Mitchell E. Nahra and John S. Bucchieri
DEFINITION
Ganglion Cysts
Ganglion cysts, although not true cysts, are the most common tumors of the hand and wrist.
These fluid-filled cysts are a frequent cause of hand and wrist pain.
Ganglion cysts typically arise from either a joint or tendon sheath.
Most ganglion cysts occur in the wrist. Dorsal wrist ganglion cysts account for 60% to 70% of all ganglion cysts, with volar wrist ganglion cysts accounting for about 18% to 20%.1
Ganglion cysts may also arise from a tendon sheath (volar retinacular cyst), or occur in association with arthritis (degenerative mucous cyst).
Giant Cell Tumors
Giant cell tumors of the tendon sheath—also referred to as localized nodular synovitis,11 fibrous xanthoma, and pigmented villonodular synovitis—are benign, slow-growing soft tissue tumors.
After ganglion cyst cysts, these lesions are the second most common tumor in the hand.6
Epidermal Inclusion Cysts
Epidermal inclusion cysts are benign, slow-growing soft tissue tumors.
They are the third most common type of hand tumor.
ANATOMY
Ganglion Cysts
Ganglion cysts typically consist of a cyst sac that communicates through a stalk to an underlying joint or tendon sheath (FIG 1).
The cyst sac may have a single cavity or be multilobulated.
Although not a true cyst, lacking an epithelial lining, ganglion cysts are typically filled with a clear, viscous, jelly-like mucinous fluid made up of glucosamine, albumin, globulin, and a high concentration of hyaluronic acid.17
Giant Cell Tumors
The tumor is usually a multilobular, well-circumscribed mass, ranging in size from 0.5 to 7 cm.6
The color ranges from yellow to deep brown depending on the amount of hemosiderin, histiocytes, and collagen present in the lesion.
These lesions have a thin pseudocapsule. Aggressive lesions may invade adjacent soft tissue, tendon, and capsular structures and can envelop neurovascular bundles. A large study showed joint involvement in one fifth of all cases.7Longstanding lesions may erode into cortical bone but will not involve cartilage or the medullary canal of bone. Satellite lesions may occur.
Histologically, giant cell tumors contain collagen-producing polyhedral-shaped histiocytes, scattered multinucleated giant cells, and hemosiderin deposits.6
Epidermal Inclusion Cysts
Epidermal inclusion cysts are well-circumscribed, firm, and slightly mobile lesions.
They are often superficial and adherent to overlying skin.
They may be flesh-colored, yellow, or white.
They contain a thick white keratinous material.
Cysts in the fingertip may erode into the distal phalanx, causing a lytic lesion.
Histologically, they are cysts filled with keratin and lined with epithelial cells.
FIG 1 • A. Ganglion cyst arising from dorsal scapholunate joint. B. Ganglion cyst arising from flexor sheath.
PATHOGENESIS
Ganglion Cysts
The true causes of ganglion cysts remain unclear, although multiple theories have been proposed.
Some early investigators theorized that ganglion cysts occurred as the result of synovial herniation, and others felt that ganglion cysts resulted from mucoid degeneration.
A more recent theory proposes that ganglion cysts arise from stress at the synovial capsular interface. This stress, such as stretching of the capsular and ligamentous structures, stimulates the production of mucin from modified synovial, mesenchymal, and fibroblast cells, all of which have been shown to produce hyaluronic acid. The mucin then dissects through the capsular and ligamentous tissues, forming the main cyst. The fluid may enter the cyst from the capsular ligamentous interface via a one-way valve type of mechanism and then decrease as the water component is resorbed, accounting for the often-fluctuating cyst size.1
Giant Cell Tumors
The cause of giant cell tumors is not known. There is a strong association of giant cell tumors with rheumatoid arthritis. There are no clinical studies associating these tumors with trauma.6
Although these tumors are histologically similar to the pigmented villonodular synovitis seen in large joints in the lower extremity, they are thought to be clinically distinct lesions.
Epidermal Inclusion Cysts
Epidermal inclusion cysts occur as a result of trauma when epithelial cells are introduced into the underlying subcutaneous tissues or bone. These cells slowly grow to produce a cyst lined with epithelial cells and filled with keratin.
NATURAL HISTORY
Ganglion Cysts
Ganglion cysts typically arise spontaneously and are most common in the second through the fourth decade but may arise in the pediatric population20 as well as the aged.
Once present, ganglion cysts tend to fluctuate in size depending on the amount of fluid present in the cyst at any given time. Patients often note that the cyst becomes larger after increased periods of activity and decreases in size with inactivity.
Ganglion cysts tend to be self-limiting and do not typically continue to expand in size.
