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Ganglion Cyst of the Wrist and Hand

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function, or has an unacceptable appearance, there are several treatment options available.

Description

ganglion cyst1

A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

Ganglion cysts can develop in several of the joints in the hand and wrist, including both the top and underside of the wrist, as well as the end joint of a finger, and at the base of a finger. They vary in size, and in many cases, grow larger with increased wrist activity. With rest, the lump typically becomes smaller.

Cause

It is not known what triggers the formation of a ganglion. They are most common 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 — also known as mucous cysts — are typically associated with arthritis in the finger joint, and are more common in women between the ages of 40 and 70 years.

Symptoms

Most ganglions form a visible lump, however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms, if a cyst puts pressure on the nerves that pass through the joint, it can cause pain, tingling, and muscle weakness.

Large cysts, even if they are not painful, can cause concerns about appearance.

Doctor Examination

Medical History and Physical Examination

During the initial appointment, your doctor will discuss your medical history and symptoms. He or she may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful.

Pressure may be applied to identify any tenderness. Because a ganglion is filled with fluid, it is translucent. Your doctor may shine a penlight up to the cyst to see whether light shines through.

Imaging Tests

X-rays. These tests create clear pictures of dense structures, like bone. Although x-rays will not show a ganglion cyst, they can be used to rule out other conditions, such as arthritis or a bone tumor.

Magnetic resonance imaging (MRI) scans or ultrasounds. These imaging tests can better show soft tissues like a ganglion. Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

Treatment

Nonsurgical Treatment

Initial treatment of a ganglion cyst is not surgical.

Observation. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur.

Immobilization. Activity often causes the ganglion to increase in size and also increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.

Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.

This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Aspiration frequently fails to eliminate the ganglion because the “root” or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not removed. In many cases, the ganglion cyst returns after an aspiration procedure.

Aspiration procedures are most frequently recommended for ganglions located on the top of the wrist.

Surgical Treatment

Your doctor may recommend surgery if your symptoms are not relieved by nonsurgical methods, or if the ganglion returns after aspiration. The procedure to remove a ganglion cyst is called an excision.

Surgery involves removing the cyst as well as part of the involved joint capsule or tendon sheath, which is considered the root of the ganglion. Even after excision, there is a small chance the ganglion will return.

Excision is typically an outpatient procedure and patients are able to go home after a period of observation in the recovery area. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed 2 to 6 weeks after surgery.

Summary

A ganglion cyst is a benign ball of fluid that grows on a tendon or joint, usually in the hand or wrist. Most ganglion cysts go away by themselves. Treatment options include surgery or needle aspiration.

A tendon is a tough band of connective tissue that joins muscle to bone. Tendons and joints have a covering of membrane that produces a lubricating fluid to assist their function. A ganglion cyst is a benign (non-cancerous) ball of fluid that grows on the membrane or sheath that covers these tendons and joints. The backs of the hands and wrists are most commonly affected, but ganglion cysts can sometimes grow on the feet, knees and ankles. A ganglion cyst is the most common lump on the hand, and tends to target women between the ages of 20 and 40 years of age, for reasons unknown. 

As tendons anchor muscle to bone, a ganglion cyst on a tendon may cause muscle weakness. Depending on the individual, there may be just one large lump or a collection of many smaller ones attached to a single ‘stalk’ deeper in the tissue. Around one third to one half of ganglion cysts disappear on their own without the need for medical treatment. However, it is best to consult your doctor to make sure the swelling is not a symptom of some other type of illness.

Symptoms of ganglion cysts

The symptoms of a ganglion cyst include:

Noticeable swelling or lump.

The lump is able to change its size, including going away completely only to return.

The lump is usually soft and immobile.

In some cases, the lump is painful and aching, particularly those at the base of fingers.

The ache and pain is made worse by moving any nearby joints.

The affected tendon may cause a sensation of muscular weakness.

The back of the hands and wrists are most commonly affected.

Other sites include the back of the knee (Bakers cyst), ankle, foot, palm and fingers.

