INTRAOSSEOUS GANGLION DIAGNOSIS AND
CYST OF THE LUNATE: MANAGEMENT
S. THAM and D. C. R. IRELAND
From the Alfred Hospital, Monash University,Melbourne, Australia Intraosseous ganglion cyst of the lunate is an uncommon lesion and cause of wrist pain. Histopathologically it is identical to the common dorsal wrist ganglion and treatment by arthrotomy, curettage of the ganglion and bone graft resulted in clinical improvement in nine patients, six of whom became symptom-free. Journal of Hand Surgery (British Volume, 1992) 17B : 429-432 margin within the lunate (Fig. 1). In two patients the lesion was central. Eccentric lesions were noted in the remaining seven, with two adjacent to the luno-triquetral articulation, one occupying the dorsal lunate pole and four adjacent to the scapho-lunate joint. A technetium 99 radionuclide scan showed focal increased uptake within the lunate in eight patients (Fig. 2). The indication for arthrotomy was wrist pain which significantly affected the normal activities and which failed to settle with conservative treatment including splinting and intra-articular corticosteroid injection.
Intraosseous ganglion cysts are an infrequent cause of wrist pain. Isolated cases of intraosseous ganglion of the carpal bones have been reported most commonly in the lunate and scaphoid (Crane and Scarano, 1967; Feldman and Johnston, 1973; Schajowicz et al, 1979; Mogan et al, 1981; Iwahara et al, 1983; Eiken and Jonsson, 1980). The condition presents as chronic wrist pain with radiological lucency evident within the lunate. Radiolucent carpal lesions however may be symptom-free and the differential diagnosis includes osteoarthritic cyst, post-traumatic cyst and simple bone cysts, whereas osteoid osteoma and osteoblastoma present with pain. This study is a review of the clinical presentation, diagnostic investigation and the results of treatment in nine patients with intraosseous ganglion of the lunate.
Material and methods Between 1980 and 1990, nine patients with intraosseous ganglion of the lunate were treated surgically. In the same period two further patients were also diagnosed but their pain to date has not warranted surgery, leaving their diagnoses unconfirmed. This study is confined to the nine surgically confirmed cases. There were two male and seven female patients aged between 21 and 45 years, the average being 28. In seven patients the lesion occurred in the dominant hand. Only two patients recalled a specific traumatic episode to the wrist, involving forced extension. No patients except a chiropractic student were involved in an occupation which required strenuous or repetitive use of the wrist. The average duration of symptoms was 53 months and ranged from two to 120 months. Patients presented with dorsal wrist pain made worse by extension and power grip. This restricted activity to an extent that led them to seek treatment. All patients localized their pain dorsally in the peri-lunate region either directly over the lunate, towards the scapho-lunate articulation or at the lunotriquetral articulation. The wrist was examined for localized tenderness, range of motion and grip strength Using a hand held dynamometer. Scapho-lunate joint stability was assessed using the test described by Watson (Brown and Lichtman, 1984). X-rays revealed a lucent area with a thin sclerotic
Fig. 1 PA radiograph showing an intraosseous ganglion cyst of the lunate as a circumscribedlucent eccentric lesion demarcated by a thin scleroticrim. 429
430
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992
Results
Fig. 2
Technetium 99 bone scan showing an area of increased uptake within the lunate of the right wrist.
Surgicalfindings The wrist joint was opened through an oblique dorsal incision centred over the lunate. In two wrists the ganglion was immediately obvious through a defect on the dorsal surface of the lunate. The other seven lunates were probed through small dorsal drill holes. In all cases typical gelatinous ganglion fluid was extracted from the cavity. In only four cases was there sufficient material for histopathological confirmation of a ganglion membrane, making the presence of ganglion contents at operation diagnostically critical. In five cases the ganglion was located within the lunate with no obvious joint communication. In one it communicated with the scapho-lunate joint and in another with the luno-triquetral joint. In the remaining two of the nine cases the ganglion was attached to an intracapsular scapho-lunate ganglion by a communication through the scapho-lunate joint. There was no evidence at operation of intercarpal degenerative change, scapho-lunate instability or scapho-lunate ligament attenuation. After curettage of the lesion, the cavity was packed with cancellous bone taken from the distal radius. The distal 4 cm of the posterior interosseous nerve was resected to desensitize the operative area of the wrist capsule. The joint capsule and wound were closed in layers. A bulky compression dressing was applied for two weeks followed by a removable extension splint for four weeks. Latterly, owing to the delay in regaining palmar flexion, the splinting was abandoned in favour of active mobilization two weeks post-operatively.
