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Updated: Jun 2 2023

Ganglion Cysts

Images cyst.jpg 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
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