Joint, Ligament and Muscle Disorders

Hand and Wrist Ganglion Cyst

Anatomy

There are 27 bones in the hand and wrist, including the metacarpals (5 bones in the palm of the hand), phalanges (14 bones in the fingers), and carpals (8 bones in the wrist). The wrist is formed where the carpals meet the distal radius and ulna (lower end of the forearm bones). Ligaments (strong bands of connective tissue) connect one bone to another and provide support for the joint.

Description

A ganglion cyst is a fluid-filled mass or lump. Although they can develop in various locations, the most common location is on the back of the wrist. Ganglion cysts are not cancerous. They may quickly appear, disappear or change in size, often growing larger with increased wrist activity and becoming smaller with rest. In most cases, ganglion cysts are harmless and do not require treatment. If, however, the cyst becomes painful, interferes with function, or has an unacceptable appearance, several treatment options are available.

Cause

What triggers the formation of a ganglion cyst is unknown, however, they occur most frequently in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist. Ganglion cysts that develop at the end joint of a finger (mucous cysts) are typically associated with arthritis in the finger joint, and are commonly experienced in women between the ages of 40 and 70 years.

Symptoms

Although most form a visible lump, many ganglion cysts produce no other symptoms. Smaller ganglions can remain hidden under the skin (occult ganglions), while large cysts, even if they are not painful, may cause concerns about appearance. If a ganglion cyst puts pressure on nerves that pass through the joint, it can cause pain, tingling and muscle weakness.

Diagnosis

After discussing your symptoms and medical history, your doctor may ask how long you have had the cyst, whether it changes in size, and if it is painful. Pressure may be applied to identify any tenderness. A ganglion cyst is translucent because it is filled with fluid, so your doctor may shine a penlight up to the cyst to see if light shines through.

• X-Rays—Although they create clear pictures of dense structures such as bone, X-rays will not show a ganglion cyst. They can, however, be useful in ruling out other conditions, such as arthritis or a bone tumor.
• Magnetic resonance imaging (MRI) scans or ultrasounds—These imaging tests can be used to reveal soft tissues like a ganglion cyst. An MRI or ultrasound may be needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

Nonsurgical Treatment

Typically, the initial treatment of a ganglion cyst includes only nonsurgical options, such as:

• Observation—A ganglion cyst is not cancerous and may disappear on its own in time, so if you have no symptoms, your physician may recommend simply waiting and watching to make sure no unusual changes occur in the cyst.
• Immobilization—Activity often causes a ganglion to increase in size which can increase pressure on nerves, resulting in pain. Use of a wrist brace or splint may relieve symptoms and allow the cyst to decrease in size. As pain is relieved, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
• Aspiration—If the ganglion cyst causes a great deal of pain or severely limits activities, your physician may drain the fluid from it. During this procedure (aspiration), the area around the ganglion is numbed and the cyst is punctured with a needle so that fluid can be withdrawn. In many cases, the ganglion cyst returns after an aspiration procedure because the "root" or connection to the joint or tendon sheath has not been removed. Aspiration is most commonly recommended for ganglions located on the top of the wrist.

Surgery

If symptoms are not relieved by nonsurgical methods, or if the ganglion returns after aspiration, your orthopaedic surgeon may recommend surgical removal (excision) of the ganglion cyst, as well as part of the involved joint capsule or tendon sheath, which is considered to be the root of the ganglion. Excision is typically an outpatient procedure and most patients are able to return home after a period of observation in the recovery area. There may be some tenderness, discomfort and swelling following the surgery, but normally activities can usually be resumed 2-4 weeks later. Even after excision, there is a small chance that the ganglion cyst will return.

With any surgery, there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.