Murat KAYALAR, Aziz VATANSEVER, Emin BAL, Tulgar TOROS, Kemal ÖZAKSAR, Sait ADA

Okült gangliyon tanısında parmak ekstansiyon testinin önemi

Amaç: Dorsal el bileği ağrısı nedenlerinden biri olan okült dorsal el bileği gangliyonunda tanı araçlarının kesinlik değeri cerrahi tedavi sonuçlarıyla karşılaştırmalı olarak incelendi. Çalışma planı: Çalışmaya okült gangliyon öntanısıyla cerrahi tedavi uygulanan 25 hasta (4 erkek, 21 kadın; ort. yaş 29; dağılım 16-46) alındı. Yakınma süresi ortalama 29 ay (dağılım 3 ay-10 yıl) olan hastalarda daha önce konservatif tedavi denenmişti. Tanı için 24 hastada parmak ekstansiyon testi kullanıldı. Altı hastada ultrasonografik incelemeye, 13 hastada manyetik rezonans görüntülemeye (MRG) başvuruldu. Cerrahi sırasında üç hastada posterior interosseöz sinir nörektomisi uygulandı. Ortalama izlem süresi 31 aydı (dağılım 6-72 ay). Sonuçlar: Yirmi beş hastanın 22’sinde (%88) okült dorsal gangliyon skafolunat bileşkeden çıkarıldı. Üç hastada gangliyon kitlesine rastlanmadı. Bu hastalarda skafolunat bağda dejenerasyon gözlendi. Parmak ekstansiyon testi 24 hastanın 23’ünde pozitif bulundu. Testin negatif olduğu hastada, cerrahi sırasında skafolunat bağda dejenerasyon gözlendi. Parmak ekstansiyon testi iki hastada yanlış pozitif sonuç verdi. Bu hastaların birinde MRG negatifti. Manyetik resonans görüntüleme yapılan 13 hastanın 11’inde, ultrasonografi yapılan altı hastadan dördünde cerrahi olarak sonuç doğrulandı. Buna göre MRG’nin tanı koyduruculuğu %92, ultrasonografinin %66, parmak ekstansiyon testinin %92 bulundu. Cerrahi sonrasında nüks gözlenen iki hastada (%8) ikincil ameliyat gerekti. Geç dönem instabilite bulgusu ile karşılaşılmadı. Biri dışında tüm hastalar (%96) semptomsuz hale geldi. Çıkarımlar: Parmak ekstansiyon testi, okült gangliyon tanısında %92’lik tanı değeriyle önemli bir testtir. Okült gangliyon tanı ve tedavisi gelişen tanı yöntemleri nedeniyle kolaylaşmıştır.

Anahtar Kelimeler:

El parmakları, Ağrı, Testlerin kestirim değeri, Duyarlılık ve özgüllük, Gangliyon kistleri, El bileği, Hareket açıklığı, eklem, Manyetik rezonans görüntüleme

The importancy of finger extension test in the diagnosis of occult wrist ganglion

Objectives: The aim of this study was to evaluate the accuracy of diagnostic tools in comparison with surgical results of occult ganglion cyst of the wrist, which is one of the causes of chronic wrist pain. Methods: Twenty-five patients (4 males, 21 females; mean age 29 years; range 16 to 46 years) underwent surgery with an initial diagnosis of occult ganglion following unsuccessful conservative treatment. The mean symptom duration was 29 months (range 3 months to 10 years). Diagnosis was based on finger extension test performed in 24 patients. Six patients and 13 patients were assessed by ultrasonography and magnetic resonance imaging (MRI), respectively. Interosseous neurectomy was performed in three patients. The mean follow-up was 31 months (range 6 to 72 months). Results: Occult dorsal ganglion was resected from the scapholunate interval in 22 patients (88%). No ganglion was found in three patients, who had only degeneration of the scapholunate ligament. Finger extension test was positive in 23 patients. One patient with a negative test result was found to have degeneration of the scapholunate ligament. The test yielded two false positive results, one of which was negative by MRI. Surgical confirmation was achieved in 11 patients evaluated by MRI and in four patients evaluated by ultrasonography. Diagnostic accuracy rates for MRI, ultrasonography, and finger extension test were 92%, 66%, and 92%, respectively. Two patients (8%) underwent reoperation for recurrence. None of the patients complained of instability in the late period. Except for one patient, all patients (96%) were asymptomatic at final evaluations. Conclusion: Finger extension test is an important diagnostic tool for occult ganglion with 92% accuracy. Both diagnosis and treatment of occult ganglion cysts have become easier by evolving diagnostic tools.