The effect of treatment was evaluated by comparing the ipsilateral pre- and post-operative subjective pain and function, and objective grip strength and range of motion. The contralateral normal side was also used for comparison. After an initial average follow-up of six months with a range from two to 15 months, six patients had obtained an excellent result with no pain and normal function, two a good result with mild discomfort and normal function and one a poor result with no improvement. This patient had an associated intra-capsular scapho-lunate ganglion communicating with the intraosseous lunate ganglion through the scapho-lunate joint. All five patients with the intraosseous ganglion confined to the lunate achieved an excellent result. In four patients whose lesions were either associated with an intracapsular ganglion or with a communication, either to the scapho-lunate or to the . luno-triquetral joint, the results were excellent in one, fair in two and poor in one. Two patients were uncontactable. Subsequent follow-up of the remaining seven patients for the purpose of this article on average 32 months after surgery revealed further marginal improvement in all seven patients with only one patient (the single poor result at initial follow-up) complaining of moderate pain unchanged post-operatively. None of these seven patients had radiographic evidence of recurrent cyst formation at follow-up. There was no relationship between the duration of symptoms and their severity or the clinical outcome. Both patients with a documented traumatic event preceding the onset of symptoms had excellent results. No patient developed wound complications and none have had further wrist surgery. Discussion
Intraosseous ganglion has been reported most commonly in the epiphyses of long bones around the hip, knee and ankle, with the femoral head and the medial malleolus being the two most common locations (Schajowicz et al, 1979). Of the 88 cases they reported, 16 involved the carpal bones, including scaphoid, lunate, triquetrum and capitate. Kambolis et al (1973) reported three cases of intraosseous ganglia involving the carpus including the triquetrum, scaphoid and hamate. Eiken and Jonsson (1980) reported 80 cases of carpal bone cyst with the majority in the scaphoid and lunate, only nine of which were treated surgically. Iwahara et al (1983) in their report of a single case of intraosseous ganglion of the lunate noted six previous reports of this lesion. Pathologically the intraosseous ganglion is identical to its soft tissue counterpart in all respects, with a smooth translucent wall composed of compressed collagen fibres devoid of synovial lining. It contains viscous clear mucous consisting of glucosamine, albumin, globulin and a high concentration of hyaluronic acid (Young et al,
431
G A N G L I O N OF T H E L U N A T E
1988). Johnson et al (1965) identified proliferative cells within the ganglion wall as fibroblasts, and Psaila and Mansel (1978), studying the surface ultra structure of ganglia with a scanning electron microscope, identified occasional fibroblasts and multi-functional mesenchymal cells within the ganglion wall. These cells have the ability to secrete mucin-like substances in tissue culture (Morris and Goodman, 1960). Schajowicz et al (1979) described two types of intraosseous ganglion: the penetrating type which arises from invasion of a juxta-articular ganglion into the underlying cortical bone to become intraosseous, and the idiopathic type which arises de novo in the medullary cavity, without obvious communication with the contiguous joint. Schajowicz's series of 88 cases included only 14 of the penetrating type. The subperiosteal location of ganglia in association with intramedullary lesions (Fisk, 1949) supports the penetrating theory. Extraosseous juxta-cortical ganglia were seen in association in seven of 15 intraosseous ganglia reported by Kambolis et al (1973), but in only four of these seven could a direct communication be demonstrated. Eiken and Jonsson (1980) proposed an intraosseous degenerative process from which the cyst developed by expansion, with increasing pain and radiographic sclerosis, before bursting into the adjacent joint. Using tomography they identified six cases of carpal bone cysts with communication to this contiguous joint. They found no associated
extraosseous ganglia in their series. In contrast, two out of our nine cases connected with the contiguous joints through an obvious bone defect, in one the scapho-lunate joint (Fig. 3) and in the other the luno-triquetral joint. Two ganglia also had an extraosseous component, as an intracapsular ganglion attached to the dorsal scapholunate ligament which was connected via the scapholunate joint to a large intraosseous lunate ganglion.
