GANGLION CYSTS OF THE WRIST

BY PHIL MINOTTI, MD, AND JOHN S. TARAS, MD

The ganglion cyst is the most common soft-tissue mass of the hand and wrist. The
etiology remains unclear, but it is thought to involve mucoid degeneration.
Presenting complaints include pain, tenderness, and deforming mass. Treated
nonsurgically, ganglion cysts have a high rate of recurrence. Knowledge of
regional anatomy is essential for safe surgical excision. Complete excision of the
cyst and pedicle as well as a swath of surrounding joint capsule minimizes the risk
for recurrence.
Copyright © 2002 by the American Society for Surgery of the Hand

he most common soft-tissue mass presenting rize that a history of repeated minor trauma is a factor

T in the hand and wrist is the ganglion cyst,

accounting for 50% to 70% of all masses in
this anatomic region.1 Ganglion cysts occur at all ages
in their development.1-4
In general, ganglions are firm or rubbery, not fixed
to the skin, and usually range in size from 1 to 3 cm.5
but are most prevalent during the second, third, and They are often nontender to palpation. Wrist motion,
fourth decades of life. Women are affected 3 times as particularly at the extremes, exacerbates pain, which is
often as are men.2 Surgical excision is often required to usually dull and persistent. Several investigators have
eliminate the pain and deformity associated with the noted smaller ganglions to be more painful than larger
ganglion cyst. ones.3,6 Dellon and Seif7 postulate that an emerging
ganglion cyst may compress the posterior interosseous
nerve as it passes through the fourth extensor com-
CLINICAL CHARACTERISTICS partment. Less typical presenting symptoms include
carpal tunnel syndrome or trigger digit resulting from
ain, weakness, and unsightly appearance are the a volar carpal ganglion cyst’s interference with the
P most common presenting complaints of patients
with wrist ganglion cysts. At least 10% of patients
flexor tendon sheaths.
Office diagnostic procedures include aspiration of the
associate a preceding traumatic event with the appear- mucinous, jelly-like material, and radiographs, which
ance of a ganglion cyst, and most investigators theo- will reveal any related interosseous component. The dif-
ferential diagnoses include solid tumors and proliferative
tenosynovitis. The examiner will note that a proliferative
From Thomas Jefferson University; and the Division of Hand Sur- tenosynovitis will move along with the long extensors or
gery, Department of Orthopaedic Surgery, MCP/Hahnemann Uni- flexors, but a ganglion cyst will remain stationary.
versity, Philadelphia, PA.
Address reprint requests to John S. Taras, MD, The Philadelphia
Hand Center, PC, 834 Chestnut St, Ste G-114, Philadelphia, PA
PATHOGENESIS
19107.
here have been numerous theories about the eti-
Copyright © 2002 by the American Society for Surgery of the Hand
1531-0914/02/0202-0008$35.00/0
doi:10.1053/jssh.2002.33318
T ology of the ganglion cyst, and confusion exists
about their origin. Eller in 1746 and Volkmann in

102 JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND 䡠 VOL. 2, NO. 2, MAY 2002
 GANGLION CYSTS 䡠 MINOTTI & TARAS 103

