Case Reports

Supinator Cyst in a Young Female Softball Player Successfully Treated With Aspiration

Am J Orthop. 2015 July;44(7):E235-E238

References

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Most ganglion cysts are formed when joint fluid extrudes through a defect in the joint capsule; they have also been described originating from a nonunion site.¹⁸ When conservative treatment fails, surgical excision has been recommended.^{5,6,8-10,12-16} We present the first known case of successful ultrasound-guided aspiration and injection of a ganglion cyst from the proximal radiocapitellar joint.

In the earliest described case in 1955, Broomhead¹⁹ noted exploration was essential to establish the diagnosis of nerve palsy. In 1966, Bowen and Stone⁷ were the first to report PIN compression by a ganglion and that compression was likely where nerves pass through confined spaces. In keeping with the known potential for compression of the common peroneal nerve around the fibular head, Bowen and Stone⁷ posited that the same could be true of the PIN coursing through the supinator and around the radial neck.

Many authors have noted that nerve palsy either improves with rest or worsens with heavy manual work.^3,20,21 These observations suggest that dynamic factors in addition to compression of the nerve by the ganglion may influence the occurrence of the nerve palsy.¹⁴ This is in line with our patient whose symptoms worsened after pitching.

Ogino and colleagues²⁰ reported on the first use of ultrasonography as a screening examination for a ganglion, particularly when palpation was difficult. Ultrasound allows a detailed assessment of peripheral nerve continuity with a mass, differentiating an intraneural lesion from an adjacent extrinsic ganglion.¹³ Tonkin¹⁰ published the first description of MRI used for the diagnosis of an elbow cyst, and its use has been supported by others.^5,8,20 The typical appearance of ganglion cysts on MRI include low signal on T1-weighted images and very high signal on T2-weighted images. Only the periphery of the mass is enhanced by gadolinium, if used.

As recently as 2009, Jou and associates¹³ suggested that surgical excision should be performed promptly to ensure optimal recovery from a nerve palsy. Many authors agree that early diagnosis and careful surgical excision is associated with a satisfactory outcome without recurrence of the cyst.^{5,6,8-10,12-15} There are only 4 published case reports^14-17of ganglions causing isolated compression of the superficial radial sensory nerve, as in our case. Their patients had pain with exertional trauma¹⁴ as did our patient, a positive Tinel sign,¹⁵ and resolution of symptoms after surgical excision without recurrence.^14-16 Mileti and colleagues¹⁶ state that standard management for resistant radial tunnel syndrome is open decompression of the radial nerve.

In the last decade, a few reports of arthroscopic excision being a viable and safe alternative to open excision have been published.^16,22,23 In 2000, Feldman²² described the benefits of an arthroscopic approach as decreased soft-tissue dissection, increased ability to identify intra-articular pathology, and similar recurrence rates to open procedures. He reported 1 transient neurapraxia of the superficial radial nerve from the arthroscopy, highlighting a risk of arthroscopic treatment.

An alternative to open or arthroscopic cyst decompression is aspiration. The only mention of aspiration in the literature comes from Broomhead¹⁹ in 1955 when he described 2 patients in whom treatment by aspiration was unsuccessful in relieving their symptoms. Yamazaki and colleagues¹² noted that 1 of their 14 patients with PIN palsies caused by ganglions at the elbow underwent puncture of the ganglion with recovery of the paralysis. With the aid of ultrasound guidance, we were able to accurately locate the ganglion cyst, aspirate its contents, and inject methylprednisolone sodium succinate. Our patient continued to be symptom-free and was an active pitcher on a varsity softball team 26 months after aspiration.

Conclusion

This case report describes a rare location for a ganglion cyst in a high-level softball player. To our knowledge, successful treatment with ultrasound-guided aspiration and injection of a supinator cyst has not been reported in the literature. This case report highlights the importance of a careful diagnosis of this condition and an alternative treatment algorithm.