Natural History of Pediatric Hand and Wrist Ganglion Cysts: Longitudinal Follow-Up of a Prospective, Dual-Center Cohort

PURPOSE

This investigation describes the outcomes of pediatric ganglion cysts in a prospective cohort that elected not to undergo cyst aspiration or surgical treatment. Our primary aim was to investigate the rate of spontaneous resolution over time among the subset of patients who did not undergo specific treatments.

METHODS

Children (aged ≤18 years) who presented to the clinic with ganglion cysts of the hand or wrist were enrolled in a prospective two-center registry between 2017 and 2021. Enrolled subjects who never elected to undergo cyst aspiration or surgical treatment were analyzed. The data collected included age, sex, cyst location and laterality, hand dominance, Wong-Baker pain scale scores, and Patient-Reported Outcome Measurement Information System upper-extremity scores. Follow-up surveys were completed for up to 5 years.

RESULTS

A total of 157 cysts in 154 children, with an average age of 9.4 years and a female-to-male ratio of 1.4:1, were eligible. The most common ganglion location was dorsal wrist (67/157, 42.7%), followed by volar wrist (49/157, 31.2%), the flexor tendon sheath (29/157, 18.5%), and the extensor tendon synovial lining (8/157, 5.1%). The average follow-up duration was 2.5 years after initial presentation to the clinic, and 63.1% (99/157) of the patients responded to follow-up surveys. Among them, 62.6% (62/99) of cysts spontaneously resolved; the resolution rates ranged from 51.9% of volar wrist ganglions to 81% of flexor tendon sheath cysts, with an average time to resolution of 14.1 months after cyst presentation. Cysts were more likely to resolve in the hand than in the wrist (84.0% vs 55.4%, respectively). Cysts present for >12 months at initial evaluation were less likely to resolve spontaneously (41.2% vs 67.1%).

CONCLUSIONS

Of children who elected not to undergo aspiration or surgical treatment, approximately two-thirds of families reported that their child's ganglion cyst resolved spontaneously. Cysts that resolve spontaneously usually do so within 2 years of presentation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) Detect Change in Dynamic Position and Spontaneous Function of the Upper Limb in People With Hemiplegic Cerebral Palsy?

BACKGROUND

The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery.

METHODS

In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively.

RESULTS

Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05).

CONCLUSIONS

The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Factors Influencing Why Children and Their Families Choose Surgery for Ganglion Cysts

PURPOSE

Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients.

METHODS

This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up.

RESULTS

A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients.

CONCLUSIONS

Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Variation Among Surgeons Regarding the Use of Preoperative Antibiotics in Percutaneous Pinning Procedures of the Upper Extremity in the Pediatric Population

Background: Preoperative antibiotics may not be necessary, given the very low infection rates associated with percutaneous pinning (PP) procedures of the upper extremity (UE). The purpose of this study was to determine the patterns and variation surrounding the use of preoperative antibiotics when performing PP procedures of the child's UE. Methods: A survey was sent to all members of Pediatric Orthopedic Society of North America to assess the use and opinions regarding preoperative antibiotics for PP procedures of the UE. Queries included the surgeon's current practice and thoughts regarding the need for preoperative antibiotics based on the anatomical location of the procedure. Results: Eight-one percent of the 295 respondents routinely order preoperative antibiotics for all PP procedures of the UE; however, only 60% felt that all patients must receive preoperative antibiotics. The requirement for preoperative antibiotics varied based on the anatomical location-81% for shoulder, 70% for elbow, 66% for wrist, and 62% for hand/finger. Canadian surgeons were significantly less likely to believe that preoperative antibiotics must be used in all UE cases, all shoulder cases, and all elbow cases (all Ps = .04). Conclusion: The vast majority (81%) of surgeons surveyed routinely prescribe antibiotics for PP procedures of the UE despite the fact that 40% of surgeons felt that antibiotics were not necessary for all procedures. As the PP procedure is performed more distally on the UE, fewer surgeons feel preoperative antibiotics are necessary. Future studies assessing infection rates with and without the use of preoperative antibiotics are necessary to determine the true need for these medications.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children

PURPOSE

Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort.

METHODS

A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores.

RESULTS

A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores.

CONCLUSIONS

Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

The Ice and Salt Challenge: An Atypical Presentation of a Cold Injury: A Case Report

CASE

We present a case of a healthy seventeen-year-old adolescent with a cold injury to the hands from a new phenomenon known as the "ice and salt challenge," where adolescents hold an ice cube and salt against their skin in competition to see which participant can withstand the discomfort the longest. This competition results in a characteristic injury pattern to the hands. The patient was treated with local wound care and had no long-term deficits.