Fig. 3 PA radiograph of the wrist showing an intraosseous lunate ganglion extruding into the scapho-lunate joint through a lunate corticaldefect.
b
d Fig. 4 (a) Occult intracapsular scapho-lunate ganglion in typical location at superficial dorsal and distal aspect of scapho-lunate ligament. (b) Intra-articular scapho-lunate ganglion extending from the deep surface of dorsal scapho-lunate ligament. (c) Intraosseous lunate ganglion eccentrically located in dorsal pole. Possibly arising from within the dorsal scapho-lunate ligament. (d) Combined occult intracapsular scapho-lunateganglionand intra-articularscapho-lunateganglionarising from superficialand deep aspectsof dorsal scapholunate ligament respectively.(e) Combined intraosseousand intra-articularganglion. (f) Combinedoccult intracapsularand scapho-lunate ganglion, intra-articular scapho-lunateganglionand intraosseouslunate ganglion.
432
Tomography and CT scanning provides details of the spatial orientation of the cyst within the carpal bone, and MRI may also help in delineating the presence of an extraosseous extension of the ganglion (Sullivan and Berquist, 1991). These investigations were not used in this series as the cyst could be easily located by plain PA and lateral radiographs. In retrospect these studies might have been useful in identifying extraosseous communications. The pathogenesis of ganglion cyst remains obscure. Theories include synovial herniation, neoplasia, proliferation of synovial rest cells and traumatic mucoid degeneration of connective tissue (Young, 1988) or within the carpal bone (Schajowicz et al, 1979; Eiken and Jonsson, 1988). Intramedullary metaplasia of mesenchymal precursor cells was proposed by Feldman and Johnston (1973), who suggested that they gave rise to hyaluronic acid-producing fibroblasts and histiocytes to form a ganglion. The trigger for this might be trauma, explaining the high incidence of ganglia in the scapholunate region, where force and motion is concentrated. Just as occult intracapsular scapho-lunate ganglia arise from the superficial aspect of the dorsal scapho-lunate ligament, related to shear stress (Gunther, 1985), so intraosseous lunate ganglia may arise from the deep surface or from within the scapho-lunate ligament before penetrating the lunate (Fig. 4). The surgical findings in this series revealed combinations of intraosseous lunate ganglion with occult intracapsular scapho-lunate ganglion (Fi. 4a), with intra-articular scapho-lunate joint ganglion (Fig. 4b), and with both (Fig. 40.
