0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation |

Periosteal Ganglia Presenting as Subcutaneous Nodules on the Tibia FREE

Nkanyezi N. Ferguson, MD1; Adam Asarch, MD1; Amanda J. Tschetter, MD1; Mary Stone, MD1
[+] Author Affiliations
1Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City
JAMA Dermatol. 2014;150(6):663-664. doi:10.1001/jamadermatol.2013.6352.
Text Size: A A A
Published online

Herein we describe a case of periosteal ganglia presenting as asymptomatic subcutaneous nodules on the anterior lower extremity.

REPORT OF A CASE

A woman in her 40s presented with a 3-month history of asymptomatic grouped subcutaneous nodules on the left shin. The lesions appeared spontaneously without any preceding trauma. Physical examination of the left anterior lower extremity revealed grouped, soft, immobile nodules without overlying epidermal changes (Figure 1A). A punch biopsy of a characteristic nodule induced extrusion of a gelatinous, clear, myxoid material (Figure 1B). Histopathologic findings revealed normal skin and subcutaneous tissue with deep soft-tissue mucinous debris that was separated from the overlying skin. Magnetic resonance imaging of the left lower extremity showed a lobulated cystic lesion overlying the anterior tibia, with no communication with the knee joint (Figure 2). The absence of diffusion restriction ruled out an underlying abscess. No underlying bony abnormalities were identified. These findings confirmed a diagnosis of a periosteal ganglion of the tibia. The patient was referred to the orthopedic surgery service, where she declined standard surgical excision and instead opted for aspiration with subsequent compression. At the time of writing, she continued to be monitored through the orthopedic surgery service.

Place holder to copy figure label and caption
Figure 1.
Periosteal Ganglia of the Tibia

A, The ganglia presented as grouped and immobile nodules without overlying epidermal changes on the left anterior lower extremity. B, A punch biopsy of a nodule on the left lower extremity demonstrated a periosteal ganglion of the tibia, with extrusion of a gelatinous, clear, myxoid material.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Imaging of Periosteal Ganglia of the Tibia

Magnetic resonance imaging of the left lower extremity demonstrated a lobulated cystic mass overlying the anterior tibia.

Graphic Jump Location

DISCUSSION

Periosteal ganglia are uncommon single or multiloculated subcutaneous cystic nodules. These lesions are rarely encountered by dermatologists and are usually seen in the orthopedic setting. Although described mainly in men, these lesions also have been reported1,2 in children. Periosteal ganglia typically involve the tibia, but reports24 have also described involvement of the medial malleolus, femur, ilium, radius, and ulna. Duration before presentation varies from several weeks to years.1 Lesions can be asymptomatic or tender, and a history of trauma is variable.3

Mucoid degeneration of the periosteum is the most frequently proposed pathogenesis for the formation of periosteal ganglia.16 Fibroblasts are thought to form intercellular mucin, which coalesces to form cystic lesions. Accumulation of mucoid material compresses the surrounding tissue, thereby inducing further fibroblast proliferation, collagen production, and ultimately an encapsulating fibrous wall.4 The central cystic contents are composed of an acellular mucinous or gelatinous fluid.4 Although communication with the underlying joint space has not been reported, cases have shown3,5 varying degrees of underlying cortical erosion with scalloping and spiculated bone reactions. Choi and colleagues4 described a case with an underlying interosseous component. However, as in our patient, these cysts frequently have no underlying connection to the cortical bone.

Several imaging modalities to evaluate periosteal ganglia have been described. Plain radiographs, although helpful in detecting underlying bony changes, are nonspecific and do not differentiate pretibial ganglion cysts from other surface tumors.3 Computed tomography is helpful in further discerning characteristics of the soft-tissue mass, but magnetic resonance imaging is the modality of choice.3 Magnetic resonance imaging demonstrates a homogeneous signal intensity, which appears isointense to muscle on T1-weighted images and has a high signal intensity when compared with fat on T2-weighted images.3,5

Definitive treatment of periosteal ganglia is by surgical excision. Some authors13 recommend excising an adjacent margin of normal periosteum to prevent recurrence. Although recurrence after surgical excision has been described,1,3 this may represent continued mucoid degeneration rather than incomplete excision.