Causes of ganglion cysts
No one knows what causes a ganglion cyst to form. Some of the theories include:

The body responds to injury, trauma or overuse by forming an internal ‘blister’.

Small tears in the tendon membrane or joint capsule allow the contents to squeeze out.

Ganglion cysts can disappear
Around 30 to 50 per cent of ganglion cysts disappear by themselves without the need for medical treatment. However, it is always best to consult your doctor to make sure the lump isn’t a symptom of some other disease. If your ganglion cyst is painful, or if it interferes with your mobility or causes sensations of numbness or pins and needles, see your doctor.

Diagnosis of ganglion cysts

Ganglion cysts are diagnosed using a number of tests including:

Medical history

Physical examination

Ultrasound

X-rays

Needle aspiration (a fine needle is used to draw off fluid, which is then examined in a laboratory).

Treatment for ganglion cysts

Ganglion cysts used to be treated by slamming them with a heavy book such as a Bible – which explains the term ‘Bible therapy’. This isn’t a good idea, as you could cause further injury. Medical treatment options include:

Close monitoring – if the ganglion cyst isn’t causing pain or interfering with movement, some doctors prefer to wait and see. The cyst may simply disappear on its own.

Needle aspiration – one of the tests to diagnose ganglion cysts involves drawing off the fluid with a fine needle. In many cases (around 75 per cent), this treatment empties the cyst and no further action is needed.

Surgery – the cyst or cysts are surgically removed, usually by a specialist such as an orthopaedic surgeon. Ganglion cysts of the feet will usually require surgery.

Joint mobility after treatment

Whether your ganglion cyst is aspirated or surgically removed, you will be fitted with a splint for around one week or so. Depending on the location of the excised ganglion cyst, full recovery can be anywhere from two to eight weeks. Be guided by your doctor or health care professional, but generally it is best to get the joint moving again as soon as possible. Using splints for extended periods of time can actually hamper joint mobility. Your doctor will give you specific exercises to perform.

Ganglion cysts may return

Ganglion cysts may grow back after treatment. This is less likely if your cysts were surgically removed rather than aspirated with a needle. Some estimates suggest that around half of patients who undergo needle aspiration can expect a recurrence. Since the cause of ganglion cysts is unknown, prevention is impossible. If you suspect your ganglion cyst is recurring, see your doctor for further treatment. A ganglion cyst that is aspirated three times has a better than 80 per cent chance of being cured.

Things to remember

A ganglion cyst is a benign ball of fluid that grows on a tendon or joint.

The backs of the hands and wrists are most commonly affected, but ganglion cysts can also grow on the feet, knees and ankles.

The cause is unknown, but it is thought that small tears in the tendon membrane or joint capsule allow the contents to squeeze out.

In many cases, ganglion cysts go away by themselves without the need for medical treatment.

Treatment options include surgery or draining the cyst with a needle.

A ganglion cyst appears as a fluid enclosed bump usually around a joint or tendon sheath in the hand, wrist, or foot.

Ganglion cysts are the most common soft tissue mass of the hand and wrist (55 per 100,000 of population per year.) They occur in a 3 to 1 female to male ratio. These cysts can arise at any age with the majority presenting between the second and fourth decades (60-70%). There does not appear to be any relationship between ganglion cysts and dominant hand or occupation.

Causes

Currently, no single theory adequately explains what causes ganglion cysts to appear. Most modern theories are based on the belief that ganglion cysts arise from within the connective tissue.

Some theories:

Repetitive trauma stimulates hyaluronic acid/mucin production by modified synovial cells at the synovial-capsular interface. Mucin dissects along the attached ligament and capsule to form capsular ducts. These ducts, in turn, act as valve-like structure that leads to the formation of mucin lakes. The mucin in the ducts and lakes accumulates to eventually form a ganglion cyst.

Mucinous degeneration results in cyst formation due to chronic damage. Later degeneration of the joint capsule results in cyst communication with the joint. Ganglion cysts may arise due to herniations of synovial tissue from the joints.

