performed curettage and bone grafting, via volar
approach. Patient was symptom free at three months follow up and radiologically occurrence
of trabeculations within 6 months. Complications due to intraosseous ganglion cyst are
fracture and repeated erosion leading to rupture of tendon mainly flexor tendon of finger. Reoccurrence of cyst can occur after bone graft. Castellanos reported a case of pathological
fracture of the scaphoid due to intraosseous ganglion followed by regression of the cyst after
healing of the fracture (13).Regression of scaphoid ganglion can occur with uneventful
healing of the fracture (14)

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11. Schajowicz F, Clavel Sainz M, Slullitel JA. Juxta-articular bone cysts (intra-osseous
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FIGURES
Fig. 1: Radiograph of lytic lesion in scaphoid

Fig 2. CT of scaphoid showing lesion in scaphoid

Fig 3. Intraoperative photograph of cyst curetted from scaphoid.

Fig 4. Cyst excised enbloc.

Fig 5. Post operative radiograph of scaphoid.