If left untreated, ganglion cysts can persist for years. They may resolve or rupture spontaneously. One cannot predict how long that they will persist or if and when they will resolve.
Resolution is far more common in the pediatric population.
Giant Cell Tumors
The lesion begins as a single nodule, becoming multinodular as it enlarges.
Malignant transformation of giant cell tumor of the tendon sheath in the hand has not been reported.6
Epidermal Inclusion Cysts
These lesions occur months to years after a traumatic event. They grow slowly to produce a painless mass, most commonly seen in the fingertip.
Malignant transformation of these lesions in the hand has not been reported.12
PATIENT HISTORY AND PHYSICAL FINDINGS
Ganglion Cysts
Patients often present with an asymptomatic mass that has been present for weeks to years.
A history of trauma is often absent.
Pain if present is often described as a dull ache. Nocturnal pain is uncommon and pain is more common with active hand use.
Paresthesias are rare but can occur if the ganglion cyst compresses any local nerves.
Patients often report that the mass tends to fluctuate in size, a characteristic typical of ganglion cysts and not typical of other types of soft tissue tumors.
Patients with wrist ganglion cysts—particularly dorsal wrist cysts—will often complain of weakness of grip.
Patients with dorsal wrist ganglion cysts most commonly note a mass over the dorsum of the wrist, typically over the dorsal scapholunate region. In contrast, patients with volar wrist ganglion cysts typically note a mass over the volar aspect of the wrist in the interval between the flexor carpi radialis and first extensor compartment tendons.
Volar retinacular cysts or ganglion cysts of tendon sheath usually present as a mass in the palm in the region of the first and second annular pulleys. The cyst is typically fluctuant but may feel like a firm nodule. The cyst is usually slightly mobile but does not often glide with flexor tendon movement.
These types of cysts are often painless at rest but become painful when patients perform activities that involve forceful grip.
Degenerative mucous cysts are ganglion cysts that arise from the distal interphalangeal joint, usually in association with underlying osteoarthritis.4 Patients often note a painless soft tissue mass that arises from the dorsal surface of the joint, radially or ulnarly (less commonly in the midline), often extending into the eponychial fold region.
Commonly, the cyst will thin the overlying dermis, resulting in rupture of the skin, and the patient often reports drainage.
Physical examination begins with inspection (FIG 2).
Being fluid-filled, ganglion cysts will often transilluminate, whereas other more solid soft tissue lesions will not.
Ganglion cysts usually occur in specific locations in the hand and wrist. Swelling or masses in these locations are diagnostic clues that a ganglion cyst may be present.
The examiner should palpate the mass for fluctuance and mobility and assess tenderness.
Ganglion cysts are generally fluctuant and slightly mobile. When they become more distended with fluid they may feel more firm and less fluctuant. Firm, less mobile masses suggest the possibility of other soft tissue lesions.
Ganglion cysts of tendon sheath do not usually glide with tendon motion, but less common ganglion cysts, such as those that arise in the fourth extensor compartment, are often adherent and do glide with tendon motion.
The examiner should assess joint mobility through the range of motion. With the exception of dorsal wrist ganglion cysts, which may cause some loss of wrist dorsiflexion secondary to impingement, loss of joint range of motion suggests the possibility of an underlying joint abnormality.
FIG 2 • A. Dorsal wrist ganglion cyst. B. Volar wrist ganglion cyst. C. Ganglion cyst arising from ulnocarpal joint. D. Ganglion cyst arising from flexor carpi radialis sheath. E. Degenerative mucous cyst.
Giant Cell Tumors
Giant cell tumors are most common in the fourth to sixth decade, with a slight predominance in women.
Patients typically present with a slow-growing, multilobulated, firm, painless mass present for several months to years.
Lesions usually occur in the radial three digits of the hand on the volar surface. Dorsal involvement, particularly around the distal interphalangeal joint, is not uncommon.7
These lesions are typically firmer than ganglion cysts and do not transilluminate.
Large lesions may limit range of motion or result in neuropathic symptoms as a result of compression of digital nerves.
Direct palpation typically reveals a firm, multinodular, nontender lesion.
Loss of range of motion may occur when large lesions occur near the interphalangeal joints.
Patients may have sensory deficits secondary to digital nerve compression. These can be revealed by testing twopoint discrimination.
Epidermal Inclusion Cysts
Epidermal inclusion cysts are more common in men than in women and occur in the third to fourth decade.2
Patients commonly present with a painless, slow-growing mass after a laceration, puncture wound, or traumatic amputation of the finger.2
These lesions should be suspected in laborers who have a painless mass in the palm.12
Erythematous and painful lesions have been reported. One study reported two cases mimicking a collar button abscess resulting from rupture of the cyst in the palmar soft tissues.21
These lesions are typically firmer than ganglion cysts and do not transilluminate.