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992 References BROWN, D. E and LICHTMAN, D. M. (1984). The evaluation of chronic wrist pain. Orthopedic Clinics of North America, 15 : 2: 183-205. CRANE, A. R. and SCARANO, J. J. (1967). Synovial cysts (ganglia) of bone: report of two cases. Journal of Bone and Joint Surgery, 49A: 2: 355-361. EIKEN, O. and JONSSON, K. (1980). Carpal bone cysts: a clinical and radiographic study. Scandinavian Journal of Plastic and Reconstructive Surgery, 14: 285-290. FELDMAN, F. and JOHNSTON, A. (1973). Intraosseous ganglion. American Journal of Rocntgenology, 118: 328-343. FISK, G. R (1949). Bone concavity caused by a ganglion. Journal of Bone and Joint Surgery 31B: 220-221. GUNTHER, S. F. (1985). Dorsal wrist pain and the occult scapholunate ganglion. Journal of Hand Surgery, 10A : 5 : 697-703. IWAHARA, T., HIRAYAMA, T. and TAKEIMITU, Y. (1983). Intraosseous ganglion of the lunate. The Hand, 15: 3: 297-299. JOHNSON, W. C., GRAHAM, J. H. and HELWIG, E. B. (1965). Cutaneous myxoid cyst: A clinicopathological and histochemical study. Journal of the American Medical Association, 191 : 1 : 15-20. KAMBOLIS, C., BULLOUGH, P. G and JAFFE, H. L. (1973). Ganglionic cystic defects of bone. Journal of Bone and Joint Surgery, 55A: 3: 496-505. MOGAN, J. V., NEWBERG, A. H. and DAVIS, P. H. (1981). Intraosseous ganglion of the lunate. The Journal of Hand Surgery, 6: 61~ 3 . MORRIS, C. and GODMAN, G. (1960). Productionof acid mucopolysaccharides by fibroblasts in cell culture. Nature, 1988: 407. PSAILA, J. V. and MANSEL, R. E. (1978). The surface ultrastrncture of ganglia. Journal of Bone and Joint Surgery, 60B: 228-233. SCHAJOWICZ, F., SAINZ, M. C. and SLULLITEL, J. A. (1979). Juxtaarticular bone cysts (Intra-osseous ganglia). Journal of Bone and Joint Surgery, 61B: 107-116. SULLIVAN, P. P. and BERQUIST, T. H. (1991). Magnetic resonance imaging of the hand, wrist, and forearm: utility in patients with pain and dysfunction as a result of trauma. Mayo Clinic Proceedings. 66: 1217-1221. YOUNG, L., BARTELL, T. and LOGAN, S. E. (1988). Ganglions of the hand and wrist. Southern Medical Journal, 81 : 6:751-760.
Accepted: 19 February 1992 Damian C. R. Ireland, Melbourne Hand and Rehabilitation Centre, 316 Malvern Road, Prahran, Victoria, Australia 3181. 9 1992The British Society for Surgeryof the Hand
CYST OF THE LUNATE: MANAGEMENT
S. THAM and D. C. R. IRELAND
From the Alfred Hospital, Monash University,Melbourne, Australia Intraosseous ganglion cyst of the lunate is an uncommon lesion and cause of wrist pain. Histopathologically it is identical to the common dorsal wrist ganglion and treatment by arthrotomy, curettage of the ganglion and bone graft resulted in clinical improvement in nine patients, six of whom became symptom-free. Journal of Hand Surgery (British Volume, 1992) 17B : 429-432 margin within the lunate (Fig. 1). In two patients the lesion was central. Eccentric lesions were noted in the remaining seven, with two adjacent to the luno-triquetral articulation, one occupying the dorsal lunate pole and four adjacent to the scapho-lunate joint. A technetium 99 radionuclide scan showed focal increased uptake within the lunate in eight patients (Fig. 2). The indication for arthrotomy was wrist pain which significantly affected the normal activities and which failed to settle with conservative treatment including splinting and intra-articular corticosteroid injection.
Intraosseous ganglion cysts are an infrequent cause of wrist pain. Isolated cases of intraosseous ganglion of the carpal bones have been reported most commonly in the lunate and scaphoid (Crane and Scarano, 1967; Feldman and Johnston, 1973; Schajowicz et al, 1979; Mogan et al, 1981; Iwahara et al, 1983; Eiken and Jonsson, 1980). The condition presents as chronic wrist pain with radiological lucency evident within the lunate. Radiolucent carpal lesions however may be symptom-free and the differential diagnosis includes osteoarthritic cyst, post-traumatic cyst and simple bone cysts, whereas osteoid osteoma and osteoblastoma present with pain. This study is a review of the clinical presentation, diagnostic investigation and the results of treatment in nine patients with intraosseous ganglion of the lunate.
