Ganglion Cyst


Article Author:
Roger Gregush


Article Editor:
Steven Habusta


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/24/2019 2:04:39 PM

Introduction

Ganglion cysts are synovial cysts that are filled with gelatinous mucoid material and commonly encountered in orthopedic clinical practice. Although the exact etiology of the development of ganglion cysts is unknown, they are believed to arise from repetitive microtrauma resulting in mucinous degeneration of connective tissue. They are the most common soft tissue mass found within the hand and wrist, but they are also commonly encountered in the knee and foot. Although the majority of ganglion cysts are asymptomatic, patients may present with pain, tenderness, weakness, and dissatisfaction with cosmetic appearance. Both non-operative and surgical treatments are available, but a high recurrence rate has historically plagued non-surgical treatment. Surgical excision can provide resolution of patients' symptoms, but an understanding of the underlying anatomy adjacent to the cyst is crucial to avoid injuring neurovascular structures within proximity to the cyst.[1][2]

Etiology

Numerous theories have been presented in the past regarding the etiology of ganglion cysts with no present consensus. One theory introduced by Eller in 1746 is that ganglion cysts are the result of the herniation of synovial tissue from joints. Another theory postulated by Carp and Stout in 1926, which forms the basis of most modern belief, suggests that ganglion cysts result from mucinous degeneration of connective tissue secondary to chronic damage. Currently, most authors agree that ganglion cysts arise from mesenchymal cells at the synovial capsular junction as a result of the continuous micro-injury. Repetitive injury to the supporting capsular and ligamentous structures appears to stimulate fibroblasts to produce hyaluronic acid, which accumulates to produce the mucin "jelly-like" material commonly found in ganglion cysts.[3][4][5]

Epidemiology

Ganglion cysts account for 60% to 70% of soft-tissue masses found in the hand and wrist. Although they can form at any age, they are most commonly found in women between the ages of 20 to 50. Women are three times more likely to develop a ganglion cyst than men. These cysts are also frequently encountered amongst gymnasts, likely secondary to repetitive trauma and stress of the wrist joint.

Pathophysiology

Ganglion cysts are mucin filled synovial cysts containing paucicellular connective tissue. They may be filled with fluid from a tendon sheath or joint. Ganglion cysts are most commonly found (70%) on the dorsal aspect of the wrist arising from the scapholunate ligament or scapholunate articulation. Approximately 20% of ganglion cysts are located on the volar aspect of the wrist arising from the radiocarpal joint or scaphotrapezial joint. The remaining 10% of ganglion cysts can arise from multiple areas of the body including the volar retinaculum of the wrist, distal interphalangeal joint, ankle joint, and foot. Wrist volar retinacular cysts arise from herniated tendon sheath fluid that protrudes out. Ganglion cysts arising from the dorsal DIP joint are called mucous cysts and are associated with Herbeden's nodules. They are commonly found in women between the ages of 40 and 70 with osteoarthritis.[6][7][8]

Histopathology

Biopsies of ganglion cysts are not routinely indicated because of their inherently benign nature. Typical histopathological appearance is a mucin-filled synovial cell lined sac without a true epithelial lining. Ganglion cysts can be single or multiloculated. When examined under electron microscopy, their walls contain sheets of collagen fibers arranged in multidirectional layers with intermittent flattened cells resembling fibroblasts. The thick mucinous material present in the majority of ganglion cysts is highly viscous, which is attributed to a high concentration of hyaluronic acid and mucopolysaccharides.

History and Physical

The majority of ganglion cysts are asymptomatic, but patients may seek treatment because of their unsightly cosmetic appearance. Patients may present with pain, tenderness, or weakness that is exacerbated by wrist motion. Ganglion cysts usually present as firm, well circumscribed, freely mobile masses approximately 1 cm to 3 cm in size. They are often fixed to deep tissue and not to the overlying skin. Patients with volar wrist ganglion cysts less commonly may present with carpal tunnel syndrome or a trigger finger secondary to compression of the median nerve or intrusion on the flexor tendon sheath. Volar wrist ganglion cysts can also cause ulnar nerve neuropraxia and compression of the radial artery leading to ischemia. Ganglion cysts will usually transilluminate on the exam.

Evaluation

Radiographs may be ordered to rule out any related intraosseous manifestation, but will generally be unremarkable. MRI is usually not indicated for ganglion cysts unless there is a concern for a possible solid tumor. MRI will show a well-circumscribed mass with uniform fluid intensity on T2 weighted imaging. Ultrasound can be used to differentiate a cyst from a vascular malformation and to avoid accidental puncture of the radial artery during needle aspiration of a cyst.

