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