Ganglion Cysts

Ganglion cysts, which are common benign tumors, may arise from a joint capsule or the synovial sheath of a tendon. They may maintain their connection to the synovial sheath or joint, in which case they may vary in size. The dorsal or volar wrist is the region where most ganglia occur. Ganglia may occur at any age but are most commonly seen between the ages of 20 and 40 and in women.25 Ganglia may be obvious or occult. With occult cysts, patients may complain of a dull ache and tenderness, but no mass is palpable.26 They may become evident by causing a compression neuropathy or compartment syndrome. This condition should be kept in mind when wrist pain of unknown etiology is encountered. Magnetic resonance imaging (MRI) or ultrasound techniques may be helpful in assessing the anatomy of the wrist when an occult cyst is suspected. With obvious cysts the onset is usually insidious, although some patients report a history of acute onset associated with heavy use or trauma. Patients may report weakness or altered range of motion of the wrists or fingers. Radiation of pain into the forearm is not unusual. The examination reveals a firm, usually nontender cyst that feels like a small marble under the skin. A characteristic history and physical examination are usually sufficient to make the diagnosis, but aspiration of jellylike fluid confirms the diagnosis. A large-bore needle is usually required because of the viscous nature of the fluid. Instillation of steroids into the cyst may be helpful. If patients are symptomatic or if the appearance is unacceptable to the patient, surgical removal is the treatment of choice. When counseling patients or assessing the effectiveness of treatment, one must remember that approximately half of these cysts disappear without therapy 26 and that regardless of therapy recurrence is common. [Ganglion cyst; Jones J.G and Poplin D in Taylor's Musculoskeletal Problems and Injuries; 1st.ed.2006.Springer.]

Chapter 51 Ganglion Cyst David Bozentka A 20-year-old woman has developed a prominence about the dorsal radial aspect of the wrist. It is not painful and does not limit activities. Clinical Presentation Ganglion cyst is the most common soft tissue mass of the hand and wrist. Of all soft tissue masses of the hand and wrist, between 50% and 70% are diagnosed as ganglions cysts. The cysts most commonly occur in the second to fourth decades of life. Women are three times more likely than men to develop a ganglion cyst. Most ganglion wrist cysts are asymptomatic

and are often present for months to years prior to evaluation. Approximately 10% of patients will give a history of preceding trauma.1,2 Patients with a cyst may have discomfort that is often described as an ache. Small cysts of the dorsal wrist in the region of the scapholunate ligament tend to be more painful than large cysts. It has been proposed that pain associated with these dorsal wrist cysts is related to impingement of the terminal branch of the posterior interosseous nerve branch, which innervates the dorsal wrist capsule. Therefore, these patients may note pain particularly when the wrist is held in full extension. Volar wrist ganglion cysts occasionally arise from the carpal canal and can lead to compression of the median nerve (Fig. 51.1). In this setting, symptoms of carpal tunnel syndrome may develop, with numbness occurring in the median nerve distribution. Similarly, cysts arising from the volar ulnar carpus may lead to compression of the ulnar nerve at the Guyon canal. These patients may present initially with symptoms of clumsiness and difficulty with fine manipulation due to ulnarly innervated intrinsic muscle weakness. The motor symptoms develop prior to the sensory symptoms because the motor fibers of the nerve are dorsal and the sensory fibers are more volar in the cross-sectional makeup of the ulnar nerve in this region. Clinical Points

The majority of soft tissue masses of the hand and wrist appear to be ganglion cysts. Cysts may develop at joints, tendons, or nerves. Cysts contain thick, gelatinous material. Women are three times more likely to be affected than men.

Ganglion cysts can arise from a variety of locations, including joints, tendons, and nerves. Wrist joint cysts arise most commonly dorsally from the region of the scapholunate ligament (Fig. 51.2). These dorsal cysts account for approximately 60% to 70% of all ganglion cysts of the hand P.267 and wrist. Approximately 20% of wrist cysts arise from the volar aspect of the wrist.1 These volar cysts most often arise from the radiocarpal joint or scaphotrapezial joints. Volar radial cysts typically lie just radial to the flexor carpi radialis tendon and are often adherent to the radial artery (Fig. 51.3). Ganglion cysts may also arise from the ulnar aspect of the wrist, including the ulnar carpus and distal radial ulnar joint.