Symptoms

The vast majority of ganglion cysts arise as small painless bumps ranging in size from 1 to 3 cm. Most have a firm or rubbery consistency and are mobile. Occasionally these cysts can be symptomatic. The most common presenting symptoms include:

Pain

Typically the pain is dull and persistent and worse at the extremes of wrist motion. More frequently, pain is associated with dorsal ganglion and smaller ganglion size.

Weakness
Sometimes a ganglion puts pressure on the nerves that pass near the joint; this may weaken hand strength, affect joint motion, or cause tingling in the fingers, hand, or forearm.

Physical Exam
Appearance and location is often sufficient to diagnose a ganglion cyst. In addition, the cysts will trans-illuminate with a flashlight on physical exam.

Aspiration
Cyst fluid may be removed and examined to confirm the diagnosis

X-rays
Often reserved for cases in which there is suspicion for other etiologies such as osteoarthritis, bone spurs, bone tumors, or fractures. However, x-rays can also be used to determine cyst related damage to wrist bones.

MRI or Ultrasound
Rarely used for the purpose of diagnosing ganglion cysts.

Treatment

You must take into consideration that most ganglions will disappear without any treatment and often return despite treatment. If the cyst is not painful or interfering with function, often all that is needed is education, reassurance, and expectant management. More aggressive treatment is indicated if a ganglion becomes symptomatic, infected, or is affecting adjacent bones or ligaments.

Treatment options include:

Aspiration
A large, 16 gauge needle is used to aspirate the cyst. This is rarely a permanent solution. In one study with 34 patients, 59% of cysts reoccurred within three months.

Aspiration with a Steroid Injection
Most commonly used approach. Thought to be more effective than aspiration alone. However, studies have shown cure rates ranging from 57-79%

Newer Approaches:

Injection of Hyaluronidase followed by Aspiration:
95% cure rate at 6 months
Aspiration and instillation of steroid
With the prior use of hyaluronidase (87% cure at 2 years compared to 57% without hyaluronidase)

Surgical Excision
Open procedure versus less invasive arthroscopic approach. The goal is to remove the ganglion sac and connecting tissue. Has a 5 to 10% recurrence rate.

A wrist ganglion cyst is a swelling that usually occurs over the back of the hand or wrist. These are benign, fluid-filled capsules. Ganglion cysts are not cancerous, will not spread, and while they may grow in size, they will not spread to other parts of your body.

Ganglion cysts arise as outpouchings from fluid filled areas such as the fluid within the small joints of the wrist, or fluid within the sheath that surrounds the wrist tendons. When the fluid, called synovial fluid, leaks out from these spaces, it can become a sack-like structure.

The fluid within the ganglion cyst is identical to the normal fluid found within a joint or within a tendon sheath. The fluid is gelatinous, and looks and feels like hair gel.

Lumps and Bumps of the Hand and Wrist

It is important to have this type of lump checked by your doctor to ensure it is simply a ganglion cyst. While mostlumps and bumps of the hand and wrist are ganglion cysts (by far the most common), there are other conditions that have different treatments. Other type of tumors such as a lipoma or giant cell tumor, infections, carpal bossing (bone spur), and other conditions can cause lumps around the wrist.

Treatment of a Ganglion Cyst

Sometimes, wrist ganglion cysts go away with no treatment, or they may linger around or even grow larger. The cysts typically form a type of one-way valve such that fluid enters the cyst easily, but cannot escape. When the ganglion cyst becomes large enough, it will begin to put pressure on surrounding structures. This pressure can cause painful symptoms, and is usually the reason these ganglion cysts are removed.

There are several methods of treatment for a wrist ganglion cyst. Putting a needle into the ganglion cyst and aspirating the fluid may work. However, the gelatinous fluid within the cyst does not always come through a needle very well. Furthermore, this treatment leaves the cyst lining behind, and the ganglion cyst will return about 50% of the time.

Another alternative, that some call traditional, others call a bit barbaric, is to smash the wrist ganglion cyst with a hard object such as a book. This pops the cyst, and ruptures the lining of the cyst. While many people are familiar with this treatment, it is not considered acceptable as there is the potential for other damage from the trauma of the treatment.