Material and methods Between 1980 and 1990, nine patients with intraosseous ganglion of the lunate were treated surgically. In the same period two further patients were also diagnosed but their pain to date has not warranted surgery, leaving their diagnoses unconfirmed. This study is confined to the nine surgically confirmed cases. There were two male and seven female patients aged between 21 and 45 years, the average being 28. In seven patients the lesion occurred in the dominant hand. Only two patients recalled a specific traumatic episode to the wrist, involving forced extension. No patients except a chiropractic student were involved in an occupation which required strenuous or repetitive use of the wrist. The average duration of symptoms was 53 months and ranged from two to 120 months. Patients presented with dorsal wrist pain made worse by extension and power grip. This restricted activity to an extent that led them to seek treatment. All patients localized their pain dorsally in the peri-lunate region either directly over the lunate, towards the scapho-lunate articulation or at the lunotriquetral articulation. The wrist was examined for localized tenderness, range of motion and grip strength Using a hand held dynamometer. Scapho-lunate joint stability was assessed using the test described by Watson (Brown and Lichtman, 1984). X-rays revealed a lucent area with a thin sclerotic
Fig. 1 PA radiograph showing an intraosseous ganglion cyst of the lunate as a circumscribedlucent eccentric lesion demarcated by a thin scleroticrim. 429
430
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992
Results
Fig. 2
Technetium 99 bone scan showing an area of increased uptake within the lunate of the right wrist.
Surgicalfindings The wrist joint was opened through an oblique dorsal incision centred over the lunate. In two wrists the ganglion was immediately obvious through a defect on the dorsal surface of the lunate. The other seven lunates were probed through small dorsal drill holes. In all cases typical gelatinous ganglion fluid was extracted from the cavity. In only four cases was there sufficient material for histopathological confirmation of a ganglion membrane, making the presence of ganglion contents at operation diagnostically critical. In five cases the ganglion was located within the lunate with no obvious joint communication. In one it communicated with the scapho-lunate joint and in another with the luno-triquetral joint. In the remaining two of the nine cases the ganglion was attached to an intracapsular scapho-lunate ganglion by a communication through the scapho-lunate joint. There was no evidence at operation of intercarpal degenerative change, scapho-lunate instability or scapho-lunate ligament attenuation. After curettage of the lesion, the cavity was packed with cancellous bone taken from the distal radius. The distal 4 cm of the posterior interosseous nerve was resected to desensitize the operative area of the wrist capsule. The joint capsule and wound were closed in layers. A bulky compression dressing was applied for two weeks followed by a removable extension splint for four weeks. Latterly, owing to the delay in regaining palmar flexion, the splinting was abandoned in favour of active mobilization two weeks post-operatively.
The effect of treatment was evaluated by comparing the ipsilateral pre- and post-operative subjective pain and function, and objective grip strength and range of motion. The contralateral normal side was also used for comparison. After an initial average follow-up of six months with a range from two to 15 months, six patients had obtained an excellent result with no pain and normal function, two a good result with mild discomfort and normal function and one a poor result with no improvement. This patient had an associated intra-capsular scapho-lunate ganglion communicating with the intraosseous lunate ganglion through the scapho-lunate joint. All five patients with the intraosseous ganglion confined to the lunate achieved an excellent result. In four patients whose lesions were either associated with an intracapsular ganglion or with a communication, either to the scapho-lunate or to the . luno-triquetral joint, the results were excellent in one, fair in two and poor in one. Two patients were uncontactable. Subsequent follow-up of the remaining seven patients for the purpose of this article on average 32 months after surgery revealed further marginal improvement in all seven patients with only one patient (the single poor result at initial follow-up) complaining of moderate pain unchanged post-operatively. None of these seven patients had radiographic evidence of recurrent cyst formation at follow-up. There was no relationship between the duration of symptoms and their severity or the clinical outcome. Both patients with a documented traumatic event preceding the onset of symptoms had excellent results. No patient developed wound complications and none have had further wrist surgery. Discussion
