Ganglion Cysts

Dorsal Wrist Ganglion (60-70%):

The most common location. Arises from the scapholunate ligament attachment on the dorsal capsule. Presents as a firm, smooth swelling on the dorsum of the wrist, typically between EPL (radially) and EDC (ulnarly) tendons.

Clinical Features:

• Firm, smooth, well-circumscribed mass on dorsal wrist
• Usually 1-3 cm diameter (range 0.5-4 cm)
• Mobile with skin but fixed to deeper structures
• Fluctuant on palpation
• Transilluminates with penlight
• May be asymptomatic or cause vague wrist pain
• Pain typically worse with wrist extension (increases pressure on stalk)
• Size may fluctuate with activity (larger after use)
• Becomes more prominent with wrist flexion (pushes dorsally)

Occult Dorsal Ganglion:

• Pain without visible or palpable mass
• Localized tenderness over scapholunate ligament
• Diagnosed on MRI (high signal on T2) or ultrasound
• May present as activity-related wrist pain or weakness
• Can be intraosseous (within scaphoid or lunate bone)

Associated Findings:

• Usually no joint instability
• Wrist range of motion typically normal
• May have tender scapholunate interval

This concludes the dorsal wrist ganglion description.

Volar Wrist Ganglion (18-20%):

Typically arises from the radioscaphoid or scaphotrapezial joint on the volar capsule. Located between FCR tendon (ulnarly) and radial artery (radially) - this anatomic relationship is critical during surgical excision.

Clinical Features:

• Firm mass at volar radial aspect of wrist
• Located in "soft spot" between FCR and radial artery
• 1-2 cm diameter typically
• Transilluminates
• May have visible pulsation transmitted from radial artery
• More likely to be symptomatic than dorsal ganglia
• Can compress median nerve causing carpal tunnel symptoms (rare)
• Becomes more prominent with wrist extension

Surgical Anatomy Considerations:

• Radial artery is immediately adjacent (radially/laterally)
• Branches of lateral antebrachial cutaneous nerve cross field
• Superficial branch of radial nerve nearby
• Allen test essential preoperatively to confirm dual hand circulation
• May need vessel loops around radial artery during excision
• Cyst often deep to FCR tendon - retract tendon ulnarly

Complications Risk:

• Radial artery injury (thrombosis, pseudoaneurysm)
• Superficial radial nerve injury (numbness over dorsal thumb)
• Higher recurrence than dorsal (cuff of capsule harder to obtain)

This concludes the volar wrist ganglion section.

Volar Retinacular Cyst (Seed Ganglion):

Arises from the A1 or less commonly A2 pulley at the base of the finger. Small but often symptomatic due to confined space in palm and fingers.

Clinical Features:

• Small (3-10 mm), very firm nodule
• Located at base of finger in distal palm
• Corresponds to MCP flexion crease
• Exquisitely tender to palpation
• May cause triggering or locking of digit
• Patient often describes clicking or catching
• Transillumination may be difficult due to small size
• Usually solitary, occasionally multiple

Differential Diagnosis:

• Trigger finger nodule (tendon nodule vs ganglion)
• Giant cell tumor of tendon sheath (solid, does not transilluminate)
• Dupuytren nodule (in palmar fascia, not tender)
• Fibroma (solid, slow growing)

Treatment Considerations:

• Often responds to aspiration due to small size
• Surgical excision requires careful dissection
• Protect digital nerves and vessels
• May need to release A1 pulley if contributing to triggering
• Low recurrence after excision

This completes the flexor sheath ganglion section.

Mucous Cyst (Digital Mucoid Cyst):

Arises from the DIP joint, typically in setting of DIP osteoarthritis. Located dorsally between DIP joint and nail matrix. Represents mucin extrusion through capsular defect.

Clinical Features:

• Small (2-10 mm) translucent nodule on dorsal finger
• Located between DIP joint crease and nail fold
• Most common in long and index fingers
• Transilluminates (appears bluish)
• Associated with DIP osteoarthritis (Heberden nodes)
• May cause nail deformity - longitudinal groove in nail
• Groove corresponds to position of cyst
• Occasionally ruptures with clear viscous drainage
• May become infected after rupture

Pathophysiology:

• DIP osteophytes create focal capsular weakness
• Mucin extrudes through defect
• Stalk connects to DIP joint
• Pressure on nail matrix causes nail deformity
• Chronic pressure leads to matrix damage

Treatment Considerations:

• Aspiration often ineffective (high recurrence)
• Surgical excision requires:
  • Remove cyst and stalk
  • Debride DIP osteophytes (essential to prevent recurrence)
  • May need capsular repair
  • Occasionally requires local flap if skin thinned
  • Nail deformity may improve after excision but can persist

Complications:

• Infection after spontaneous rupture
• DIP joint infection if cyst communicates with joint
• Persistent nail deformity despite excision
• Recurrence if osteophytes not addressed

This concludes the mucous cyst section.

