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 Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Surgical Excision of Dorsal Ganglion Cyst Orthobullets Team Hand - Ganglion Cysts
QUESTIONS 1 of 12 1 2 3 4 5 6 7 8 9 10 11 12 Previous Next (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: A B Type & Select Correct Answer 1 Uniform distribution of stromal cells and giant cells 3% (53/2083) 2 Mixture of mature fat cells and spindle cells 2% (33/2083) 3 Fibroblasts with mixed Schwann cells, mast cells, and lymphocytes 3% (59/2083) 4 Lobular pattern of vascular proliferation with inflammation 2% (45/2083) 5 Mucin-filled space with occasional spindled fibroblasts 89% (1864/2083) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 The superficial branch of the radial nerve is dorsal and radial to the radial artery 1% (31/2118) 2 The median nerve is ulnar to the radial artery 7% (156/2118) 3 The ulnar nerve is dorsal and radial to the ulnar artery 21% (454/2118) 4 The ulnar nerve is volar and radial to the ulnar artery 23% (490/2118) 5 The ulnar nerve is ulnar and dorsal to the ulnar artery 45% (958/2118) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B Type & Select Correct Answer 1 Intralesional excision; synovial cells with mucin accumulation 17% (317/1874) 2 Incision & drainage; polymorphonuclear cells 1% (10/1874) 3 Wide excision; histiocytes with frequent giant cells 1% (27/1874) 4 Marginal excision; synovial cells with mucin accumulation 80% (1504/1874) 5 Intralesional excision; histiocytes with frequent giant cells 1% (10/1874) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Definitive aspiration yields low recurrence rate 89% (5704/6393) 2 Lacks a true epithelial lining 5% (301/6393) 3 Lined by synovial cells with mucinous accumulation 2% (154/6393) 4 Most commonly originate from the STT joint 1% (75/6393) 5 Wide excision is necessary 2% (130/6393) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ11UE.109.1) Which of the following factors is inconsistent with a retinacular cyst of the flexor tendon sheath? QID: 214244 Type & Select Correct Answer 1 Small size (2-8mm) 2% (39/1920) 2 Palpable under metacarpophalangeal flexion crease 10% (194/1920) 3 May be excised with a small portion of the flexor sheath to prevent recurrence 7% (130/1920) 4 Aspiration may be a successful treatment 37% (705/1920) 5 Mass moves with the tendon 44% (845/1920) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B C Type & Select Correct Answer 1 Referral to a orthopaedic oncologist 2% (64/3622) 2 Surgical excision with wide margins 4% (153/3622) 3 Observation 93% (3351/3622) 4 Autologus bone marrow aspirate injection 0% (3/3622) 5 Injection of N-Butyl-Cyanoacrylate 1% (32/3622) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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