What is a Ganglion Cyst?
Ganglion cysts are the most common type of swelling in the hand and wrist. They are completely harmless, and usually disappear within a few years.
A ganglion is a collection of thickened fluid, usually arising from a nearby joint. Joints have a fine lining (synovium) which produces a lubricating fluid in order for the joint to move freely without friction.
If this fluid ‘leaks’ from the joint, the soft tissues react by forming a barrier to stop it spreading – this barrier is the wall of the ganglion.
Where do Ganglions Cysts Occur?
There are four common locations in the hand and wrist where ganglion cysts are likely to appear:
- in the middle of the back of the wrist (dorsal wrist ganglion cyst)
- on the palm side of the wrist at the base of the thumb (palmar wrist ganglion cyst)
- on the back of a finger at the end joint nearest the nail (dorsal digital ganglion cyst)
- at the base of a finger on the palm side (flexor tendon sheath ganglion cyst)
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Types of Ganglion
1. Dorsal wrist ganglion cyst
These typically occur in young adults and teenagers. They usually last up to two years before disappearing.
They usually disappear spontaneously.
Aspiration (removing fluid with a needle) can reduce the swelling but it very often returns.
The risk of recurrence after surgery is around 25%.
Problems after surgery include:
– persistent pain
– loss of wrist movement
– painful trapping of nerve branches within the scar.
Surgery for this type of ganglion is rarely recommended, because of poor satisfaction rates.
2. Palmar wrist ganglion cyst
This type of ganglion may occur in young adults, but is also seen in association with wrist arthritis in older individuals. Once again, although aspiration and surgery are options, these are rarely undertaken.
These ganglion sometimes lie quite close to the artery at the wrist (where you can feel the pulse). Even after surgery the risk of recurrence is around 30%, and problems after surgery include persistent pain, loss of wrist movement and trapping of nerve branches within the scar.
For these reasons, many surgeons advise against an operation for these cysts
3. Dorsal digital ganglion cyst
This type of ganglion usually occurs in middle-aged or older people and is often associated with early osteoarthritis of the end joint of a finger. Pressure from the cyst may cause a furrow or ridge in the finger nail. Occasionally the cyst fluid leaks through the thin overlying skin from time to time. The risk of recurrence after surgery is around 10% and problems after surgery include infection, stiffness and pain from the arthritic joint.
4. Flexor tendon sheath ganglion cyst
This type of ganglion typically occurs in young adults, causing pain when gripping and feeling like a dried pea sitting on the tendon sheath at the base of a finger. Puncture of the cyst with a fine needle can disperse it (like puncturing a balloon) and fewer than half return. Persistent cysts can be removed surgically and the risk of recurrence is small.
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What causes a Ganglion Cyst?
Most ganglion cysts arise spontaneously but occasionally there is a history of injury or the joint is starting to develop arthritis in which case it will arise from a point of relative weakness around a joint. Ganglions tend to fluctuate in size with time, often getting bigger when the wrist is loaded. An increase in the pressure generated by the wrist joint can ‘push’ fluid out into the ganglion, but there is no good way of the fluid returning to the joint.
What are the Symptoms?
All ganglions produce a swelling or lump. When small, this lump may only be seen when the wrist is bent, but often the lump is fairly obvious, and occasionally the lump itself gets quite big.
Ganglions generally do not cause any pain and if they do, this is usually only mild discomfort. The presence of pain or discomfort does not indicate damage or harm here.
It is a completely harmless pain, and it is very safe to use the hand normally.
How is the Diagnosis Made?
The diagnosis is usually straightforward as ganglion cysts tend to be smooth and round, fluctuate in size and occur at characteristic locations in the hand and wrist. The diagnosis is commonly made clinically. If the diagnosis is uncertain then a scan may be helpful.
What is the natural history?
The majority of ganglions will fluctuate in size over the course of weeks or months, but most will disappear within a couple of years.
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What are the treatment options for Ganglion Cysts?
As mentioned previously, ganglion cysts are harmless and can safely be left alone. Many disappear spontaneously and many others cause little trouble. There are no long term consequences from leaving a ganglion untreated and the strong recommendation from doctors is to leave it alone and not to worry about it.
For any individual cyst, the recommendations for treatment will depend on the location of the cyst and on the symptoms that it is causing however surgery is not routinely recommended as:
- it results in a permanent scar
- the ganglion may come back
- rarely nerve damage, stiffness and chronic pain may occur
For ganglion cysts in general, the possibilities of treatment include:
1. Explanation, reassurance and wait to see if the cyst disappears spontaneously.
2. Removal of the liquid contents of the cyst with a needle (aspiration).
Aspiration
Aspiration can be useful to confirm the diagnosis, but is not recommended in palmar wrist ganglions because of the risk of damage to the radial artery, which often overlies the ganglion.
Aspiration of a dorsal ganglion is often done with some local anaesthetic to numb the skin. The ganglion fluid itself is thick and jelly-like, and cannot be removed with a small needle. A large needle inserted into the cyst will remove the fluid and the lump will reduce in size.
It does not disappear completely.
Aspiration does not cure the problem; it simply confirms the diagnosis and temporarily settles the lump. The lump re-accumulates over the course of days to weeks.
Aspiration of a ganglion has some potential risks, including infection and bleeding. Occasionally severe and unpredicted complications are encountered with potential harm to patients.
Surgical removal of the cyst
Surgery is not usually recommended. This is because a ganglion is a harmless and self-limiting condition, whereas surgery always carries a risk which can leave patients worse off following an operation than they were before.
In general, satisfaction rates one year following this type of surgery are far lower than most surgeons would hope for. It is possible to remove the ganglion surgically, but this should be discussed with the surgeon carefully before such a decision is made.
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