Ganglions Treatment & Management


Background

Ganglions are among the most common tumors of the hand and wrist. [12For the most part, they are asymptomatic masses that are primarily cosmetic rather than functional disturbances. In most instances, observation is the only management necessary. However, some ganglions can exert a mass effect on nearby structures, such as arteries, veins, tendons, and nerves. The impingement of such structures can cause pain, triggering of tendons, and vascular compromise. In these instances, the patient often seeks surgical attention. [3456]

People have been seeking treatment for ganglions for many centuries. Historically, treatment consisted of crushing the ganglion with a heavy object (eg, a Bible). Often, a firm strike with a heavy object was all that was needed to cure the patient. In current practice, simple observation, aspiration, and surgical excision are the treatment modalities of choice. It should be kept in mind that each type of ganglion can cause local symptoms, depending on its anatomic location.

For patient education resources, see Ganglion Cyst and Carpal Tunnel Syndrome.

Pathophysiology

Hippocrates described ganglions as "knots of tissue containing mucoid flesh." Since this description, several hypotheses have been proposed, including the following:

  • Synovial herniation or rupture through the tendon sheath (Eller, 1746)
  • Synovial dermoid or rest due to "arthrogenesis blastoma cell nests" or embryonic periarticular tissue (Hoeftman, 1876)
  • New growths from synovial membranes (Henle, 1847)
  • Modifications of bursae or degenerative cysts (Vogt, 1881)

The theory of mucoid degeneration offered by Ledderhose in 1893 was widely accepted. Green, however, replaced this theory with one based on microtrauma and hyaluronic acid production. [4The latter theory postulated that local tissue trauma or irritation causes production of hyaluronic acid at the synovial-capsular interface. The hyaluronic acid creates small mucin lakes that coalesce into subcutaneous cysts with stalks or ganglions.

Etiology

The etiology of ganglions is unknown. Theories include mucoid degeneration and trauma. Some patients (< 10%) recall minor or major trauma to the area before the development of the mass. No known occupational risk factors exist. Mucous cysts and some other ganglions are associated with degenerative joint disease.

Epidemiology

Ganglions in general represent 50-70% of all soft-tissue tumors of the hand and wrist. The prevalence in women is three times that in men. Most ganglions occur in persons aged 10-40 years, with a range from childhood to the ninth decade of life.

These tumors may occur in a variety of locations. Mucous cysts are ganglions of the distal interphalangeal (DIP) joint that occur primarily in persons aged 40-70 years. These also occur more commonly in females than in males.

Prognosis

Given that ganglions are benign lesions, the overall prognosis is excellent with open surgical treatment. [7Recurrence 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. [8 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.


History and Physical Examination

Ganglions are tumors that present adjacent to joints or tendons. The most common sites for ganglions are the dorsal aspect of the wrist near the scapholunate (SL) joint (60-70%; see the image below), the volar wrist near the radioscaphoid joint or the pisotriquetral joint (18-20%), and the volar retinaculum between the A1 and A2 pulleys (10-12%). Mucous cysts occur over the dorsal digit at the level of the distal interphalangeal (DIP) joint.

Typical appearance of dorsal ganglion cyst. Typical appearance of dorsal ganglion cyst.

Other sites include the carpometacarpal (CMC) joint, the extensor tendons (especially associated with the first dorsal compartment), the carpal tunnel, and the Guyon canal. Ganglions may also arise within bone; these are called intraosseous ganglion cysts.

Ganglions are usually minimally symptomatic. However, depending on the location of the cyst, patients may present with a myriad of symptoms, such as dull aching pain, change in size, spontaneous drainage, and sensory nerve dysfunction. Each type of ganglion is associated with a particular set of symptoms.

Dorsal wrist ganglion

Dorsal wrist ganglions typically present in proximity to the SL interosseous ligament. Approximately 75% of these ganglions are connected to the radiocarpal joint through a stalk from the SL ligament. Some ganglions may present at a site distant to the SL ligament, but they are attached to the ligament by a long pedicle. Careful palpation over the cyst and pedicle often reveals the extent of the cyst and the direction in which it is traveling. Most are asymptomatic masses that change in size.

Some patients may present with pain and tenderness due to compression of the posterior interosseous nerve (PIN) or the superficial radial nerve. The mass itself is compressible, subcutaneous, transilluminating, and slightly mobile without associated skin changes.