1882 believed that ganglion cysts were herniations of DORSAL WRIST GANGLION CYSTS
synovial tissue from joints. The belief that ganglion
cysts arise de novo from within the connective tissue he dorsum of the wrist is the most common
forms the basis of most modern theories. This idea was
first postulated by Ledderhose in 1893. In 1928, Carp
T location of ganglion formation, accounting for
60% to 70% of all hand and wrist ganglion cysts.1,3
and Stout8 furthered this premise by theorizing that Ganglions in this region usually are directly over the
ganglion cysts resulted from mucinous degeneration scapholunate ligament, though they appear anywhere
of connective tissue because of chronic damage. The between the long thumb extensor laterally and the
accumulation of collagen fibers, intra- and extracellu- common finger extensors medially (Fig 1). The main
lar mucin, and decreased collagen fibers and stroma body of the cyst is tethered to the wrist capsule by a
cells supported this theory.1 Carp and Stout8 felt that pedicle. This pedicle often penetrates the capsule and
a ganglion cyst’s communication with the joint cap-
sule was the result of later degeneration of the capsule.
Soren5 in 1966 reinforced this theory and postulated
that a constitutional factor may contribute to the
development of ganglion cysts because some patients
display multiple ganglion cysts on their wrists and
ankles.
At present, most investigators agree that ganglion
cysts arise from modified synovial or mesenchymal
cells at the synovial-capsular interface in response to
repetitive minor injury.1 Repetitive stretching of the
capsular and ligamentous supporting joint structures
appears to stimulate the production of the tissue
lubricant hyaluronic acid by fibroblasts at the syno-
vial-capsule interface. The resultant mucin accumu-
lates in small channels, eventually pooling in the
ganglion cyst. These observations, however, do not
explain why the cyst fluid reaccumulates after aspira-
tion or incomplete excision. There is currently no
single theory that fully explains the pathogenesis of
ganglion cysts.

MICROSCOPIC ANATOMY

ight microscopy reveals ganglion cysts to be sin-

L gle or multiloculated, having a smooth, shiny
lining. Extensive studies by Psaila and Mansel4 by
using scanning electron microscopy showed that the
walls of ganglion cysts consist mainly of sheets of
collagen fibers arranged in multidirectional strata.
The walls show sparse, flattened cells resembling fi-
broblasts, but an epithelial or synovial lining is dis-
tinctly absent.
Most cysts contain a clear, highly viscous, jelly-like
fluid, significantly thicker than synovial fluid. This
viscosity is attributed to its high concentration of
hyaluronic acid and other mucopolysaccharides.5 FIGURE 1. Common locations of dorsal wrist ganglion cysts.
104 GANGLION CYSTS 䡠 MINOTTI & TARAS

FIGURE 2. A representation of a ganglion cyst with its pedicle attachment to the scapholunate ligament.

enters the scapholunate ligament (Fig 2). Angelides and 65% originated from the radioscaphoid-scapholu-
and Wallace9 found this to be true in all of 500 nate interval.
(100%) ganglion cysts excised over a 25-year period. Volar wrist ganglion cysts can be quite extensive,
Clay and Clement10 showed this in 47 of 62 (76%) tracking under the thenar muscles, into the carpal
cases and found most of the remainder to have arisen canal, or along the flexor carpi radialis tendon. Ad-
from the region of the capitate. herence to the radial artery is common. Jacobs and
In 1985, Gunther6 presented a series of patients in Govaers13 noted adherence of volar ganglion cysts to
which he showed that an occult scapholunate ganglion the radial artery in their series of 38 of 78 (54%)
cyst could be the cause of wrist pain and tenderness. surgical excisions. Their study underscores the impor-
He postulated that shear stresses generated in the tance of preoperative Allen’s testing when considering
scapholunate ligament incited ganglion cysts for form, surgery because injury to the radial artery during
and that the patients’ pain was related to pressure that excision can lead to ischemia of the radial digits in
the cyst generated within the ligament. patients in whom an incomplete palmar arterial arch
is present.
VOLAR WRIST GANGLION CYSTS
NONSURGICAL TREATMENT
olar wrist ganglion cysts account for 18% to
V 20% of all ganglion cysts of the hand and wrist.1
They generally occur under the volar wrist crease, just T he indications for treatment include pain, weak-
ness, and disfigurement. Asymptomatic patients
radial to the flexor carpi radialis tendon (Fig 3). Volar often require only reassurance that the ganglion cyst is
ganglion cysts arise most frequently from the radio- not malignant and may occasionally spontaneously
carpal joint or the scaphotrapezial joint.11 In a series of regress. Historically, nonsurgical treatment consisted
104 patients with surgically treated volar wrist gan- of a sharp blow to the ganglion cyst with a mallet,
glion cysts, Greendyke et al12 noted that 34% of dictionary, or Bible. Other nonsurgical treatments
ganglions originated from the scaphotrapezial joint, that have come and gone include heat, radiation, and
 GANGLION CYSTS 䡠 MINOTTI & TARAS 105

100% recurrence rate in patients who required mul-

tiple injections.

