Ganglion cysts of the wrist and hand

INTRODUCTION — A ganglion cyst is one of the most common soft tissue swellings in the hand and wrist. Although ganglion cysts are benign lesions, they may lead to pain, weakness, and loss of function, and sometimes require treatment.

The presentation, diagnosis, differential diagnosis, and treatment of ganglion cysts of the wrist and hand will be discussed here. The evaluation of the adult with hand or wrist pain are discussed separately. (See "Evaluation of the adult with acute wrist pain" and "Evaluation of the adult with subacute or chronic wrist pain" and "History and examination of the adult with hand pain".)

DEFINITION — A ganglion cyst is a fluid-filled swelling overlying a joint or tendon sheath. Ganglion cysts are thought to arise from a herniation of dense connective tissue from tendon sheaths, ligaments, joint capsules, bursae, and menisci. They contain a mucinous, gelatinous fluid.

The most common location for ganglion cysts is the dorsal side of the wrist (70 percent) (picture 1) [1]. Most of the dorsal wrist ganglions can be traced by their stalk as originating from the radiolunate ligament [2]. The cysts can be unilocular or multilocular. The second most common location for ganglion cysts in the hand is the volar side of the wrist (20 percent) over the scaphotrapezoid joint. Ganglions can also arise from the digital flexor tendon sheath, which has classically been described as arising from the first annular (A1) pulley (figure 1) of the fingers. A small mass may be palpable in the flexion crease at the base of the finger.

A digital mucous (or mucinous) cyst is a ganglion cyst that forms over the dorsal side of the distal interphalangeal (DIP) joint (picture 2) [3]. They occur most commonly in the fifth to seventh decades and are usually associated with an underlying diagnosis of osteoarthritis.

Ganglion cysts can occur anywhere in the body and can also be found over the dorsum of the foot and may, less often, arise in the knee, shoulder, spine, or other intraarticular, extraarticular soft tissue, intraosseous, or periosteal locations [4,5].

EPIDEMIOLOGY — Ganglion cysts are the most common soft tissue tumors of the hand. They can occur at all ages, but are most common in the second to fourth decades with a slight female predominance [1].

PATHOGENESIS — The pathogenesis of ganglion cysts unknown, but is has been suggested that they represent mucoid degeneration of periarticular structures [6]. The role, if any, of repetitive movement in causation is uncertain; it may induce enlargement of the lesion and may provoke symptoms.

PRESENTATION — Ganglia may present as an obvious swelling on physical examination or may only be manifested by joint (particularly wrist) pain. The cyst is typically firm, smooth, rounded, rubbery, and at times tender. Patients may notice that the size of the cyst changes over time. Occasionally, the cyst can impinge and cause nerve compression, resulting in sensory and/or motor loss [7].

In addition, many patients seek medical attention for cosmetic reasons or out of concern for possible malignancy rather than due to any symptoms [8].

DIAGNOSIS — The diagnostic approach depends upon the physical examination:

●In patients with a readily palpable lesion, transillumination provides an easy in-office method for differentiating ganglia from solid tumors: ganglion cysts transilluminate while solid tumors do not.

●If available, ultrasonography is useful in the diagnosis of ganglia. Most ganglia have well-defined margins, thick walls, and acoustic enhancement. A solid-appearing ganglion, although unusual, may mimic a benign neoplasm [9].

●In patients with occult wrist pain, magnetic resonance imaging (MRI) can differentiate most ganglia from other types of masses. One study of 14 patients with chronic dorsal wrist pain of unknown etiology, for example, found that the positive predictive value of MRI was 100 percent for the diagnosis of occult ganglia [10]. Ganglion cysts on MRI look like smooth, well-circumscribed, and homogeneous cystic masses of variable size. Sometimes, a thin stalk connecting to the joint space may occur. The internal content is typically hypo- to isointense on T1-weighted images and homogenously hyperintense on T2 and short tau inversion recovery (STIR). Rupture results in surrounding edema and fluid tracking [11]. However, many MR abnormalities and variants may be detected in the wrists of asymptomatic subjects [12]. These could be confused with pathologic findings usually associated with inflammatory arthritis [12].

Cyst aspiration only reveals aspecific findings and has no added diagnostic value. The only indication for aspiration would be in case there is clinical suspicion of an infectious process in the cyst, to provide material for culture. A potentially infectious cutaneous or subcutaneous process overlying the cyst (eg, erysipelas) is a contraindication for aspiration.

The combination of transillumination, ultrasonography, and MRI are generally sufficient to distinguish between a benign ganglion cyst and other potentially neoplastic soft tissue masses. However, the presence of certain clinical features such as rapid growth, pain at rest, functional impairment, and atypical location (eg, proximal or distal to the wrist rather than overlying the wrist) should prompt consideration for a surgical biopsy [13,14].