Occult dorsal ganglion

Patients with occult dorsal ganglions can present with the same symptoms as those with dorsal ganglions without a clinically evident mass. These ganglions are small and not palpable. Patients often experience pain, and these lesions may go undiagnosed for extended periods. [10]

Volar wrist ganglion

Two thirds of volar wrist ganglions come from the radioscaphoid joint, the remaining third from the scaphotrapezial joint. They rarely occur at the pisotriquetral joint. The cyst usually appears between the radial artery and the flexor carpi radialis (FCR). The cyst appears small clinically, but considerable extension may be found at the time of surgery. These ganglions have been found to track along the thenar muscles or along the FCR; they may extend into the carpal tunnel, and they have multiple appendages intertwined with the radial artery.

Patients present with pain or tenderness at the site of the ganglion and a palpable cyst. They may have sensory symptoms (palmar cutaneous branch of the median nerve) or, less commonly, motor nerve dysfunction.

Volar retinacular ganglion

Volar retinacular (flexor tendon sheath) ganglions arise from the A1 or A2 pulley of the flexor tendon sheath and present as a small (3-10 mm), firm, tender, and mobile mass near the proximal digital crease or the metacarpophalangeal (MCP) joint. The mass does not move with the tendon. Patients may have associated paresthesias of the involved digit secondary to pressure on the digital nerve. The lesion may also be associated with stenosing tenosynovitis. The diagnosis is made on the basis of physical examination findings.

Mucous cyst

The mucous cyst may be heralded by a groove in the nail bed and usually presents as a 3- to 5-mm cyst eccentrically located at the DIP between the dorsal distal joint crease and the eponychium. The mass is firm, is minimally mobile, and can be transilluminated. Mucous cysts are associated with Heberden nodes and osteophytes. A mucous cyst may be ruptured on presentation.

Carpometacarpal boss

A CMC boss is not a true ganglion cyst but a large spur that develops most frequently at the base of the second and third CMC joints in response to osteoarthritis. It appears as a firm, bony, nonmobile, tender mass on the dorsum of the hand. Many patients are asymptomatic; others may experience dull aching pain. A palpable ganglion is associated with a boss in 30% of cases. Some consider trauma to be the cause of the lesion.

Proximal interphalangeal joint ganglion

A proximal interphalangeal (PIP) ganglion is similar to a mucous cyst of the DIP. A 3- to 5-mm mass arises along either side of the extensor tendon at the PIP joint. Usually, the mass pierces through the oblique fibers between the central slip and the lateral band. Patients may present with pain and limited range of motion.

Extensor tendon ganglion

An extensor tendon ganglion primarily occurs dorsally over the metacarpal joints as a subcutaneous mass. It can be tender and cause a dull ache, as well as snapping of the tendon with motion.

Dorsal retinacular ganglion

A dorsal retinacular ganglion lies within the first dorsal compartment and often is associated with de Quervain stenosing tenosynovitis. The ganglion is attached to the first dorsal extensor compartment.

Carpal tunnel ganglion

Carpal tunnel 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. [11]

Ulnar canal ganglion

Ganglions within the Guyon canal can cause compression of the ulnar nerve, causing sensory and motor disturbances. These ganglions seem to arise from the hamate and travel through the hypothenar muscles to the canal. They can cause atrophy of the interosseous muscles by compressing the motor branch of the ulnar nerve. When suspected, these ganglions should be removed early to prevent permanent damage.

Intraosseous ganglion cyst

Intraosseous ganglions represent rare incidental radiographic findings. They can, however, be a cause of dull, aching wrist pain. In such situations, all other possible diagnoses should be pursued before an intraosseous ganglion is diagnosed as the source of the wrist pain. The scaphoid and lunate are most commonly affected. Interosseous ganglions also are known to occur in the other carpal bones, metacarpals, phalanges, and distal ulna. They may have an etiology distinctly different from that of soft-tissue ganglions. 


Diagnostic Considerations

The differential diagnosis of dorsal wrist ganglion includes the following:

  • Infection
  • Extensor digitorum brevis manus muscle belly
  • Proximal pole of scaphoid (dorsiflexed intercalated segment instability [DISI])
  • Proximal pole of lunate (volar-flexed intercalated segment instability [VISI])
  • Scaphotrapezial arthritis
  • Carpometacarpal (CMC) boss
  • Venous aneurysm
  • Neuroma
  • Sarcoma

The differential diagnosis of volar wrist ganglion includes the following:

  • Tenosynovitis
  • Infection
  • Carpal osteoarthritis
  • Lipoma
  • Sarcoma
  • Radial artery aneurysms or arteriovenous malformations
  • Hamartoma
  • Intraneural cysts