Direct palpation will reveal a lesion that is firm, nontender, superficial, and mobile.
Loss of range of motion may occur when large lesions occur near the interphalangeal joints.
Two-point discrimination testing may reveal sensory deficits secondary to digital nerve compression.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Ganglion Cysts
Radiographs are obtained if there is clinical suspicion of an underlying bony abnormality noted on physical examination, such as joint crepitation, swelling, carpal instability, or a history of trauma.
Radiographs are also useful in identifying an intraosseous ganglion cyst in patients with wrist pain of uncertain cause (FIG 3A).
Radiographs are also often obtained in patients with a degenerative mucous cyst of the digit since the cysts typically arise as the result of degenerative arthritis of the distal interphalangeal joint.
If the clinical findings suggest the possibility of an occult ganglion cyst, or if there is suspicion that the patient may have a symptomatic intraosseous ganglion cyst, magnetic resonance imaging (MRI) can be a useful tool to confirm the diagnosis (FIG 3B).
MRI can also be used to better localize the site of origin as part of preoperative planning in ganglion cysts that occur in atypical locations (FIG 3C,D).
Ultrasound can also be used to diagnose ganglion cysts, but this test is examiner-dependent and less sensitive and specific than MRI.
Computed tomography scans are generally obtained only for preoperative planning to better localize and evaluate the bony architecture of intraosseous ganglion cysts.
Giant Cell Tumors
Plain radiographs show a soft tissue mass. Juxtacortical lesions may show bony erosion.
MRI demonstrates a benign-appearing encapsulated mass, with decreased signal on T1and T2-weighted images.
FIG 3 • A. Radiograph showing an intraosseous ganglion cyst within the scaphoid. B. MRI of a dorsal wrist ganglion cyst extending into the scapholunate joint. C. MRI of a ganglion cyst arising from the scaphotrapezial joint and extending into the thenar eminence. D. MRI of a ganglion cyst in the snuffbox but arising from the dorsal scapholunate ligament.
Epidermal Inclusion Cysts
Plain radiographs show a soft tissue mass.
A lytic lesion may be seen in the distal phalanx if it erodes into bone.
DIFFERENTIAL DIAGNOSIS
Ganglion Cysts
Epidermoid inclusion cyst
Giant cell tumor of tendon sheath
Lipoma
Synovial cyst
Giant Cell Tumors
Fibroma of the tendon sheath, synovial chondromatosis, synovial hemangioma, tophaceous gout, foreign body granuloma, periosteal chondroma
Epidermal Inclusion Cysts
Tophaceous gout, foreign body granuloma, giant cell tumor, ganglion cyst, sebaceous cyst
Bony destruction may mimic a malignant or infectious process.11 Some patients with these lesions have been treated with primary amputation before pathologic diagnosis.6
NONOPERATIVE MANAGEMENT
Of the three tumors discussed in this chapter, only ganglion cysts can be managed without surgery.
Ganglion cysts are benign cysts that may resolve spontaneously. Treatment often depends on the level of a patient's symptoms. Many patients seek medical care because they are concerned about the presence of a soft tissue mass and possibility of malignancy.23 Once a diagnosis of a ganglion cyst is made, with proper counseling as to the nature of these lesions, many patients will be satisfied with a course of observation.
In patients who are symptomatic, typical nonoperative treatments include rest and immobilization, oral analgesics such as nonsteroidal anti-inflammatories and acetaminophen, and aspiration of the cyst with or without injection.3,13,14,23
In wrist ganglion cysts, the results of aspiration have variable cure rates in the literature, ranging from 15% to 89%.12Various agents have been injected into the ganglion cyst after aspiration, including hyaluronidase and methylprednisolone.15
On average, injection does not seem to increase the cure rate after aspiration, and we now typically perform aspiration alone. We generally inform patients that aspiration has about a 50% cure rate. The use of sclerosing agents is frowned on since these agents may cause articular damage.10
Traditional methods of traumatic rupture of the cyst from a direct blow with an object such as a large book (hence the term “Bible cyst”) are mostly of historical significance.
Ganglion cysts of tendon sheath (volar retinacular cysts) when symptomatic often respond to aspiration and injection and rarely require surgery when not associated with stenosing tenosynovitis. When they occur in association with stenosing tenosynovitis (trigger finger, De Quervain tendinitis), they often resolve with successful treatment of the underlying tendinitis.