Treatment / Management

Asymptomatic patients can be observed and reassured that ganglion cysts are benign and may spontaneously regress. Non-surgical treatment may be attempted depending on the location of the cyst. Dorsal wrist ganglion cysts can be aspirated, but there is a much higher recurrence rate than with surgical excision. Aspiration of volar wrist ganglion cysts is not generally performed due to their proximity to the radial artery. Surgery is indicated for patients with continuing symptoms who have failed conservative management. Surgical excision is usually performed as an outpatient procedure. Dorsal wrist ganglion cysts are approached through a transverse incision made directly over the cyst. Careful dissection is performed to expose the pedicle of the cyst and to avoid rupturing it, which would make excision of the capsular attachments more difficult. The pedicle and capsular attachments should be detached as close to the scapholunate ligament as possible without disrupting the integrity of the ligament. Failure to resect the pedicle of the ganglion cyst, its capsular attachments, and part of the capsule has been associated with a high rate of recurrence. Volar wrist ganglion cysts are often close to the radial artery or sometimes may surround the vessel. Blunt dissection should be used to mobilize the artery from the cyst with care taken to avoid injuring the vessel. The palmar cutaneous branch of the median nerve arises 5 cm proximal to the wrist joint and is also at risk with volar wrist ganglion cyst excision. The most common complication of surgical excision is a recurrence, and volar wrist ganglion cysts have a higher recurrence rate than dorsal wrist ganglion cysts. Ganglion cysts have a recurrence rate of approximately 15% to 20%.[9][10]

Enhancing Healthcare Team Outcomes

Ganglion cysts may be encountered by a number of healthcare professionals including the nurse practitioner, primary care provider, hand surgeon, plastic surgeon and orthopedic surgeon. These harmless lesions do not always require treatment. Only symptomatic patients should undergo treatment but if not completely excised, there is a risk of recurrence. Asymptomatic patients can be followed. The prognosis for most patients is excellent. [11] (Level V)


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Ganglion Cyst - Questions

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Which is the most common tumor of the hand and wrist?



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A cystic, nontender structure located on the dorsum of the hand near the tendon sheaths is probably a:



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A 43-year-old male presents for a “bump” on the back of his wrist that first appeared approximately six months ago and has continued to increase in size since then. The patient reports some tenderness with prolonged movement of the wrist. What is the most likely cause of this patient’s etiology and from where does it most often arise?



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A 36-year-old woman presents with a “mass” on the dorsum of her wrist. The mass is freely mobile, non-tender to palpation, and compressible. She is diagnosed with a ganglion and she elects to have it surgically excised. After removal, the cyst is sent to pathology for analysis. What is the most likely histological appearance of a ganglion?



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Which one of the following statements about ganglion cysts is true?



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Which one of the following statements about ganglion cysts is false?



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A young male patient presents to the outpatient clinic with a lesion on his hand seen in the image below. He has had the lesion for several months and denies any trauma. Which of the following is true about the lesion? Select all that apply.

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Ganglion Cyst - References

References

Odom EB,Hill E,Moore AM,Buck DW 2nd, Lending a Hand to Health Care Disparities: A Cross-sectional Study of Variations in Reimbursement for Common Hand Procedures. Hand (New York, N.Y.). 2019 Feb 6;     [PubMed]
Spinner RJ,Mikami Y,Desy NM,Amrami KK,Berger RA, Superficial radial intraneural ganglion cysts at the wrist. Acta neurochirurgica. 2018 Dec;     [PubMed]
Murai NO,Teniola O,Wang WL,Amini B, Bone and Soft Tissue Tumors About the Foot and Ankle. Radiologic clinics of North America. 2018 Nov;     [PubMed]
Li S,Sun C,Zhou X,Shi J,Han T,Yan H, Treatment of Intraosseous Ganglion Cyst of the Lunate: A Systematic Review. Annals of plastic surgery. 2018 Jul 27;     [PubMed]
Safran T,Hazan J,Al-Halabi B,Al-Naeem H,Cugno S, Scaphoid Cysts: Literature Review of Etiology, Treatment, and Prognosis. Hand (New York, N.Y.). 2018 Apr 1;     [PubMed]
Bojanić I,Dimnjaković D,Smoljanović T, Ganglion Cyst of the Knee: A Retrospective Review of a Consecutive Case Series. Acta clinica Croatica. 2017 Sep;     [PubMed]
Angelini A,Zanotti G,Berizzi A,Staffa G,Piccinini E,Ruggieri P, Synovial cysts of the hip. Acta bio-medica : Atenei Parmensis. 2018 Jan 16;     [PubMed]
Meyerson J,Pan YL,Spaeth M,Pearson G, Pediatric Ganglion Cysts: A Retrospective Review. Hand (New York, N.Y.). 2018 Jan 1;     [PubMed]
Kim JY,Lee J, Considerations in performing open surgical excision of dorsal wrist ganglion cysts. International orthopaedics. 2016 Sep;     [PubMed]
Büchler L,Hosalkar H,Weber M, Arthroscopically assisted removal of intraosseous ganglion cysts of the distal tibia. Clinical orthopaedics and related research. 2009 Nov;     [PubMed]
Kuliński S,Gutkowska O,Mizia S,Martynkiewicz J,Gosk J, Dorsal and volar wrist ganglions: The results of surgical treatment. Advances in clinical and experimental medicine : official organ Wroclaw Medical University. 2019 Jan;     [PubMed]

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