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Ganglia

(Ganglion Cysts)

by David R. Steinberg, MD

Ganglia are cystic swellings occurring usually on the hands, especially on the dorsal aspect of the wrists. Aspiration or excision is indicated for symptomatic ganglia.

Ganglia constitute about 60% of chronic soft-tissue swellings affecting the hand and wrist. They usually develop spontaneously in adults aged 20 to 50, with a female:male preponderance of 3:1.

Etiology

The cause of most ganglia is unknown. The cystic structures are near or attached (often by a pedicle) to tendon sheaths and joint capsules. The wall of the ganglion is smooth, fibrous, and of variable thickness. The cyst is filled with clear gelatinous, sticky, or mucoid fluid of high viscosity. The fluid in the cyst is sometimes almost pure hyaluronic acid.

Most ganglia are isolated abnormalities. The dorsal wrist ganglion arises from the scapholunate joint and constitutes about 65% of ganglia of the wrist and hand. The volar wrist ganglion arises over the distal aspect of the radius and constitutes about 20 to 25% of ganglia. Flexor tendon sheath ganglia and mucous cysts (arising from the dorsal distal interphalangeal joint) make up the remaining 10 to 15%. Ganglia may spontaneously regress.

Diagnosis

  • Examination

Ganglia are evident on examination. Another type of ganglion on the dorsal wrist occurs in patients with RA; it is easily differentiated by its soft irregular appearance and association with proliferative rheumatoid extensor tenosynovitis.

Treatment

  • Aspiration or excision if troublesome

Most ganglia do not require treatment. However, if the patient is disturbed by its appearance or if the ganglion is painful or tender, a single aspiration with a large-bore needle is effective in about 50% of patients. Attempting to rupture the ganglion by hitting it with a hard object risks local injury without likely benefit. Nonsurgical treatment fails in about 40 to 70% of patients, necessitating surgical excision. Excision can be done via arthroscopic or standard open surgery. Recurrence rates after surgical excision are about 5 to 15%.

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