Figure 51.1 MRI wrist T2-weighted images coronal (A) and axial (B) views demonstrating a ganglion cyst (asterisk) arising from the carpal canal, which led to compression of the median nerve.

Figure 51.2 Diagrammatic representation of a dorsal wrist ganglion cyst arising from the dorsal scapholunate interval. (From Minotti P, Taras J. Ganglion cysts of the wrist. J Am Soc Surg Hand 2002;20(2):104.)

Figure 51.3 Diagrammatic representation of common locations for volar wrist to arise, including the volar radial and ulnar wrist. (Minotti P, Taras J. Ganglion cysts of the wrist. J Am Soc Surg Hand 2002;20(2):105.) P.268 The histologic features of a ganglion cyst from the dorsal wrist, volar wrist, dorsal distal interphalangeal joint, and tendon sheath are similar. The outer layer of a ganglion cyst is composed of randomly oriented collagen fibers with a few fibroblasts and mesenchymal cells. There is no synovial tissue within the cyst and no epithelial lining. The thick, gelatinous material contains glucosamine, hyaluronic acid, albumin, and globulin. Injection studies have shown that fluid communicates from the wrist into the cyst but not from the cyst back into the wrist. Patient Assessment

Asymptomatic Often present for months to years Generally on dorsum of wrist Nontender

There are multiple theories regarding the pathogenesis of ganglion cysts. A herniation of synovial tissue through the wrist capsule has been proposed, although the lack of synovial tissue within the cyst is not consistent. It has been proposed that the leakage of synovial fluid from a rent in the joint capsule may cause an irritation of the surrounding tissue. The local tissue reacts by forming a pseudocapsule. The ganglion fluid develops related to the irritation of the synovial fluid and this tissue. An alternative theory considers mucinous degeneration as the main factor. The breakdown products of collagen collect in pools, leading to the

formation of the cyst. Microtrauma involving repetitive stretching of the capsular tissues may also lead to the formation of hyaluronic acid by the mesenchymal cells and fibroblasts.1,3 Physical Findings Ganglion cysts are well-circumscribed, compressible subcutaneous structures. They are firm, rubbery, and often lobulated structures that transilluminate. Small dorsal wrist ganglion cysts may not be palpable unless the wrist is fully flexed. Cysts are typically nontender structures that are not adherent to the skin. Ganglions are slightly moveable but have a pedicle or stalk, which leads to adherence of the cyst to the joint capsule. Occult dorsal wrist ganglion cysts are not palpable, but tenderness is elicited while palpating the dorsal scapholunate interval, which lies just distal to the Lister tubercle of the radius.4 Pain may be reproduced with the wrist placed in maximal extension. In evaluating a volar radial wrist cyst, it is important to perform an Allen test to determine patency of the radial artery. The differential diagnosis includes an active tenosynovitis (Figs. 51.4, 51.5). On physical examination, an active tenosynovitis will move proximally and distally with tendon excursion while the ganglion will remain stationary. Carpometacarpal (CMC) bossing, which lies more distal than a dorsal wrist cyst from the scapholunate interval, is often misdiagnosed as a ganglion cyst (Fig. 51.6). The prominence in CMC bossing is due to the bone at the base of the index and long finger metacarpals, and in 50% of patients, a small ganglion may arise from the CMC joint. P.269

Figure 51.4 Photograph of a patient with extensor tenosynovitis about the dorsal wrist. The prominence becomes more evident with extension of the fingers.

Figure 51.5 MRI T2-weighted axial image of the wrist with edema surrounding the fourth extensor compartment consistent with an active extensor tenosynovitis.

