Ganglion Cysts of the Hand & Wrist

Ganglion cysts are common soft tissue tumors in the hand, often linked to joint capsules or tendons. Their diagnosis is primarily clinical. Treatment options are observation, aspiration, injection & surgical excision.
Ganglion Cysts of the Hand & Wrist

Summary Card

Definition
The most common soft tissue tumours in the hand, mostly arise from joint capsules or tendons. Main sites: dorsal wrist (60-70%) and volar wrist (15-20%).

Pathophysiology
Resulting from repetitive microtrauma, containing a viscous fluid from hyaluronic acid production—theories related to mucoid and synovium.

Clinical Presentation
Soft-tissue swellings vary in size and symptoms based on location.

Investigations
Ultrasound and MRI can refine diagnosis and pinpoint location. MRIs have ~95% accuracy.

Treatment & Outcomes
Observation, aspiration ± injection, and excision. Aspiration has the highest recurrence rate, and open surgical excision has the highest complication rate.

Further Readingcontaining
Recommendations by P'Fella

Clinical Scenario
Diagnose, manage ganglion cysts, & make decisions.


Definition of Ganglion Cysts


Key Point

Ganglions are the most common soft tissue tumours in the hand, often arising from joint capsules or tendons. Predominant sites include the dorsal wrist (60-70%) and volar wrist (15-20%).

Ganglions are cysts filled with mucin. They represent the most prevalent soft tissue tumour in the hand. These cysts typically originate from neighbouring or underlying structures, including joint capsules, tendons, or tendon sheaths.

Definition of Ganglion Cysts

Ganglion cysts commonly occur in specific sites of the hand and wrist, but not always. These are detailed below.

  • Dorsal wrist: 60-70%, originating from the scapholunate ligament.
  • Volar wrist: 15-20%, associated with the STT joint.
  • Volar Retinacular: 5-10%, arising from the A1 pulley.
  • Distal Interphalangeal Joint: Typically referred to as mucous cysts.

These types of ganglion cysts are visualised below:

Locations of Ganglion Cysts

Less frequently, ganglions are observed in the carpal tunnel, Guyon's canal, or intraosseous.

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Tip: The location of the ganglion cyst significantly influences the clinical presentation. This is discussed in further detail below.

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Pathophysiology of a Ganglion


Key Point

Ganglions arise from repetitive trauma to joint structures, leading to fluid accumulation, and are characterized by interconnected ducts, compressed collagen, and a jelly-like substance. There is debate regarding the cyst's origin: whether it's due to mucoid degeneration or synovial growth/rupture.


Origin & Composition

Ganglions are believed to form due to repetitive microtrauma to a joint's capsular and ligamentous structures. This trauma stimulates fibroblasts at the synovial-capsule interface, leading them to produce hyaluronic acid. The outcome is a clear and highly viscous fluid, which accumulates, giving rise to the ganglion.

Characteristics of Ganglions

  1. Interconnected with nearby structures through continuous, intricate ducts.
  2. Compressed collagen fibers.
  3. Lacks an epithelial or synovial lining.
  4. Filled with a high-viscosity, clear, jelly-like substance.

Pathophysiology of ganglion cysts

Debate on the Aetiology

There are two main theories regarding the formation of the ganglion cyst:

  1. Mucoid Theory: This theory suggests that the cyst results from mucoid degeneration. This degeneration is marked by an increase in mucin and a decrease in fibrillated collagen fibers. However, this theory does not explain the recurrence of fluid after aspiration or incomplete resection.
  2. Synovium Theory: This theory proposes that the cysts arise from herniation, rupture, or growth of the synovium.

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Fun Fact: A one-way valvular mechanism has been suggested for the cyst and wrist joint. As communications are evidenced on arthrograms but not cystograms.


Clinical Picture of Ganglions


Key Point

Ganglion cysts appear as soft-tissue swellings in the hand with varying symptoms based on location and can change in size, cause pain, or compress nerves.


Ganglion cysts, generally speaking, present as a soft-tissue swelling in a specific location in the hand. Key points identified in history:

  • Timeline: can be acute or slowly progressive
  • Size: can fluctuate in size or self-resolve.
  • Pain: present if the cyst originates from a degenerated or arthritic joint. Typically non-tender upon palpation
  • Compression symptoms if adjacent to a nerve (parasethesia, weakness)
  • Transillumination

There are more specific clinical pictures based on the location of the ganglion cyst. This is detailed below in the table:

Clinical Features of Ganglions

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Tip: Volar ganglions may appear small clinically but multiloculated cysts can extender under thenar muscles.


