Age / Sex : 15 / F

Chief complaint: Lt. wrist pain for 2 weeks

What is your impression? 

Two weeks later, you can see the final diagnosis with a brief discussion of this case. (Please submit only one answer)

Periosteal ganglion

Discussion

Answer: Periosteal
ganglion

Findings:

X-ray

-
juxtacortical mass at medial side of distal radius metaphysis

- cortical
saucerization with linear periosteal reaction perpendicular to the cortex

- no
marginal buttress-type periosteal reaction

- no chondroid
mineralization

MRI

- lobulating
subperiosteal mass involving medial half of distal radius

-
multiseptated appearance with fluid-like T2 hyperintensity

- thin
peripheral and septal enhancement

- cortical
saucerization without intramedullary extension

-
extraperiosteal fluid-like signal adjacent to distal radioulnar joint

Differential Diagnosis:

1. Periosteal
ganglion

2. Periosteal
chondroma

Diagnosis:
Periosteal ganglion

Discussion:

The
radiographic features of periosteal ganglion cysts include a scalloped cortical
defect with a sclerotic margin, and reactive formation of periosteal new bone. The
periosteal spicules may be orientated perpendicular to the cortex of the
underlying bone. They appear thick and well-defined, and bridges of ossification
may be evident between spicules, indicative of a slowly growing lesion. The
endosteal surface of the cortex is intact. The differential diagnosis includes
a periosteal chondroma, subperiosteal hematoma, subperiosteal abscess and
parosteal lipoma.

On
MR images ganglion cysts demonstrate low signal intensity on T1- and high
signal intensity on T2-weighted images. After intravenous administration of
contrast agent, the periosteal ganglion cyst typically enhances only at the
periphery and along the septa.

There
is no agreement regarding the ideal management of periosteal ganglion cysts.
Reported treatments include excision, puncture and aspiration, with or without
injection of corticosteroids. When a communication between the ganglion cyst
and the adjacent joint is present there may be a recurrence after excision if
this communication is left in place.

References:

1.    
Valls R,
Melloni P, Darnell A, Muñoz J, Canalies J. Diagnostic imaging of tibial
periosteal ganglion. Eur Radiol 1997;7:70-72

2.    
Benedett
GE1, Parsons TW, Smith DK. A periosteal ganglion of the distal part of the
radius, A case report. J Bone Joint Surg Am 1996;78:1415-1418

3.    
De Maeseneer
M1, De Boeck H, Shahabpour M, Hoorens A, Oosterlinck D, Van Tiggelen R.
Subperiosteal ganglion cyst of the tibia. A communication with the knee
demonstrated by delayed arthrography. J Bone Joint Surg Br 1999;81:643-646

4.    
Hutchinson
DT, Green RK Jr, Rohr LR. Subperiosteal ganglion of the distal radius: a case
report. J Hand Surg Am. 2000;25:571-576