Clinical Diagnosis

Ganglion cysts are primarily a clinical diagnosis. Imaging is not required if clinical features are typical (well-defined fluctuant mass, transilluminates, typical location). The combination of characteristic location, transillumination, and fluctuance has high diagnostic accuracy.

Plain Radiographs

Indications:

• Rule out bony pathology if diagnosis uncertain
• Assess for DIP osteoarthritis if mucous cyst
• Evaluate for intraosseous ganglion

Findings:

• Usually normal (ganglia are soft tissue)
• May show DIP osteophytes (mucous cyst)
• May show cystic lucency in bone (intraosseous ganglion)
• Can show scapholunate widening if instability present (unusual)

Ultrasound

Advantages:

• Non-invasive, inexpensive, no radiation
• Confirms cystic nature (anechoic or hypoechoic)
• Shows stalk connecting to joint or tendon sheath
• Useful for occult ganglion
• Can guide aspiration

Findings:

• Well-defined anechoic (fluid-filled) or hypoechoic mass
• May show internal septations
• Stalk visible as communication with joint
• Doppler confirms no internal vascularity

Limitations:

• Operator dependent
• Less useful for intraosseous or deep ganglion

MRI

Indications:

• Occult ganglion (pain without palpable mass)
• Atypical presentation or location
• Failed conservative treatment
• Concern for alternative diagnosis
• Intraosseous ganglion suspected

Findings:

• T1: Low to intermediate signal (same as muscle)
• T2: High signal (bright - follows fluid)
• Well-defined margins
• Stalk may be visible connecting to joint
• Surrounding tissue normal (no edema)

Special Sequences:

• T2 fat saturation: Ganglion very bright
• Contrast: No enhancement (acellular)
• If enhances, consider infection or solid tumor

Aspiration

Dual Purpose: Diagnostic and therapeutic

Technique:

• 18 or 20 gauge needle (mucin is viscous)
• Aspirate yields clear, thick, jelly-like fluid
• Consistency like hair gel or petroleum jelly
• Color: Clear, colorless to pale yellow

Diagnostic Confirmation:

• Gross appearance confirms diagnosis
• Can send for cell count (acellular)
• Cytology (scattered mesenchymal cells, no malignant features)
• Gram stain and culture if infection suspected

Differential Based on Aspirate:

• Clear viscous mucin: Ganglion
• Turbid fluid: Infection
• Blood: Trauma, solid tumor
• Chalky material: Calcific tendinitis
• No fluid obtained: Solid tumor (giant cell tumor, lipoma)

When Imaging Is Required

Mandatory Imaging:

• Pain without palpable mass (occult ganglion)
• Does not transilluminate (solid tumor)
• Atypical location or features
• Rapid growth (concern for malignancy)
• Aspiration yields atypical fluid
• Failed treatment with recurrence (evaluate for underlying pathology)

Optional Imaging:

• Patient preference for confirmation
• Medical-legal documentation
• Research or teaching purposes

Watch and Wait:

Many ganglion cysts resolve spontaneously without intervention. Observation is appropriate first-line management for asymptomatic or minimally symptomatic ganglia.

Evidence:

• Dias et al (2007): 58% of untreated dorsal wrist ganglia resolved at mean 70-month follow-up; symptom outcomes similar whether observed, aspirated or excised
• Head et al (2015) meta-analysis: aspiration was not significantly better than reassurance in cohort studies
• No reliable predictors of spontaneous resolution have been identified

Patient Counseling:

• Explain benign nature (not cancer, not dangerous)
• May fluctuate in size with activity
• Can resolve completely without treatment
• Safe to observe indefinitely
• Treatment available if symptoms develop

Follow-up:

• No routine follow-up required
• Advise return if enlarges, becomes painful, or cosmetically unacceptable
• Consider imaging if features change (rule out other pathology)

Advantages:

• No risk of complications
• No cost
• Many resolve spontaneously

Disadvantages:

• May persist or enlarge
• Ongoing cosmetic concern
• Psychological impact of "lump"

This completes the observation section.

Needle Aspiration:

Office-based procedure with local anesthesia. Simple and quick but high recurrence rate.