Keywords:

Fingers, Pain, Predictive Value of Tests, Sensitivity and Specificity, Ganglion Cysts, Wrist, Range of Motion, Articular, Magnetic Resonance Imaging,

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1. Clay NR, Clement DA. The treatment of dorsal wrist ganglia by radical excision. J Hand Surg [Br] 1988;13:187-91.
2. Sanders WE. The occult dorsal carpal ganglion. J Hand Surg [Br] 1985;10:257-60.
3. Hayashi H, Kojima T, Fukumoto K. The fourth-compartment syndrome: its anatomical basis and clinical cases. Handchir Mikrochir Plast Chir 1999;31:61-5.
4. Carr D, Davis P. Distal posterior interosseous nerve syndrome. J Hand Surg [Am] 1985;10(6 Pt 1):873-8.
5. Keith PP, Nuttall D, Trail I. Long-term outcome of nonsurgically managed Kienbock’s disease. J Hand Surg [Am] 2004;29:63-7.
6. Steinberg BD, Kleinman WB. Occult scapholunate ganglion: a cause of dorsal radial wrist pain. J Hand Surg [Am] 1999;24:225-31.
7. Gunther SF. Dorsal wrist pain and the occult scapholunate ganglion. J Hand Surg [Am] 1985;10:697-703.
8. Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg [Am] 2006;31:491-8.
9. Mitsuyasu H, Patterson RM, Shah MA, Buford WL, Iwamoto Y, Viegas SF. The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand Surg [Am] 2004;29:279-88.
10. Read JW, Conolly WB, Lanzetta M, Spielman S, Snodgrass D, Korber JS. Diagnostic ultrasound of the hand and wrist. J Hand Surg [Am] 1996;21:1004-10.
11. Osterwalder JJ, Widrig R, Stober R, Gachter A. Diagnostic validity of ultrasound in patients with persistent wrist pain and suspected occult ganglion. J Hand Surg [Am] 1997;22:1034-40.
12. Teefey SA, Middleton WD, Patel V, Hildebolt CF, Boyer MI. The accuracy of high-resolution ultrasound for evaluating focal lesions of the hand and wrist. J Hand Surg [Am] 2004;29:393-9.
13. Ogino T, Minami A, Fukada K, Sakuma T, Kato H. The dorsal occult ganglion of the wrist and ultrasonography. J Hand Surg [Br] 1988;13:181-3.
14.Vo P, Wright T, Hayden F, Dell P, Chidgey L. Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion. J Hand Surg [Am] 1995;20:667-70.
15. Cardinal E, Buckwalter KA, Braunstein EM, Mih AD. Occult dorsal carpal ganglion: comparison of US and MR imaging. Radiology 1994;193:259-62.
16. Lluch AL, Garcia-Elias M. Occult ganglions of the dorsal scapho-lunate ligament. Histological and long term review of 65 operated cases. J Hand Surg [Am] 2003;28 Suppl 1:23.
17.Watson HK. Weinzweig J. Examination of the wrist. In: Watson HK, Weinzweig J, editors. The wrist. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 47-59.
18.Watson HK. Weinzweig J. Dorsal wrist syndrome. In: Watson HK, Weinzweig J, editors. The wrist. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 483-90.
19. Hwang JJ, Goldfarb CA, Gelberman RH, Boyer MI. The effect of dorsal carpal ganglion excision on the scaphoid shift test. J Hand Surg [Br] 1999;24:106-8.
20. Grafe MW, Kim PD, Rosenwasser MP, Strauch RJ. Wrist denervation and the anterior interosseous nerve: anatomic considerations. J Hand Surg [Am] 2005;30:1221-5.