We typically do not aspirate ganglion cysts of tendon sheath but have had great success by injecting these cysts with local anesthetic and a small amount of corticosteroid (1.5 to 2 mL of 1% lidocaine and 10 mg of Depo-Medrol). The cyst is entered with a 25-gauge needle and then distended to the point of rupture. The remaining fluid in the syringe is then injected into the tendon sheath. If necessary, gentle digital massage can be used to rupture the cyst after injection if the cyst fails to rupture with distention.
SURGICAL MANAGEMENT
Indications Ganglion Cysts
Surgery is generally indicated in patients who have symptoms and who either have failed nonoperative treatment or choose to proceed directly with surgery.
In patients who have been diagnosed with a symptomatic wrist ganglion cyst, we generally describe the nature of the condition and outline the available forms of treatment, allowing the patient to decide which treatment is best for him or her. Some patients will choose observation, others will elect to undergo an aspiration, and some will chose to proceed directly with surgical excision.
In the case of symptomatic ganglion cysts of tendon sheath, most of these will resolve with a corticosteroid injection, and surgery is reserved for cysts that continue to recur.
Degenerative mucous cysts that are draining or have a history of draining should be treated operatively, since these cysts are at risk for infection that may extend into the distal interphalangeal joint and result in septic arthritis. If not draining, these cysts can be treated nonoperatively or surgically, depending on the patient's symptoms and choice of treatment.
Intraosseous ganglion cysts that are symptomatic or have resulted in pathologic fracture or may exhibit an impending pathologic fracture are often treated operatively.
Giant Cell Tumors
Indications for surgery include appearance, neuropathic symptoms, or loss of function.
Careful, meticulous marginal excision of the lesion is the treatment of choice.
Care must be taken to protect the neurovascular structures.
Satellite lesions must be identified and carefully removed to minimize the chance of recurrence.
Epidermal Inclusion Cysts
Indications for surgery include appearance, diagnosis, pain, and loss of function.
Marginal excision of the lesion is the treatment of choice.
Preoperative Planning
Ganglion Cysts
When removing ganglion cysts arising in atypical locations, MRI studies can help to identify the cyst origin and plan appropriate surgical exposure.
MRI and CT scans, along with plain radiographs, are valuable to determine the ideal exposure and for treating intraosseous ganglion cysts with curettage and bone grafting.
Plain radiographs are reviewed before excising degenerative mucous cysts to determine the extent of underlying osteophytes that may need to be addressed.
Giant Cell Tumors
While the diagnosis of giant cell tumor is primarily made based on history and clinical examination, radiographic studies should be reviewed to rule out other conditions.
The patient should be advised that even with careful surgical techniques, the recurrence rate can be as high as 5% to 50%. Risk factors for local recurrence include proximity to the distal interphalangeal joint, degenerative joint disease, and bony erosion.16
Temporary digital nerve neurapraxias may also occur after extrication of these tumors during surgery.
Epidermal Inclusion Cysts
While the diagnosis of epidermal inclusion cyst is primarily made based on history and clinical examination, radiographic studies should be reviewed to rule out other conditions.
If a lytic lesion is present in the distal phalanx, a biopsy should be considered before surgical removal.
The recurrence rate after marginal excision is low.
Positioning
Patients undergoing hand or wrist surgery are positioned supine on the operating table with the operative extremity resting on a hand table. This position allows for circumferential access to the hand and wrist.
The procedure is performed under regional anesthesia with a tourniquet applied to the upper arm, or under a digital block with a tourniquet applied to the digit.
For arthroscopic procedures, a traction tower or longitudinal fingertrap traction is used (FIG 4).
Approach Ganglion Cysts
Standard approaches to the hand and wrist are used, depending on the location of the cyst.
It is important to have a good understanding of the anatomy and the most likely origin of the cyst to best plan the incision and dissection to avoid injury to important neurovascular structures.
When treating ganglion cysts in atypical locations, preoperative studies can aid in determining the best surgical approach, since the origin of the cyst can be remote from the cyst (Fig 3D).
FIG 4 • The patient is positioned supine with an armboard attached to the operating table, and the upper extremity is prepared and draped in a standard manner. The surgeon is generally seated in the axilla with full access to the hand and wrist.
Volar giant cell tumors and epidermal inclusion cysts are approached through Brunner zigzag incisions (FIG 5A).
Dorsal giant cell tumors require dorsal midline or curvilinear incisions, whereas dorsal epidermal inclusion cysts can be approached through small longitudinal incisions directly over the lesion (FIG 5B).
Incisions should be designed for a possible extensile exposure, which may be necessary for complete excision of the lesion.
