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Musculoskeletal » Upper Extremity
Ganglion cyst in flexor Digitorum Longus tendon
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Presentation A 7-month-old male baby presented with a hard mass in the left hand just proximal and ventral to the left 2nd metacarpo-phalangeal joint. An ultrasound was performed.
Caption: Transverse view of the ventral aspect of the hand over 2nd MCJ
Description: An oval anechoic lesion demonstrating good posterior enhancement is seen ventral to the second phalanx, at the site of the palpable swelling. The lesion is completely anechoic and shows no debris or soft tissue nodules.
Caption: Sagittal image of the palpable swelling
Description: The anechoic lesion is seen here again overlying the ventral aspect of the second phalanx.
Caption: Color Doppler scan of the lesion
Description: The lesion displays no vascularity, and given the other typical ultrasound features, it is consistent with the diagnosis of a simple cystic mass.
Caption: Transverse image of the ventral hand
Description: This image demonstrates the metacarpals, which are numbered. The cystic lesion in concern is clearly seen overlying the second metacarpal.
Differential Diagnosis Ganglion cyst, lymphangioma, malignancy [less likely]
Final Diagnosis A presumptive diagnosis of ganglion cyst in the flexor digitorum longus tendon was made and was supported by MRI.

Ganglion cysts, foreign bodies and vascular malformations are some of the most common causes of a palpable mass in the pediatric hand. There are other rare tumors such as digital fibromas, which are unique to the pediatric population. Malignant tumors in the hands of children are very rare.

Volar ganglia are more common in the hands of children less than 10 years old. A high recurrence rate (36%) following surgery was observed, putting in question the value of surgery. Thus, many are treated conservatively.

In the series by Wang et al the average age of the patient at the time of diagnosis in their series was 38 months (range, 2 months to 9 years 3 months). Cysts had been present for an average of 3.3 months (range, 1-12 months) before medical advice was sought. None of the cysts were painful. Follow-up averaged 33 months (range, 9-112 months), with 79% of all cysts spontaneously resolving, the majority within a year. These findings suggest that a child presenting with a benign hand lesion characteristic of a ganglion cyst should initially be treated by observation.

Case References 1. Satku K, Ganesh B. Ganglia in children. J Pediatr Orthop. 1985 Jan-Feb; 5(1):13-5
2. Colon F, Upton J. Pediatric hand tumors. A review of 349 cases. Hand Clin. 1995 May; 11(2):223-43.
3. Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg [Am]. 2001 Jul; 26(4):599-602.
Follow Up This mass is being followed on ultrasound and till date shows no changes.
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