منو منو

Ganglion Cysts

  • SUMMARY

    • Ganglion Cysts are mucin-filled synovial cysts and are the most common masses found in the wrist and hand. 

    • Diagnosis can be made clinically with a firm and well circumscribed mass that transilluminates.

    • Treatment can be observation for majority of ganglions. Surgical excision is indicated for ganglion cysts associated with severe symptoms or neurovascular manifestations.

  • EPIDEMIOLOGY

    • Incidence

      • common

        • most common hand mass (60-70%)

    • Anatomic location

      • dorsal carpal (70%)

        • originate from SL articulation

      • volar carpal (20%)

        • originate from radiocarpal or STT joint

      • volar retinacular (10%) 

         

        • originate from herniated tendon sheath fluid

      • dorsal DIP joint (mucous cyst, associated with Heberden's nodes) 

      • may also occur in the lower extremity

        • most commonly about the knee 

  • ETIOLOGY

    • Mechanism

      • trauma

      • mucoid degeneration

      • synovial herniation

    • Pathophysiology

      • filled with fluid from tendon sheath or joint

      • no true epithelial lining

    • Associated conditions

      • median or ulnar nerve compression 

         

        • may be caused by volar ganglion

      • hand ischemia due to vascular occlusion

        • may be caused by volar ganglion

  • PRESENTATION

    • Symptoms

      • usually asymptomatic

      • may cause issues with cosmesis

    • Physical exam

      • inspection

        • transilluminates (transmits light through tissue)

      • palpation

        • firm and well circumscribed

        • often fixed to deep tissue but not to overlying skin

      • vascular exam

        • Allen's test to ensure radial and ulnar artery flow for volar wrist ganglions

  • IMAGING

    • Radiographs

      • normal

    • MRI

      • indications

        • not routinely indicated

      • findings

        • shows well marginated mass with homogenous fluid signal intensity 

    • Ultrasound

      • useful for differentiating cyst from vascular aneurysm

      • may provide image localization for aspiration while avoiding artery

  • HISTOLOGY

    • Biopsy

      • indications

        • not routinely indicated

      • findings

        • will show mucin-filled sac with no true epithelial/synovial lining 

           

  • TREATMENT

    • Nonoperative

      • observation

        • indications

          • first line of treatment in adults

          • children 

             

            • 76% resolve within 1 year in pediatric patients 

      • closed rupture

        • home remedy

        • high recurrence

      • aspiration

        • indications

          • second line of treatment in adults with dorsal ganglions

          • aspiration typically avoided on volar aspect of wrist due to radial artery

        • outcomes

          • higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to attempt 

             

    • Operative

      • surgical resection

        • indications

          •  
        • technique

          • requires adequate exposure to identify origin and allow resection of stalk and a portion of adjacent capsule

          • at dorsal DIP joint: must resect underlying osteophyte

        • results

          • volar ganglions have higher recurrence after resection than dorsal ganglions (15-20% recurrence) 

  • COMPLICATIONS

    • With aspiration

      • infection (rare)

      • neurovascular injury

    • With excision

      • infection

      • neurovascular injury (radial artery most common)

      • injury to scapholunate interosseous ligament

      • stiffness

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