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SUMMARY
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Ganglion Cysts are mucin-filled synovial cysts and are the most common masses found in the wrist and hand.
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Diagnosis can be made clinically with a firm and well circumscribed mass that transilluminates.
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Treatment can be observation for majority of ganglions. Surgical excision is indicated for ganglion cysts associated with severe symptoms or neurovascular manifestations.
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EPIDEMIOLOGY
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Incidence
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common
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most common hand mass (60-70%)
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Anatomic location
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dorsal carpal (70%)
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originate from SL articulation
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volar carpal (20%)
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originate from radiocarpal or STT joint
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- volar retinacular (10%)
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originate from herniated tendon sheath fluid
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dorsal DIP joint (mucous cyst, associated with Heberden's nodes)
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may also occur in the lower extremity
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most commonly about the knee
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ETIOLOGY
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Mechanism
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trauma
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mucoid degeneration
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synovial herniation
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Pathophysiology
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filled with fluid from tendon sheath or joint
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no true epithelial lining
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Associated conditions
- median or ulnar nerve compression
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may be caused by volar ganglion
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hand ischemia due to vascular occlusion
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may be caused by volar ganglion
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- median or ulnar nerve compression
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PRESENTATION
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Symptoms
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usually asymptomatic
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may cause issues with cosmesis
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Physical exam
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inspection
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transilluminates (transmits light through tissue)
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palpation
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firm and well circumscribed
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often fixed to deep tissue but not to overlying skin
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vascular exam
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Allen's test to ensure radial and ulnar artery flow for volar wrist ganglions
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IMAGING
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Radiographs
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normal
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MRI
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indications
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not routinely indicated
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findings
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shows well marginated mass with homogenous fluid signal intensity
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Ultrasound
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useful for differentiating cyst from vascular aneurysm
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may provide image localization for aspiration while avoiding artery
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HISTOLOGY
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Biopsy
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indications
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not routinely indicated
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findings
- will show mucin-filled sac with no true epithelial/synovial lining
- will show mucin-filled sac with no true epithelial/synovial lining
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TREATMENT
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Nonoperative
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observation
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indications
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first line of treatment in adults
- children
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76% resolve within 1 year in pediatric patients
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closed rupture
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home remedy
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high recurrence
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aspiration
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indications
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second line of treatment in adults with dorsal ganglions
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aspiration typically avoided on volar aspect of wrist due to radial artery
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outcomes
- higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to attempt
- higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to attempt
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Operative
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surgical resection
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indications
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technique
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requires adequate exposure to identify origin and allow resection of stalk and a portion of adjacent capsule
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at dorsal DIP joint: must resect underlying osteophyte
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results
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volar ganglions have higher recurrence after resection than dorsal ganglions (15-20% recurrence)
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COMPLICATIONS
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With aspiration
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infection (rare)
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neurovascular injury
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With excision
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infection
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neurovascular injury (radial artery most common)
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injury to scapholunate interosseous ligament
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stiffness
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