Ganglions in the Hand and Wrist: Advances in 2 Decades

Abstract

Ganglion cysts represent the most common soft-tissue mass in the hand and wrist. Ganglion cysts are most commonly encountered at the dorsal or volar aspects of the wrist, although cysts may arise from the flexor tendon sheath, interphalangeal joint, and extensor tendons. Intraosseous and intraneural ganglion cysts have also been described. Diagnosis of ganglion cysts relies primarily on history and physical examination. Transillumination and aspiration of masses may be useful adjuncts to diagnosis. Imaging such as radiography and ultrasonography may be indicated to evaluate for associated conditions, such as degenerative joint disease, or to rule out a solid or heterogeneous mass. Advanced imaging such as MRI is generally reserved for patients in whom occult ganglions, intraosseous ganglions, or solid tumors, including sarcoma, remain a concern. Treatment of ganglion cysts includes observation, aspiration or puncture with possible corticosteroid injection, and surgical excision. Nonsurgical management may result in cyst resolution in over 50% of patients. Surgical excision is associated with recurrence rates of 7% to 39%. Advances in surgical techniques have allowed surgeons to conduct arthroscopic ganglion excision, with recurrence rates similar to those of open management. This study highlights the advances in diagnosis, treatment, and outcomes that have taken place over the past 2 decades for this common condition affecting the hand and wrist in the adult population.

Benign Tumors of the Wrist, Hand, and Fingers

“…A ganglion cyst is the most common benign fluid-filled tumor of the wrist (can also occur in the knee and foot) and accounts for up to 70% of the tumors in the wrist and hand 1 . Women are affected at a rate 3 times that of men and occur more in the second to fourth decades of life [2][3][4] . Ganglion cysts are frequently found in the dorsal wrist (70%), volar (palmar) wrist (20%), volar reticular cyst (10%), dorsal aspect of the distal interphalangeal (DIP) joint (mucous cyst), flexor tendon sheath at the level of the metacarpophalangeal (MCP) joint, intraosseous (within bone), and intraneural ganglions [1][2][3][4][5] .…”

“…However, Ledderhose proposed that mucoid degeneration was the origin of ganglion cyst formation due to repetitive connective tissue microtrauma with surrounding soft tissues that wall off mucin forming a cyst. 3,5 More recent research has shown that a fluid-filled stalk connects the cyst to adjacent periarticular structures. The lack of retrograde flow contributes to cyst formation and an increase in size over time.…”

“…Hemangiomas are benign vascular neoplasms that originate from the proliferation of endothelial cells. Cutaneous hemangiomas, in children, are not commonly present at birth but appear in the first few weeks of life and exhibit a rapid growth phase followed by partial regression, size changes, and changes in visual appearance 3 . Seventy percent of cutaneous hemangiomas will occur by the age of 7 years, and musculoskeletal hemangiomas do not spontaneously regress 2,3 .…”

“…The index finger is most affected, followed by the middle, small (little) ring, and the thumb (Figs. 2 and 3) 2,3,6,7 . TGCTs are nonmetastasizing tumors and usually present as a single nodule.…”

“…While composed primarily of fatty tissue, lipomas evolve from mesenchymal preadipocytes 8,9 . Lipomas present as slowly enlarging, nontender, mobile, painless, doughy soft-tissue masses 1,3,[8][9][10] . However, subfascial lipomas are much less mobile than subcutaneous lipomas and can present with more pain resulting from space restrictions associated with the subfascial region 6 .…”