SURGICAL TREATMENT

fter failure or patient intolerance of conservative

A therapy, surgery becomes the treatment of
choice. Ganglion cyst excision generally takes place as
an outpatient procedure. General anesthesia is pre-
ferred, though axillary block anesthesia is also suit-
able. A pneumatic tourniquet ensures a bloodless
field. Loupe magnification is encouraged because fail-
ure to identify the pedicle and its attachment to
underlying ligaments accurately has been strongly
associated with a higher rate of recurrence.1,10,11
Dorsal ganglion cysts are approached through a
transverse incision centered directly over the ganglion
cyst. Extensile skin incisions are rarely necessary be-
cause the dorsal skin is freely mobile. The main cyst is
mobilized from the surrounding tissues by using teno-
tomy scissors. Avoid rupturing the cyst because this
makes identification and full excision of the pedicle
and capsular attachments more difficult. Following
the technique described by Angelides,1 a curvilinear
incision is made through the capsule adjacent to the
cyst, along the proximal pole of the scaphoid. The
capsule is elevated and retracted as the capsular inci-
sion is continued around the ganglion. At this point,
the capsular attachments and associated mucin ducts
adherent to the scapholunate ligament can be appre-
ciated. These attachments should be excised tangen-
tially off the scapholunate ligament without cutting
into the ligament itself. A wide swath of dorsal cap-
FIGURE 3. Typical location of volar wrist ganglion. sule is excised with the cyst, greatly reducing the
chance of recurrence. Maintaining the integrity of the
injection with sclerosing agents. These methods have scapholunate ligament will eliminate the possibility
been shown to be ineffective, or in the case of sclero- of iatrogenic scapholunate instability. Do not close the
therapy, dangerous. capsule primarily or with a flap because such closures
The mainstay of conservative treatment is aspira- only serve to delay early mobilization. For dorsal
tion of the cyst with a large bore needle followed by ganglion cysts presenting with significant pain, exci-
injection of lidocaine and a corticosteroid. In the case sion of the posterior interosseous nerve proximal to
of dorsal wrist ganglion cyst, up to 80%10 of patients the extensor retinaculum can limit pain caused by
can expect at least a temporary resolution of their stretching of the posterior interosseous nerve coursing
symptoms, but recurrence is common. Volar wrist through the capsule. The posterior interosseous nerve
ganglion cysts generally respond poorly to nonsurgical is found between the third and fourth dorsal extensor
treatment. Wright et al11 noted recurrence in 20 of 24 tendon compartments on the radius and is accompa-
(83%) patients after aspiration and injection and a nied by the posterior interosseous artery.
106 GANGLION CYSTS 䡠 MINOTTI & TARAS

FIGURE 4. (A)Volar wrist ganglion dissected to show long

pedicle. (B) Connection to radiocarpal joint noted at base of
wound. (C) Excision of a side swath of capsule decreases
chance or recurrence.

