Ganglion Cyst

Ganglion cysts are benign tumorous and account for 50-70% of hand tumours. They come in a wide range of sizes, and range from firm and elastic to hard lumps. Also, depending on their location, they can not only be unsightly, but also cause real and painful issues such as joint impingement symptoms and compression of the nerves and blood vessels.

Ganglion cysts are often pedicled, but also often sit broad-based across the joint capsule or tendon sheath. They are filled with a bile-like viscous fluid. Ganglion cysts can develop almost anywhere on the hand, but the most common appear on the extensor side of the wrist (wrist ganglion cysts) stemming outward from the scapholunate ligament. On the flexor (palmar) side, they are most commonly found in the palmar radioscaphoid or scapholunate spaces – between the radius and the carpal bones. However, they can develop in any of the hand joints.

Ganglion cysts can be caused by degeneration of the joint capsule tissue, over-straining, and chronic irritation. However, in many cases, no actual cause can be determined. Approx. 70% of ganglia develop between 30 and 50 years of age, with women three times more likely to be affected than men. Despite this, ganglion cysts can develop in patients of any age and are not uncommon in children. In many cases, ganglion cysts will subside without treatment with the regression of the underlying irritation or at least reduce in size. However, they can reoccur if irritation (e.g., straining of the hand) is again increased.

Diagnosis and Examination

The examining physician or hand surgeon will likely palpate a firm and elastic tumour, with dorsal wrist ganglion cysts typically located at the tendinous connection between the scaphoid bone and the lunate bone. The clinical examination will often identify painful pressure sensitivity over the ganglion cyst on the extensor side of the scapholunate ligament region. The pain is usually more pronounced when bending the wrist. Radiopalmar ganglion cysts (flexor side) are most commonly palpable under the skin between the tendon of the flexor carpi radialis, the radial artery of the forearm, to which the ganglion cyst is attached.

Ganglion cysts can also develop on the ring finger ligaments. They cause pain when pressure is placed on the cysts when holding an object. During examination, a small nodule is typically palpable between the skin which also remains static during finger flexion and extension.

Ultrasound is the classic method used to identify the presence of ganglion cysts. MRI examination using contrast agents can also be very helpful to determine the size and attached anatomical structures. A standard x-ray assessment should be used, especially for dorsal wrist ganglion cysts, to rule out other possible causes, such as a wrist ligament injury.

Conservative Therapy

Conservative treatment measures such as flattening, aspiration (suction removal) of the contents with a needle, or ganglion obliteration are very rarely successful in the long term.

Operative Therapy

Surgical removal is the first-choice treatment for ganglion cysts. The operation should be carried out by an experienced hand surgeon using magnifying spectacles. To reduce the risk of recurrence, the ganglion and its pedicle (stalk) must be removed. A transversal incision on the extensor side of the wrist is commonly used.

During the operation, special attention should be paid to the proximity to important structures, such as tendons, nerves, and blood vessels. This is why the operation is carried out using a tourniquet around the arm. This requires anaesthetising of the arm or general anaesthetic. In some cases, where possible taking into account the location of the cyst, removal can be carried out using local anaesthesia.

Alternatively, arthroscopic removal of the ganglion cysts from the extensor and flexor side of the wrist is also possible (wrist arthroscopy, arthroscopic ganglion cyst resection).

Generally, ganglion cysts are removed in an outpatient setting under local anaesthesia (wide-awake technique), general anaesthesia, or partial anaesthesia of the arm (plexus anaesthesia), depending on the wishes and condition of the patient. In the event of an unfavourable position of the cysts, where possible circulatory disorders of the fingers or other complications are to be expected, a short period of inpatient monitoring will be required. This also applies to patients with severe secondary illnesses such as coronary heart disease, severe vascular diseases, severe diabetes, renal insufficiency, and bronchial asthma, among others.

As with any surgical procedure, ganglion cyst removal can result in complications, such as haemorrhaging, swelling, haematoma, or wound infection.

Such complications are rare and can generally be well controlled if they do develop. Rare severe complications, such as CRPS (Complex Regional Pain Syndrome, formerly known as Sudeck’s atrophy) require early follow-up treatment. It is possible for ganglion cysts to return to the same area; this is known as a recurrence. The recurrence rate varies greatly between 1 and 40%. This appears to depend on the complete removal of the ganglion stalk. Here, the experience of the surgeon plays a major role.

Aftercare

After the 15- to 30-minute procedure has been completed, the patient is fitted with a splint bandage for 1 or 2 days. After this, especially following excision of ganglion cysts from the wrist, physiotherapy or pain-adapted hand therapy should begin. Following the removal of ganglion cysts from the dorsal wrist region, the focus should be on the restoration of the full range of wrist motion. The suture material is removed after 12 to 14 days. The hand can return to normal use after 4 to 6 weeks.

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