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CASE REPORT
Year : 2015  |  Volume : 15  |  Issue : 3  |  Page : 288-290

Tubercular compound palmar ganglion causing carpal tunnel syndrome


Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu and Kashmir, India

Date of Web Publication2-Sep-2015

Correspondence Address:
Khurshid Ahmad Bhat
Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu and Kashmir
India
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DOI: 10.4103/1319-6308.164318

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  Abstract 

Compound palmar ganglion of tubercular origin with carpal tunnel syndrome is an uncommon condition. The aim of this study is to make awareness among practitioners so that the condition can be diagnosed and treated at an early stage before it spreads and destroy the surrounding structures. We present a 50-old-female with a painless swelling of the right wrist and palm of 1-year duration. Furthermore, the patient had a history of paresthesias and numbness of median nerve distribution. Local examination revealed a fluctuating, dumbbell-shaped swelling of the right wrist and palm with numbness of radial three and a half fingers. All the radiographic and laboratory tests were within the normal limits. Patient was treated with thorough debridement and decompression of carpal tunnel along with anti-tubercular therapy. Although rare, tubercular tenosynovitis with carpal tunnel syndrome must be kept in mind as a differential diagnosis of chronic tenosynovitis especially in the developing countries.

  Abstract in Arabic 

العُقد العضبية المركبة درنية المنشأ مع متلازمة النفق الرسغي
تعدّ العقد العصبية المركبة درنية المنشأ مع متلازمة النفق الرسغي حالة نادرة . الهدف من هذه الدراسة رفع الوعي لدى ممارسي مهنة الطب بهذه الحالة لتشخيصها وعلاجها في مراحل مبكرة قبل أن تنتشر وتدمر الأعضاء المحيطة بها. قدمت سيدة تبلغ من العمر 50 عاما بورم غير مؤلم في اليد والكف الأيمن بدأ منذ عام, و قد شكت المريضة من خدر في القصب الأوسط و تفرعاته. أظهر الكشف الموضعي وجود ورم متحرّك بالكف الأيمن وراحة اليد مع خدر في العصب العكبري لثلاث أصابع. جميع الفحوصات المعملية والأشعة كانت معدلاتها في الحدود الطبيعية. عولجت المريضة عن طريق إزالة الأنسجة والضغط من النفق الرسغي ما استخدام العقاقير المضادة للدرن.

Keywords: Carpal tunnel syndrome, compound palmar ganglion, tubercular tenosynovitis


How to cite this article:
Bhat KA, Gani MH, Singh O, Khan Ad. Tubercular compound palmar ganglion causing carpal tunnel syndrome. Saudi J Sports Med 2015;15:288-90

How to cite this URL:
Bhat KA, Gani MH, Singh O, Khan Ad. Tubercular compound palmar ganglion causing carpal tunnel syndrome. Saudi J Sports Med [serial online] 2015 [cited 2019 Nov 20];15:288-90. Available from: http://www.sjosm.org/text.asp?2015/15/3/288/164318


  Introduction Top


Chronic tenosynovitis of flexor tendons of the wrist or compound palmar ganglion is due to the tubercular infection of the tenosynovium. It is more common in males involving the dominant hand. [1] Although rare, it should be kept as a possibility in cases of chronic tenosynovitis in developing countries. Once infected, it can lead to the carpal tunnel syndrome due to the median nerve compression, [2] however, early surgical debridement can prevent the destruction of the surrounding bones.


