1. And other joint fluid collections
Ganglion Cysts
And other joint fluid collections
Jenelle Beadle
2/18/2016

2. Objectives Basic anatomy of a synovial joint
Types of joint fluid collections
Bursitis
Joint Effusions
Synovial & Ganglion Cysts
Compare and contrast synovial and ganglion cysts
Identify common ganglia locations

3. Synovial Joint Articular cartilage specialized connective tissue
covers bone at joints
reduces friction, allowing for smooth movement

4. Synovial Joint Joint capsule – 2 Layers Outer layer: fibrous capsule
Inner layer: synovial membrane
secretes synovial fluid

5. Synovial Joint Joint Recess
fold of joint capsule that allows for free movement
excess joint fluid can collect here

6. Synovial Joint Bursa between bones and tendons 160 in the body
reduces friction, allowing for smooth movement

7. Synovial Joint Fluid Collections
Bursitis
Joint Effusions
Synovial / Ganglion Cysts
Several different types of joint fluid collections
Briefly discuss bursitis and joint effusions, and go into more detail on cysts

8. Bursitis Inflammation of the bursa Specific Locations
dilated with increased synovial fluid
thickened, hyperemic synovial lining
Specific Locations

9. Bursitis Classic locations Prepatellar
Help identify these fluid collections as bursa based on location

10. Bursitis Classic locations Prepatellar Infrapatellar
Help identify these fluid collections as bursa based on location

11. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Help identify these fluid collections as bursa based on location

12. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Help identify these fluid collections as bursa based on location

13. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Help identify these fluid collections as bursa based on location

14. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Iliopsoas
Help identify these fluid collections as bursa based on location

15. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Iliopsoas
Subacromial
Subacromial
Bursa
Help identify these fluid collections as bursa based on location

16. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Iliopsoas
Subacromial
Olecranon
Help identify these fluid collections as bursa based on location

17. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Iliopsoas
Subacromial
Olecranon
Subcutaneous Calcaneal
Help identify these fluid collections as bursa based on location

18. Bursitis Classic locations Prepatellar Infrapatellar Anserine
Trochanteric
Ischial
Iliopsoas
Subacromial
Olecranon
Subcutaneous Calcaneal
Retrocalcaneal
Help identify these fluid collections as bursa based on location

19. Bursitis Inflammation of the bursa
dilated with increased synovial fluid
thickened, hyperemic synovial lining

20. Joint Effusion Presence of increased intra-articular fluid Causes:
joint recesses
communicating bursa
suprapatellar
Causes:
trauma, inflammation, infections, hematologic conditions
Knee and hip are most common locations

21. Joint Effusion
Hip

22. Joint Effusion
Knee

23. Joint Effusion
Thickened synovium

24. Synovial Cyst
Focal herniation of the synovial membrane through the joint capsule
Or tendon sheath

25. Synovial Cyst
Focal herniation of the synovial membrane through the joint capsule
Inflammatory or post-traumatic disease causes an increase in joint fluid production
increased pressure in the joint from accumulation of fluid
herniation occurs at a point of low resistance in joint capsule
It is thought that inflammatory or post-traumatic disease causes an increase in joint fluid production, which increases pressure within the joint.

26. Synovial Cyst
Focal herniation of the synovial membrane through the joint capsule
Inflammatory or post-traumatic disease causes an increase in joint fluid production
increased pressure in the joint from accumulation of fluid
herniation occurs at a point of low resistance in joint capsule
Always communicates with the joint
same composition as the joint synovium
one way valve phenomenon
Arthrography – contrast dye injected into the joint will move into the cyst, but dye injected into the cyst never moves into the joint; uncertain what the mechanism is for this assumed valve (perhaps simply a pressure gradient)

27. Baker’s Cyst Classic example of a synovial cyst
Communicates to the knee joint capsule
Specific popliteal cyst that originates from between two tendons
medial gastrocnemius
semimembranosus tendons
It is just a popliteal cyst until the origin is demonstrated

28. Baker’s Cyst
Med
Lat
medial gastrocnemius & semimembranosus tendons

29. Synovial Cyst Appearance Solitary or multiple Smooth or lobulated
Uniloculated or multiloculated
Simple or complicated
medial gastrocnemius & semimembranosus tendons

30. Ganglion versus Synovial Cysts
Ganglion Cyst
focal joint fluid collection
always communicates with the joint
identical to joint synovium
continuous mesothelial lining
true synovial cells
secrete fluid
mucinous fluid
gelatinous (thicker than joint fluid)
focal joint fluid collection
often communicates with the joint
similar to joint synovium
discontinuous mesothelial lining
flattened pseudo-synovial cells
secrete fluid
mucinous fluid
gelatinous (thicker than joint fluid)

31. Ganglion Cyst Pathophysiology is controversial Theories include:
displacement of synovial tissue during embryogenesis
degeneration of connective tissues after trauma
tear in the joint capsule and fluid leakage
degeneration of a synovial cyst
Second most accepted – tear in capsule, fluid leaks out and walls itself off (doesn’t account for the neck that is sometimes present)

