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Ganglion cyst

Ganglion cyst seen most frequently in the dorsal aspect of the wrist ( DWG – dorsal wrist ganglia ) and communicates with the jt via pedicle other locations palmar wrist ganglion cysts , flexor sheath GC , dorsal digital GC underlying etiology is poorly understood – few suggested mechanisms
○ cysts or tumours ( this is not supported by pathological findings )
○ increase ligamentous and soft tissue laxity
○ cumulative microtrauma or chronic repetitive motions ( repetitive stress -> capsular rent -> one way valve for fluids -> mass in the soft tissues )
○ repetitive trauma leading to mucinous degeneration of connective tissues
○ studies do not support an inflammatory cause

 

Differentials – lipoma aneurysmal bone cyst epidermoid cyst giant cell tumour of tendon sheath ,tenosynovitis chondroblastoma , tendinous xanthoma soft tissue sarcoma osteosarcoma tophus ,rheumatoid nodules

 

most common soft tissue mass seen on hands and wrists may also happen in the knee and foot seen more commonly in women 20-50 ( although can occur at any age ) usually insidious onset with no predisposing risk factors / conditions

 

majority are asymptomatic patient can c/o pain , tenderness , weakness , paraesthesia reduced ROM and decreased grip strength worry that it may be a tumour / malignant malignant transformation is not seen cosmetic appearance O/E – 1 to 2 cm cystic structure- feels like a firm rubber ball , transilluminates readily US can help differentiate a cyst from a vascular malformation , MRI if a solid tumour is suspected

 

Reassurance – spontaneous resolution is common studies have shown that 33 % of dorsal & 45 % of volar ganglia will resolve spontaneously as most are asymptomatic , harmless reassurance can be an option for those who do not wish intervention & no N/V compromise

 

Aspiration – non-surgical method simple way to treat high recurrence rate ganglia of the flexor tendon sheath of the hand have shown better outcome with aspiration numerous adjunctive measures have been tried to improve the outcome as steroid inj after aspiration , instillation of hyaluranidase prior to aspiration , splinting the wrist & surgery after aspiration , aspiration with multiple punture of walls, injection of a sclerosant

 

surgical excision is the gold standard treatment studies have shown a low rate of recurrence with techniques which involve the excision of the entire ganglion complex including cyst , pedicle , cuff of the entire joint capsule recurrence rates also vary based on the location of the ganglion arthroscopic excision.

 

Referral -treatment policies may vary locally NICE has not produced any guidance on this topic no treatment unless symptomatic for e.g tingling / numbness / significant pain seed ganglia at the base of digits with significant pain mucoid cyst at DIP jt disrupting the nail growth -> functional impairment / pain / cysts that discharge treatment may be considered of low clinical value and aspiration may be offered for reassurance or if there is diagnostic uncertainty surgical excision if aspiration fails.

REFERENCES

  1. Greater Manchester EUR Policy Statement on: Ganglion Cyst Removal GM Ref: GM025 Version: 3.4 (15 January 2019) 3d84b326-c78d-40d9-9764-5e16f9318f64 (northwestcsu.nhs.uk)
  2. Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN Orthop. 2013 May 28;2013:940615. doi: 10.1155/2013/940615. PMID: 24967120; PMCID: PMC4045351.
  3. Gregush RE, Habusta SF. Ganglion Cyst. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470168/
  4. Gude, Warren, and Vincent Morelli. “Ganglion cysts of the wrist: pathophysiology, clinical picture, and management.” Current reviews in musculoskeletal medicine vol. 1,3-4 (2008): 205-11. doi:10.1007/s12178-008-9033-4
  5. Visual DX Ganglion Cyst Ganglion cyst (visualdx.com)

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