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ISSN 2470-0991

Journal of Surgery: Open Access

Case Report Volume: 2.3 Open Access

Pediatric Ganglion Cysts: Case Series and Received date: 12 Feb 2016; Accepted date: 23
Mar 2016; Published date: 28 Mar 2016.

Review of the Literature Citation: Gendy A, Ayyala HS, Datiashvili R (2015)

Pediatric Ganglion Cysts: Case Series and Review
Adam Gendy1, Haripriya S Ayyala2 and Ramazi Datiashvili2* of the Literature. J Surg Open Access 2(3): doi http://
dx.doi.org/10.16966/2470-0991.119
Temple University, 3500 N. Broad St, Philadelphia, PA 19140, USA
1

Division of Plastic Surgery, New Jersey Medical School, Rutgers, 140 Bergen Street, Suite E1620, Newark,
2
Copyright: © 2016 Gendy A, et al. This is an
NJ 07103, USA open-access article distributed under the terms
of the Creative Commons Attribution License,
Corresponding author: Ramazi Datiashvili, Rutgers, New Jersey Medical School, Division of Plastic
* which permits unrestricted use, distribution, and
Surgery, 140 Bergen Street, Suite E1620, Newark, NJ 07103, E-mail: datiasro@njms.rutgers.edu reproduction in any medium, provided the original
author and source are credited.

Abstract
Background: Although there is an abundance of information about hand and wrist ganglion cysts in the adult patient population, there
is limited data about these lesions in children. The purpose of this article is to present our clinical experience and review the epidemiology,
etiological factors, clinical presentation, treatment, and outcomes of pediatric patients with hand and wrist ganglion cysts.
Methods: A literature review was thoroughly conducted along with a chart review of all cases of ganglion cysts operated on at a single
institution, University Hospital, between May 2014 and October 2015.
Results: Five consecutive patients, between ages 2-16 years, who presented with symptomatic lesions of the hand or wrist, underwent
treatment by a single surgeon (R.D.). The mean age of patients was 9.4 years, with one of the patients being female. Functional limitation was
the most common indication for surgical treatment. Only one patient had a history of previous trauma. In 80% of the cases, the diagnosis was
made clinically. The most common site of occurrence was the dorsal wrist (4/5), followed by the volar wrist. Surgical excision was the treatment
of choice for all patients that presented with symptomatic lesions (100%). Patients were followed up on one week post-operatively and told to
return if they developed any recurrences.
Conclusions: While observation has been reported to be worthwhile in the cases of the asymptomatic pediatric hand and wrist ganglia,
surgical excision should be employed in those lesions that are symptomatic or do not resolve with observation alone.

Keywords: Ganglion cyst; Hand; Pediatric; Wrist

Introduction explains the pathogenesis of this lesion. The most prevailing belief is that
ganglion cysts arise as a response to repetitive minor trauma to synovial
Ganglion cysts are well-circumscribed, mucin-filled benign tumors
or mesenchymal cells at the synovial-capsular interface. Under the
that usually arise from underlying joint capsules or tendon sheaths [1].
stress of repetitive stretching of the capsular and ligamentous structures
They are the most common soft tissue lesions found within the upper that support the chronically aggravated joint, these cells appear to
extremity, accounting for approximately 33-69% of all hand masses [2]. produce hyaluronic acid at the synovial-capsular interface which then
Although they occur at all ages, they are most frequently seen in adults accumulates within small channels and eventually pools together to
between the second and fourth decades of life with females affected two become a ganglion cyst [5].
to three times as often as males [2,3]. Ganglion cysts are most commonly
located over the dorsum of the wrist (60-70%) followed by the volar wrist While a great deal of information exists for hand and wrist ganglia that
(20%) and the volar retinaculum (10-20%) [4]. occur within the adult patient population, there is a limited amount of
data on pediatric ganglion cysts. The true incidence of these lesions within
On gross examination, these benign growths usually have a smooth, this patient population in all likelihood is underreported as their presence
translucent, shiny appearance and may either consist of a single main cyst is usually painless and often does not cause functional deficiency. We
or may be multi-loculated [2]. Microscopically, the walls of these cysts present a single surgeon’s (R.D.) experience with pediatric ganglion cysts
are primarily composed of sheets of collagen fibers that are organized along with a review of the current literature.
within many different layers and are adorned by flattened cells that
are not organized into an epithelium or synovium [1]. The capsular Case Series
attachment of these structures can be shown in serial sections to In our case series, we reviewed the charts of all 5 patients between 2-16
contain mucin-filled clefts, which intercommunicate with each other years of age with primary ganglia of the hand and wrist that were treated
and the underlying adjacent joint, thus forming an intricate and consecutively by a single surgeon between May 2014 and October 2015.
continuous duct between the ganglion cyst and the associated joint During this time period, five patients underwent surgical excision of
[5]. The clear and viscous jelly-like fluid material within the cyst their ganglion cysts, all of which were symptomatic lesions. Information
consists of high concentrations of hyaluronic acid, albumin, globulin and was then collected on each patient, including age, gender, cyst location,
mucopolysaccharides such as glucosamine [1]. symptoms, and recurrence (Table 1).
There have been several theories postulated to explain the etiology of The mean age was 9.4 years old, ranging from 2 years to 16 years, with 3
the ganglion cyst. However, to date, there is no single theory that fully of the five patients being 10 years of age or younger. There was one female

