A ganglion cyst is a common soft tissue swelling often found in the hand and wrist. It is a cyst filled with viscous, sticky, and mucinous fluid that can be single or multiloculated. They are benign lesions, they may lead to pain, weakness, and loss of function, and may require treatment. They are masses located on the dorsal or volar aspect of the wrist or surrounding structures (Blazar, 2017).
Incidence and Prevalence
It is not known exactly what causes a ganglion cyst to develop but seems to occur when the tissue that surrounds a joint or a tendon bulges out of place. Risk factors include sex and age, osteoarthritis and joint or tendon injury. Ganglion cysts can develop in anyone, but they most commonly occur in women between the ages of 20 and 40. People who have wear-and-tear arthritis in the finger joints closest to their fingernails are at higher risk of developing ganglion cysts near those joints. Joints or tendons that have been injured in the past are more likely to develop ganglion cysts (Mayo Clinic, 2017). Ganglion cysts are the most common soft tissue mass of the hand and wrist (55 per 100,000 of population per year.) They occur in a 3 to 1 female to male ratio (University of California San Francisco, 2017). According to Blazar (2017), dorsal ganglion cysts can occur at any age and account for roughly 60% to 70% while volar wrist ganglions account for the remainder. In adults, these cysts originate within the wrist joint and in the pediatric population, they have a higher percentage of ganglions arising from the tendon sheath compared to adults.
Pathophysiology
Ganglia are benign soft tissue tumors most commonly encountered in the wrist, but which may occur in any joint. Sixty to seventy percent of ganglion cysts are found in the dorsal aspect of the wrist and communicate with the joint via a pedicle. This pedicle usually originates not only at the scapholunate ligament, but also may arise from a number of other sites over the dorsal aspect of the wrist capsule. They also may occur in the ankles and feet. Ganglion cysts are typically round or oval. There is no documented history of malignancy of a ganglion cyst. According to Blazar (2017), the outer wall of a ganglion is comprised of randomly oriented collagen fibers with no definitive endothelial lining. He further states that the cyst itself is filled with thick gelatinous, clear mucin comprised of glucosamine, globulin, hyaluronic acid, and albumin.
The cyst can be singular or multiloculated, mobile, and nonadherent to the underlying tissue. The ganglia cyst can be painful if they press on a nearby nerve. Their location can sometimes interfere with joint movement. Thirteen to twenty percent of ganglia are found on the volar aspect of the wrist, arising via a pedicle from the radio scaphoid/scapholunate interval, scaphotrapezial joint, or the metacarpotrapezial joint, in that order of frequency. Ganglia arising from a flexor tendon sheath in the hand account for approximately 10% of ganglia. Occurrence in other joints, as well as intraosseus and intratendinous ganglia, are much less common (Gude & Morelli, 2008).
Physical Assessment and Examination
The lumps associated with ganglion cysts can be characterized by location, shape and size, and pain. The cysts most commonly develop along the tendons or joints of the wrists or hands. The next most common locations are the ankles and feet. These cysts can occur near other joints as well. Ganglion cysts are round or oval and usually measure less than an inch in diameter. Some are so small that they can’t even be felt. The size of the cyst can fluctuate, often getting larger with repetitive motions. Ganglion cysts are usually painless, however, if it presses on a nerve it can cause pain, tingling, numbness or muscle weakness.
On physical exam, patients with a ganglion cyst may present with joint pain and swelling particularly on the wrist. The pain may be due to the cyst pressing or impinging on a nerve and may cause sensory-motor loss. The cyst may feel firm, rounded, smooth, rubbery, and at times tender to touch. Patients may notice that the cyst has changed in size over time. The cyst may typically be between 1 to 4 cm in diameter, although it may reach up to 8cm (Blazar, 2017). It is believed that these cysts increase temporarily with the strenuous activity of the involved extremity but will return to normal during periods of rest. During the exam, the provider may apply pressure to the cyst to test for tenderness or discomfort. The provider may also shine a light through the cyst to determine if it’s a solid mass or filled with fluid. Follow-up testing may include x-ray ultrasound or magnetic resonance imaging (MRI) to rule out other conditions such as arthritis or a tumor. Confirmation through fluid aspiration may be done, but is not necessary (Mayo Clinic, 2017).
