Ganglions Treatment & Management

For wrist ganglions, initial therapy may consist of simple splint immobilization and nonsteroidal anti-inflammatory drugs (NSAIDs). Closed rupture (by a sharp blow with a heavy object) is associated with a 22-66% recurrence rate and is inappropriate in-office treatment. One wrist fracture was reported from a direct blow.^{[1, 2, 3, 12, 13, 14, 15]}

Multiple punctures with a needle preceded by the administration of a local anesthetic is associated with a 13% cure rate. The cure rate increases to 40% if splinted for 3 weeks after one aspiration or puncture. This rate increases to 85% after 3 sessions. The addition of injectable steroids has no apparent benefit. Treatment by suturing the lesion externally is associated with a 95% 6-month cure rate but an unacceptable rate of infection. The patient should be reassured that these are benign cysts and rarely cause much disability.

Management for occult dorsal ganglions is similar to that of dorsal ganglions. Aspiration can be accomplished with sonographically guided needle placement, but surgical excision is sometimes necessary.

Caution must be exercised in the aspiration of volar radial lesions because of the proximity of the radial artery. This procedure, especially when combined with the injection of steroids, is not recommended.

For volar retinacular (flexor tendon sheath) ganglions, needle rupture followed by steroid injection and digital massage may work in as many as 70% of patients. Digital nerve injury is a reported complication. Needle rupture in these cysts on the radial or ulnar aspect relative to the midline is risky for this reason.

Observation is also appropriate for mucous cysts. Aspiration with or without steroids has been associated with a recurrence rate of as high as 50%. This and other methods commonly used by dermatologists (freezing, etc) are associated with a risk of septic arthritis.

Nonsurgical management for CMC boss, PIP joint ganglions, extensor tendon ganglions, and intraosseous ganglions consists of observation.

The most accepted surgical treatment for ganglion cyst involves removal of the masses with an open surgical technique.^{[1, 2, 3, 12, 13, 14]}

Arthroscopic resection of dorsal ganglions has become popular over the past 10 years. Use of the arthroscope affords the surgeon the added benefit of completely evaluating the joint.^{[12, 16]}

For volar wrist ganglion, the patency of the patient's radial and ulnar arteries should be preoperatively assessed with an Allen test. This test is important because the volar wrist ganglion may interdigitate with the radial artery. In some instances, the radial artery may need to be repaired or even ligated. A standard complete hand and wrist examination, including a range-of-motion assessment, a strength assessment, and neurologic function testing, should be performed preoperatively.

Dorsal ganglions can be approached through a transverse or longitudinal dorsal wrist incision. A smaller secondary incision may be required if the ganglion lies elsewhere but its stalk is attached to the SL ligament. The ganglion usually resides between the extensor pollicis longus (EPL) and extensor digitorum communis (EDC) tendons.

The main cyst and pedicle are mobilized down to the dorsal wrist capsule, which is opened along the border of the radius and scaphoid. The ganglion and its capsular attachments then are excised from the SL ligament, taking great care to avoid injury to that ligament. A limited synovectomy is performed, and the joint is thoroughly irrigated. The resected tissue is submitted for pathologic analysis to confirm the diagnosis. The capsule is not closed, and the skin is sutured after the tourniquet is released and hemostasis obtained. A bulky, mildly compressive dressing with or without a volar splint is applied.

Dorsal wrist ganglions

The arthroscope is set up with a tower and finger traps to provide 10-12 lb of distraction across the wrist. General or regional anesthesia can be used. A tourniquet should be applied above the elbow in case the surgeon needs to convert to an open procedure.

First, an arthroscopic examination of the wrist joint is performed with the arthroscope placed in the 3-4 portal, and a blunt probe is placed in the 4-5 portal. Once the ganglion cyst is identified and localized, the arthroscope is placed in the 6R portal, and a full radius resector is placed through the 3-4 portal. Often, the 18-gauge needle used to establish the 3-4 portal pierces the ganglion. The ganglion often appears as a pearl suspended from the dorsal capsule (61% of cases). The ganglion is resected from the dorsal capsule and the SL ligament.