FIG 5 • A. A Brunner incision is made for a volar multilobular mass. B. A dorsal epidermal inclusion cyst is approached through a small longitudinal incision directly over the lesion.
TECHNIQUES
OPEN EXCISION OF A DORSAL WRIST GANGLION CYST
The location of the cyst is typically dorsal to the scapholunate interosseous ligament. The incision needs to provide access to this ligament. The scapholunate ligament is found just distal to the tubercle of Lister in the third and fourth extensor compartment interval (TECH FIG 1A).
We generally perform a transverse skin incision centered over the scapholunate ligament region and cyst. This incision heals with the best appearance (TECH FIG 1B).
Dissect the subcutaneous tissues with blunt dissection, taking care to protect and preserve any branches of the dorsal radial and ulnar sensory nerves. Loupe magnification is often helpful.
The extensor retinaculum is generally not well developed at this level and is incised transversely as the cyst is dissected from the surrounding soft tissues (TECH FIG 1C).
The cyst is identified typically in the interval between the third and fourth extensor compartments. Retract the second and third extensor compartment tendons radially and the fourth extensor compartment tendons ulnarly (TECH FIG 1D).
The dorsal wrist capsule is also incised transversely as the cyst is traced to a stalk, which usually arises from the dorsal aspect of the scapholunate interosseous membrane, just proximal to the dorsal scapholunate ligament (TECH FIG 1E).
Excise the cyst at the base of the stalk and send it for pathologic examination (TECH FIG 1F).
Although excision of a small window of tissue at the site of cyst origin has been previously recommended, we have concern that overzealous excision may lead to injury to the scapholunate ligamentous complex. We recommend the use of a bipolar cautery to precisely cauterize the site of origin (TECH FIG 1G).
TECH FIG 1 • A. The dorsal scapholunate ligament is found just distal to the tubercle of Lister. B. Dorsal ganglion cysts typically arise from the dorsal scapholunate ligament. C. The extensor retinaculum is incised transversely. D. The extensor tendons are retracted, allowing visualization of the cyst. E. Cyst stalk arising from the dorsal scapholunate ligament. F. Excised cyst and stalk. G. The area of origin of the cyst is cauterized, taking care to preserve the ligament and interosseous membrane. H. Closure with running subcuticular suture.
After excision of the cyst, inspect the joint for any abnormalities.
Allow the capsular tissues and tendons to return to their anatomic position. Avoid capsular closure, as this may lead to joint stiffness.
Skin closure is usually accomplished with a running subcuticular nonabsorbable monofilament suture (TECH FIG 1H).
We prefer to dress the wound with an antibiotic ointment and petroleum gauze, and a bulky hand dressing is applied with a plaster palmar splint maintaining the wrist in a neutral position.
The dressing is removed along with the sutures at about 1 week postoperatively and Steri-Strips are applied to the wound.
OPEN EXCISION OF A VOLAR WRIST GANGLION CYST
Volar wrist ganglion cysts most often arise from the volar radiocarpal ligaments. They may also arise from the scaphotrapezial joint or at times from the flexor carpi radialis (FCR) sheath. The cysts are typically located in the interval between the FCR sheath and first extensor compartment tendons, just proximal to the wrist flexion crease.
Under tourniquet control, we prefer to use a zigzag type of incision that begins at the wrist flexion crease and extends proximally over the cyst in the FCR and first extensor compartment interval. This incision provides access in both the longitudinal and transverse planes. A longitudinal incision may heal with scar contracture, whereas a transverse incision may not provide adequate exposure in the longitudinal plane (TECH FIG 2A).
Under loupe magnification, the subcutaneous tissues are carefully dissected and branches of the lateral antebrachial cutaneous nerve and dorsal radial sensory nerve are carefully protected. If dissection ulnar to the FCR tendon is required, the palmar cutaneous branch of the median nerve must also be identified and protected.
Ganglion cysts in this location are commonly adherent to the radial artery and its venae comitantes (TECH FIG 2B). Take care to avoid injury to the artery. If the cyst cannot be freely dissected from the artery, a small cuff of cyst wall can be left adherent to the artery without a significant increase in recurrence.
The cyst is traced to a stalk that most often arises from the volar radial carpal ligaments (TECH FIG 2C). The cyst is excised at the base of the stalk. We routinely send the cyst for pathologic evaluation.
TECH FIG 2 • A. A Brunner type of incision allows for more exposure and avoids contracture associated with straight longitudinal incisions in this location. B. A volar cyst adherent to the radial artery and venae comitantes. C. A volar wrist ganglion stalk arising from the volar radial carpal ligaments.
As with dorsal ganglion cysts, we cauterize the site of origin of the cyst with a bipolar electrocautery.