Intraosseous ganglion has been reported most commonly in the epiphyses of long bones around the hip, knee and ankle, with the femoral head and the medial malleolus being the two most common locations (Schajowicz et al, 1979). Of the 88 cases they reported, 16 involved the carpal bones, including scaphoid, lunate, triquetrum and capitate. Kambolis et al (1973) reported three cases of intraosseous ganglia involving the carpus including the triquetrum, scaphoid and hamate. Eiken and Jonsson (1980) reported 80 cases of carpal bone cyst with the majority in the scaphoid and lunate, only nine of which were treated surgically. Iwahara et al (1983) in their report of a single case of intraosseous ganglion of the lunate noted six previous reports of this lesion. Pathologically the intraosseous ganglion is identical to its soft tissue counterpart in all respects, with a smooth translucent wall composed of compressed collagen fibres devoid of synovial lining. It contains viscous clear mucous consisting of glucosamine, albumin, globulin and a high concentration of hyaluronic acid (Young et al,
431
G A N G L I O N OF T H E L U N A T E
1988). Johnson et al (1965) identified proliferative cells within the ganglion wall as fibroblasts, and Psaila and Mansel (1978), studying the surface ultra structure of ganglia with a scanning electron microscope, identified occasional fibroblasts and multi-functional mesenchymal cells within the ganglion wall. These cells have the ability to secrete mucin-like substances in tissue culture (Morris and Goodman, 1960). Schajowicz et al (1979) described two types of intraosseous ganglion: the penetrating type which arises from invasion of a juxta-articular ganglion into the underlying cortical bone to become intraosseous, and the idiopathic type which arises de novo in the medullary cavity, without obvious communication with the contiguous joint. Schajowicz's series of 88 cases included only 14 of the penetrating type. The subperiosteal location of ganglia in association with intramedullary lesions (Fisk, 1949) supports the penetrating theory. Extraosseous juxta-cortical ganglia were seen in association in seven of 15 intraosseous ganglia reported by Kambolis et al (1973), but in only four of these seven could a direct communication be demonstrated. Eiken and Jonsson (1980) proposed an intraosseous degenerative process from which the cyst developed by expansion, with increasing pain and radiographic sclerosis, before bursting into the adjacent joint. Using tomography they identified six cases of carpal bone cysts with communication to this contiguous joint. They found no associated
extraosseous ganglia in their series. In contrast, two out of our nine cases connected with the contiguous joints through an obvious bone defect, in one the scapho-lunate joint (Fig. 3) and in the other the luno-triquetral joint. Two ganglia also had an extraosseous component, as an intracapsular ganglion attached to the dorsal scapholunate ligament which was connected via the scapholunate joint to a large intraosseous lunate ganglion.
Fig. 3 PA radiograph of the wrist showing an intraosseous lunate ganglion extruding into the scapho-lunate joint through a lunate corticaldefect.
b
d Fig. 4 (a) Occult intracapsular scapho-lunate ganglion in typical location at superficial dorsal and distal aspect of scapho-lunate ligament. (b) Intra-articular scapho-lunate ganglion extending from the deep surface of dorsal scapho-lunate ligament. (c) Intraosseous lunate ganglion eccentrically located in dorsal pole. Possibly arising from within the dorsal scapho-lunate ligament. (d) Combined occult intracapsular scapho-lunateganglionand intra-articularscapho-lunateganglionarising from superficialand deep aspectsof dorsal scapholunate ligament respectively.(e) Combined intraosseousand intra-articularganglion. (f) Combinedoccult intracapsularand scapho-lunate ganglion, intra-articular scapho-lunateganglionand intraosseouslunate ganglion.
