Deep ulnar intraneural ganglia in the palm

Abstract

While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood. We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation. A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts. Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.