After excision of the cyst, the tourniquet is deflated to ensure that the radial artery is uninjured. Satisfactory hemostasis is achieved.
We generally close the wound with a running subcuticular suture, removed about 7 to 10 days after surgery.
We prefer to dress the wound with antibiotic ointment and petroleum gauze, and a bulky hand dressing is applied with a plaster palmar splint maintaining the wrist in a neutral position.
The dressing is removed along with the sutures at about 1 week postoperatively and Steri-Strips are applied to the wound.
OPEN CURETTAGE AND BONE GRAFTING OF AN INTRAOSSEOUS GANGLION CYST
The patient is positioned supine on the operating table with the operative hand resting on a hand table.
Symptomatic intraosseous ganglion cysts most often involve the carpal bones. Surgical incisions are planned according to the preoperative studies (MRI and CT scans) to identify the best location for creating a cortical window and avoiding injury to cartilaginous surfaces.
Under tourniquet control, make an appropriate incision and carry dissection to the level of the wrist capsule. Loupe magnification is often helpful during the dissection. Enter the wrist capsule, preserving important capsular ligaments.
The bony cortex is generally weakened in the area of the cyst and access is easily accomplished with a handheld curette. If the cortex is not weak, a small cortical window can be created using 0.045-inch Kirschner wires to create small drill holes to create a cortical window.
Curette the cyst cavity along with any mucinous material. Remove the cyst membrane.
Pack the cyst cavity with bone graft or a bone graft substitute.
Wound closure is accomplished in the usual manner.
We usually immobilize the patient in a plaster splint for 1 week and then a cast for 3 to 5 weeks, depending on the cyst size and bone integrity.
Obtain postoperative radiographs to monitor and ensure incorporation of the bone graft.
EXCISION OF A DEGENERATIVE MUCOUS CYST
Mucous cysts can be excised under local digital block anesthesia.
The hand is prepared in the standard fashion.
A finger tourniquet is applied to the involved digit.
We usually use a Brunner type of incision or a simple transverse incision incorporating the cyst and allowing access to the origin of the cyst, which arises from the distal interphalangeal joint capsule between the terminal extensor tendon and collateral ligament (TECH FIG 3A).
During the dissection, take care to avoid injury to the germinal matrix of the nail bed (TECH FIG 3B).
Excise the cyst at the base of its stalk along with a portion of the joint capsule (TECH FIG 3C).
Excising underlying osteophytes and hypertrophic synovial tissue is the key to preventing recurrence of the cyst (TECH FIG 3D).
The wound is irrigated, the tourniquet is removed, and hemostasis is achieved with bipolar cautery.
Wound closure is accomplished with nonabsorbable monofilament sutures.
I dress the wound with antibiotic ointment, petroleum gauze, gauze fluff, and tube gauze dressing.
The patient is instructed to remove the dressing in 3 to 5 days and then cleanse the wound daily with antibacterial soap and water.
Sutures are removed at 7 to 10 days.
TECH FIG 3 • A. Degenerative mucous cyst in the eponychial region resulting in nail plate deformity. B. Aggressive dissection is avoided distally to protect the nail germinal matrix. The cyst is traced proximally to its origin at the distal interphalangeal joint. C. The cyst is excised along with a portion of the joint capsule at its point of origin between the central tendon and collateral ligament. D. A rongeur is used to débride underlying osteophytes.
EXCISION OF A GANGLION CYST OF TENDON SHEATH (VOLAR RETINACULAR CYST)
The patient is supine on the operating table with the involved upper extremity resting on a hand table.
Anesthesia is usually accomplished with local anesthetic.
Under tourniquet control (well tolerated by most awake patients for the 10 to 15 minutes required), a skin incision is made over the suspected ganglion cyst.
Loupe magnification aids in limiting the size of the incision and identifying important anatomic structures. Retract the soft tissues and the digital neurovascular bundles.
The ganglion cyst is commonly identified arising from the first or second annular pulley region.
Dissect the ganglion cyst from the surrounding soft tissues and excise it at its base. We usually cauterize the site of origin with the bipolar cautery, which lowers the chance of a recurrence.
The tourniquet is released, hemostasis is achieved, and wound closure is performed.
A light hand dressing is applied for 7 to 10 days.
ARTHROSCOPIC EXCISION OF A DORSAL WRIST GANGLION CYST
The patient is positioned supine on the operating room table with the operative upper extremity positioned in an arthroscopic traction tower (TECH FIG 4).
Identify the standard wrist arthroscopic and anatomic landmarks.
The 3–4, 4–5, 6R, and 6U portals are typically used.
