Ganglion Cyst
What is a Ganglion Cyst?
A ganglion cyst is the most common lump that develops in the hand or wrist. Ganglion cysts are harmless fluid-filled sacs arising from a joint or tendon sheath. Joints and tendon sheaths (tunnels) are lined with synovial or tenosynovial (for tendons) cells which create the fluid that lubricates joints and tendon tunnels for smooth gliding of joints and tendons.
Ganglions of the wrist often occur in teenagers and young adults. They are so common that one study showed 40% of adults having an MRI will have a ganglion, most of them do not cause symptoms. Ganglions can be so small that they are not visible or there may be a swelling under the skin on the back or underside of the wrist. In older patients they may be a sign of underlying arthritis causing increased fluid production in the joint. If there is any suspicion of arthritis, an x-ray will be arranged
A ganglion can form from almost any joint or tendon sheath. The cyst may change size and can occasionally disappear. No treatment is needed if the ganglion is not causing symptoms.
Dorsal carpal ganglion
Volar carpal ganglion
Flexor sheath ganglion
What causes Ganglion Cysts?
Ganglion cysts are believe to occur due to one of the following:
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Injury of the ligaments in the wrist. The injury may be minor and overlooked or major, causing pain and swelling long after the incident. Mucoid degeneration of the injured ligament can result in increased fluid forming a a fliud-filled cyst (or ganglion.
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Arthritis. Arthritic joints create increased fluid which can leak outside the joint, forming a cyst, much like a balloon.
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Tendonitis. Wherever tendons travel through tunnels in the wrist and hand, there is a layer of tenosynvial cells that create fluid so the tendon/s can glide. When the tendons become thickened or the tunnel narrows, there is increased friction which irritates the tenosynovial cells, resulting in increased fluid formation and ganglion cyst formation. The most common forms of tendonitis resulting in ganglion cysts are trigger finger and De Quervain's tendinopathy.
Phone
02 6185 2705
Fax
02 6185 2705
Location
Suite 4A, Level 2
Peter Yorke Building
173 Strickland Cres
Deakin ACT 2600
Risk factors for Ganglion Cysts
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Family history
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Wrist injury
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Arthritis
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Repetitive activities can precipitate the symptoms.
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Inflammatory conditions such as that cause tendon swelling (rheumatoid arthritis, psoriatic arthritis).
What are the signs & symptoms?
Apart from the localised swelling, wrist ganglions may cause pain with loading and gripping, particularly putting your bodyweight through the hand such as pushing off the ground. The symptoms may last a week or two then settle again, only to recur in the future. The symptoms often become more frequent and annoying. The symptoms do not always coincide with the size of the swelling.
A painless, pea-sized swelling in the palm, at the base of a finger, may be the first sign of a trigger finger developing. In De Quervain's tendinopathy, a ganglion may appear over the first dorsal compartment when the the symptoms have been present for weeks or months.
Diagnosis
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No imaging may be needed if the diagnosis and cause are clear.
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When there is no visible ganglion, an ultrasound +/- xray may be needed.
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MRI may be required if the diagnosis and cause are not evident on ultrasound or xray, particularly if a ligament repair may be required at the time of ganglion excision surgery.
Treatment Options
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Steroid injection & splinting for 4 weeks followed by physiotherapy.
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Surgical excision of the ganglion (in Trigger Finger and De Quervain's Tendinopathy, the tendon sheath will also be released).
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Surgical excision and wrist ligament repair
Non-Operative Treatment
Dorsal carpal ganglia in teenagers may respond to "aspiration" and steroid injection. This procedure is performed by a radiologist using ultrasound-guidance. Local anaesthetic cream can be applied to the wrist if requested at the time of booking. The procedure involves multiple small holes being made in the cyst with a needle so the fluid can disperse. It is not truly an aspiration as the fluid is to thick and gelatinous to aspirate. A steroid injection with local anaesthetic is injected at the neck of the cyst. Panadol or nurofen should be taken for 1-2 days as there will be some aching discomfort. A wrist brace should be worn for 4 weeks, removing only for showering. This procedure has a 25-30% cure rate.
Dorsal carpal ganglia in adults rarely respond to aspiration and steroid injection and usually require surgical treatment.
Volar Carpal Ganglia - non-operative treatment is not recommended as these ganglia often surround the radial artery and there is a risk of injury to the artery. Injury to the artery can cause a false aneurysm (a ainful, tender, pulsatile (throbbing) lump under the skin, often with bruising. Surgical treatment is preferred so the artery can be protected.
Ganglions associated with Trigger Finger and De Quervain's tendinopathy may respond to steroid injection and splinting.
Surgical Treatment
Surgery for wrist ganglion cysts is a common, safe, and reliable procedure. It is performed as day surgery under general anaesthetic. The cyst is removed, and the area is cauterised (burned) with diathermy forceps to encourage scar tissue to form and prevent the cyst reforming.
If there is evidence of a significant wrist ligament injury on MRI scan or during the operative procedure, 1mm suture anchors will be used to repair the dorsal intercarpal (DIC), dorsal radiocarpal ligament (DRL) or scapholunate interosseous ligament (SLIL).
The wound is closed with dissolving stitches and fibreglass splint and bandage are applied. A sling and prescription for strong pain relief is provided. The arm is to be kept elevated at chest height.
Dorsal carpal ganglion excision 2 weeks post surgery
Risks of Surgery
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Infection <1% - single dose intravenous antibiotic given at time of surgery.
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Wrist stiffness - avoided by following the physiotherapy exercises, using a heat pack and taking paracetamol osteo 3 times daily.
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Recurrence of ganglion 10% - avoided by NOT do any heavy lifting or push ups for at least 3 months following surgery. Load should be very gradually increased under the guidance of your hand therapist.
Recovery
2 Days
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Pain relief may be required, and the hand should be kept elevated to chest height.
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Hand therapist visit to reduce dressing, make a custom wrist splint and start exercises.
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Keep bandage dry for first 2 weeks - Waterproof protective sleeves for showering or more expensive options for swimming can be found at your chemist or online.
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May use hand for light activities but should mostly be kept elevated.
2 weeks
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Recommence driving
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May now get would wet.
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Continue wearing splint except for exercises.
2 months
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Splint no longer required.
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Completing all light daily activities with minimal discomfort.
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No heavy lifting or push ups. Return to light gym activities.
4 months
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Returned to normal activities without discomfort.
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Swelling and stiffness resolved and movement returned to normal.