Caution must be used to prevent damage to the SL ligament and overlying extensor tendons. The portals are closed with simple sutures, and the wrist is placed in a volar splint. Use of the midcarpal portals facilitates the removal of ganglions that emanate from the confluence of the capitate, lunate, and scaphoid.

Occult dorsal ganglions

Occult dorsal wrist ganglions are excised through a transverse or longitudinal dorsal wrist incision, depending on the location of the lesion.

Volar wrist ganglions

The approach to the excision of a volar ganglion must allow for extension into the carpal tunnel or thenar muscles. A serpiginous incision centered on the ganglion, usually just radial to the FCR tendon, is used. Care must be used to protect the radial artery, the lateral antebrachial cutaneous nerve, and the superficial radial nerve. The radial artery must be dissected free from the cyst and its appendages. This step may require leaving a wall of the cyst attached to the radial artery.

The FCR is released from its sheath and retracted in an ulnar direction. The palmar cutaneous branch of the median nerve lies on the ulnar side of this tendon in approximately 90% of patients. The ganglion then is tracked down to the volar capsule and excised with a ring of capsule. The volar carpal ligaments should be protected. A limited synovectomy is performed, and the joint is thoroughly irrigated. The capsule should not be closed. After the tourniquet is released and hemostasis is obtained, the skin is closed, and a bulky dressing is applied with or without a splint.

For ulnar-sided ganglions, a longitudinal incision is used along the flexor carpi ulnaris (FCU) tendon. The ulna neurovascular bundle should be identified and retracted in a radial direction while the FCU is retracted in an ulnar direction. The dorsal sensory branch of the ulnar nerve should be identified and protected during proximal dissection. Because many of these cysts arise from the pisotriquetral joint, the Guyon canal may need to be opened and its contents protected, for adequate exposure and resection of the stalk. Once excised, the incision is closed as noted previously.

Volar retinacular ganglions

With volar retinacular (flexor tendon sheath) ganglions, a Bruner incision is used to dissect the mass and tendon sheath. Both digital bundles should be identified and protected. The mass and a small part of the tendon sheath are excised. The tendon sheath is not repaired, and the skin is sutured. A bulky dressing is applied, and early unrestricted motion is allowed.

Mucous cysts

Multiple incisions have been described for resection of the cyst. What is clear is that excision of the skin overlying the cyst, and subsequently a skin graft, is not necessary. Generally, any skin defect that remains heals readily by secondary intention. The incision for a mucoid cyst is performed at the level of the joint not over the cyst itself. Generally, a simple transverse incision at the joint level suffices. A curved L- shaped incision or an H- shaped incision allows wider access to the cyst and the underlying osteophytes.

Care must be taken not to injure the germinal matrix, which may extend more than 5 mm proximal to the eponychial fold. Also, the insertion of the terminal extensor tendon is left intact. The joint is approached through a longitudinal incision just radial or ulnar to the extensor tendon. Repairing this incision during closure is not necessary. The cyst, stalk, dorsal capsule, synovium, and all associated osteophytes must be removed. An extension splint is used for 10-14 days.

Proximal interphalangeal joint ganglions

A longitudinal incision is made over the PIP joint. The lateral band is released from the transverse ligament and retracted dorsally. The ganglion and its pedicle are traced to the capsule through the extensor system. A small elliptical incision through the oblique fibers is usually necessary to mobilize the ganglion. The joint capsule and synovial lining between the collateral ligament and the extensor insertion on the middle phalanx are excised. The skin is closed, and a soft dressing or short-term splint is applied. Early motion is recommended.

Extensor tendon ganglions

A transverse incision is made over the mass. The ganglion is mobilized and dissected off the extensor tendon, and it is stalk traced to the adjacent MCP joint. Nearby synovial tissue is removed, as well as an ellipse of capsular tissue from the MCP joint where the stalk originates. The skin is closed, and early motion is recommended. Recurrence is rare.

