Ganglion cysts that contain gelatinous fluid can occur in any joint or tendon with a tendon sheath, most often in the wrist or palm.
A symptomatic longstanding ganglion can be treated by surgery.
Incidence
A ganglion is a lump containing gelatinous fluid attached to a joint or tendon sheath.
Ganglions on the dorsal side of the wrist are common in young women with highly mobile wrist joints.
A ganglion may also be associated with osteoarthritis and is therefore often seen in people past middle age.
A ganglion is most often situated on the dorsal side of the wrist, but sometimes it may occur also on the volar side by the radial artery. Ganglions are also seen in flexor tendon sheaths in the distal palm and in the foot or in any joint.
Diagnosis
The diagnosis of a ganglion is usually clear based on the clinical picture.
As the amount of the gelatinous contents increases the ganglion may become painful, but most often the symptoms are mild. Especially a small ganglion attached to a flexor tendon sheath may be painful.
A ganglion situated on the dorsal side of the wrist may sometimes be small enough not to cause any bulging of the skin (occult ganglion). Such a ganglion may still produce symptoms on dorsiflexion of the wrist, thus affecting doing press-ups or other weight bearing on the hands, for example.
Translucency of the gelatinous contents can easily be seen by shining a flashlight through the skin on the lump (transillumination test), or the ganglion can be punctured to confirm the diagnosis.
Volar carpal ganglions, in particular, may be associated with osteoarthritis. X-ray examination is recommended to detect the presence and level of any osteoarthritis.
Treatment
Treatment is necessary only if the ganglion causes pain or other inconvenience. About half of carpal ganglia resolve spontaneously.
A ganglion can be punctured and aspirated to provide temporary pain relief, but recurrence is highly probable.
A corticosteroid preparation (triamcinolone, methylprednisolone) in depot form can be injected into the ganglion although there is no evidence on the effectiveness of this treatment.
If the ganglion causes symptoms preventing work or full-scale pursuit of hobbies, it should be treated surgically. Surgical removal of a ganglion attached to a flexor tendon sheath is a minor procedure. Carpal ganglions must be removed carefully ‘root and all'.
The ganglion often recurs after surgery (10-30%).
Ganglions in the distal phalanx of the finger (distal interphalangeal joint, DIP joint), i.e. mucous cysts, should not be aspirated or punctured due to the high risk of infection associated with the procedure. An infection almost always leads to purulent arthritis of the DIP joint. A ganglion in the DIP joint that causes symptoms may be surgically treated in a specialist unit for hand surgery.
References
Head L, Gencarelli JR, Allen M et al. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am 2015;40(3):546-53.e8. [PubMed]
Strike SA, Puhaindran ME. Tumors of the Hand and the Wrist. JBJS Rev. 2020 Jun;8(6):e0141.[PubMed]