Ganglia and nodules
- Filip De Keyser, MD, PhD
Filip De Keyser, MD, PhD
- Professor of Rheumatology
- Ghent University
Soft tissue masses are usually benign and of little clinical consequence. However, benign lesions such as ganglia and nodules may interfere with joint function and, therefore, require treatment. The differential diagnosis of nodular soft tissue masses is extensive and includes a number of systemic diseases and solid tumors  (table 1A-B).
A ganglion is a cystic swelling overlying a joint or tendon sheath. Ganglia are thought to arise due to herniation of synovial tissue from a joint capsule or tendon sheath. They represent myxoid degeneration and may be of congenital origin. The role, if any, of repetitive movement in causation is uncertain; it may induce enlargement of the lesion and may provoke symptoms.
Common locations for ganglia include the wrist and tissue adjacent to finger joints (picture 1). They also occur over the dorsum of the foot and, less often, may arise in the knee, in the shoulder, in the spine, or in other intraarticular, extraarticular soft tissue, intraosseous, or periosteal locations [2,3]. The lesions may be unilocular or multilocular. A jelly-like fluid can be aspirated from the lesion.
Ganglia may present as an obvious swelling on physical examination or may only be manifested by joint (particularly wrist) pain. Most wrist ganglia originate from the palmar capsule near the radioscaphocapitate ligament and are not caused by ligamentous disruption, soft tissue edema, or intraosseous communication .
The diagnostic approach depends upon the physical examination:
- Handa R, Verma K, D'Souza P. Cutaneous nodules in a patient with polyarthritis. Postgrad Med J 1999; 75:111.
- Steiner E, Steinbach LS, Schnarkowski P, et al. Ganglia and cysts around joints. Radiol Clin North Am 1996; 34:395.
- McCarthy CL, McNally EG. The MRI appearance of cystic lesions around the knee. Skeletal Radiol 2004; 33:187.
- Lowden CM, Attiah M, Garvin G, et al. The prevalence of wrist ganglia in an asymptomatic population: magnetic resonance evaluation. J Hand Surg Br 2005; 30:302.
- Teefey SA, Dahiya N, Middleton WD, et al. Ganglia of the hand and wrist: a sonographic analysis. AJR Am J Roentgenol 2008; 191:716.
- Vo P, Wright T, Hayden F, et al. Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion. J Hand Surg Am 1995; 20:667.
- Robertson PL, Page PJ, McColl GJ. Inflammatory arthritis-like and other MR findings in wrists of asymptomatic subjects. Skeletal Radiol 2006; 35:754.
- Backhaus M, Schmidt WA, Mellerowicz H, et al. [Technique and diagnostic value of musculoskeletal ultrasonography in rheumatology. Part 6: ultrasonography of the wrist/hand]. Z Rheumatol 2002; 61:674.
- Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd, Williams & Wilkins, Baltimore 1996.
- Stephen AB, Lyons AR, Davis TR. A prospective study of two conservative treatments for ganglia of the wrist. J Hand Surg Br 1999; 24:104.
- Otu AA. Wrist and hand ganglion treatment with hyaluronidase injection and fine needle aspiration: a tropical African perspective. J R Coll Surg Edinb 1992; 37:405.
- Kang L, Akelman E, Weiss AP. Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg Am 2008; 33:471.
- Kim SK, Kim HJ, Lee YH, et al. Erosive arthropathy with osteolysis as a typical feature in polyfibromatosis syndrome: a case report and a review of the literature. J Korean Med Sci 2009; 24:326.
- Elhadd TA, Ghosh S, Malik MI, Collier A. Plantar fibromatosis and Dupuytren's disease: an association to remember in patients with diabetes. Diabet Med 2007; 24:1305.
- Strzelczyk A, Vogt H, Hamer HM, Krämer G. Continuous phenobarbital treatment leads to recurrent plantar fibromatosis. Epilepsia 2008; 49:1965.
- Fetsch JF, Laskin WB, Miettinen M. Palmar-plantar fibromatosis in children and preadolescents: a clinicopathologic study of 56 cases with newly recognized demographics and extended follow-up information. Am J Surg Pathol 2005; 29:1095.
- Pentland AP, Anderson TF. Plantar fibromatosis responds to intralesional steroids. J Am Acad Dermatol 1985; 12:212.
- Ehrlich GE. Painter's bosses. Arch Intern Med 1965; 116:776.
- Hönig JF, Brink U, Korabiowska M. Severe granulomatous allergic tissue reaction after hyaluronic acid injection in the treatment of facial lines and its surgical correction. J Craniofac Surg 2003; 14:197.
- Funt SA, Hidalgo A, Panicek DM. Subcutaneous nodules at the injection site of low-molecular-weight heparin: a mimic of metastatic disease at CT. J Comput Assist Tomogr 2002; 26:520.
- Fogel GR, Younge DA, Dobyns JH. Pitfalls in the diagnosis of the simple wrist ganglion. Orthopedics 1983; 6:990.
- Campen RB, Sang CN, Duncan LM. Case records of the Massachusetts General Hospital. Case 25-2006. A 41-year-old woman with painful subcutaneous nodules. N Engl J Med 2006; 355:714.
- BALDWIN JS, KERR JM, KUTTNER AG, DOYLE EF. Observations on rheumatic nodules over a 30-year period. J Pediatr 1960; 56:465.
- Pottage JC Jr, Trenholme GM, Aronson IK, Harris AA. Panniculitis associated with histoplasmosis and alpha 1-antitrypsin deficiency. Am J Med 1983; 75:150.
- Fernandes SS, Carvalho J, Leite S, et al. Erythema induratum and chronic hepatitis C infection. J Clin Virol 2009; 44:333.
- Jhaveri K, Halperin P, Shin SJ, Vahdat L. Erythema nodosum secondary to aromatase inhibitor use in breast cancer patients: case reports and review of the literature. Breast Cancer Res Treat 2007; 106:315.
- Soon SL, Crawford RI. Recurrent erythema nodosum associated with Echinacea herbal therapy. J Am Acad Dermatol 2001; 44:298.
- Heller M, Soldano AC. Sarcoidosis with subcutaneous lesions. Dermatol Online J 2008; 14:1.
- Demirkesen C, Tüzüner N, Mat C, et al. Clinicopathologic evaluation of nodular cutaneous lesions of Behçet syndrome. Am J Clin Pathol 2001; 116:341.
- Karanjia ND, Stiles PJ. Cubital bursitis. J Bone Joint Surg Br 1988; 70:832.
- Ehrlich GE. Antecubital cysts in rheumatoid arthritis--a corollary to popliteal (Baker's) cysts. J Bone Joint Surg Am 1972; 54:165.
- Harrington AC, Mellette JR Jr. Hernias of the anterior tibialis muscle: case report and review of the literature. J Am Acad Dermatol 1990; 22:123.
- Fibroblastic rheumatism
- Nodules associated with repetitive trauma
- Silicone and other injectables
- Epidermoid cysts
- AIDS-related Kaposi sarcoma
- Sweet syndrome
- Rheumatoid nodules
- Rheumatic fever nodules
- Pseudorheumatoid nodules
- Atypical infections
- Other conditions
- APPROACH TO THE PATIENT WITH A NODULAR LESION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS