Excision of Ganglion Cysts of the Wrist and Hand

Daniel J. Nagle, MD, FACS, FAAOS

Jay V. Kalawadia, MD

Dr. Nagle or an immediate family member serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand. Neither Dr. Kalawadia nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

INTRODUCTION

Ganglion cysts are commonly seen by both hand and general orthopaedic surgeons. Although the true etiology of ganglion cysts is unknown, pathologic analysis suggests that some form of mucoid collagen degeneration is responsible for the process.¹ Injection studies suggest that ganglion cysts are created by a rent in the joint capsule, causing synovial fluid to leak into the surrounding tissues. This theory postulates the formation of a one-way valve that leaks joint fluid from the joint space to the cyst via a pedicle. In addition, proponents of this theory believe that underlying joint pathology usually exists and leads to thinning of the capsule, allowing the initial formation of the rent.² Other theories postulate that metaplasia of cells derived from connective tissue (ie, ligaments, joint capsules, and tendon sheaths) produces mucin, which coalesces into cysts. In contrast, this theory suggests that the cyst forms initially, followed by the formation of the pedicle.²^,³

Regardless of etiology, histologic analysis shows that mucin-filled cysts are usually composed of randomly organized collagen fibers without any endothelial lining.²^,⁴ The viscous material found within the ganglion cysts is composed predominantly of hyaluronic acid, with smaller amounts of glucosamine, globulins, and albumin.²^,⁵ Ganglions can occur at any joint or over any tendon sheath, but they most often occur in the wrist, followed by the flexor tendon digital sheaths (retinacular cysts) and the distal interphalangeal joints (mucous cysts).¹

PATIENT SELECTION

Patient Presentation

Patients with ganglion cysts present to the clinic for several reasons. Westbrook et al⁶ showed that about 28% of patients are worried about malignancy, 38% are bothered cosmetically, 26% are in pain, and 8% are experiencing compromised sensation or function. Ganglion cysts manifest in all age groups. Carpal ganglions most often present in young adults, with women presenting three times more commonly than men. Mucous cysts have an arthritic component and are more common in the elderly.³ In children younger than 12 years, ganglion cysts occur nearly twice as often in girls as in boys. In the pediatric population, volar ganglion cysts are more common than dorsal cysts (1.2:1); this differs from adults.⁷

Ganglion cysts occurring along the dorsal aspect of the wrist are most common, comprising 60% to 70% of these cysts; they manifest over the scapholunate ligament in 75% of cases¹^,²^,³ (Figure 1). Ganglion cysts manifest in the volar wrist 13% to 20% of the time.² Of volar wrist ganglion cysts, 67% occur over the radioscaphoid joint; the remaining 33% occur over the scaphotrapezial and metacarpotrapezial joints.¹^,² Ganglion cysts can occur at any joint, however, and they often are seen over the ulnocarpal and distal radioulnar joints as well. Retinacular
and mucous cysts occur much less frequently, comprising only about 10% of all ganglion cysts each.²

FIGURE 1 Illustration shows a dorsal ganglion cyst, which typically manifests over the scapholunate ligament. A, cyst; B, stalk of cyst at its confluence with dorsal wrist capsule and scapholunate interosseous ligament; C, dorsal wrist capsule; D, scapholunate interosseous ligament; E, scaphoid; F, lunate; G, capsular microcyst.

A patient’s history and physical examination is often the best diagnostic modality. Physical examination will reveal a soft, firm mass with well-circumscribed edges. When masses become large enough, they will transilluminate, which can help differentiate them from solid masses.

Patients generally describe a classic history of waxing and waning of the cyst over months to years. Other symptoms include pain (usually described as an annoyance), tenderness with palpation, and decreased range of motion or grip strength.² Small occult dorsal wrist ganglion cysts can be a cause of chronic dorsal wrist pain. Interestingly, the dorsal wrist pain often dissipates once the ganglion becomes palpable or visible. Less commonly, ganglion cysts can cause nerve irritation of the palmar cutaneous nerve, the deep ulnar motor branch, the median nerve within the carpal tunnel, or the ulnar nerve within the Guyon canal due to their compressive effects on adjacent nerves. The location and size of the ganglion cyst usually do not correlate with patient symptoms; many people with ganglion cysts are asymptomatic.

Patients with retinacular cysts also may report pain and paresthesias as a result of compression of the digital nerves. In addition to being unsightly, mucous cysts can cause pain, thinning of the overlying skin, and irregularities of the nail.⁸

Although ganglion cysts are the most commonly occurring soft-tissue mass in the wrist and hand, accounting for 60% of hand and wrist tumors, a broad differential diagnosis should be considered.¹^,³ Other commonly presenting soft-tissue masses in the wrist and hand include vascular aneurysms and malformations, giant cell tumors, brown tumors, tendon sheath fibromas, lipomas, hemangiomas, glomus tumors, osteophytes, and schwannomas. Although rare, synovial cell sarcoma also must be included in the differential diagnosis.

INDICATIONS

Patient symptoms and impairment in quality of life generally dictate whether to pursue surgical treatment. From 50% to 79% of ganglion cysts of the wrist resolve spontaneously over 5 years.²^,⁴^,⁹ Observation is thus a reasonable treatment option in select patients with minimal symptoms. Surgical indications include pain, stiffness, and interference with performance of certain movements of the hand and wrist. Although less frequent, nerve compression or impending overlying skin necrosis, especially from large mucous cysts, are other surgical indications.³

Aspiration of the cyst sometimes provides temporary pain relief as well as serving as a diagnostic modality when the viscous mucin is extracted. Recurrence rates are between 13% and 100%, however; thus, aspiration is considered only a temporary solution for carpal ganglion cysts and mucous cysts.³^,⁴^,⁵^,⁸ Studies have shown aspiration to be more successful in treating retinacular cysts than carpal ganglion and mucous cysts, leading to recurrence less than 30% of the time.²^,³ In performing aspiration of retinacular cysts, the surgeon should be cautious not to injure the digital nerves. Variations of aspiration, such as using concomitant steroid injection or performing a trephination technique, have shown no benefit and yield similar recurrence rates.³^,⁹ In addition, postaspiration splinting has shown no benefit.³

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