Copyright: © 2016 Gendy A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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rates of recurrence following aspiration (57-83%) as compared to dorsal
Age Gender Cyst Location Symptoms Recurrence ganglion cysts. The aspiration of volar ganglia further carries with it the
2 M R volar wrist Pain no additional risk of injuring nearby neurovascular structures [9,12]. The
Pain
aspiration of any ganglion cyst is a challenging procedure to perform
6 M L dorsal wrist no on younger children in the office with higher rates of recurrence and
Functional limitation
8 M L dorsal wrist Functional limitation no
the potential to inflict damage to adjacent vital structures, therefore, it is
generally not recommended for the pediatric population.
15 F R dorsal wrist Pain no
Pain
Indications for surgical excision noted in the literature as well as in
16 M L dorsal wrist no our experience include associated pain, functional limitation, or gross
Functional limitation
deformity [13]. The surgical excision of hand and wrist ganglion cysts
Table 1: Pediatric hand and wrist ganglia patient demographics
F=Female; M=Male; L=Left; R=Right
in the adult patient population has been reported to be very successful
with reported recurrence rates as low as 4% for dorsal cysts and 7% for
and four males in the study. Functional limitation was the most common volar cysts [3]. For the pediatric patient population, however, recurrence
indication for surgical management of the lesion. Other indications for rates after excision are much more variable, ranging between 2.8%to 35%
surgery included pain, discomfort at rest, a progressive increase in cyst [6,13]. In this age group, recurrence rates seem to vary depending on both
size, and emotional distress to the patients and their parents. Only 1 patient age and the location of the excised cyst. Colon and Upton [11] had
patient reported a history of previous trauma. In 4 cases, the diagnosis a recurrence rate of 6% for dorsal and volar ganglion cysts in mostly older
was made on clinical presentation alone. In the remaining case, imaging teenaged patients, with no recurrences for retinacular cysts in younger
was utilized in the investigation of the mass based on its location over patients following extirpation.
the projection of the radial artery (Figure 1). The right side was affected Proper management of these lesions requires complete resection of the
in 40% of cases and the most common site of occurrence was the dorsal ganglion, its stalk, and if large enough, a portion of the joint capsule to
wrist (4/5), (Figure 2) followed by the volar wrist (1/5). There were no avoid recurrence [3]. As volar wrist ganglions are often located between
complications with any of the procedures performed in any patient. Long the radial artery and the flexor carpi radial is tendon, they must be gently
term follow-up was performed by means of telephone interview of the dissected off the radial artery to avoid the possibility of compromising
patients and their parents and ranged from 4 to 18 months. To date, there
blood supply to the hand. If the cyst is large enough, it can be punctured
have been no recurrences or any other complications noted from any one
to allow for better visualization of the stalk during the dissection [2].
of these patients.
The potential complications of this treatment modality include vascular
Discussion compromise of the hand, decreased range of motion secondary tendon
injury, scapholunate dissociation, joint stiffness, and wound-healing
The epidemiology of pediatric hand and wrist ganglia differ than that
sequel and that can include infection, neuroma, and keloid formation.
of adults. Satku and Ganesh [6] showed that in children aged less than
Simon Cypel et al. [13] reported an 8.5% complication rate in their series,
10 years, volar cysts (77%) were more commonly seen than dorsal cysts
(14%). Coffey et al. [7] corroborated this observation with children under
the age of 12 years, with 55% of their patients suffering from volar cysts. a) b)
Of note, the pediatric population classically exhibits a similar gender bias
as the adult population with the proportion of females being affected by
these lesions ranging in the literature from 1:6 to 4.7:1 [4,8].
The most common symptoms of ganglion cysts include pain, especially
upon movement, weakness, and an aesthetically displeasing appearance.
Although they are often non-tender to palpation, pain can be elicited during
flexion or extension of the wrist [5]. Ganglion cysts can range in size from
1-3 cm but may wax and wane with time. On physical examination, they
may be firm or rubbery, mobile, and may move with associated tendons
[5]. In addition, these lesions can be successfully transilluminated with
light as compared to other hand and wrist lesions [2]. While radiographic
Figure 1: a) Preoperative radiograph (oblique view) of the right wrist
imaging has not been shown to be very helpful in making the diagnosis, in in a volar ganglion cyst in a four-year-old; b) Ultrasound of the same
children presenting with an unusual-appearing or atypical mass, further patient (sagittal view) showing the cyst located volar to the distal radial
testing is warranted to rule-out underlying articular pathology or soft metaphysic
tissue calcifications to establish a proper diagnosis.
There are several treatment options for ganglions of the wrist and hand.
a) b)
Aspiration and other similar cyst puncture techniques have been shown
to have variable success in adult patients presenting with dorsal ganglion
cysts, with cure rates reported in the literature anywhere between 13% [9]
and 85% [10]. Aspiration within the pediatric population has also been
reported in the literature but has been shown to have less favorable results.
Mac Collum [8] reviewed 14 children with wrist ganglia that were treated
by aspiration, puncture, or indwelling suture and experienced a 43%
recurrence rate with those techniques. Colon and Upton [11] reported
only a 20% success rate in their case series with the aspiration of dorsal and
volar ganglion cysts and a less than 20% success rate with the aspiration Figure 2: a) Preoperative view of the left wrist with a dorsal ganglion
cyst in an eight-year-old male; b) Postoperative view
of retinacular cysts. Volar ganglion cysts have been shown to have higher