Technique:

1. Clean skin with antiseptic
2. Local anesthesia (1% lidocaine, optional)
3. 18 or 20 gauge needle (mucin is thick)
4. Enter cyst from side (not directly over stalk)
5. Aspirate contents (clear, viscous, jelly-like)
6. Compress cyst after aspiration
7. Apply pressure dressing

Steroid Injection:

• Controversial - no strong evidence of benefit
• Some inject 0.5-1 mL triamcinolone after aspiration
• Theory: Reduce inflammation, encourage stalk closure
• Trials have not shown a clear advantage of added steroid over aspiration alone

Recurrence:

• 50-80% recur within 1-2 years
• Recurrence lower if:
  • Complete aspiration achieved
  • Pressure dressing applied
  • Dorsal location (vs volar)
• Can repeat aspiration if recurs

Complications:

• Minimal - very low risk procedure
• Infection (rare, less than 1%)
• Nerve injury if inadvertent puncture
• Incomplete aspiration (mucin too thick)

Advantages:

• Simple office procedure
• Immediate relief if symptomatic
• Low risk
• Can repeat

Disadvantages:

• High recurrence (50-80%)
• Does not address stalk (source of problem)
• May need multiple aspirations

This completes the aspiration section.

Wrist Splinting:

Occasionally used for dorsal wrist ganglion but limited evidence.

Rationale:

• Immobilization may reduce pumping of fluid into cyst
• Wrist neutral or slight extension
• Worn at night or with activities

Evidence:

• No high-quality studies
• Historical use but falling out of favor
• Not superior to observation or aspiration

Current Recommendation:

• Not routinely recommended
• May offer symptom relief if activity-related pain
• Does not prevent recurrence or promote resolution

This completes the splinting section.

Indications for Surgical Excision:

1. Symptomatic ganglion causing pain or functional impairment
2. Failed conservative treatment (observation or aspiration)
3. Patient preference for definitive treatment
4. Recurrent ganglion after multiple aspirations
5. Diagnostic uncertainty (excision allows histology)
6. Neurovascular compression (rare - median nerve, ulnar artery)
7. Cosmetic concerns (patient preference)

Relative Contraindications:

• Medical comorbidities increasing surgical risk
• Unrealistic patient expectations (must counsel about recurrence)
• Inability to comply with post-op restrictions
• Active infection at surgical site

Timing:

• Elective procedure
• Can delay for patient convenience
• No urgency unless neurovascular compromise

This concludes the indications section.

Open Excision of Dorsal Wrist Ganglion:

Preoperative:

• Mark ganglion with patient awake (may be difficult to palpate under anesthesia)
• Regional or general anesthesia
• Tourniquet control
• Supine with arm on hand table

Incision:

• Transverse (Langer lines, better cosmesis) or longitudinal (better exposure)
• Directly over palpable ganglion
• 2-3 cm length
• Respect dorsal cutaneous nerve branches

Superficial Dissection:

1. Incise skin and subcutaneous tissue
2. Protect dorsal cutaneous nerves (radial and ulnar branches)
3. Identify ganglion (translucent, may be multilobulated)
4. Develop plane around ganglion

Deep Dissection:

1. Ganglion located between EPL (radial) and EDC (ulnar)
2. Retract tendons to expose ganglion
3. Trace ganglion to its stalk
4. Stalk penetrates to scapholunate ligament attachment
5. Excise ganglion with stalk and 5mm cuff of dorsal capsule
6. Do NOT destabilize scapholunate ligament
7. Inspect joint capsule - repair if large defect

Technical Pearls:

• Mark ganglion preoperatively (disappears under anesthesia)
• Use loupe magnification
• Identify and protect dorsal cutaneous nerves
• Completely excise stalk to capsular origin
• Include cuff of capsule (reduces recurrence)
• Check for satellite cysts

Closure:

• Irrigate wound
• Hemostasis (bipolar cautery)
• Close capsule if large defect (4-0 absorbable)
• Close subcutaneous tissue (4-0 absorbable)
• Close skin (5-0 nylon or subcuticular)
• Soft dressing

This completes the dorsal wrist technique.

Open Excision of Volar Wrist Ganglion:

Preoperative:

• Allen test mandatory (confirm dual hand circulation)
• Mark radial pulse
• Mark ganglion
• Regional or general anesthesia
• Tourniquet

Incision:

• Longitudinal along volar radial wrist crease
• 3-4 cm length
• Centered over ganglion

Superficial Dissection:

1. Incise skin and subcutaneous tissue
2. Protect lateral antebrachial cutaneous nerve (crosses radially)
3. Protect superficial radial nerve branches (dorsal)
4. Identify FCR tendon

Deep Dissection:

1. Retract FCR ulnarly
2. Identify radial artery (immediately lateral to ganglion)
3. Use vessel loops around radial artery for protection
4. Ganglion deep to FCR, between FCR and radial artery
5. Carefully dissect ganglion from radial artery
6. Trace stalk to volar capsule origin
7. Excise ganglion with stalk and cuff of volar capsule

