You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Ganglion CystArticle Last Updated: Nov 30, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: George J Kouris, MD, Senior Fellow, Department of Plastic and Reconstructive Surgery, Rush-Presbyterian-St Luke's Medical Center George J Kouris is a member of the following medical societies: American College of Surgeons Coauthor(s): Gordon Derman, MD, Associate Director, Hand and Upper Extremity Surgery, Assistant Professor, Department of Plastic and Reconstructive Surgery, Rush University Medical Center Editors: Peter M Murray, MD, Associate Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas R Hunt III, MD, John D Sherrill Professor of Surgery, Director, Division of Orthopedic Surgery, Surgeon in Chief, UAB Upper Extremity Fellowship, UAB Highlands Hospital, University of Alabama at Birmingham School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: ganglia, ganglions, hand cyst, hand tumor, wrist tumor, soft tissue tumor of the hand and wrist, mucous cyst, dorsal wrist ganglion, volar wrist ganglion, volar retinacular ganglion, distal interphalangeal ganglion, wrist cyst, mucin, ganglionectomy INTRODUCTIONSection 2 of 12
  This article focuses on the clinical presentation and treatment of the ganglion cyst. A complete history and thorough physical examination, complimented by radiographs and basic knowledge of the anatomy of the hand and common clinical patterns of presentation for ganglion cysts, vastly improve the accuracy of diagnosis and further direct treatment options. Once the diagnosis is established, both operative and nonoperative treatment options are available. History of the ProcedureMultiple nonsurgical modalities have been used over the years for ganglion cyst, including closed rupture, simple aspiration, heat, radiation, steroid injection, and sclerotherapy. The predominant nonsurgical method of treatment involves aspiration,1 sometimes followed by steroid injection. ProblemGanglion cysts are generally asymptomatic or minimally symptomatic. Symptoms such as limitation of motion, pain, paresthesias, and weakness are possible. FrequencyGanglion cysts are the most common soft-tissue tumors of the hand and wrist. They can occur in patients of any age, including children; approximately 15% of ganglion cysts occur in patients younger than 21 years. Seventy percent of ganglion cysts occur in patients between the second and fourth decades of life. Women are affected 3 times as often as men. No predilection exists for the right or left hand, and occupation does not appear to increase the risk of ganglion formation. EtiologyUncertainty exists regarding the origin of ganglion cysts. The most widely held physiologic explanation attributes cyst formation to mucoid degeneration of collagen and connective tissues. This theory implies that a ganglion represents a degenerative structure that houses the myxoid changes of connective tissue. A more recent theory, postulated by Angelides, attributes cyst formation to trauma or tissue irritation.2, 3 Modified synovial cells lining the synovial-capsular interface are stimulated to produce mucin. Mucin dissects along the attached joint ligament and capsule to form capsular ducts, which function as valvelike structures producing lakes. The ducts and lakes of mucin eventually coalesce to form a solitary ganglion cyst. PathophysiologyGanglion cysts may be single or multilobulated. They are smooth-walled, translucent, and white. Their contents are characterized as clear and highly viscous mucin that consists of hyaluronic acid, albumin, globulin, and glucosamine. The cyst wall is made up of collagen fibers. Multilobulated cysts may communicate through a network of ducts. No necrosis or epithelial or synovial cellularity of the wall occurs. ClinicalAlthough ganglion cysts are generally asymptomatic, presenting symptoms may include limitation of motion, pain, paresthesias, and weakness. Ganglions are usually solitary, and they rarely exceed 2 cm in diameter. They can involve almost any joint of the hand and wrist. Dorsal wrist, volar wrist, volar retinacular, and distal interphalangeal ganglion cysts constitute the vast majority of ganglions of the hand and wrist. Dorsal wrist ganglia occurring over the scapholunate ligament of the wrist represent 60-70% of all ganglia. The volar wrist is the next most common site of occurrence; 20% of all ganglia occur in the volar wrist. The flexor tendon sheath of the fingers, particularly at the level of the A1 pulley, is involved in 10-12% of ganglia.4 A ganglion of the distal interphalangeal joint is also known as a mucous cyst.5 This cyst usually arises dorsally between the distal joint crease and the eponychium on either the radial or ulnar side of the extensor tendon. Mucous cysts are usually associated with joint abnormalities and degenerative arthritis at the distal interphalangeal joint. A mucous cyst can produce longitudinal grooving of the nail plate that results from chronic local pressure on the germinal matrix of the nail bed.5 The experienced hand surgeon is also familiar with the occult dorsal ganglion, which can manifest with tenderness around the scapholunate fossa region.6 Pain occurs with extreme wrist motion, especially in extension. Radiographic findings are often normal, and MRI is useful in confirming the diagnosis. Surgical excision of the occult ganglion is successful for alleviating pain and symptoms in the majority of cases.6 INDICATIONSSection 3 of 12
Indications for treatment include limitation of motion, pain, weakness, and paresthesias. Treatment is also indicated if malignancy is a concern or if the patient finds the lesion aesthetically displeasing. Cysts that drain externally require attention because of the risk of development of a serious joint or soft-tissue infection. RELEVANT ANATOMYSection 4 of 12