Figure 51.6 A lateral wrist x-ray, with an arrow localizing the CMC boss, often misdiagnosed as a ganglion cyst. Studies The diagnosis of a ganglion cyst is typically made following a thorough history and physical examination. An aspiration can confirm the diagnosis if gelatinous material consistent with a cyst is obtained. Laboratory studies are not required in the assessment of ganglion cysts. Xrays are unremarkable. MRI is the study of choice to verify the diagnosis. A ganglion cyst will demonstrate high signal intensity on the T2-weighted images. MRI is very helpful in the evaluation of the patient with dorsal radial wrist pain related to a small, nonpalpable ganglion cyst. Ultrasound has been used in the diagnosis of ganglion cysts but is operator dependent. Although less expensive than MRI, ultrasound provides less information in ruling out alternative etiologic factors. Not to Be Missed
Extensor tenosynovitis Giant cell tumor of tendon sheath

Extensor digitorum brevis manus CMC bossing

Treatment

Some spontaneously resolve Aspiration and injection with cortisone Recurrences can be removed surgically

Asymptomatic ganglion cysts are observed. Studies have shown up to 50% spontaneous resolution of ganglion cysts, with a higher rate in children. Other options include closed compression, aspiration, or surgical excision. Aspiration can be both diagnostic and therapeutic in nature. The gelatinous material aspirated from the cyst will confirm the diagnosis, and 80% of patients will have at least temporary relief of their symptoms. Unfortunately, recurrence is common, and the cyst will recur in >50% of cases following aspiration.1 A large-bore 18-gauge needle is used to drain the thick, gelatinous fluid, and a corticosteroid can be injected. Dorsal cysts may be aspirated with no significant risk of neurovascular injury. Volar P.270 radial carpal cysts lie adjacent to the radial artery and its venae comitantes. Aspiration of volar radial carpal cysts risks injury to the vascular structures. Surgical Intervention Surgical treatment is considered for patients who have a symptomatic cyst despite nonoperative treatment modalities. Cosmesis is often a consideration when the cysts become quite large. The surgical options include an open excision in which the cyst and stalk are removed with a cuff of adjacent capsule (Fig. 51.7). Alternatively, arthroscopic treatment can be performed for certain cysts.

Figure 51.7 Intraoperative photo of a cyst being removed from the dorsal wrist. (Minotti P, Taras J. Ganglion cysts of the wrist. J Am Soc Surg Hand 2002;20(2):105.) Refer to Physical Therapy Clinical Course A ganglion cyst is the most common soft tissue mass of the wrist and hand. The cysts are usually asymptomatic, and some resolve spontaneously, but occasionally, a cyst will lead to a

nerve compression syndrome. Typically, treatment is observation, and if symptomatic, aspiration or excision is considered. When to Refer

Symptomatic cyst despite nonoperative treatment Associated nerve palsy

ICD9

727.41 Ganglion of joint 727.42 Ganglion of tendon sheath 727.43 Ganglion, unspecified 727.49 Other ganglion and cyst of synovium, tendon, and bursa

References 1. Minotti P, Taras JS: Ganglion cysts of the wrist. JASSH 2002;2:102107. 2. Nelson CL, Sawmiller S, Phalen G: Ganglions of the wrist and hand. JBJS 1972;54:1459 1464. 3. Thornburg LE: Ganglions of the hand and wrist. J Am Acad Ortho Surg 1999;7:231238. 4. Steinberg BD, Kleinman WB. Occult scapholunate ganglion: a cause of dorsoradial wrist pain. J Hand Surg Am 1999;24:225231.

Carpal tunnel syndrome : The carpal tunnel is formed by the flexor retinaculum anteriorly and by the distal row of the carpus posteriorly through which flexor tendons and median nerve passes. Any swelling likely to result in compression and ischaemia of median nerve in carpal tunnel this may occur in acromegaly, myxoedema, multiple myeloma, rheumatoid arthritis, pregnancy, osteoarthritis of wrist etc. causes carpal tunnel sydrome. Clinical features : tingling, numbness or discomfort in the radial three and half digits and difficulty in carrying out fine movements. Shaking the hands in the air gives relief flick test. Flexion of wrist for 60 sec causes pain Phalens sign. Tinels sign sharp, shooting pain along the distribution of median nerve when the flexor retinaculum is tapped gently. Treatment : longitudinal incision of flexor retinaculam gives relief.