Critical Anatomy:

• Radial artery: Immediately adjacent (lateral) - MUST protect
• Superficial radial nerve: Dorsoradial, easily injured
• Lateral antebrachial cutaneous nerve: Crosses radially
• Median nerve: Ulnar to ganglion, usually safe

View larger

Technical Pearls:

• Allen test preoperative (essential)
• Use vessel loops on radial artery
• Loupe magnification
• Gentle dissection (artery fragile)
• Complete stalk excision
• Obtain capsular cuff (harder than dorsal due to depth)

Closure:

• Irrigate
• Hemostasis
• Close capsule if needed
• Close subcutaneous and skin
• Soft dressing

This completes the volar wrist technique.

Arthroscopic Ganglion Excision:

Emerging technique for dorsal wrist ganglion. Resects from inside joint.

Advantages:

• Smaller incisions (portals)
• Direct visualization of stalk origin
• Ability to address intra-articular pathology
• Potentially faster recovery
• Similar or lower recurrence vs open

Technique:

1. Standard wrist arthroscopy portals (3-4, 6R)
2. Identify ganglion stalk at SL ligament
3. Use shaver to debride stalk and cuff of capsule
4. Thermal shrinkage of capsule
5. Ensure complete stalk resection

Evidence:

• Head et al (2015) meta-analysis: pooled recurrence arthroscopic 6% vs open 21%
• Clark et al (2022): recurrence 9.4% arthroscopic vs 11.2% open across 1,670 cases
• Neuropraxia (1-2%) from portal placement; requires arthroscopic skills

Limitations:

• Not suitable for volar ganglia
• Learning curve
• Equipment required
• Portal complications

This concludes the arthroscopic section.

Aspiration Complications

Recurrence (50-80%):

• Most common "complication"
• Due to persistent stalk and one-way valve
• Can re-aspirate or proceed to excision
• No limit on number of aspirations

Infection (Less than 1%):

• Rare with aseptic technique
• Presents as cellulitis or abscess
• Treat with antibiotics +/- drainage

Nerve Injury (Rare):

• Inadvertent puncture of nerve
• Usually neuropraxia (temporary)
• Avoid by identifying anatomy

Surgical Complications

Recurrence (5-10%):

• Most common after excision
• Usually within first year
• Risk factors:
  • Incomplete stalk excision
  • No capsular cuff removed
  • Volar location (higher than dorsal)
  • Flexor sheath location
• Management: Can re-excise

Nerve Injury:

Dorsal Wrist:

• Dorsal cutaneous branch of radial nerve (most common)
• Dorsal cutaneous branch of ulnar nerve
• Presents as numbness over dorsal hand/thumb
• Usually neuropraxia, recovers in 3-6 months
• Permanent injury rare
• Avoid by identifying and protecting nerves

Volar Wrist:

• Superficial radial nerve (dorsal sensory)
• Lateral antebrachial cutaneous nerve
• More common than dorsal due to nerve proximity
• Same presentation and management

Vascular Injury:

Radial Artery Injury (volar ganglion):

• Laceration (intraoperative bleeding)
• Thrombosis (post-operative)
• Pseudoaneurysm (delayed)
• Prevention: Perform Allen test preop, use vessel loops, gentle dissection
• Management: Primary repair if lacerated, vascular surgery consult

Tendon Injury:

• EPL or EDC injury during dorsal excision
• FCR injury during volar excision
• Rare with careful technique
• Management: Primary repair

Scar Issues:

• Hypertrophic scar or keloid
• Tender scar
• Cosmetically unacceptable scar
• Prevention: Respect Langer lines, careful closure
• Management: Scar massage, steroid injection, revision

Stiffness:

• Reduced wrist range of motion
• Usually mild and temporary
• Prevention: Early mobilization
• Management: Hand therapy, stretching

Infection:

• Superficial (cellulitis) or deep (abscess)
• Risk less than 2%
• Higher risk if mucous cyst (DIP joint communication)
• Management: Antibiotics, washout if deep

Complex Regional Pain Syndrome (CRPS):

• Rare (less than 1%)
• Disproportionate pain, swelling, stiffness
• Management: Hand therapy, desensitization, pain management

Mucous Cyst Specific Complications

Nail Deformity:

• Longitudinal groove may persist despite cyst excision
• Due to permanent nail matrix damage
• Counsel patient preoperatively

Skin Necrosis:

• Mucous cysts thin overlying skin
• Risk of skin necrosis after excision
• May require local flap coverage

DIP Joint Infection:

• If cyst communicates with joint
• Higher risk than other ganglion locations
• Requires antibiotics +/- washout