DEPARTMENT OF ORTHOPAEDICS

KASTURBA MEDICAL COLLEGE MANGALORE

Moderators:

Presented by: -

Dr.Surendra U Kamath

Dr.Praveen Patil

Dr Harshvardhan

Date: 29/01/2008

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.
Etiology
In most cases it is caused by infection with the tubercle bacillus. Sometimes other
organisms are responsible. A similar condition may complicate rheumatoid arthritis
without demonstrable bacterial infection.
Pathology
Commonly flexor tendon sheaths in the lower foreman & hand are affected.
Extensor sheath are less commonly involved. The walls of the tendon sheath may
be thin & almost translucent or thick and fibrotic.
The affected sheaths are greatly thickened & show the changes of chronic
inflammation.
The lining membrane is replaced by tubercular granulation tissue.
The swelling may contain serous fluid, masses of fibrinous material, melon seed
bodies or caseous material.Melon-seed bodies resemble grains of boiled sago.
They are composed of collection of fibrin ,cellular debris, and occasional tubercle
bacilli.
The 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 The bursa becomes distended with clear fluid containing melon-seed
bodies & its lining membrane is thickened & granular.
In dry type The lining membrane becomes replaced by tubercular granulation tissue
which proliferates to encompass & invade the tendons.

Clinical features
Is a hour glass swelling
Gradual onset of swelling with mild aching pain, in the region of the affected
tendon sheaths.
The 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.
At first range of movements of the fingers & thumb is impaired slightly.
Later there is moderate restriction of flexion & extension of digits, with
corresponding loss of functions.
Diagnosis
Persistent swelling of gradual onset in the line of tendon sheaths in the lower
forearm & hand always suggests chronic tenosynovitis. Fluctuation 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.
Complications
The adjacent bones, joint or tendons may get involved, with obvious wasting of
adjacent muscles.
Rupture of tendons especially sublimes.
Discharging sinuses & involvement of radial & ulnar busae.
Median nerve compression in the carpal tunnel.
Treatment
It depends on the severity of the lesions.
Conservative
Operative
Conservative
In mild cases where the function of fingers & thumb is not impaired,
conservative treatment is advised.
Immobilization 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.
Operative
-

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

synovium is carried out, the affected part of the hand is immobilized, during the
period of wound healing.

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

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

Brunners Zig-Zag approach provides excellent visualization 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 adjacent tendon with intact
motor.

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

REFERENCES:
1. Outline of Orthopaedics, 7th Ed, John Crawford, Adams.
2. Surgery of hand, J.B.Lippincott, 4th Ed 1964.
3. Baily & Loves Short practice of surgery, 16th edition.
4. The Infected Hand, David & Bailey 1963 1st Ed.
5. Tuberculosis in the wrist and hand, Robert. H.C.Robins.
6. JBJS, Feburary 1957, vol 39B,91-101.
7. Green s Operative Hand Surgery, 4th Ed ,1073-1078, 1661-1669,2022-2025