432
Tomography and CT scanning provides details of the spatial orientation of the cyst within the carpal bone, and MRI may also help in delineating the presence of an extraosseous extension of the ganglion (Sullivan and Berquist, 1991). These investigations were not used in this series as the cyst could be easily located by plain PA and lateral radiographs. In retrospect these studies might have been useful in identifying extraosseous communications. The pathogenesis of ganglion cyst remains obscure. Theories include synovial herniation, neoplasia, proliferation of synovial rest cells and traumatic mucoid degeneration of connective tissue (Young, 1988) or within the carpal bone (Schajowicz et al, 1979; Eiken and Jonsson, 1988). Intramedullary metaplasia of mesenchymal precursor cells was proposed by Feldman and Johnston (1973), who suggested that they gave rise to hyaluronic acid-producing fibroblasts and histiocytes to form a ganglion. The trigger for this might be trauma, explaining the high incidence of ganglia in the scapholunate region, where force and motion is concentrated. Just as occult intracapsular scapho-lunate ganglia arise from the superficial aspect of the dorsal scapho-lunate ligament, related to shear stress (Gunther, 1985), so intraosseous lunate ganglia may arise from the deep surface or from within the scapho-lunate ligament before penetrating the lunate (Fig. 4). The surgical findings in this series revealed combinations of intraosseous lunate ganglion with occult intracapsular scapho-lunate ganglion (Fi. 4a), with intra-articular scapho-lunate joint ganglion (Fig. 4b), and with both (Fig. 40.
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992 References BROWN, D. E and LICHTMAN, D. M. (1984). The evaluation of chronic wrist pain. Orthopedic Clinics of North America, 15 : 2: 183-205. CRANE, A. R. and SCARANO, J. J. (1967). Synovial cysts (ganglia) of bone: report of two cases. Journal of Bone and Joint Surgery, 49A: 2: 355-361. EIKEN, O. and JONSSON, K. (1980). Carpal bone cysts: a clinical and radiographic study. Scandinavian Journal of Plastic and Reconstructive Surgery, 14: 285-290. FELDMAN, F. and JOHNSTON, A. (1973). Intraosseous ganglion. American Journal of Rocntgenology, 118: 328-343. FISK, G. R (1949). Bone concavity caused by a ganglion. Journal of Bone and Joint Surgery 31B: 220-221. GUNTHER, S. F. (1985). Dorsal wrist pain and the occult scapholunate ganglion. Journal of Hand Surgery, 10A : 5 : 697-703. IWAHARA, T., HIRAYAMA, T. and TAKEIMITU, Y. (1983). Intraosseous ganglion of the lunate. The Hand, 15: 3: 297-299. JOHNSON, W. C., GRAHAM, J. H. and HELWIG, E. B. (1965). Cutaneous myxoid cyst: A clinicopathological and histochemical study. Journal of the American Medical Association, 191 : 1 : 15-20. KAMBOLIS, C., BULLOUGH, P. G and JAFFE, H. L. (1973). Ganglionic cystic defects of bone. Journal of Bone and Joint Surgery, 55A: 3: 496-505. MOGAN, J. V., NEWBERG, A. H. and DAVIS, P. H. (1981). Intraosseous ganglion of the lunate. The Journal of Hand Surgery, 6: 61~ 3 . MORRIS, C. and GODMAN, G. (1960). Productionof acid mucopolysaccharides by fibroblasts in cell culture. Nature, 1988: 407. PSAILA, J. V. and MANSEL, R. E. (1978). The surface ultrastrncture of ganglia. Journal of Bone and Joint Surgery, 60B: 228-233. SCHAJOWICZ, F., SAINZ, M. C. and SLULLITEL, J. A. (1979). Juxtaarticular bone cysts (Intra-osseous ganglia). Journal of Bone and Joint Surgery, 61B: 107-116. SULLIVAN, P. P. and BERQUIST, T. H. (1991). Magnetic resonance imaging of the hand, wrist, and forearm: utility in patients with pain and dysfunction as a result of trauma. Mayo Clinic Proceedings. 66: 1217-1221. YOUNG, L., BARTELL, T. and LOGAN, S. E. (1988). Ganglions of the hand and wrist. Southern Medical Journal, 81 : 6:751-760.
Accepted: 19 February 1992 Damian C. R. Ireland, Melbourne Hand and Rehabilitation Centre, 316 Malvern Road, Prahran, Victoria, Australia 3181. 9 1992The British Society for Surgeryof the Hand