Investigations for Ganglions


Key Point

Ganglions are primarily clinically diagnosed; radiology refines diagnosis and location. Radiographs miss cysts, ultrasounds show hypoechoic structures and MRIs (95% accuracy) depict multiloculated lesions

Radiological investigations, although not imperative, serve to validate the diagnosis, ascertain the precise location, and identify any concomitant degenerative joint disease.

  • Plain radiograph: Ganglion cysts are invisible, but key differential diagnoses or joint disease. may be evident
  • Ultrasound: Hypoechoic to anechoic with smooth walls; may have internal septations and exhibit acoustic enhancement.
  • MRI: ~95% accuracy, shows distinct multiloculated lesions with a stalk. T1 is typically hypointense, T2 and PDFS/T2FS are hyperintense (Mckeon, 2015)

Investigations of Ganglions

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Tip: Occult ganglions are not clinically palpable but a potential source of pain. They are identified on imaging.


Treatment of Ganglions


Key Point

Treatment options include observation (40% self-resolve), surgical excision (21% recurrence), or aspiration (59% recurrence). Open excision has higher risks, including wrist weakness, while long-term arthroscopic data is limited



The three main treatments for ganglions are observation, aspiration, and excision.

  • Observation: reassurance with education on change of self-resolution
  • Excision: open or arthroscopic
  • Aspiration ± injection (commonly corticosteroids)

Observation

Interventions for dorsal wrist ganglia should offer better symptom relief, fewer recurrences, and reduced risks compared to non-treatment. Approximately 40% of untreated ganglia self-resolve (Dias, 2007).

However, this treatment option is limited by:

  • Longer time for symptom resolution compared to surgery
  • Less patient satisfaction in this cohort of patients (Dias, 2007)

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Fun Fact: Historically, non-surgical treatment consisted of a sharp blow to the ganglion cyst with a mallet, dictionary, or Bible.

Surgical Excision

Ganglions can be excised through the standard open surgical approach or arthroscopic. The specific surgical technique varies based on the specific location. However, there are some key themes as detailed below:

  • Incision: Transverse or longitudinal incision can be advocated.
  • Dissection: preserve capsule and neurovascular bundles, identify the pedicle
  • Resection: capsule, cyst and soft tissue attachment excised.
  • Post-op: There's no agreed-upon post-operative immobilisation strategy, and no data indicates one method as superior (Wong, 2023)

An in-depth review of each surgical technique based on anatomical location is outside the scope of this article. Below is a video of a dorsum wrist ganglion excision.

Excision of a Dorsum Wrist Ganglion

Aspiration ± Injection

Each surgeon has their own specific technique for aspiration and injection. It is generally accepted the benefits of this treatment option includes:

  • Low-resource courses
  • Low risk of complications
  • Definitive confirmation of the diagnosis

In 2010, Paramhans introduced the double dart technique: using concurrent 16-gauge (for aspiration) and 24-gauge needles (for triamcinolone acetonide injection) in the ganglion. This is visualised below.

Aspiration of Ganglion Cysts

Outcomes

The two commonly assessed outcomes in current literature relates to recurrence and complications.

Recurrence:

As detailed in a recent systematic review (Head, 2015):

  • Aspiration: 59% (limited improvement vs. observation).
  • Open Excision: 21% (noteworthy for a higher complication rate).
  • Arthroscopic: 6% (limited comparative data; not clearly superior).

Recurrence Rates for Ganglion Treatment

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Fun Fact: Surgical excision may necessitate up to 2 weeks off work, while aspiration typically requires 3-4 days (Dias, 2007)

Complications

Complications reported in surgical excision were comparatively more serious than those reported with aspiration and included radial artery damage and neurapraxia. The literature suggests the following mean complication rate (Head, 2015):

  • Open Excision: 14% complication rate, with risks including radial artery damage and neurapraxia.
  • Aspiration: 2% complication rate.
  • Arthroscopic: 2% complication rate.

Open excision has a higher rate of post-operative wrist weakness (Dias, 2007). The exact reason for this weakness has not been established and this observation may be a consequence of surgery, the possible severity of any underlying intercarpal laxity.

Please note: The long-term data is currently limited on arthroscopic treatment.


Wrist ganglion treatment: systematic review and meta-analysis - PubMed
Therapeutic I.

The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention - PubMed
We have evaluated the long-term outcome of excision, aspiration and no treatment of dorsal wrist ganglia prospectively in 236 (83%) of 283 patients who responded to a postal questionnaire at a mean of 70 months. The resolution of symptoms was similar between the treatment groups (p>0.3). Pain and …


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