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of ganglion cysts of the wrist and hand includes conditions associated with nodular lesions of the hand, several of which are presented below.

Tenosynovial giant cell tumor — A tenosynovial giant cell tumor is a firm, fixed swelling that generally develops on the flexor surfaces of the tendons of the hands. It can be distinguished from ganglion cysts in that it is a fixed, enlarging mass that does not transilluminate (picture 3).

Epidermoid cysts — Epidermoid cysts, also called epidermal cysts or epidermal inclusion cysts, are small, hard, pearl-like cysts or nodules, often with a central punctum, that is freely mobile on palpation. They tend to disappear spontaneously over time. The most common locations are the volar aspect of the distal phalanx of the index or middle finger or are within the interdigital webs. They are rarely larger than 1 centimeter and do not transilluminate. (See "Overview of benign lesions of the skin", section on 'Epidermoid cyst'.)

Lipoma — Lipomas of the hand and wrist may present as a soft, painless slow-growing mobile nodule. Unlike ganglion cysts, lipomas do not transilluminate. (See "Overview of benign lesions of the skin", section on 'Lipoma'.)

Infectious tenosynovitis — Infectious tenosynovitis can occur in any joint, but occurs most frequently in the hands and wrist. Infectious tenosynovitis is characterized by diffuse swelling and tenderness that tracks along the tendon in a longitudinal fashion, and should be suspected in the setting of a preceding puncture or bite wound. Infection of the hand requires immediate surgical consultation for possible exploration and drainage. (See "Infectious tenosynovitis".)

Rheumatoid nodules — Rheumatoid nodules are firm, nontender, flesh-colored, subcutaneous lesions that occur in approximately 20 percent of patients with rheumatoid arthritis. Rheumatoid nodules may be fixed or movable and when present on the hand or wrist, are usually on the extensor surface. (See "Rheumatoid nodules".)

Tendinous xanthoma — These pinkish, yellow papules may be the first evidence of hyperlipidemia. Usually asymptomatic and bilateral, they may occur abruptly (eruptive xanthomas) over pressure points and extensor surfaces or gradually over Achilles, patellar, and digital extensor tendons. Often, the patient pays no attention to them; the clinician may be the first to realize their significance. (See "Hypertriglyceridemia in adults: Management".)

Tophus — Uric acid deposits can produce firm subcutaneous nodules in patients with gout. They typically originate at the joint margin and may be yellow with overlying erythema when close to the surface. Although tophi can occur at any site, they can be observed in the hands and wrist (picture 4). Tophi from chronic tophaceous gout are typically not painful or tender. (See "Clinical manifestations and diagnosis of gout".)

Synovial sarcoma — A synovial sarcoma is a rare cause of a soft tissue mass around a joint. It can arise at any age and anatomic area but tends to favor the distal extremities in young adults. Larger size of the tumor (>5 cm) is associated with a greater risk for metastases and local recurrence. Synovial sarcoma is a translocation-associated soft tissue malignancy. The translocation t(X;18) has been identified in synovial sarcoma only, and its sensitivity and specificity have been both established. In certain difficult cases, the detection of this fusion event (by RT-PCR or cytogenetic studies) has been instrumental to the correct diagnosis [15]. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma".)

TREATMENT — Our overall approach to treatment is generally to start with nonsurgical interventions which consist of observation or needle aspiration, given the limited morbidity of the lesion and the potential for spontaneous resolution. Surgical therapy is generally reserved for patients who have persistent or recurrent symptoms in spite of initial conservative therapy.

Observation — We suggest reassurance and observation for patients who are asymptomatic or do not want any intervention. Over 50 percent of patients may experience spontaneous resolution of ganglion cysts and do not require intervention. Published series of spontaneous resolution indicate that the majority of the spontaneously resolving cysts disappear within a year [16-18]. A brace can be used temporarily based on clinical symptoms, but use should be limited to avoid muscle atrophy that can be associated with long-term immobilization. Systematic joint inactivity due to pain from a ganglion cyst is also not recommended for the same reason for prolonged bracing. In general, pain severe enough to significantly limit activity would be an indication for surgical intervention. (See 'Surgical therapy' below.)

Ganglion cyst aspiration — For patients with bothersome symptoms, we suggest aspiration of the ganglion cyst. However, the patient should be informed that more than half of ganglion cysts treated with aspiration will recur within approximately one year [16]. In the case of volar cysts, caution is needed in order not to damage neurovascular structures, particularly the radial artery and the palmar cutaneous branch of the median nerve. We perform aspiration with an 18-gauge needle and a 3 mL syringe, or larger volume, depending upon the estimated volume contained by the cyst.