Dorsal retinacular ganglions

The ganglion lies within the first dorsal compartment. The first compartment is appropriately released and explored, and the ganglion is excised.

Carpal tunnel ganglions

Ganglions can arise within the carpal tunnel, compressing the median nerve and causing carpal tunnel syndrome. Some of the volar wrist ganglions have been known to extend into the carpal tunnel as well. In either instance, when the carpal tunnel is being released, the ganglion, if present, should be removed.

Ulnar canal ganglions

Ganglions within the Guyon canal can cause compression of the ulnar nerve, resulting in sensory and motor disturbances. These ganglions seem to arise form the hamate and travel through the hypothenar muscles to the canal. These ganglions can cause atrophy of the interosseous muscles by compressing the motor branch of the ulnar nerve. When suspected, these ganglions can be imaged by means of MRI prior to Guyon canal exploration.

Interosseous ganglions

In cases in which the patient is experiencing pain and in which all other sources for the pain are excluded, surgical treatment of these ganglions may be undertaken. When indicated, curettage and bone grafting of the lesion are performed. At the time of the surgery, the joints of the involved bone should be explored to rule out other sources for the patient's symptoms.

With dorsal wrist ganglions, a volar wrist splint is applied postoperatively. The splint and dressing are removed between postoperative days 10 and 14. Early motion is encouraged. Sutures are removed on postoperative day 14, and physical therapy continues until the full range of motion and strength is achieved.

The postoperative care for most of the other types of ganglions is similar to that described above. Infected mucous cysts may be left open, and wet-to-dry dressing changes may be required.

Patients are followed up for approximately 2 months after surgery to ensure their full return to activities. The surgeon must check the final pathologic report about the nature of the tissue removed at the time of ganglion excision.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education articles Ganglion Cyst and Carpal Tunnel Syndrome.

The most common complication with the surgical treatment of dorsal ganglions is recurrence secondary to inadequate or incomplete resection. If the cyst returns many years after treatment, it most likely represents a new ganglion. Stiffness can occur, particularly the loss of volar flexion if early motion is not initiated or if the patient remains in a splint for too long. Neuromas can occur if the sensory branches of the radial or ulna nerves are damaged. Perhaps the most devastating complication is iatrogenic SL ligament injury.

With volar wrist ganglions, neuromas can arise from branches of the radial sensory nerve, the lateral antebrachial cutaneous nerve, and the palmar cutaneous branch of the medial nerve. Injuries to the radial artery that result in primary ligation have not been reported to cause long-term morbidity. However, Green advocates primary repair of the artery. Recurrence rates are higher for these ganglions (33%) than for others, most likely because of inadequate stalk resection.^[3]

Regarding volar retinacular (flexor tendon sheath) ganglions, injury to the digital bundles has been reported, and recurrences are rare.

With mucous cysts, recurrences may be secondary to incomplete excision of the stalk, capsule, or associated DIP joint osteophyte. However, reformation of the mass is usually the result of the development of a new cyst, not recurrence of the previous cyst. Skin complications are not unusual. Loss of terminal DIP joint extension may occur if the insertion of the extensor tendon is disturbed.

Given that ganglions are benign lesions, the overall prognosis is excellent with open surgical treatment. Recurrence rates of 10-15% are typically reported. Excision of the cyst with a small ring of capsule has been shown to reduce the recurrence to 4% when compared with resection of the cyst alone (13-40%).

Osterman and Raphael found that arthroscopic treatment was also safe and reliable.^[12] They had recurrences equal to those reported with open procedures. Arthroscopic resection also resulted in smaller surgical scars.

Sanders reported dramatic improvement of function and relief of pain in selected patients who had a suspected occult ganglion.^[13]

Currently, the only controversial treatment for dorsal wrist ganglions is arthroscopy. Many articles support the use of the arthroscopy for ganglion excisions.