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Ganglion Cyst of Wrist and Hand

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function, or has an unacceptable appearance, there are several treatment options available.

A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

Ganglion cysts can develop in several of the joints in the hand and wrist, including both the top and underside of the wrist, as well as the end joint of a finger, and at the base of a finger. They vary in size, and in many cases, grow larger with increased wrist activity. With rest, the lump typically becomes smaller.

Ganglion Wrist Cyst

CAUSES

It is not known what triggers the formation of a ganglion. They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Ganglion cysts that develop at the end joint of a finger — also known as mucous cysts — are typically associated with arthritis in the finger joint, and are more common in women between the ages of 40 and 70 years.

SYMPTOMS

Most ganglions form a visible lump, however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms, if a cyst puts pressure on the nerves that pass through the joint, it can cause pain, tingling, and muscle weakness.

Large cysts, even if they are not painful, can cause concerns about appearance.

DOCTOR EXAMINATION

Medical History and Physical Examination

During the initial appointment, your doctor will discuss your medical history and symptoms. He or she may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful.

Pressure may be applied to identify any tenderness. Because a ganglion is filled with fluid, it is translucent. Your doctor may shine a penlight up to the cyst to see whether light shines through.

Imaging Tests

X-rays. These tests create clear pictures of dense structures, like bone. Although x-rays will not show a ganglion cyst, they can be used to rule out other conditions, such as arthritis or a bone tumor.

Magnetic resonance imaging (MRI) scans or ultrasounds. These imaging tests can better show soft tissues like a ganglion. Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

TREATMENT

Nonsurgical Treatment

Initial treatment of a ganglion cyst is not surgical.

    • Observation. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur.
    • Immobilization. Activity often causes the ganglion to increase in size and also increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
    • Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.

This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Aspiration frequently fails to eliminate the ganglion because the “root” or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not removed. In many cases, the ganglion cyst returns after an aspiration procedure.

Aspiration procedures are most frequently recommended for ganglions located on the top of the wrist.

Nonsurgical Treatment

Initial treatment of a ganglion cyst is not surgical.

    • Observation. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur.
    • Immobilization. Activity often causes the ganglion to increase in size and also increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
    • Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.

This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Aspiration frequently fails to eliminate the ganglion because the “root” or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not removed. In many cases, the ganglion cyst returns after an aspiration procedure.

Aspiration procedures are most frequently recommended for ganglions located on the top of the wrist.

Surgical Treatment

Your doctor may recommend surgery if your symptoms are not relieved by nonsurgical methods, or if the ganglion returns after aspiration. The procedure to remove a ganglion cyst is called an excision.

Surgery involves removing the cyst as well as part of the involved joint capsule or tendon sheath, which is considered the root of the ganglion. Even after excision, there is a small chance the ganglion will return.

Excision is typically an outpatient procedure and patients are able to go home after a period of observation in the recovery area. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed 2 to 6 weeks after surgery.

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Removal of Ganglion Cyst

Ganglion cyst removal, or ganglionectomy, is the removal of a fluid-filled sac on the skin of the wrist, finger, or sole of the foot. The cyst is attached to a tendon or a joint through its fibers and contains synovial fluid, which is the clear liquid that lubricates the joints and tendons of the body. The surgical procedure is performed in a doc tor’s office. It entails aspiration, or draining fluid from the cyst with a large hypodermic needle. The cyst may also be excised (removed by cutting).

Purpose

Ganglion cysts are sacs that contain the synovial fluid found in joints and tendons. They are the most common forms of soft tissue growth on the hand and are distinguished by their sticky liquid contents. The cystic structures are attached to tendon sheaths via a long thin tube-like arm. About 65% of ganglion cysts occur on the upper surface of the wrist, with another 20%–25% on the volar (palm) surface of the hand. Most of the remaining 10%–15% of ganglion cysts occur on the sheath of the flexor tendon. In a few cases, the cysts emerge on the sole of the foot.