The treatment for a persistent or painful ganglion cyst is to remove it with a surgical procedure. During surgery, the wrist ganglion is completely excised, including the sac that surrounded the fluid. In addition, the connection to the joint or tendon sheath that supplied the fluid can be occluded. While this usually is effective, a small percentage of removed wrist ganglion will still return.

How to Treat and Prevent Ganglion Cysts

A ganglion cyst is a fluid-filled bump that forms under the skin near a joint, most commonly in the wrist area, and sometimes in the shoulder, elbow, hip, knee, ankle, or foot regions.

The conventional medical view of ganglion cysts is that they are idiopathic, meaning that definitive causes are not known. Ganglion cysts are usually left alone, aspirated, or excised.

All of your joint surfaces are cushioned by a layer of tissue called synovial lining, as well as by liquid called synovial fluid.

 If the joints in your wrist region are not moving properly and/or under constant strain, the synovial lining in this area can get irritated to a point where it begins to get squeezed out from between your wrist bones, creating a pouch-like appearance below the surface of your skin. Synovial fluid follows an outpouching as it develops, leading to a fluid-filled bump.

 Many years ago, ganglion cysts were also called Bible bumps because the standard treatment for such bumps involved having one’s doctor slam down on it with a heavy book, usually a Bible.

 Smashing a ganglion cyst may cause it to break apart or shrink, but without addressing the root cause of a cyst, it will usually return over time; this is also true of cysts that are removed via aspiration or excision, though the recurrence rate for cysts that are properly excised is lower than that for those that are simply aspirated.

 If you have a bump around one of your joints that resembles a ganglion cyst, the first step to take is to visit your physician to confirm that your bump is indeed a ganglion cyst. Sometimes, other conditions like lipomas, bone spurs, local infections, and in rare cases, even bone tumors, can present like ganglion cysts.

 Once you and your physician are sure that you have a ganglion cyst, the next step to take is to think about ways in which the affected joint is being strained on a regular basis. If you can identify an everyday activity that could be irritating the affected area, look for a way to reduce or modify that activity. In the case of a ganglion cyst in the foot or ankle region, the cause might be poor choice in footwear.

 If appropriate rest and/or addressing the aggravating activity doesn’t lead to significant improvement, you may want to visit a chiropractor, physiotherapist, osteopath, naturopath, or other health care practitioner who has experience mobilizing joints.

 Joint mobilization involves putting the bones that make up your joints through basic ranges of motion to help ensure smooth and full joint motion, which is critical to addressing and preventing ganglion cysts since restricted joints can be a primary cause of ganglion cyst formation.

 For example, in your wrist region, you have eight small carpal bones that are neatly arranged in two rows. Each of these carpal bones should have a certain amount of give, called joint play. An experienced practitioner can put each of your carpal bones (and the bones that lie below and above your carpal bones) through various ranges of motion to help ensure that the synovial linings in this region aren’t being irritated by your everyday activities.

 A good practitioner can also provide guidance on how to do specific stretches and exercises with the affected area to help promote optimal joint motion and reduce the likelihood of having a ganglion cyst come back.

 Sometimes, a ganglion cyst arises from a tendon sheath, though this scenario is less common than cysts that arise from within joints. In the case of a cyst that comes from a tendon sheath, it’s still wise to follow the steps above i.e. visit your physician to confirm the diagnosis, and try to identify everyday activities that may be aggravating the tendon/muscle involved.

The bottom line on ganglion cysts is this: They’re benign, and only present a problem if they restrict range of motion or cause discomfort during everyday activities. For some people, ganglion cysts create psychological and emotional burden, as they look unusual.

If there is significant joint restriction or discomfort, the best first step is to have an experienced practitioner ensure optimal health of the joints and soft tissues involved; if this doesn’t lead to significant improvement, it’s best to have an experienced surgeon excise the ganglion cyst, and then to continue with alternative treatments to ensure that the joints and soft tissues involved return to optimal health, which will reduce the likelihood of having the cyst return.