The efficacy of aspiration for ganglion cysts has been demonstrated in several small observational studies [19,20]. As an example, a trial of simple aspiration of hand and foot ganglia in 34 patients found that 14 patients (41 percent) had no recurrence when reevaluated at least one year after treatment [19]. Another study including 47 patients with ganglion cysts of the wrist and hand and found that 35 patients (74 percent) were successfully treated with a single aspiration after a follow-up period of at least one year [20]. Among the patients with recurrent ganglia, another five improved with repeat aspirations. There were no complications from ganglia aspirations.

Adjunctive techniques such as performing multiple punctures of the ganglion walls or immobilization after aspiration have not shown added benefit [21,22].

In our experience, if the cyst recurs rapidly (eg, within two to four weeks) after the first aspiration, a second aspiration is unlikely to be successful. However, if the cyst recurs after a longer period of symptom relief (eg, closer to one year), another aspiration may be attempted.

We do not recommend injection of ganglion cysts with glucocorticoids based upon evidence that there is no added benefit, and there is a potentially increased risk of subcutaneous fat atrophy and skin depigmentation. A trial including 85 patients who were randomized to aspiration alone or aspiration plus glucocorticoid injection found that after a follow-up period of almost one year, 67 percent of ganglions recurred in both groups [23]. Adverse effects were not reported in the study. Success rates with the injection of hyaluronidase into the ganglion are highly variable and there are insufficient data to recommend its use [24,25].

Surgical therapy — Surgical treatment is suggested for patients with persistent or recurrent symptoms despite initial treatment with conservative therapy. Surgical removal of the ganglion cyst entails either open or arthroscopic excision of the cyst along with its stalk.

Surgery is generally quite effective; however, if not properly removed, the ganglion may recur postoperatively. Approximately 10 percent recur with either standard or arthroscopic surgery [26]. Some studies have shown that arthroscopic excision of ganglion cysts are as effective as open excision, and may heal faster; however, more studies are needed to determine whether there is a true functional benefit [27].

Potential complications from surgery include infection, decreased range of motion, tendon injury, neurovascular injury, and an unsightly scar.

Ineffective therapy — Closed rupture of ganglion cysts on the dorsum of the wrist with a book, hence the phrase "bashing it with a bible," is generally thought to be inconsistent and unreliable and is not a recommended treatment modality.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Ganglion cyst (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – A ganglion cyst is a fluid-filled swelling overlying a joint or tendon sheath. Ganglion cysts are thought to arise from a herniation of dense connective tissue from tendon sheaths, ligaments, joint capsules, bursae, and menisci. They contain a mucinous, gelatinous fluid. They can occur almost anywhere in the body, but the most common location for ganglion cysts is the dorsal side of the wrist (picture 1). (See 'Definition' above.)

●Epidemiology – Ganglion cysts are the most common soft tissue tumors of the hand. They can occur at all ages, but are most common in the second to fourth decades with a slight female predominance. (See 'Epidemiology' above.)

●Clinical presentation – Ganglia may present as an obvious swelling on physical examination or may only be manifested by joint (particularly wrist) pain. The cyst is typically firm, smooth, rounded, rubbery, and at times tender. Patients may notice that the size of the cyst changes over time. Occasionally, the cyst can impinge and cause nerve compression, resulting in sensory and/or motor loss. In addition, many patients seek medical attention for cosmetic reasons or out of concern for possible malignancy rather than due to any symptoms. (See 'Presentation' above.)

●Diagnosis – The diagnostic approach depends on the physical examination. In patients with a readily palpable lesion, transillumination provides an easy in-office method for differentiating ganglia from solid tumors; ganglion cysts transilluminate while solid tumors do not. If available, ultrasonography is useful in the diagnosis of ganglia. For patients with occult wrist pain, MRI can differentiate most ganglia from other types of masses. (See 'Diagnosis' above.)

●Differential diagnosis – The differential diagnosis of ganglion cysts of the wrist and hand includes conditions associated with nodular lesions of the hand such as tenosynovial giant cell tumors, epidermoid cysts, lipomas, infectious tenosynovitis, rheumatoid nodules, tendinous xanthomas, tophi, and synovial sarcomas. (See 'Differential diagnosis' above.)

●Treatment

•Observation – Patients with asymptomatic ganglion cysts of the wrist or hand can be managed with reassurance and observation. Over 50 percent of patients may experience spontaneous resolution of ganglion cysts, and do not require intervention. (See 'Observation' above.)

•Aspiration of cyst – For patients with bothersome symptoms, we suggest aspiration of the ganglion cyst rather than surgical treatment (Grade 2C). However, the patient should be informed that more than half of ganglion cysts treated with aspiration will recur. Injection with glucocorticoids does not confer an added benefit. (See 'Ganglion cyst aspiration' above.)

•Surgical therapy – For patients who fail conservative therapy, surgical excision of the ganglion cyst may help relieve symptoms. (See 'Surgical therapy' above.)