Background

Tumors of the hand are found to be benign 95% of the time when excluding a cutaneous malignancy.
[1] 
Representing about 60% of these benign tumors is the ganglion cyst. [2] While a definitive etiology is
unknown, the theory that the ganglion is the degeneration of the mucoid connective tissue, specifically
collagen, has dominated since 1893, when Ledderhose described it as such. [3] Nonsurgical treatment,
arthroscopic surgery, and open surgery have all been used to treat the ganglion cyst, with arthroscopy
leading the way with some promising results, especially in reducing the incidence of recurrence of dorsal
ganglion cysts.[4]

Retinacular ganglion Transillumination of

recurrent multilobulated left volar ganglion cyst. Mucous cyst on the radial side of the

right long finger. Typical appearance of dorsal ganglion cyst.

Recurrent multilobulated left volar ganglion cyst.

Recent studies
Edwards and Johansen prospectively evaluated outcomes of arthroscopic dorsal wrist ganglia resection
and found that the patients experienced significant increased function and decreased pain within 6 weeks
after arthroscopic resection; recurrence and complication rates appeared comparable to those of open
resections. Ganglion cysts also had a high association with certain interosseous laxities, and recurrent
cysts originating from the midcarpal joint were not contraindications for arthroscopic resection. The
authors noted that assessment of the midcarpal joint is necessary for complete resection of most ganglion
cysts, and identification of a discrete stalk is an uncommon finding and is not necessary for successful
resection.[5]

Rocchi et al compared 2 forms of treatment of volar wrist ganglia: open excision via longitudinal volar skin
incision and arthroscopic resection through 2 or 3 dorsal ports. The results of the study suggested that
arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia,
because it is associated with less postoperative morbidity and a better cosmetic result. Midcarpal volar
ganglia, however, according to the authors, should still be treated by open removal. [6]

History of the Procedure

Multiple nonsurgical modalities have been used over the years for ganglion cyst, including simple
aspiration. Surgery often becomes necessary, and recent findings suggest that arthroscopic ganglion
excision is a practical and successful means of dorsal ganglion cyst removal. [4, 5, 6, 7]

Problem
The problems that ganglion cysts present can be varied and are due to their location. Most often, the cyst
will present at the dorsal wrist, accounting for 60-70% of all hand and wrist ganglia [4] , and arise from the
scapholunate joint.[8] A ganglion cyst can also arise from the radioscaphoid or scaphotrapezial joint volarly.
[8] 
These locations can cause joint instability, weakness, and limitation of motion. [8]

Compression of the median nerve can occur when a volar radial ganglion arises within the carpal canal.
[8] 
The ulnar nerve may also be compressed within the tunnel of Guyon when the ganglion presents on the
ulnar side of the wrist. The patient can experience paresthesias and pain from a ganglion cyst, and in
such cases, surgical treatment should be considered, to provide a favorable outcome with few
complications.

Epidemiology
Frequency
Ganglion cysts are the most common soft-tissue tumors of the hand and wrist. Although anyone can be
affected by ganglion cysts, they occur 3 times as often in women as they do in men. Mucous cysts are
found in the distal interphalangeal (DIP) joint and generally present with osteoarthritis, and therefore, they
are most commonly seen in older patients. Ganglion cysts are predominantly seen in young adults and
are rare in children.[2]

Etiology
The etiology of the ganglion cyst has been described as an outpouching of synovium; as an irritation of
articular tissue, creating a new formation; and, the most common and accepted theory, as a degeneration
of connective tissue and cystic space formation.[3] It has also been suggested that degeneration of the
connective tissue is caused by an irritation or chronic damage causing the mesenchymal cells or
fibroblasts to produce mucin.[2]

Pathophysiology
Although ganglion cysts can be unilobulated, they are most often multilobulated, with septa made from
connective tissue separating the lobes or cavities.[3] Thornburg points out that because there is no
epithelial lining of the cyst wall, a ganglion cyst is not a true cyst and, because of this histologic
observation, the theories of synovial herniation or synovial tumor formation are not supported and may be
disputed.[2]
Hyaluronic acid predominates the mucopolysaccharides that make up the fluid within the cyst’s cavity,
while collagen fibers and fibrocytes make up the wall lining. [3] The development of these cysts is
histologically observable beginning with swollen collagen fibers and fibrocytes, followed by a
degeneration and liquefaction of these elements, a termination of degeneration, and, lastly, a proliferation
of the connective tissue, resulting in a border that is dense in texture. [3]

Presentation
Ganglion cysts can occur at any joint or tendon sheath, but they most often present in the dorsum of the
wrist at the scapholunate joint, followed by the volar wrist. They can also occur in the flexor tendon
sheaths, and when located at the DIP joints, they are termed mucous cysts [2, 8] Of the dorsal wrist ganglia,
75% connect with the dorsal scapholunate interosseous ligament. [2] Many patients who have had
asymptomatic cysts for months or even years can present with newly developed pain or limitation of
activity.

The skin above the cyst is unchanged, but the mass itself is compressible and movable and
transilluminates. Compression of the median nerve cutaneous branches may elicit a sensory or motor
nerve palsy when a volar carpal ganglion is present[9] ; this is an indication for surgical removal. A mucous
cyst, at the DIP joint on the dorsum of the hand, will frequently be associated with osteoarthritis and may
place pressure on the germinal matrix and cause malformation of the nail. Unlike with the ganglia of the
wrist, mucous cysts can cause the overlying skin to become thinned and may even lead to skin rupture.
[2]
 Patients presenting with mucous cysts may complain of pain; however, the cause of the pain is often
the associated osteoarthritis rather than the cyst itself. [2]

Ganglion cysts can also be associated with a tendon and may be adherent to the tenosynovium; however,
the presence of an extensor digitorum brevis manus muscle must be excluded. Ganglion cysts within
bone, termed interosseous cysts, most often affect the scaphoid and lunate and require open surgery for
removal; therefore, it is important to determine whether the cyst is the cause of the pain. [2]

Indications
Because the hand and wrist are very visible in day-to-day activity, aesthetics can be an indication for
treatment but may favor a less invasive intervention,[3]while pain, limitation of movement, and nerve
palsies are indications for surgical excision.[2]

Relevant Anatomy
Dorsal ganglia most often affect the scapholunate joint, and the scaphoid interosseus ligament and
extensor tendons must be considered because they are closely associated with the joint capsule. Volar
ganglia are commonly associated with the radioscaphoid and scaphotrapezial joints, with proximity to the
palmar cutaneous branch of the median nerve and the median nerve itself. Mucous cysts can be
anatomically associated with the germinal matrix and are generally displaced lateral to the midline by the
extensor tendon.[2]

Contraindications
There are few contraindications for ganglion excision. Caution is advised, however, for those few patients
who have only one upper extremity and desire elective removal of a cyst. Any postoperative complication
will create a substantially larger impact on such patients.