eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Ganglion Cyst

Author: George J Kouris, MD, Senior Fellow, Department of Plastic and Reconstructive Surgery, Rush-Presbyterian-St Luke's Medical Center
Coauthor(s): Gordon Derman, MD, Associate Director, Hand and Upper Extremity Surgery, Assistant Professor, Department of Plastic and Reconstructive Surgery, Rush University Medical Center
Contributor Information and Disclosures

Updated: Nov 30, 2007

Introduction

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.

(See also the eMedicine articles Ganglion Cyst [Orthopedic Surgery] and Hand, Tumors: Benign [Plastic Surgery].)

History of the Procedure

Multiple 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.

Problem

Ganglion cysts are generally asymptomatic or minimally symptomatic. Symptoms such as limitation of motion, pain, paresthesias, and weakness are possible.

Frequency

Ganglion 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.

Etiology

Uncertainty 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.

Pathophysiology

Ganglion 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.

Presentation

Although 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

Indications

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 Anatomy

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.

Contraindications

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.

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