normal  medium  large

GANGLION WRIST

Introduction

Ganglions, soft, mucin-filled cysts, account for 50-70% of all soft-tissue tumors of the hand. Malignancy has never been reported. Ganglions respond poorly to conservative therapy, but they can subside with rest or disappear spontaneous. With proper excision, recurrence is rare.

Related Anatomy

  • Scapholunate ligament
  • Radiocarpal joint
  • Scaphotrapeziotrapezoid joint

Incidence and Related Conditions

  • More prevalent in women (3:1); ~70% occur in people aged 20-49
  • Less common ganglions often associated with bossing of second and third carpometacarpal joints, de Quervain’s syndrome and Heberden’s nodes of the distal interphalangeal joint

Differential Diagnosis

  • Lipoma
  • Extensor tenosynovitis
  • Extensor Brevis Manus muscle
  • Other hand tumors
Clinical Presentation Photos and Related Diagrams
  • Dorsal Carpal Ganglion (Hover over right edge to see more images)
    Dorsal Carpal Ganglion (Hover over right edge to see more images)
  • Dorsal Carpal Ganglion
    Dorsal Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
Symptoms
New lump on the top, side or bottom of the wrist
Pain usually only with pressure on the lump
Pain at rest or with use (intracapsular small nonviable ganglion)
Lump fluctuates in size - gets larger but sometimes smaller
Paresthesias when ganglion presses on a nerve.
Typical History

A 16-year-old female cheerleader is complaining about a sore lump on the top of her left wrist.  It has been present for 2-3 months.  There is no history of trauma or night pain.  The patient notes that the lump fluctuates in size.  A week ago it was quite big until she bumped it. Following this minor injury it was temporarily much smaller but now is getting larger.  The lump’s appearance troubles her considerably.

Positive Tests, Exams or Signs
Allen Test
Mass: Mobility, Size, Tenderness, Texture
Radial Pulse
Tenderness
Ulnar Artery Pulse
Tuck Sign
Work-up Options
Magnetic resonance imaging - MRI without contrast
Sonographic studies - Ultrasound
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • Ultrasound showing an anechoic ganglion of the wrist
    Ultrasound showing an anechoic ganglion of the wrist (Hover over right edge to see more images)
  • MRI showing ganglion in Guyon's canal
    MRI showing ganglion in Guyon's canal
Treatment Options
Conservative: 
  • Reassurance/observation
  • Aspiration with/without corticosteroid injection
  • Aspiration followed by 3 weeks of casting with short arm cast
Operative: 
  • Surgical excision
Treatment Photos and Diagrams
  • Excision of Dorsal Carpal Ganglion (Hover over right edge to see more images)
    Excision of Dorsal Carpal Ganglion (Hover over right edge to see more images)
  • Excision of Dorsal Carpal Ganglion
    Excision of Dorsal Carpal Ganglion
  • Excision of Dorsal Carpal Ganglion
    Excision of Dorsal Carpal Ganglion
  • Dorsal Capsule after ganglion excision.
    Dorsal Capsule after ganglion excision with extensor tendons retracted.
  • Extensor Tendons after ganglion excision.
    Extensor Tendons after ganglion excision.
  • Volar Carpal Ganglion with palpable pulse
    Volar Carpal Ganglion with palpable pulse
  • Volar Ganglion Adherent to radial artery.
    Volar Ganglion Adherent to radial artery.
  • Volar Ganglion being dissect off radial artery.
    Volar Ganglion being dissect off radial artery.
  • Excised Volar Ganglion with intact radial artery.
    Excised Volar Ganglion with intact radial artery.
Complications
  • Aspiration: high recurrence rates (>50%)
  • Steroid injection: skin depigmentation, subcutaneous fat atrophy
  • Hyaluronidase: high recurrence rates (>70%), allergic reaction

Volar ganglion excision:

  • stiffness
  • wound infection
  • neuroma
  • hypertrophic scar
  • nerve injury
  • radial artery injury
Outcomes
  • Conservative treatment provides symptomatic relief with higher rates of recurrence
  • Operative treatment reduces recurrences rates but increases complications
Key Educational Points
  • The majority ganglion cysts will resolve spontaneously without recurrence, hence observationis indicated.
  • Ganglions have recurrence rates of up to 43% with aspiration.
  • There is significant risk to the radial artery with aspiration in this area.
  • Surgical excision can have recurrence rates of up to 35%.
  • Needle biopsy is not necessary with the history and exam consistent with a ganglion.
Practice and CME
References

New articles

  1. Kim JP, Seo JB, Park HG, Park YH. Arthroscopic excision of dorsal wrist ganglion: factors related to recurrence and postoperative residual pain. Arthroscopy 2013;29(6):1019-24.
  2. Korkmaz M, Ozturk H, Amanvermez Senarslan D, Erdogan Y. Aspiration and methylprednisolone injection to the cavity with IV cannula needle in the treatment of volar wrist ganglia: New technique. Pak J Med Sci 2013;29(1):103-6.

Reviews

  1. Thommasen HV, Johnston S, Thommasen A. Management of the occasional wrist ganglion. Can J Rural Med 2006;11(1):51-2.
  2. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Phys 2003;67(4):745-50.

Classics

  1. Dostal GH, Lister GD, Hutchinson D, et al. Extensor digitorum brevis manus associated with a dorsal wrist ganglion: a review of five cases. J Hand Surg Am 1995;20(1):35-7.
  2. Dellon AL, Seif SS. Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain. J Hand Surg Am 1978;3(4):326-32.