  Case Report Top


A 50-year-old female housewife came to our OPD with chief complaints of a 9 months old painless and fluctuating swelling on the volar aspect of the right wrist and palm [Figure 1]. She also had a history of feeling numbness of radial three and a half fingers of right hand. As such there was no history of pulmonary tuberculosis (TB), any trauma or contact with TB patients. Also, the patient had no constitutional symptoms. On local examination, there was a dumbbell shaped swelling of around 7 cm × 2.5 cm over the volar aspect of the wrist and palm. Skin overlying the swelling was normal, and the cross fluctuation test was positive. There was a numbness of radial three and a half fingers of right hand. Wrist and chest radiographs were normal. Laboratory tests including erythrocyte sedimentation rate were within the normal limits.
Figure 1: Swelling of right wrist and palm

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Patient was taken for surgical excision through a carpal tunnel incision under regional axillary block [Figure 2]. After releasing the flexor retinaculum, a single encapsulated mass was seen extending from the wrist to mid palm [Figure 3]. Multiple rice bodies or melon seeds were seen after opening the capsule of the swelling [Figure 4]. Thorough debridement, tenosynovectomy and decompression of the carpal tunnel was done. Primary wound closure was done, and compression bandage applied. Patient was followed up at regular intervals and was put on anti-tubercular treatment for 9 months. At 18 weeks patient was symptomless with full ROM. At 1-year follow-up there were no further complaints or recurrences of the disease.
Figure 2: Carpal tunnel incision

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Figure 3: Encapsulated swelling extending from wrist to palm

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Figure 4: Multiple rice bodies

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  Discussion Top


There have been many studies on TB of upper extremity like wrist osteoarthritis, metacarpal/phalangeal TB and tenosynovitis. However, compound palmar ganglion with carpal tunnel syndrome is very rare. Mode of transmission may be direct or hematogenous spread from a primary focus in the body like lungs, gastrointestinal tract, lymph nodes, etc., TB tenosynovitis of wrist flexor tendons commonly involves the dominant hand. [3] Diagnosis of this disease is often delayed due to its slow progression and minimal symptoms. [3] Although rice bodies in chronic tenosynovitis is highly suggestive of TB, [4],[5] these can also be seen in many conditions, like SLE, rheumatoid arthritis, gouty arthritis, pigmented villonodular synovitis of tendon sheath, fungal infection, etc. [3],[6],[7],[8] TB compound ganglion should be treated with thorough debridement and decompression of carpal tunnel along with the anti-tubercular medications to prevent the complications and recurrences.


  Conclusion Top


Although rare, TB should be kept in mind while evaluating the compound palmar ganglion especially in developing countries like India. Early diagnosis and proper treatment can prevent the complications and recurrences of the disease.

 
  References Top

1.
Higuchi S, Ishihara S, Kobayashi H, Arai T. A mass lesion of the wrist: A rare manifestation of tuberculosis. Intern Med 2008;47:313-6.  Back to cited text no. 1
    
2.
Saleem S, Dab RH, Farooq T, Hameed S. Compound palmar ganglion with carpal tunnel syndrome. J Coll Physicians Surg Pak 2007;17:230-1.  Back to cited text no. 2
    
3.
Shen PH, Chu CM, Huang GS, Wu SS, Lee CH. Tuberculous tenosynovitis of the flexor tendons of the wrist and hand. J Med Sci 2002;22:227-30.  Back to cited text no. 3
    
4.
Woon CY, Phoon ES, Lee JY, Puhaindran ME, Peng YP, Teoh LC. Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist. Ann Plast Surg 2011;66:610-7.  Back to cited text no. 4
    
5.
Ergun T, Lakadamyali H, Aydin O. Multiple rice body formation accompanying the chronic nonspecific tenosynovitis of flexor tendons of the wrist. Radiat Med 2008;26:545-8.  Back to cited text no. 5
    
6.
Cuomo A, Pirpiris M, Otsuka NY. Case report: Biceps tenosynovial rice bodies. J Pediatr Orthop B 2006;15:423-5.  Back to cited text no. 6
    
7.
Lall H, Nag SK, Jain VK, Khare R, Mittal D. Tuberculous extensor tenosynovitis of the wrist with extensor pollicis longus rupture: A case report. J Med Case Rep 2009;3:142.  Back to cited text no. 7
    
8.
Tyllianakis M, Kasimatis G, Athanaselis S, Melachrinou M. Rice-body formation and tenosynovitis of the wrist: A case report. J Orthop Surg (Hong Kong) 2006;14:208-11.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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