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Ganglia of the Hand and Wrist

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Diagram of a wrist ganglion (as seen from the side with the wrist turned palm upwards)

A ganglion is a tissue sac filled with a very thick, jelly-like material. It is usually painless, however when it does become painful, it may be a sign of rapid growth or pressure on a nearby nerve. Ganglia are the most common soft tissue growths of the hand and wrist, representing about 50-70% of all tumors in this area of the body.

A ganglion is usually solitary and may arise from anywhere in the wrist and hand. The most common sites are probably the top of the wrist at its midline, palmar wrist along the thumb side, and the end joints of the fingers at the distal interphalangeal joint.

Mucous cyst near the wrist

Ganglion cyst near the wrist.

Mucous cyst before removal

Cyst before removal.


Ganglia can occur at any age but are most prevalent between age 10 and 40, including childhood. Interestingly, as with many other illnesses, they affect women about 3 times more often than men. The right and left hands are affected with equal frequency. There has been no evidence of racial predisposition identified and no occupation has been specifically identified as likely to precipitate development of a ganglion. 

Causation

Ganglia develop from the connective tissue by liquefaction of collagen fibers (decay), increasing the amount of fluid. Though many of the ganglia arise directly adjacent to a joint, they appear to be connected by a one-way valve mechanism allowing fluid from the joint to exit into the sac.

Ganglia may arise adjacent to a joint or tendon sheath and may be connected by a long stalk. Thus, their superficial appearance may not accurately represent the site of origin. Ganglia arising in response to degenerative arthritis of the interphalangeal joint are called mucous cysts and frequently result in deformity of the fingernail. If they go untreated and rupture, they may become infectedCysts commonly occur in association with arthritis related to production of inflammatory fluid.

Nebraska Hand and Shoulder

Advanced degenerative arthritis at the end joint of the

finger (DIP joint) frequently results in a cyst known as a

mucous cyst and may cause significant nail deformity. 

 


 

Cyst from arthritis Cyst caused by arthritis. 
Cyst that has popped Cyst at nail fold that has popped.
Nail groove from cyst Pressure from a cyst just above the nail fold has
caused a deep trough in the nail. Removal of
the cyst will allow the nail to grow back
normally in about 4 months.

Symptoms

A wrist ganglion may produce pain and associated weakness, or present as a painless lump. Wrist ganglia may occur in association with ligamentous instability about the wrist. However, that is not a common finding. Ganglia may be noticed suddenly with or without pain. The majority probably develop slowly over a period of months. Spontaneous disappearance of ganglia has been reported in up to 58% of patients in some series.

It is not unusual to have a person come in with a ganglion thinking that it's causing the symptom of pain in the hand or wrist, when in fact the ganglion has probably been present all along and it is not really causing any discomfort. Associated problems such as de Quervain's tendonitis or carpal tunnel syndrome can cause the symptoms, thus drawing attention to the lump. (Differential diagnosis means the alternatives, which may be considered as possible explanations appearing in a similar fashion to ganglia.)

Arthritis
Bump on wrist
resembling a ganglion,
it is synovitis from
arthritis 
 
Ganglion on thumb
side of the wrist 
MRI 
MRI of a cyst in similar location
as picture to the left 

Ganglion
 Ganglion near wrist / ganglion removed 
 Cyst before removal / Cyst removed
 Ganglion at base of thumb / ganglion removed
  Cell Tumor Removed
 Hand with giant cell tumor / tumor removed


Evaluation

Most ganglia are obvious because of the classic location, size and symptoms. Physical examination is sufficient in making a diagnosis. A ganglion is usually not mobile and it frequently has bounce to touch. However, in an attempt to identify an underlying cause such as arthritis and exclude other explanations, X-rays may be necessary. 

Non-Operative Treatment

A person who notes a lump but is not experiencing pain or limitation as a result of the lump has choices. She may observe the lump and do nothing. The lump may be struck to try and pop it in hope that it scars down and does not recur. This is unpredictable. The other option is surgical removal (excisional biopsy). If the lump is large enough to be ugly or is bothersome it may need to be removed surgically. 

An attempt at withdrawing the jelly-like fluid from the ganglion with a needle is largely unsuccessful; usually the cyst will recur. Some physicians have reported good results from cortisone injection, but in my experience there is a high recurrence rate after injection. There is no good physiological reason why corticosteroids should have any effect on this problem. 

Cyst at the base of the finger Cyst removed from the A-2 pulley
A transverse incision
is made to remove 
the flexor cyst at 
the base of the finger.
  Cyst removed from 
the A-2 pulley.

Surgical Treatment

Ganglia arising directly off the pulley holding the flexor tendon in place (flexor retinacular cysts), are usually uncomfortable, interfere with grip, and usually require surgical excision. Increased discomfort can occur on ring fingers because of pressure from the ring on the mass and the adjacent digital nerve. 

Mucous Cysts:

Mucous Cyst Nail Deformity from Mucous Cyst
Example of a
mucous cyst.
Nail deformity from
a mucous cyst.

In the case of mucus cysts involving the finger or thumb distal interphalangeal joint, it's necessary to remove osteophytes (bone) from the underlying joint in addition to the soft tissue sac. A small 1/2" incision is made to remove the cyst. The semi-line prevents the scar from pulling tightly across the finger. Nail deformity coming from pressure against the growth area will then correct itself as the nail regrows. 

Mucous cyst before removal Mucous cyst after removal
Before surgical removal
of mucous cyst. 
After surgical removal
of mucous cyst. 
Traditional Wrist Ganglionectomy
Traditional Wrist
Ganglionectomy

Traditional Surgery (Wrist Ganglion):

Ganglion removal is best done using a small 1/2" transverse incision. The ganglion is exposed down to the joint and cut out along with a small wedge of the joint capsule. 

Arthroscopic Surgery:

There is an arthroscopic technique for removing a wrist ganglion. It is straightforward and requires two small puncture wounds in the wrist. It is as equally effective as open ganglion removal only it leaves an even smaller incisional scar and it costs a lot more due to use of elaborate equipment. The person determined to absolutely minimize the size of the scar and for whom "money is no object" - there aren't many of those around - arthroscopic removal of a ganglion is a safe, straightforward outpatient procedure. Surgical removal of ganglia in general is quite effective. However, in order to obtain a good result one must do the surgery in an operating room. This prevents injury to associated structures such as the superficial nerves and arteries and minimizes incision size. It decreases the chance of recurrence by allowing careful dissection down to the base of the ganglion and excision of the entire ganglion with its origin.

Physical or Occupational Therapy

It's rare for a person who undergoes ganglion removal to require hand therapy afterwards if treated at Nebraska Hand & Shoulder Institute, P.C. There is usually minimal discomfort after surgery. Since there are no restrictions necessary, the patient is allowed to move her fingers and wrist immediately. Significant stiffness develops only if the patient babies herself and refuses to do simple exercises. Total ganglion removal provides 85-90% chance of permanent cure. Surgery achieves difinitive tissue diagnosis and treatment in one sitting. If the specimen appears classical for a benign (non cancerous) ganglion, it may not be necessary to send it to a pathologist and incur an additional charge, though hospital regulations may mandate having the pathologist look at the specimen. Having an absolute tissue diagnosis often provides an unparalleled measure of confidence in a person by eliminating the fear of an undiagnosed cancer. 

References

Nebraska Hand and Shoulder Institute, P.C.

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