Under tourniquet control, insert a 2.7-mm small joint arthroscope into the 3–4 or 4–5 portal sites to inspect the joint and identify the ganglion stalk. The stalk in the typical dorsal wrist ganglion cysts is found arising from the dorsal distal margin of the scapholunate intraosseous membrane just proximal to the dorsal scapholunate intraosseous ligament. The stalk is not always identifiable or visualized.17
Introduce a 2.9-mm resector shaver into the joint and excise the stalk (when visible) along with a 1-cm portion of dorsal wrist capsule and ganglion cyst.
Use extreme caution when resecting the ganglion stalk and capsule to avoid injury to the scapholunate ligament and intraosseous membrane as well as the overlying extensor carpi radialis brevis and extensor digitorum communis tendons.
Midcarpal arthroscopy is performed if indicated, but routine inspection is not necessary when treating a dorsal wrist ganglion cyst.
The portal sites are typically closed with a removable monofilament suture.
A light hand dressing is applied with a plaster palmar splint, which is left in place for about 5 to 7 days.
TECH FIG 4 • Standard arthroscopic setup using a traction tower. The traction tower, which can be sterilized, is typically positioned in this manner on a hand table after standard preparation and draping.
EXCISION OF A GIANT CELL TUMOR OF THE TENDON SHEATH
The standard treatment is complete surgical removal.
Careful surgical dissection is performed under loupe magnification (TECH FIG 5A).
After initial exposure, isolate the neurovascular bundle proximal and distal to the lesion (TECH FIG 5B).
Once the pseudocapsule is identified, it can be bluntly dissected or teased away from underlying structures with a Freer elevator, with care taken not to seed the surrounding tissues.6 Alternatively, a small portion of the tendon sheath may be excised with the tumor origin and the area cauterized with bipolar electrocautery12 (TECHFIG 5C,D).
Carefully examine the local tissues for satellite lesions, which may be only a few millimeters in size. These lesions need to be completely excised (TECH FIG 5E).
If the extensor tendon is involved, surgical excision of a portion of the tendon may be required. In rare cases, tendon reconstruction may be necessary. Lesions eroding into bone may require local curettage.
If the tumor appears to arise from an underlying joint, it is important to perform a capsulotomy to inspect the joint and débride any pigmented tissue.11
Arthrodesis of the distal interphalangeal joint may be necessary to completely excise some lesions.
TECH FIG 5 • A. Careful surgical dissection of the subcutaneous tissues through a Brunner incision. B. The digital nerve is identified distal to the lesion and protected throughout the procedure. C. The tumor should be carefully removed from surrounding soft tissues. D. Excision demonstrates a firm multinodular lesion. E. Any satellite lesions should be carefully identified and removed.
MARGINAL EXCISION OF AN EPIDERMAL INCLUSION CYST
Careful surgical dissection is undertaken under loupe magnification.
After initial exposure, isolate the neurovascular bundles in the area of the lesion.
Once the capsule is identified, it can be sharply dissected from overlying skin and bluntly dissected from deeper soft tissues (TECH FIG 6).
Take care to remove the entire capsule.
Lesions eroding into bone may require local curettage and bone graft.
In rare cases with advanced bony destruction, amputation is an alternative.
TECH FIG 6 • A. Through a small longitudinal incision directly over the lesion, the cyst is bluntly excised from surrounding soft tissues. B. Excision of the lesion demonstrates a firm, white, encapsulated mass.
POSTOPERATIVE CARE
Ganglion Cysts of the Wrist
The splint and sutures are removed about 1 week postoperatively and Steri-Strips applied to the wound.
Range-of-motion exercises and light use of the hand are initiated at 1 week, with gradual advancement of activities as tolerated.
Scar massage is encouraged at 2 weeks.
Ganglion Cyst of Tendon Sheath and Degenerative Mucous Cyst
Patients are instructed to remove their postoperative dressing 4 to 5 days after surgery. We prefer to have the patients clean their wound at least twice daily with antibacterial soap and water. The wound is redressed with light gauze or an adhesive bandage.
Sutures are generally removed at 1 week and Steri-Strips applied to the wound.
Range-of-motion exercises and light use of the hand are initiated, with gradual advancement of activities as tolerated.
Scar massage is encouraged at 2 weeks.
Intraosseous Ganglion Cysts
Postoperative dressing and sutures are removed at 1 week and Steri-Strips applied to the wound.
We generally apply a short-arm cast for 3 to 5 weeks. The cast is removed and range-of-motion exercises and light hand use are initiated.
Incorporation of the bone graft is monitored with use of serial radiographs. If the intraosseous ganglion cyst has weakened the bone, a protective splint may be used once the cast is removed until incorporation of the bone graft.