Volar wrist ganglion cysts are approached through technique described by Lister and Smith14 in 1978 is
a longitudinally oriented incision curving around the useful. The ganglion is freed from all surrounding
radial side of the ganglion cyst. The incision is placed connective tissue and the radial artery is mobilized
in such a way as to allow proximal and distal extension proximally and distally. As the ganglion is separated
in pursuit of remote capsular attachments. The palmar from the artery, a 1- to 2-mm cuff of cyst wall is left
cutaneous branch of the median nerve arises 5 cm with the artery to prevent vessel injury. Once the
proximal to the wrist joint and runs distally along the artery is separated and protected, the pedicle can be
ulnar side of the flexor carpi radialis tendon before traced to its capsular attachments to the scaphotrape-
piercing the volar carpal ligament to supply sensation zial or radiocarpal ligament and excised (Fig 4). Cap-
to the thenar eminence. Injury to the nerve during sular attachments are often more difficult to delineate
dissection may cause anesthesia to this area. The volar on the volar wrist than on the dorsal wrist. When the
ganglion cyst is often associated with the radial artery, connection between the ganglion and the wrist is
sometimes surrounding the vessel. If the artery is difficult to identify, digital pressure over the surgical
minimally involved, then careful blunt dissection can field causes extrusion of mucin, aiding in the identi-
successfully separate the artery from the cyst. When fication of smaller, more tortuous ducts. Alternatively,
the cyst is intimately adherent to the vessel wall, the local anesthetic agent can be injected into the radio-
 GANGLION CYSTS 䡠 MINOTTI & TARAS 107

carpal joint at a remote site and observed to leak placed elastic wrap for 2 weeks to control swelling.
through the capsular connection. As is the case for Therapy, either guided or a home exercise program, is
dorsal ganglion cysts, complete excision minimizes continued until a full range of motion has been
the possibility of early recurrence. achieved. Postoperative care proceeds in a fashion
After release of the tourniquet, meticulous hemo- similar to that described for dorsal ganglion cysts,
stasis is obtained by using bipolar electrocautery, and though a volar wrist splint is used for patient comfort
the wound is copiously irrigated. The skin edges are after extensive dissections.
infiltrated with a long-acting local anesthetic such as
bupivacaine 0.5%, and the wound is closed with CONCLUSION
interrupted 4-0 or 5-0 nylon sutures. A fluffy bandage
is applied over a nonadherent dressing. Early motion lthough the etiology of the ganglion cyst re-
is encouraged; therefore, no splint is applied unless
there has been extensive dissection as is the case with
A mains unclear, surgical treatment can be under-
taken with the confidence that patients will have
some volar ganglion cysts. The skin is closed and a resolution of their symptoms. Excising the cyst, its
bandage is applied as previously described. Sutures are pedicle, and a portion of the capsule greatly dimin-
removed in 10 to 14 days. The patient wears a loosely ishes the risk for recurrence.

REFERENCES

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DP, ed. Operative hand surgery. 3rd ed. New York: Churchill to treatment. Surg Gynecol Obstet 1928;47:460-468.
Livingstone, 1993:2171-2183. 9. Angelides AC, Wallace PF. The dorsal ganglion of the wrist:
2. Barnes WE, Larson RD, Posch JL. Review of ganglia of the its pathogenesis, gross and microscopic anatomy, and surgical
hand and wrist with analysis of surgical treatment. Plast treatment. J Hand Surg 1976;1:228-235.
Reconstr Surg 1964;34:570-578. 10. Clay NR, Clement DA. The treatment of dorsal wrist
3. Young R, Bartell T, Logan S. Ganglions of the hand and ganglia by radical excision. J Hand Surg [Br] 1988;13B:
wrist. South Med J 1988;81:751-760. 187-191.
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thop 1966;48:173-179. glia from the scaphotrapezial joint. J Hand Surg [Am] 1992;
6. Gunther SF. Dorsal wrist pain and the occult scapholunate 17A:487-490.
ganglion. J Hand Surg [Am] 1985;10A:697-703. 13. Jacobs LGH, Govaers KJM. The volar wrist ganglion: just a
7. Dellon AL, Seif SS. Anatomic dissections relating the simple cyst? J Hand Surg [Br] 1990;15B:342-346.
posterior interosseous nerve to the carpus, and the etiology 14. Lister GD, Smith RR. Protection of the radial artery in the
of dorsal wrist ganglion pain. J Hand Surg 1978;3:326- resection of adherent ganglions of the wrist. Plast Reconstr
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