Ganglion cysts have appeared in medical writing from the time of Hippocrates. Their exact cause is unknown. There are some indications, however, that ganglion cysts result from trauma to or deterioration of the tissue lining in the joints that secretes synovial fluid.

Ganglion cysts can emerge quite quickly, and can disappear just as fast. They are benign growths, usually causing problems in the functioning of the joints or tendons of the hand or finger only when they are large. Many people do not seek medical attention for ganglion cysts unless they cause pain, affect the movement of the nearby tendons, or become particularly unsightly.

An old traditional treatment for a ganglion cyst was to hit it with a Bible, since the cysts can burst when struck. Today, cysts are removed surgically by aspiration but often reappear. Surgical excision is the most reliable treatment for ganglion cysts, but aspiration is the more common form of therapy.

Demographics

Ganglion cysts account for 50%–70% of all soft tissue tumors of the hand and wrist. They are most likely to occur in adults between the ages of 20 and 50, with the female: male ratio being about 3: 1. Most ganglion cysts are visible; however, some are occult (hidden). Occult cysts may be diagnosed because the patient feels pain in that part of the hand or has noticed that the tendon cannot move normally. In about 10% of cases, there is associated trauma.

Description

Patients are given a local or regional anesthetic in a doctor’s office. Two methods are used to remove the cysts. Most physicians use the more conservative procedure, which is known as aspiration.

Aspiration

  • An 18- or 22-gauge needle attached to a 20–30-mL syringe is inserted into the cyst. The doctor removes the fluid slowly by suction.
  • The doctor may inject a medication into the joint after the fluid has been withdrawn.
  • A compression dressing is applied to the site.
  • The patient remains in the office for about 30 minutes.

Excision

Some ganglion cysts are so large that the doctor recommends excision. This procedure also takes place in the physician’s office with local or regional anesthetic.

Excision of a ganglion cyst is performed as follows:

  • The physician palpates, or feels, the borders of the sac with the fingers and marks the sac and its periphery.
  • The sac is cut away with a scalpel.
  • The doctor closes the incision with sutures and applies a bandage.
  • The patient is asked to remain in the office for at least 30 minutes.

Diagnosis/Preparation

Ganglion cysts are fairly easy to diagnose because they are usually visible and pliable to the touch. They are distinguished from other growths by their location near tendons or joints and by their fluid consistency. Ganglion cysts are sometimes confused with a carpal boss (a bony, non-mobile spur on the top of the wrist), but can usually be distinguished by the fact that they can be moved and are usually less painful for the patient.

The doctor may schedule one or more imaging studies of the hand and wrist. An x-ray may reveal bone or joint abnormalities. Ultrasound may be used to diagnose the presence of occult cysts.

Aftercare

Patients should avoid strenuous physical activity for at least 48 hours after surgery and report any signs of infection or inflammation to their physician. A follow-up appointment should be scheduled within three weeks of aspiration or excision. Excision may result in some stiffness after the surgery and some difficulties in flexing the hand because of scar tissue formation.

Risks

Aspiration has very few complications as a treatment for ganglion cysts; the most common aftereffects are infection or a reaction to the cortisone injection. Complications of excision include some stiffness in the hand and scar formation. Ganglion cysts recur after excision in about 5–15% of cases, usually because the cyst was not completely removed.

Normal results

Aspirated ganglion cysts disappear and cause no further symptoms in 27–67% of cases. They may, however, reoccur and require repeated aspiration. Aspiration combined with an injection of cortisone has more success than aspiration by itself. Excision is a much more reliable procedure, however, and the stiffness that the patient may experience after the procedure eventually goes away. The formation of a small scar is normal.

Morbidity and mortality rates

The only risks for ganglion cyst removal are infections or inflammation due to the cortisone injection. There is a small risk of damage to nearby nerves or blood vessels.

Alternatives

Alternatives to aspiration and excision in the treatment of ganglion cysts include watchful waiting and resting the affected hand or foot. It is quite common for ganglion cysts to fade away without any surgical treatment.

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