Ganglionic Cysts of the Wrist

- Discussion:
    - type of muscinous filled cyst whch is found adjacent to joint capsule or tendon sheath;
    - it consist of an outer fibrous coat and an inner synovial lining and contains a clear, colorless, gelatinous fluid;
    - ganglions usually occurs singly but may be multilocular;
    - more common in women
    - age:
            - 70% occur between the second and fourth decades
            - ganglions occurring at DIP joint (mucous cyst) are associated w/ osteoarthritis and occur at older ages;
            - rarely seen in children;
            - in the report by Wang ED, et al (2001) the authors evaluated 14 children less than 10 years of age who presented with cysts of
                   the hand and wrist;
                   - masses included 7 retinacular cysts, 5 volar wrist ganglia, and 2 dorsal wrist ganglia;
                   - none of the cysts were painful and 79% of the cysts resolved spontaneously within a year;
    - location:
            - frequent in hand and wrist, less often in ankle, foot, and knee;
            - most common soft tissue mass of hand is ganglion;
            - dorsal ganglion: 60-70% of all ganglia over scapholunate ligament;
            - volar ganglion:
                    - 20% of all ganglia
                    - most common site at volar wrist crease between the FCR and APL at the scaphotrapezoid joint;
    - differential dx: (see diff dx: dorsal wrist pain);
            - Synovial Sarcoma
            - Extra-Skeletal Chondrosarcoma
            - AVN
            - Venous Aneuysm
                   - Venous aneurysms of the wrist     

- Clinical Presentation & Exam:
    - dorsal wrist pain which is made worse w/ repeated use;
    - a slow growing, localized swelling, with mild aching and weakness;
    - cyst is firm, smooth, rubbery, rounded, slightly flutuant, and at times tender;
    - cysts will transilluminate;
    - it is usually fixed but may be slightly movable if it involves tendon sheath;
    - mass may become obvious w/ wrist flexion;
    - palpation of cyst w/ compression may not only the extent of the cyst but also the direction of pedicle;
    - occult ganglia;
             - source of similar symptoms, esp young gymnasts;
             - discomfort is usually maximal in extension;
             - point tenderness is directly over scapholunate interval;
             - attempt to palpate mass over scapholunate w/ wrist in volar flexion;
             - references:
                    - Dorsal wrist pain and the occult scapholunate ganglion.
                    - Occult scapholunate ganglion: a cause of dorsal wrist pain.  

- Radiographs:
    - usually negative;
    - arthrography is usually not helpful;
    - dorsal ganglions may be found w/ scapholunate diastasis;
          - if this is the case, inform the patient before surgery, to that excision of the ganglion is not blamed for future instability;

- Non Operative Treatment:
    - aspiration followed by 3 weeks of immobilization may be successful in 30-50% of patients;
    - usually a 16 gauge needle is required inorder to successfully aspirate the
    - note: aspiration the characteristic gelatinous fluid is also useful to rule out the rare occurance of a malignant tumor
            masquerading as a cyst;
            - in case of a malignant tumor, it is unfortunate to make diagnosis, only after a transverse incision has been made across  wrist;
    - references:
            - Aspiration of ganglia.
            - Management of ganglion cysts of the hand by simple aspiration.
            - Efficacy of immobilization following aspiration of carpal and digital ganglions.

- Surgical Treatment:
    - Dorsal Wrist Ganglions:
    - Arthroscopic Excision: (wrist arthroscopy)
          - Prospective Outcomes and Associations of Wrist Ganglion Cysts Resected Arthroscopically
    - Volar Wrist Ganglions:
         - The volar wrist ganglion: just a simple cyst?


Bilateral Extensor Digitorum Brevis Manus

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, June 20, 2016 6:54 am