GANGLION CYST
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What is a Ganglion Cyst?
A cyst is a fluid filled sac. A ganglion is a type of cyst that forms near a joint. The cyst is formed by a herniation (outpouching) of the synovial lining (stuff inside of a joint). But doctors still don’t know exactly why it occurs.
A ganglion cyst is commonly found in the hand and its filled with "mucin" (think of mucous, ie snot). Its outer lining (the capsule) is made mainly of collagen.
When someone comes into the office with a mass over their hand, 60% of the time it’s a ganglion cyst. Its most common on the back of the hand, and its from the outpouching of a joint between two of wrist bones (the SL interval), and the cyst develops between the thumb extensor tendon and the fingers extensor tendon.
In 20% of cases, its found on the palm of the hand, and this is from the radiocarpal, or scapho-trapezium-trapezoid joint. Usually the bump doesn’t cause any symptoms other than being cosmetically unattractive. But sometimes patients will experience aching wrist pain due to inflammation of the tissue around the cyst.
How is a Ganglion Cyst diagnosed?
People usually say the cyst was just noticed one day, and since that time it appears to be getting bigger over time.
Sometimes people will report that the cyst disappears (it can pop within the wrist) and then slowly reforms (new fluid collects within the same capsule). Its not uncommon for a cyst to have this pattern of growing and shrinking.
The bump is typically firm and adherent to the deep tissue, and importantly it will illuminate with a pen-light (this indicates that its filled with fluid... if the mass fails to illuminate then its a solid tissue and doctors suspect something else).
Doctors like to get x-rays to rule out any other type of soft tissue mass (like a tumor), however, further imaging like CT scan or MRI is typically not required as long as everything looks normal on x-ray. If there is something unusual about the appearance of the bump, then an MRI may be needed (but remember, its only required for unusual cases).
How is a Ganglion Cyst treated?
A ganglion cyst is not an emergency and it can be treated with or without surgery.
Sometimes people just need reassurance that bump is nothing life threatening.
In kids most doctors will just check the bump every few months because about 75% of them will spontaneously disappear within one year, and never come back.
In adults its less common for the cyst to disappear... but if its not painful, there is really no need to aggressively treat it.
About 100 years ago, the bible was used to treat the cyst. Not in the sense of prayer, but by slamming the big book onto someones wrist causing the cyst to rupture. That type of treatment can still work (as long as nothing else breaks in the process, and there are cases of a broken wrist following this technique)... but the recurrence rate is 30-60%.
Therefore, if the cyst is irritating (or cosmetically unattractive), the best next step is to aspirate the cyst, which involves placing a needle into the cyst and drawing up the fluid. Theres a 50/50 chance it will return. If it returns then surgery is recommended. In surgery the rate of recurrence is only 5% (the doctor must get the stalk of the cyst to prevent it from reforming).
What is the long term outcome?
The patients do well after this surgery. There is always a risk that the cyst will recur, but a surgery that effectively seals off the "stalk" will almost always prevent recurrence (<5% risk).
Reference
1) Thornburg LE. Ganglions of the hand and wrist. JAAOS 1999; 7: 231-38. full article. review.
2) Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin. 2004; 20: 249-60. full article. review.
3) Hopper G: Cystic swellings, in Bogumill GP, Fleegler EJ (eds): Tumors of the Hand and Upper Limb. Edinburgh: Churchill Livingstone 1993; vol 10 p172-82. citation of case of broken hand from bible technique.
4) Peh WC et al. Pictorial review: magnetic resonance imaging of benign soft tissue masses of the hand and wrist. Clin Radiol 1995; 50: 519-25. full article. highlights features common to ganglion cyst on T2 mri.
5) Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg 2001; 26: 599-602. full article. follows 18 kids with cysts, 80% spontaneously resolve. rec nonop rx in kids.
6) Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995; 11: 7-12. full article. 42% intraarticular pathology, possible assoc with ganglion cyst.
7) Edwards SG, Johansen JA. Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically. J Hand Surg 2009; 34: 395-400. full article. also high assoc with SL lig injury. 20% recurrence req. open resection.
8) Zubowicz VN, Ishii CH. Management of ganglion cysts of the hand by simple aspiration. J Hand Surg 1987; 12: 618-20. full article.