The clinical differential diagnosis for pretibial subcutaneous masses or nodules is broad and includes erythema nodosum, nodular pretibial myxedema, subcutaneous sarcoidosis, periosteal chondroma, parosteal lipoma, subperiosteal hematoma, subperiosteal abscess, periosteal aneurysmal bone cyst, chondromyxoid fibroma, or periosteal osteosarcoma.13,5 Although uncommon and rarely encountered by dermatologists, periosteal ganglion cysts remain an important condition to consider in the differential diagnosis of subcutaneous pretibial lesions. This case highlights the need for dermatologists to recognize this uncommon diagnosis to facilitate appropriate workup and referral.

ARTICLE INFORMATION

Corresponding Author: Nkanyezi N. Ferguson, MD, Department of Dermatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242 (nkanyezi-ferguson@uiowa.edu).

Published Online: February 19, 2014. doi:10.1001/jamadermatol.2013.6352.

Conflict of Interest Disclosures: None reported.

REFERENCES

Okada  K, Unoki  E, Kubota  H,  et al.  Periosteal ganglion: a report of three new cases including MRI findings and a review of the literature. Skeletal Radiol. 1996;25(2):153-157.
PubMed   |  Link to Article
Blanco  JF, De Pedro  JA, Paniagua  JC.  Periosteal ganglion in a child. Arch Orthop Trauma Surg. 2003;123(2-3):115-117.
PubMed
Abdelwahab  IF, Kenan  S, Hermann  G, Klein  MJ, Lewis  MM.  Periosteal ganglia: CT and MR imaging features. Radiology. 1993;188(1):245-248.
PubMed
Choi  YS, Kim  BS, Kim  DH, Chun  TJ, Yang  SO, Choi  KH.  Sonographic evaluation of a tibial periosteal ganglion with an intraosseous component. J Ultrasound Med. 2006;25(10):1369-1373.
PubMed
Valls  R, Melloni  P, Darnell  A, Muñoz  J, Canalies  J.  Diagnostic imaging of tibial periosteal ganglion. Eur Radiol. 1997;7(1):70-72.
PubMed   |  Link to Article
Kobayashi  H, Kotoura  Y, Hosono  M, Tsuboyama  T, Sakahara  H, Konishi  J.  Periosteal ganglion of the tibia. Skeletal Radiol. 1996;25(4):381-383.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Periosteal Ganglia of the Tibia

A, The ganglia presented as grouped and immobile nodules without overlying epidermal changes on the left anterior lower extremity. B, A punch biopsy of a nodule on the left lower extremity demonstrated a periosteal ganglion of the tibia, with extrusion of a gelatinous, clear, myxoid material.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Imaging of Periosteal Ganglia of the Tibia

Magnetic resonance imaging of the left lower extremity demonstrated a lobulated cystic mass overlying the anterior tibia.

Graphic Jump Location

Tables

References

Okada  K, Unoki  E, Kubota  H,  et al.  Periosteal ganglion: a report of three new cases including MRI findings and a review of the literature. Skeletal Radiol. 1996;25(2):153-157.
PubMed   |  Link to Article
Blanco  JF, De Pedro  JA, Paniagua  JC.  Periosteal ganglion in a child. Arch Orthop Trauma Surg. 2003;123(2-3):115-117.
PubMed
Abdelwahab  IF, Kenan  S, Hermann  G, Klein  MJ, Lewis  MM.  Periosteal ganglia: CT and MR imaging features. Radiology. 1993;188(1):245-248.
PubMed
Choi  YS, Kim  BS, Kim  DH, Chun  TJ, Yang  SO, Choi  KH.  Sonographic evaluation of a tibial periosteal ganglion with an intraosseous component. J Ultrasound Med. 2006;25(10):1369-1373.
PubMed
Valls  R, Melloni  P, Darnell  A, Muñoz  J, Canalies  J.  Diagnostic imaging of tibial periosteal ganglion. Eur Radiol. 1997;7(1):70-72.
PubMed   |  Link to Article
Kobayashi  H, Kotoura  Y, Hosono  M, Tsuboyama  T, Sakahara  H, Konishi  J.  Periosteal ganglion of the tibia. Skeletal Radiol. 1996;25(4):381-383.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

305 Views
0 Citations

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
Jobs
×