CONCLUSION

It is important for orthopaedic surgeons to be aware of the ice and salt challenge because they may be the first health-care providers to witness its effects. A high index of suspicion is critical in order to properly diagnose, treat, and counsel these patients against risk-taking behaviors.

Interclinician and intraclinician variability in the mechanics of the pivot shift test for posterolateral rotatory instability (PLRI) of the elbow

HYPOTHESIS

Posterolateral rotatory instability (PLRI) of the elbow results from injury to the lateral collateral ligament complex from trauma or iatrogenic injury. The lateral pivot-shift test (PST) is standard for diagnosing PLRI, but its subjectivity affects diagnosis and makes it difficult to train young surgeons. A well-controlled investigation has not been done to quantify interclinician and intraclinician variability in PST mechanics in the intact and unstable elbow. The authors predict that there exist differences in PST mechanics between clinicians.

MATERIALS AND METHODS

Five unpaired elbow specimens underwent PST intact and after sequential sectioning of lateral stabilizing ligaments. Multiple PST trials were performed on each specimen by 3 clinicians (1 expert, 2 in-training) while 3-dimensional motion and loads were recorded. Intraclinician and interclinician variability were analyzed.

RESULTS

Mean supination torque, valgus torque, and axial force were 3.6 ± 1.9 Nm, 5.6 ± 3.1 Nm, and -8.3 ± 15.7 N, respectively. Mean radial head displacement was 13.7 ± 4.6 mm. There were no significant differences in these measures after sequential ligament sectioning. One surgeon (in-training 2) applied significantly greater axial compressive forces across the elbow joint (5-9 N difference). Variability of axial force (380% ± 473%) was greater than that of supination torque (20% ± 11%), valgus torque (14% ± 4%), and radial head displacement (8% ± 6%; P < .05 for analysis of variance).

DISCUSSION

The clinicians performed the PST consistently and with comparable loads, with the exception of axial compressive force across the radiohumeral joint, which varied across clinicians by 1 to 2 pounds (5-9 N).

CONCLUSION

This study suggests that the PST is a mechanically reproducible clinical examination, despite differing levels of training in performing the maneuver. With the exception of axial force, PST mechanics are highly repeatable for a given surgeon applying the test on a single specimen.

Failure of differentiation: Part II (arthrogryposis, camptodactyly, clinodactyly, madelung deformity, trigger finger, and trigger thumb)

The term "failure of differentiation" describes the phenotypes of a large number of otherwise unrelated conditions. The six conditions described here (arthrogryposis, camptodactyly, clinodactyly, Madelung deformity, trigger finger, and trigger thumb) are believed to occur because various structures failed to differentiate normally; however, they have neither common features nor a common cause. We have included information about the history and diagnosis of these conditions, the cause (if known), and the current concepts of treatment and expected outcomes.

Mutations Near Amino End of α1(I) Collagen Cause Combined Osteogenesis Imperfecta/Ehlers-Danlos Syndrome by Interference with N-propeptide Processing

Patients with OI/EDS form a distinct subset of osteogenesis imperfecta (OI) patients. In addition to skeletal fragility, they have characteristics of Ehlers-Danlos syndrome (EDS). We identified 7 children with types III or IV OI, plus severe large and small joint laxity and early progressive scoliosis. In each child with OI/EDS, we identified a mutation in the first 90 residues of the helical region of alpha1(I) collagen. These mutations prevent or delay removal of the procollagen N-propeptide by purified N-proteinase (ADAMTS-2) in vitro and in pericellular assays. The mutant pN-collagen which results is efficiently incorporated into matrix by cultured fibroblasts and osteoblasts and is prominently present in newly incorporated and immaturely cross-linked collagen. Dermal collagen fibrils have significantly reduced cross-sectional diameters, corroborating incorporation of pN-collagen into fibrils in vivo. Differential scanning calorimetry revealed that these mutant collagens are less stable than the corresponding procollagens, which is not seen with other type I collagen helical mutations. These mutations disrupt a distinct folding region of high thermal stability in the first 90 residues at the amino end of type I collagen and alter the secondary structure of the adjacent N-proteinase cleavage site. Thus, these OI/EDS collagen mutations are directly responsible for the bone fragility of OI and indirectly responsible for EDS symptoms, by interference with N-propeptide removal.