The differential diagnosis of volar retinacular ganglion includes the following:

The differential diagnosis of mucous cyst includes the following:

The differential diagnosis of extensor tendon ganglion includes the following:

  • Giant cell tumor of the tendon sheath
  • Tenosynovitis
  • Extensor digiti brevis manus muscle belly
  • Dorsal wrist ganglion
  • CMC boss

The differential diagnosis of intraosseous ganglion cyst includes the following:



Imaging Studies

For wrist lesions, standard posteroanterior (PA), lateral, and oblique views should be obtained. Mucous cysts should be evaluated with standard PA, lateral, and oblique plain radiographs of the involved digit. On radiographs, interosseous ganglions may be centrally or eccentrically located in the involved bone. Radiographs may also demonstrate a juxtaosseous ganglion that has penetrated the bone. The lesions are radiolucent with a sclerotic border. These ganglions usually occur near a joint surface.

Magnetic resonance imaging (MRI) or ultrasonography (US) may be employed when the diagnosis is in question (eg, with occult ganglions). [1314151617MRI reveals ganglions not seen on conventional radiographs. Axial, coronal, or sagittal computed tomography (CT) may be helpful in localizing occult ganglion cysts. Bone scans may help in determining if intraosseous masses are metabolically active and capable of causing pain.

Other Tests

The finger extension test is an important tool in the diagnosis of ganglions. [18]

Fluid evacuated from ganglion cysts consists of mucin composed of glucosamine, albumin, globulin, and hyaluronic acid. Histologic sections of the cyst reveal compressed collagen fibers and a few flattened cells without evidence of epithelial or synovial lining. Multiple clefts may be present off the main cystic duct. No inflammatory or mitotic activity is seen.


Approach Considerations

All of the ganglions described are benign lesions. For most patients, observation, reassurance, or aspiration or injection suffices for treatment. In some cases, however, these lesions cause enough discomfort or dysfunction that the patient desires surgical treatment. Sometimes, the ganglion is situated close to a sensory or motor nerve, but more commonly, the pain results from the mass effect. In patients presenting with skin breakdown, nail deformity, or repeated episodes of drainage caused by distal interphalangeal (DIP) joint mucous cysts, surgical treatment should be considered.

Currently, the only treatment for dorsal wrist ganglions about which there is any controversy is arthroscopy. However, many articles support the use of arthroscopy for ganglion excisions, [19202122though it may be a more costly option. [23]

Medical Therapy

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 not appropriate in-office treatment. One wrist fracture was reported from a direct blow. [34892425]

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 splinting is done for 3 weeks after one aspiration or puncture; it rises to 85% after three 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 infection rate. 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 ultrasound-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 of 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 carpometacarpal (CMC) boss, proximal interphalangeal (PIP) joint ganglions, extensor tendon ganglions, and intraosseous ganglions consists of observation.

Surgical Therapy

The most accepted surgical treatment for ganglion cysts involves removal of the masses by means of an open surgical technique. [34892426However, arthroscopic resection of dorsal ganglions has become increasingly popular. Use of the arthroscope affords the surgeon the added benefit of being able to carry out a complete evaluation of the joint. [82728293019202122]

Preparation for surgery

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 have to be repaired or even ligated. A standard complete hand and wrist examination, including a range-of-motion (ROM) assessment, a strength assessment, and neurologic function testing, should be performed preoperatively.

Operative details

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 scapholunate (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, with great care taken 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 ganglion

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 ganglion

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

Volar wrist ganglion

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 made. Care must be taken 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 about 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 obtained, the skin is closed, and a bulky dressing is applied with or without a splint.

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

Volar retinacular ganglion

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 cyst

Multiple incisions have been described for resection of a mucous cyst. What is clear is that excision of the skin overlying the cyst, with subsequent skin grafting, is not necessary. Generally, any skin defect that remains heals readily by secondary intention. The incision for a mucoid cyst is placed 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 affords 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 ganglion

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 ganglion

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 metacarpophalangeal (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 ganglion

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

Carpal tunnel ganglion

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 ganglion

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 visualized by means of magnetic resonance imaging (MRI) before exploration of the Guyon canal.

Interosseous ganglion

In cases where the patient is experiencing pain and all other possible sources for the pain have been 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.

Postoperative Care

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 full ROM and strength are achieved.

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.

Complications

The most common complication associated with 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 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 advocated primary repair of the artery; recurrence rates are higher for these ganglions (33%) than for others, most likely because of inadequate stalk resection. [4]

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.

Long-Term Monitoring

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