Ganglion cyst of the wrist
A male patient with a wrist ganglion cyst on the dorsal side

Definition

A ganglion cyst of the wrist is a fluid-filled sack usually located under the skin on the back of the wrist or hand.

Ganglion cyst on the extensor tendon of the thumb

Pathology

A ganglion cyst is a benign formation that is more often present at the wrist and occasionally at the finger joints. A ganglion develops in proximity of the joint capsule, which is a multitude of ligaments enclosing the joint. The capsule contains a viscous synovial fluid to facilitate the movement of the bones within the joint. 

Ganglions are mostly located to the dorsal side of the wrist or hand. They can be protruding and visible or occult, when forming in the deeper tissues. Usually over time they grow in size but reduce with rest. In fingers, ganglion cysts are more often located at the end of the finger joint. Ganglions may interfere with function of the fingers and cause pain; however, they may also be asymptomatic.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Incorrect and repetitive use of the wrist can lead to a ganglion cyst formation

Causes

Ganglion cysts are frequently observed in younger individuals between 15 and 40 years of age and more often in elderly women. The cause of ganglion cyst formation is unknown. Hypotheses suggest that it can develop:

Following minor, repetitive injuries particularly during prolonged sport activities

Consequence of damage to the joint capsule causing the synovial fluid to leak outside the capsule and become enclosed in a cyst

Due to phalangeal joint arthritis at the finger extremities in older adults

Arthritis is a risk factor for the development of ganglion cysts

Risk factors

These are some recognised risk factors leading to ganglion cyst formation:

Micro-injuries to the wrist capsule related to prolonged sports

Ageing

Arthritis

Tenosynovitis (De Quervain’s tenosynovitis, volar flexor tenosynovitis in trigger finger)

A protuberance on the wrist is a typical symptom of a ganglion cyst

Symptoms

The most evident symptom of a ganglion cyst is the typical swelling with a round and smooth shape which varies in size from a pea to a larger protuberance. Due to its close connection to the median or ulnar nerves at the wrist, a ganglion may cause pain but also be completely pain-free. This can cause limitations in wrist function. Spontaneous leakage of the synovial fluid can occur. When located in deep tissues, a ganglion cyst may not manifest as clearly but reveals itself with pain during wrist movement.

Ultrasound image showing a ganglion at the distal interphalangeal joint of the index finger

Diagnosis

Diagnosis of a wrist ganglion only requires medical examination. No tests are necessary. Patient history and arising symptoms are discussed with the patient. Ultrasound is useful to confirm the diagnosis and determine the best treatment options. Occasionally a MRI can assist in complex cases where ganglion cyst is linked to other pathologies (lipomas and vascular lesions). Gangliography is another method used in conjunction with needle aspiration of the synovial fluid. It consists in the injection of a dye opaque to X- rays, followed by radiological imaging. This allows to determine the exact location and size of the ganglion. The strength of the wrist under grip and pinch can be undertaken to measure changes in function.

Treatment

Needle aspiration is a conservative approach for treating a wrist ganglion

Nonoperative treatment

Up to 50% of ganglion cysts do not require any treatment and recede spontaneously. Conservative management of a ganglion cyst can vary and include:

A traditional method consisting in smashing a heavy book (Bible) on the cyst, causing the cyst to burst and gradual absorption of the synovial fluid

Immobilisation of the wrist with a brace or splint to reduce pain and monitor whether the ganglion will reduce in size

Needle aspiration of the synovial fluid from the cyst and followed by steroid injection into the cavity. This approach is used particularly in dorsal cysts and may have limited success requiring repetitive aspirations or ultimate surgical removal.

Illustration of the surgical procedure to excise a ganglion

Surgical treatment

When conservative treatment or needle aspiration fail and the ganglion cyst does not recede, surgical removal is necessary, especially when associated with discomfort and pain. With position of the ganglion in the palmar (volar) side of the wrist, needle aspiration is not recommended due to the potential damage to local vessels and nerves. Surgery remains the standard treatment for this type of ganglions. This however can be complicated by the proximity or attachment of the ganglion to the radial artery. In this procedure the fibrotic tissue forming the cyst capsule including the area of the tendon sheath where the ganglion is attached is removed. The latter is considered the ganglion root. This is a simple day surgery in outpatient clinic under local anaesthesia. Normal wrist function can begin a few weeks after surgery.

Complications

Although surgery has higher success rate compared to other treatments, there is a small chance of recidivism. Complications after surgery include:

Recurrence of the ganglion

Infection

Reduced wrist motion and instability

Nerve and blood vessel damage

Flexion extension exercises of the wrist are useful during rehabilitation

Rehabilitation

Regardless of conservative treatment (use of a splint) or surgery, rehabilitation therapy for ganglion cyst includes:

Manual massage delivering pressure in the region to direct the synovial fluid out of the ganglion

Passive range of movement to mobilise the wrist

Tendon gliding exercises with wrist flexion/finger extension and wrist flexion/finger flexion

Wrist stretching to extend the scar post-surgery

A correct posture when using a computer mouse can prevent a ganglion cyst formation

Prevention

There are no specific guidelines to prevent the formation of ganglion cysts. However, it is recommended to reducing or modifying those daily or sport activities that put strain on the wrist. These may cause wear of the capsule thus increasing the risk of developing ganglion cysts.