Evidence-Based Treatment Plan
Ganglion cysts are not cancerous, are often painless and usually do not require treatment, though patients may choose to have the cyst removed for cosmetic reasons. The provider may recommend immobilization because the activity can cause the ganglion cyst to get larger. Immobilization may help the cyst to shrink, which may release pressure on the nerves and relieve pain. Depending on the location and size, the cyst may start to cause pain or interfere with joint mobility, prompting the need for removal. Cysts can be removed through the aspiration to drain the fluid or may be surgically removed if aspiration is not successful. With either option, the development of a new cyst may recur (Mayo Clinic, 2017). The home remedy for removal of the cyst was by striking the area or puncturing the cyst, neither of which is recommended and may lead to further injury.
Treatment options: If pain and discomfort are present, patients could use a compressive wrap or wrist for support and may take NSAIDs such as naproxen 250-500 mg orally twice a day as needed for pain, a maximum 1250mg per day to alleviate the aching (Blazar, 2017). Injection of corticosteroid of choices is triamcinolone acetonide 10 mg into the affected area as a single dose and lidocaine 1%, 1-2 mL into the affected area as a single dose (Blazar, 2017). Lastly, is surgical resection for those recurrent or persistent symptoms despite initial treatment with conservation therapy. Surgical removal entails either open or arthroscopic excision of cyst along with its stalk. But, like any other surgery, there is potential for complications such as infection, decreased range of motion, tendon injury, neurovascular injury, and an unsightly scar (Keyser, 2017).
Patient Education
The American Society of Hand Therapists (2015) outlines the patient education topics related to ganglion cysts. Patient education should include what a ganglion cyst is, symptoms, causes, and treatments. Providers should reiterate to patients that ganglion cysts are not cancerous and do not turn into cancer. They require no treatment, as they are often self-limiting and may resolve on their own.
Follow-Up
Follow up varies on the treatment plan chosen to treat the ganglion cyst. If the provider chose to puncture and aspirate the cyst, sometimes the procedure is not successful and multiple treatments may be necessary. If the provider chose to surgically remove the cyst, a follow up within 2 to 3 weeks to make sure there is no sign of infection. Otherwise, no monitoring is required as there are no occurrences of malignant degeneration and the problem is usually cosmetic. If the cyst continues to grow and become painful or begin to compress underlying neurovascular structures, repeat evaluation is recommended (Blazar, 2017).
References
American Society of Hand Therapists. (2015). Patient education resource: Ganglion cyst. Retrieved from https://www.asht.org/sites/default/files/docs/2018/Ganglion%20Cyst%202018.pdf
Blazar, P. (2017). Ganglion cyst Definition – Epocrates online. Retrieved from https://online.epocrates.com/diseases/98421/Ganglion-cyst/Definition
Gude & Morelli. (2008). Ganglion cysts of the wrist: Pathophysiology, clinical picture, and management.Current Review Musculoskeletal Medicine. (1)3-4, 205-211.
Keyser, F. (2017). Ganglion cysts of the wrist and hand. Retrieved from https://www.uptodate.com/contents/ganglion-cysts-of-the-wrist-and-hand?
Mayo Clinic. (2017). Ganglion cyst. Retrieved from https://www.mayoclinic.org/diseases-conditions/ganglion-cyst/symptoms-causes/syc-20351156
Mayo Clinic. (2017). Ganglion cyst – Diagnosis and treatment – Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/ganglion-cyst/diagnosis-treatment/drc-20351160
University of California San Francisco. (2017). Ganglion cyst. Retrieved from https://www.ucsfhealth.org/conditions/ganglion_cyst/