A ganglion is a well-circumscribed mucin-filled cyst with a smooth translucent wall that is closely associated with a joint or tendon sheath. Ganglions are usually connected by a stalk to an underlying joint capsule or ligament. They commonly arise from the dorsum of the wrist, where they are specifically associated with the scapholunate ligament of the wrist. Volar wrist ganglions are less common, and many are associated with the scaphotrapezial joint of the wrist. The location of the radial artery is particularly important in the assessment of volar wrist ganglions because they are often intimately associated with this vessel. Care must be taken to preserve the radial artery during dissection of a volar wrist ganglion because injury to this vessel may potentially compromise circulation to the hand. CONTRAINDICATIONSSection 5 of 12
Any underlying disease process that increases operative and/or perioperative morbidity should be closely investigated and addressed before proceeding with this surgery, which is mainly elective except in cases of infection or suspected malignancy. WORKUPSection 6 of 12
Imaging Studies
Other Tests
TREATMENTSection 7 of 12
Medical therapyThe predominant current nonsurgical method of treatment involves aspiration alone,1 sometimes followed by steroid injection. This is especially successful for tendon sheath ganglions in the hand and digits.10 Caution should be exercised when performing multiple steroid injections to avoid the complications of skin and fat atrophy and thinning, as well as hypopigmentation. Surgical therapySurgical treatment involves total ganglionectomy with removal of a modest portion of the attached capsule. Surgical treatment of dorsal carpal ganglion cysts should be directed toward removal of the cyst and attachments to the scapholunate ligament. Dorsal lesions are usually approached through a transverse incision. Excision of a volar carpal ganglion involves cyst removal along with removal of attachments to the radiocarpal capsule of the scaphotrapezial joint. Volar wrist ganglia are usually approached through a longitudinal incision. A volar retinacular ganglion that arises at the level of A1 pulley may be approached through transverse incision near the distal palmar crease. Other ganglia of the volar digits are best approached through Bruner or midlateral incisions. Once the radial and ulnar neurovascular bundles are identified and gently retracted, the cyst is removed, along with a small portion of the tendon sheath.11 A mucous cyst can be approached through a curved oblique incision, or an H-shaped incision, over the dorsal distal interphalangeal joint. If the overlying skin cannot be separated from the cyst, it is excised in an elliptical fashion. The cyst is dissected proximally to the joint capsule of the distal interphalangeal joint and then excised along with the joint capsule. If an osteophyte is present, it is usually removed at the time of mucous cyst excision. If skin coverage is insufficient, a local flap, skin graft, or both may be required for subsequent closure.12 Intraoperative detailsWith the upper extremity anesthetized (with an axillary block in most situations), the arm is prepared and draped in the standard fashion. A pneumatic tourniquet on the upper arm is inflated to maintain a bloodless operative field to avoid injury to the delicate tissues in the region. The operation includes dissection of the wall of the ganglion with careful preservation of its cystic structure if possible. Because all ganglion cysts originate from the capsule or ligament of a joint, the entire cyst and stalk must be removed down to its origin on the ligament or joint capsule. A modest excision of the capsule must be included along with the cyst and stalk. Removal is simplified if the cyst is kept intact, because decompression makes it difficult to identify the limits of the cyst borders, as well as their ligamentous and capsular attachments. Postoperative detailsPostoperative care following excision of wrist ganglion involves placement of a protective dressing, which is left in place for 2-3 days. A bulky dressing or a volar splint is used to reduce pain, bleeding, and swelling. Mobilization is initiated after several days, and range-of-motion exercises are encouraged to restore wrist and finger mobility. COMPLICATIONSSection 8 of 12
Ganglion recurrence is the most common complication following treatment. Surgical complications, including infection, bleeding, recurrence, nerve and tendon injury, scarring, joint instability, and vascular injury, are possible. Postoperative joint stiffness and decreased range of motion can also occur. Depending on anatomic location, injury to the superficial sensory branch of the radial nerve is a potential complication following dorsal ganglion excision, whereas excision of a volar ganglion may injure the radial artery. OUTCOME AND PROGNOSISSection 9 of 12
Recurrence rates after nonoperative ganglion treatment are consistently higher (30-60%) than those after surgical treatment (5-15%). Total ganglionectomy results in an 85-95% cure rate if the cyst and its stalk are removed along with a modest cuff of ligamentous or joint capsule attachments. Recurrence following surgical treatment is believed to result from incomplete removal of capsular attachments, ligamentous attachments, or both, as well as offending bony abnormalities. FUTURE AND CONTROVERSIESSection 10 of 12
Pharmacologic agents are under constant investigation in the medical arena. Potential advances in sclerosing agents specific to the treatment of ganglion cysts may perhaps lead to a definitive medical treatment of ganglions, which would avoid surgery. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Nov 30, 2007 | |||||||||||||||||||||||||||||||||
