Updated: 10/5/2016

Ganglion Cysts

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Questions
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https://upload.orthobullets.com/topic/6086/images/ganglioncysts_fig1.jpg
https://upload.orthobullets.com/topic/6086/images/mucous cyst.jpg
https://upload.orthobullets.com/topic/6086/images/wrist ganglion mri.jpg
Introduction
  • A mucin-filled synovial cyst caused by either
    • trauma
    • mucoid degeneration
    • synovial herniation
  • Epidemiology
    • incidence
      • it is the most common hand mass (60-70%)
    • 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) 
  • 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 synovial cell lined sac 
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
        • severe symptoms or neurovascular manifestations
      • 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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(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 exams shows a 1 cm palpable mass. A MRI is shown in Figure A. A biopsy of this lesion would most likely show? Review Topic

QID: 4424
FIGURES:
1

Synovial cells with mucin accumulation

93%

(4116/4436)

2

Proliferating histiocytes of moderate cellularity and frequent multinucleated giant cells

3%

(143/4436)

3

Polymorphonuclear neutrophils

0%

(20/4436)

4

Spindle cells arranged in intersecting bundles

1%

(40/4436)

5

Lipocytes, spindle cells, and scattered atypical giant cells

2%

(98/4436)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 2880
FIGURES:
1

Referral to a orthopaedic oncologist

2%

(37/2431)

2

Surgical excision with wide margins

3%

(82/2431)

3

Observation

94%

(2281/2431)

4

Autologus bone marrow aspirate injection

0%

(1/2431)

5

Injection of N-Butyl-Cyanoacrylate

1%

(19/2431)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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