Citation: Gendy A, Ayyala HS, Datiashvili R (2015) Pediatric Ganglion Cysts: Case Series and Review of the Literature. J Surg Open Access 2(3): doi
http://dx.doi.org/10.16966/2470-0991.119

2
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where in two cases, a segment of the radial artery was removed during the Disclosures
excision of a volar ganglion cyst and in one case, one patient presented
None.
post-operatively with a giant cell reaction. In light of variable
recurrence rates and the potentially serious complications associated
References
with resection, the surgical management of ganglion cysts is usually
indicated for patients that present with pain, gross deformity, and/or 1. Singhal R, Angmo N, Gupta S, Kumar V, Mehtani A (2005) Ganglion
cysts of the wrist: A prospective study of a simple outpatient
functional limitations [2].
management. Acta Orthop Belg 71: 528-534.
Only a few studies have examined the treatment of pediatric ganglia by 2. Scott W (2005) Green’s Operative Hand Surgery. 6th edition, Volume 1.
observation alone. Wang and Hutchinson [4] found a 79% spontaneous
3. Thornberg LE (1999) Ganglions of the hand and wrist. J Am Acad
resolution rate in a case series which included 14 children less than 10
Orthop Surg 7: 231-238.
years of age that presented with simple, asymptomatic hand and wrist
ganglia. None of these lesions were accompanied by the presence of pain 4. Wang A, Hutchinson DT (2001) Longitudinal observation of pediatric
hand and wrist ganglia. J Hand Surg Am 26: 599-602.
symptoms, neurovascular abnormalities, signs of wrist instability, or a
limited range of motion. In their report, the average time to a traumatic 5. Phil M, Taras JS (2002) Ganglion Cysts of the Wrist. J Hand Surg 2:
resolution by observation alone was 6 months from the time of diagnosis, 102-107.
with a range between 1.5 months and 12 months, without a single 6. Satku K, Ganesh B (1985) Ganglia in children. J Pediatr Orthop 5:
recurrence [4]. They postulated that if a cyst did not resolve within 1year, 13-15.
it was not likely to resolve spontaneously and therefore, warranted having 7. Coffey MJ, Rahman MF, Thirkannad SM (2008) Pediatric ganglion
a conversation with the patients and their family members about the cysts of the hand and wrist: An epidemiologic analysis. Hand 3: 359-
risks and benefits of continuing to observe the lesion versus undergoing 362.
surgery. They concluded that in the absence of any other symptoms, these 8. Mac Collum MS (1977) Dorsal wrist ganglions in children: Clinical
benign lesions could be initially treated conservatively with observation notes. J Hand Surg 2: 325.
with marked success prior to any surgical intervention and incurring its 9. Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ
potential complications [4]. (1987) Ganglions of the wrist and digits: results of treatment by
Although ganglion cysts are the most common soft tissues masses of aspiration and cyst wall puncture. J Hand Surg 12: 1041-1043.
the hand and wrist, there is a paucity of information about these benign 10. Zubowicz VN, Ishii CH (1994) Management of ganglion cysts of the
lesions within the pediatric population. In contrast to previous studies, hand of simple aspiration. J Hand Surg 19: 954-958.
our series of patients more commonly had a ganglion cyst on the dorsum 11. Colon F, Upton J (1995) Pediatric hand tumors. A review of 349 cases.
of the wrist rather than the volar side, and occurred more commonly Hand Clin 11: 223-243.
in males than females; no patients experienced recurrence. We believe 12. Wright TW, Cooney WP, Ilstrup DM (1994) Anterior wrist ganglion. J
children that present with these benign growths may be managed with Hand Surg 19: 954-958.
observation and reassurance in asymptomatic cases. However, those that 13. Simon Cypel TK, Mrad A, Somers G, Zuker RM (2011) Ganglion Cyst
present with associated pain, functional limitation, or gross deformity in Children: Reviewing Treatment and Recurrence Rates. Can J Plast
benefit from surgical excision. Surg 19: 53-55.

Citation: Gendy A, Ayyala HS, Datiashvili R (2015) Pediatric Ganglion Cysts: Case Series and Review of the Literature. J Surg Open Access 2(3): doi
http://dx.doi.org/10.16966/2470-0991.119