Giant Cell Tumors and Epidermal Inclusion Cysts
Patients should be instructed about the high rate of recurrence of giant cell tumors.
Range-of-motion exercises and antiedema techniques should be started immediately after surgery.
Sutures can be removed at 8 to 10 days.
OUTCOMES
Ganglion Cysts
Symptomatic relief is often accomplished after excision of most ganglion cysts.
Recurrence rates after ganglion cyst surgery have been reported to range from 4% to 40%.19 With adherence to the above principles, however, the recurrence rate in our experience is less than 5%.
Complications of ganglion cyst removal are infrequent.
The recurrence rate of giant cell tumors has varied from 5% to 50%. The high rate of recurrence is due to incomplete excision or satellite lesions.6
Recurrence rates are even higher after excision of a recurrent tumor.16
In contrast, the recurrence rate after epidermal inclusion cyst excision, even with bony involvement, is low.
COMPLICATIONS
Wound complications (eg, painful or unsightly scar), infection, digital neurapraxia, or recurrence can occur.
Ganglion cyst excision can result in a neurovascular injury. This complication is rare with adherence to good surgical technique and a good understanding of the local anatomy. Volar wrist ganglion cysts are adherent to the radial artery and can be difficult to dissect free from the artery. If necessary, a cuff of the cyst is left attached to the artery. If injury to the artery does occur, a repair should be performed.
Stiffness is a complication of ganglion cyst excision. Avoiding direct capsular closure reduces the risk of this complication.
Complications associated with degenerative mucous cysts include extensor lag, joint stiffness, infection, nail plate deformity, and distal interphalangeal joint deformity.5
REFERENCES
1. Angelides AC. Ganglions of the hand and wrist. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery, vol. 2, 4th ed. New York: Churchill Livingstone, 1999:2171–2183.
2. Athanasian EA. Bone and soft tissue tumors. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds. Operative Hand Surgery, vol. 2, 5th ed. New York: Churchill Livingstone, 2005:2211–2264.
3. Burge P. Aspiration of ganglia. J Hand Surg Br 1993;8B:409–410.
4. Dodge LD, Brown RL, Niebauer JJ, et al. The treatment of mucous cysts: long-term followup in sixty-two cases. J Hand Surg Am 1984;9A:901–904.
5. Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br 1997;22B:222–225.
6. Glowacki KA. Giant cell tumors of the tendon sheath. J Am Soc Surg Hand 2003;3:100–107.
7. Glowacki KA, Weiss APC. Giant cell tumor of the tendon sheath. Hand Clin 1995;II:245–253.
8. Greendyke SD, WIlson M, Shepier TR. Anterior wrist ganglia from the scaphotrapezial joint. J Hand Surg Am 1992;17A:487–490.
9. Lister GD, Smith RR. Protection of the radial artery in the resection of adherent ganglions of the wrist. Plast Reconstr Surg 1978; 61:127–129.
10. Mackie IG, Howard CB, Wilkins P. The dangers of sclerotherapy in the treatment of ganglia. J Hand Surg Br 1984;9B:181–184.
11. Moore JR, Weiland AJ, Curtis RM. Localized nodular tenosynovitis: experience with 115 cases. J Hand Surg Am 1982;9A:412–417.
12. Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin 2004;20:249–260.
13. Nield DV, Evans DM. Aspiration of ganglia. J Hand Surg Br 1986; 11B:264.
14. Oni JA. Treatment of ganglia by aspiration alone. J Hand Surg Br 1992;17B:660.
15. Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg Br 1997;22B:219–221.
16. Reilly KE, Stern PJ, Dale A. Recurrent giant cell tumors of the tendon sheath. J Hand Surg 1999;24A:1298–1302.
17. Rizzo M, Berger RA, Steinman SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period. J Hand Surg Am 2004;29A:59–62.
18. 18. Soren A. Pathogenesis and treatment of ganglion. Clin Orthop Relat Res 1996;48:173–179.
19. Thornburg LE. Ganglions of the hand and wrist. J Am Acad Orthop Surg 1999;7:231–238.
20. Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am 2001;26A:599–602.
21. Ward WA, Labosky DA. Ruptured epidermal inclusion cyst in the palm presenting as a collar-button abscess. J Hand Surg Am 1985;10A:899–901.
22. 22. Westbrook AP, Stephen AB, Oni J, et al. Ganglia: the patient's perception. J Hand Surg Br 2000;25B:566–567.
23. Zubowicz VN, Ishii CH. Management of ganglion cysts of the hand by simple aspiration. J Hand Surg Am 1987;12A:618–620.