Ganglionic Cyst
DEFINITION
A ganglion cyst is a fluid-filled lump that grows out of a joint or tendon sheath similar to a balloon on a stalk.
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SYNONYM
Bible bump
ETIOLOGY
• Ganglion cysts are usually attached to a nearby joint or tendon sheath.This condition is due to a defect in the synovium or joint capsule,but the exact cause of a ganglion is unknown.
• Dorsal wrist ganglions are more common than volar.
• Ganglions often change in size with increased activity and may even spontaneously disappear.
• Ganglion cysts are not malignant.
• The cyst contains a thick, clear, mucus-like fluid similar to the fluid found in the joint.
EPIDEMIOLOGY AND
DEMOGRAPHICS
• Ganglion cysts occur most often in the 20 to 60 age group.
• Women are three times more likely than men to develop a ganglion cyst.
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MECHANISM OF INJURY
There are no known causes for ganglion cysts; however, they may result from increased repetitive use of wrist or finger flexion activity.
COMMON SIGNS AND
SYMPTOMS
• Nail deformities may occur as the result of a ganglion from the DIP joint.
• Blister-like bump gets large with activity and shrinks with rest.
• A ganglion cyst can be quite painful if it presses on nerves, even if the cyst is quite small. In contrast, a large cyst without nerve involvement may be completely painless.
AGGRAVATING ACTIVITIES
• Waiting tables.
• Gymnastics.
• Weight lifting.
• Playing musical instruments.
• Irritation of a ganglion depends on where it develops. A cyst on the dorsal wrist could be irritated with wrist extension, whereas a cyst that develops from the flexor tendon sheath could be irritated with finger flexion activity.
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EASING ACTIVITIES
• Resting the involved ganglion joint may decrease pain and may reduce the size of the cyst.
• Immobilization of the wrist or fingers with splinting is an effective way to allow the joint to rest.
24-HOUR SYMPTOM PATTERN
Ganglions may be smaller and less painful in the morning. The afternoon and evening hours may bring more pain as a result of increased activity of the affected joint.
PAST HISTORY FOR THE REGION
There is no common past history for the development of a ganglion.
PHYSICAL EXAMINATION
• Blister-like bumps may or may not be painful.
• Ganglion cysts occur 60% to 70% of the time on the dorsalside of the wrist.They can also be found on the volar wrist, proximal volar side of the finger, or on the base of the fingernail just below the cuticle.
• The ganglia that arise from small joints, such as the DIP, are the result of osteoarthritis.
• Volar retinacular ganglia arise from the flexor sheath of fingers or the thumb.These ganglia can be closely associated with digital nerves and can make treatment more difficult.
IMPORTANT OBJECTIVE TESTS
Usually the diagnosis can be easily made from the appearance and location of the cyst.A hand surgeon may wish to obtain radiographs to look for associated joint abnormalities.
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DIFFERENTIAL
DIAGNOSIS
• Arthritis
• Bone tumor
• MC boss
CONTRIBUTING FACTORS
• Possible genetic predisposition
• Gender
• Osteoarthritis
• Repetitive use
TREATMENT
SURGICAL INDICATORS
A ganglion cyst that has failed multiple aspirations, remains painful, limits activity, or that has an appearance unacceptable to the patient may warrant surgical removal.
SURGICAL OPTIONS
• The ganglion cyst can be removed in outpatient surgery. This procedure includes removing the outer shell and cauterizing the stalk of the ganglion so that it may never reform and reappear.
• Aspiration is an office procedure conducted by the hand surgeon. The area around the cyst is numbed, and a needle is used to puncture the ganglion and drain the fluid. Recurrence is common after one aspiration; however, research has shown three or more aspirations have an 85% cure rate.
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SURGICAL OUTCOMES
• Surgical removal of a ganglion cyst has a lower recurrence rate than aspiration;however, this does not guarantee the cyst will not return in the future.
• Research suggests that surgical removal of the cyst can cause additional problems for the patient such as joint instability and persistent symptoms.
REHABILITATION
• Typically, rehabilitation for a ganglion cyst is unnecessary. The majority of patients only require explanation that the cyst is benign. Nearly half of all ganglions can disappear without any treatment at all. It is important to continue observation of the cyst to make sure that no unusual changes occur.
• Initial exercises
Immobilization is a safe and effective way to reduce pain and appearance of the ganglion cyst. Activity often causes the ganglion to increase in size.This increase in size is due to increased pressure on nerves, causing pain.A wrist brace or splint may relieve symptoms by allowing the ganglion to decrease in size.
• Postsurgical:
A bulky compressive dressing will be applied after surgery. Gentle AROM exercise can be initiated to avoid stiffness of the joint.A custom splint may be fabricated to provide rest for the joint once the surgical dressing is removed.Usual recovery time for ganglion cysts ranges from 2 to 3 weeks for small ganglions of the finger and 6 to 8 weeks for ganglions involving the wrist.
PROGNOSIS
The exact cause for ganglions in unknown; however, vocations or hobbies that force the wrist and hand into extreme positions may increase a person’s chance of a cyst. Many cysts will resolve spontaneous and others will be present long term. Even if cysts are aspirated, many cysts will reappear spontaneously.
SIGNS AND SYMPTOMS
INDICATING REFERRAL
TO PHYSICIAN
If any unusual changes are observed in the cyst,referral to a hand surgeon is recommended. It may also be beneficial to the patient to see a hand surgeon to provide imaging to rule out abnormal anatomy under the skin causing the cyst to become painful.
SUGGESTED READINGS
1-Mehdian H, McKee MD. Scapholunate instability following dorsal wrist ganglion excision: a case report. Iowa Orthop J.2005;25:203–206.
2-Stephen AB, Lyons AR, Davis TR. A prospective study of two conservative treatments for ganglia of the wrist. J Hand Surg Br.1999;24(1):104–105.
3-Zubowicz VN, Ishii CH. Management of ganglion cysts of the hand by simple aspiration.J Hand Surg Am. 1987;12(4):618–620.
