Updated: 2/7/2022

Ganglion Cysts

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https://upload.orthobullets.com/topic/6086/images/wrist ganglion mri.jpg
  • summary
    • Ganglion Cysts are mucin-filled synovial cysts and are the most common masses found in the wrist and hand. 
    • Diagnosis can be made clinically with a firm and well circumscribed mass that transilluminates.
    • Treatment can be observation for majority of ganglions. Surgical excision is indicated for ganglion cysts associated with severe symptoms or neurovascular manifestations.
  • Epidemiology
    • Incidence
      • common
        • most common hand mass (60-70%)
    • Anatomic location
      • dorsal carpal (70%)
        • originate from SL articulation
      • volar carpal (20%)
        • originate from radiocarpal or STT joint
      • volar retinacular (10%)
        • originate from herniated tendon sheath fluid
      • dorsal DIP joint (mucous cyst, associated with Heberden's nodes)
      • may also occur in the lower extremity
        • most commonly about the knee
  • Etiology
    • Mechanism
      • trauma
      • mucoid degeneration
      • synovial herniation
    • Pathophysiology
      • filled with fluid from tendon sheath or joint
      • no true epithelial lining
    • Associated conditions
      • median or ulnar nerve compression
        • may be caused by volar ganglion
      • hand ischemia due to vascular occlusion
        • may be caused by volar ganglion
  • Presentation
    • Symptoms
      • usually asymptomatic
      • may cause issues with cosmesis
    • Physical exam
      • inspection
        • transilluminates (transmits light through tissue)
      • palpation
        • firm and well circumscribed
        • often fixed to deep tissue but not to overlying skin
      • vascular exam
        • Allen's test to ensure radial and ulnar artery flow for volar wrist ganglions
  • Imaging
    • Radiographs
      • normal
    • MRI
      • indications
        • not routinely indicated
      • findings
        • shows well marginated mass with homogenous fluid signal intensity
    • Ultrasound
      • useful for differentiating cyst from vascular aneurysm
      • may provide image localization for aspiration while avoiding artery
  • Histology
    • Biopsy
      • indications
        • not routinely indicated
      • findings
        • will show mucin-filled sac with no true epithelial/synovial lining
  • Treatment
    • Nonoperative
      • observation
        • indications
          • first line of treatment in adults
          • children
            • 76% resolve within 1 year in pediatric patients
      • closed rupture
        • home remedy
        • high recurrence
      • aspiration
        • indications
          • second line of treatment in adults with dorsal ganglions
          • aspiration typically avoided on volar aspect of wrist due to radial artery
        • outcomes
          • higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to attempt
    • Operative
      • surgical resection
        • indications
        • technique
          • requires adequate exposure to identify origin and allow resection of stalk and a portion of adjacent capsule
          • at dorsal DIP joint: must resect underlying osteophyte
        • results
          • volar ganglions have higher recurrence after resection than dorsal ganglions (15-20% recurrence)
  • Complications
    • With aspiration
      • infection (rare)
      • neurovascular injury
    • With excision
      • infection
      • neurovascular injury (radial artery most common)
      • injury to scapholunate interosseous ligament
      • stiffness
Technique Guides (1)
Flashcards (24)
Cards
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Questions (12)

(SBQ17SE.1) An 18-year-old female military recruit falls and sprains her wrist during basic training. One month later she reports to clinic with a dorsal wrist mass. A wrist MRI is reviewed (Figures A and B). The histopathology of the lesion would reveal what cellular pattern?

QID: 211116
FIGURES:

Uniform distribution of stromal cells and giant cells

3%

(52/2034)

Mixture of mature fat cells and spindle cells

2%

(31/2034)

Fibroblasts with mixed Schwann cells, mast cells, and lymphocytes

3%

(54/2034)

Lobular pattern of vascular proliferation with inflammation

2%

(45/2034)

Mucin-filled space with occasional spindled fibroblasts

90%

(1824/2034)

L 1 A

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(SBQ17SE.31) A 35-year-old jack-hammer operator presents with progressive hand weakness over the last year. He has been reluctant to see a physician. He notes some loss of coordination but otherwise denies any numbness. When asked to pinch a piece of paper, his thumb IPJ and index finger DIPJ flex. Electrodiagnostic studies demonstrate positive sharp waves in the adductor pollicis. An MRI is obtained and is seen in Figure A. What is the physical relationship of the affected neurovascular bundle?

QID: 211446
FIGURES:

The superficial branch of the radial nerve is dorsal and radial to the radial artery

1%

(25/2063)

The median nerve is ulnar to the radial artery

7%

(152/2063)

The ulnar nerve is dorsal and radial to the ulnar artery

22%

(444/2063)

The ulnar nerve is volar and radial to the ulnar artery

23%

(476/2063)

The ulnar nerve is ulnar and dorsal to the ulnar artery

45%

(938/2063)

L 1 A

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(OBQ16.28) A 25-year-old male presents to the clinic with a painful, enlarging mass at the volar radial wrist. He initially noticed the mass 6 months ago after he hurt his wrist golfing. Figure A shows a clinical photograph of the patient's wrist. Radiographs are unremarkable. An ultrasound of the mass is shown in Figure B. Surgical excision is planned. Which of the following is the most appropriate type of resection and histologic finding?

QID: 8790
FIGURES:

Intralesional excision; synovial cells with mucin accumulation

17%

(313/1821)

Incision & drainage; polymorphonuclear cells

1%

(10/1821)

Wide excision; histiocytes with frequent giant cells

1%

(25/1821)

Marginal excision; synovial cells with mucin accumulation

80%

(1457/1821)

Intralesional excision; histiocytes with frequent giant cells

1%

(10/1821)

L 2 A

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(OBQ12.64) A 54-year-old male presents with a slowly enlarging mass on the dorsum of his left wrist which has been present for 3 years. He denies any significant symptoms. Physical exam shows a 1 cm palpable mass. An MRI is shown in Figure A. Based on these findings, which of the following is true regarding the most likely diagnosis?

QID: 4424
FIGURES:

Definitive aspiration yields low recurrence rate

90%

(5702/6344)

Lacks a true epithelial lining

4%

(277/6344)

Lined by synovial cells with mucinous accumulation

2%

(133/6344)

Most commonly originate from the STT joint

1%

(74/6344)

Wide excision is necessary

2%

(129/6344)

L 1 B

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(SBQ11UE.109.1) Which of the following factors is inconsistent with a retinacular cyst of the flexor tendon sheath?

QID: 214244

Small size (2-8mm)

2%

(38/1903)

Palpable under metacarpophalangeal flexion crease

10%

(191/1903)

May be excised with a small portion of the flexor sheath to prevent recurrence

7%

(127/1903)

Aspiration may be a successful treatment

37%

(700/1903)

Mass moves with the tendon

44%

(840/1903)

L 4 C

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(OBQ09.67) A 10-year-old boy presents with a painless mass on the dorsal aspect of his wrist that has been present for 3 weeks. A clinical image is shown in Figure A. T1 and T2 magnetic resonance images are shown in Figure B and C, respectively. On your exam, the mass transilluminates and Allen test reveals patent radial and ulnar arteries. What is the most appropriate next step in management?

QID: 2880
FIGURES:

Referral to a orthopaedic oncologist

2%

(63/3575)

Surgical excision with wide margins

4%

(145/3575)

Observation

93%

(3313/3575)

Autologus bone marrow aspirate injection

0%

(3/3575)

Injection of N-Butyl-Cyanoacrylate

1%

(32/3575)

L 1 C

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Evidence (25)
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