32. Ganglion Cyst Pathophysiology is controversial
One of the most accepted theories:
a ganglion cyst represents an advanced degenerative stage of a synovial cyst
Synovial Cyst Structure
Ganglion Cyst Structure
Degenerates

33. Ganglion Cyst = Degenerated Synovial Cyst
Fluctuations in pressure may cause degeneration
cellular lining becomes discontinuous
individual cells flatten
communication with the joint may become obliterated

34. Imaging: Ganglion Cyst = Synovial Cyst
Ganglion and synovial cysts are differentiated histologically
As far as imaging is concerned, they are one and the same
For the rest of this presentation, I will use the term ganglion cyst

35. Ganglion Cyst Risk Factors Symptoms Location Treatment women
20-50 years old
gymnasts
trauma
Symptoms
lump
sometimes painful
Location
any joint
most common: hand & wrist (88%); foot & ankle (11%)
Treatment
approximately 50% spontaneously disappear
aspiration (40-86% cure rate)
with or with out corticosteroid injection
surgical removal (75-85% cure rate)

36. Ganglion Cyst – Hand/Wrist
Dorsal (60-70%)
scapholunate
Volar (13-20%)
radioscaphoid/scapholunate
scaphotrapezial
metacarpotrapezial
Volar Flexor Tendon Sheath (10-12%)
A1/A2 pulleys

37. Ganglion Cyst - Hand/Wrist
Carpals
So Long To Pinky Here Comes The Thumb

38. Ganglion Cyst - Hand/Wrist
Carpals
Right
Volar/Palmar
Dorsal

39. Ganglion Cyst - Hand/Wrist
Dorsal (60-70%)
scapholunate

40. Ganglion Cyst - Hand/Wrist
Dorsal (60-70%)
scapholunate
Trans
Trans

41. Ganglion Cyst - Hand/Wrist
Dorsal (60-70%)
scapholunate
Scapholunate Ligament
Trans
Trans

42. Ganglion Cyst - Hand/Wrist
Volar (13-20%)
radioscaphoid/scapholunate
scaphotrapezial
metacarpotrapezial

43. Ganglion Cyst - Hand/Wrist
Volar (13-20%)
radioscaphoid/scapholunate
scaphotrapezial
metacarpotrapezial
Long
Long R S R S
Ganglion
Normal

44. Ganglion Cyst - Hand/Wrist
Volar (13-20%)
radioscaphoid/scapholunate
scaphotrapezial
metacarpotrapezial
Often intimately related to the radial artery

45. Ganglion Cyst - Hand/Wrist
Volar Flexor Tendon Sheath (10-12%)
A1-A2 pulleys

46. Ganglion Cyst - Hand/Wrist
Volar Flexor Tendon Sheath (10-12%)
A1/A2 pulleys
Typically anterior to the proximal margin of A2 pulley

47. Ganglion Cyst – Foot/Ankle
Dorsal
Tarsal Joints
talonavicular
Lateral
Sinus Tarsi
funnel shaped tunnel between the talus and calcaneus
narrow medial opening and wide lateral opening
Medial
Tarsal Tunnel
posterior to sinus tarsi
tibial nerve compression
Tendon Sheaths

48. Ganglion Cyst – Foot/Ankle
Seven Tarsals
Calcaneus, Talus, Navicular, Cuboid & Cuneiforms (x3)

49. Ganglion Cyst – Foot/Ankle
Dorsal
Tarsal Joints
talonavicular
Cun
Nav
Identify surrounding anatomy and neck if possible

50. Ganglion Cyst – Foot/Ankle
Lateral
Sinus Tarsi
funnel shaped tunnel between the talus and calcaneus
narrow medial opening and wide lateral opening

51. Ganglion Cyst – Foot/Ankle
Lateral
Sinus Tarsi
Lat
Med
Lateral Approach
Sup
Inf
Cor
Sag

52. Ganglion Cyst – Foot/Ankle
Medial
Tarsal Tunnel
posterior and superior to sinus tarsi

53. Ganglion Cyst – Foot/Ankle
Medial
Tarsal Tunnel
Three Tendons
Tibialis Posterior
Flexor Digitorum
Flexor Hallucis
Posterior Tibial Vessels
Posterior Tibial Nerve

54. Ganglion Cyst – Foot/Ankle
Medial
Tarsal Tunnel
risk for tibial nerve compression
Yellow arrows = tibial nerve

55. Ganglion Cyst – Foot/Ankle
Tendon Sheaths
Synovium is everywhere in the foot and ankle!
Ganglia can arise from numerous locations

56. Ganglion Cyst – Foot/Ankle
Tendon Sheaths

57. Identify and label surrounding anatomy
Take Home Message:
Identify and label surrounding anatomy
Thank you.