Ganglia of the Hand and Wrist

Causation

Ganglia develop from the connective tissue by liquefaction (decay) of collagen fibers, increasing the amount of fluid. Though many of the ganglia arise directly adjacent to a joint, they appear to be connected by a one-way valve mechanism allowing fluid from the joint to exit into the sac.

Ganglia may arise adjacent to a joint or tendon sheath and may be connected by a long stalk. Thus, their superficial appearance may not accurately represent the site of origin. Ganglia arising in response to degenerative arthritis of the interphalangeal joint are called mucous cysts and frequently result in deformity of the fingernail. If they go untreated and rupture, they may become infected. Ganglia cysts commonly occur in association with arthritis related to production of inflammatory fluid.

Advanced degenerative arthritis at the end joint of the finger (DIP joint) frequently results in a cyst known as a mucous cyst and may cause significant nail deformity.

Pressure from a cyst just above the nail fold has caused a deep trough in the nail. Removal of the cyst will allow the nail to grow back normally in about 4 months.

Evaluation

Most ganglia are obvious because of the classic location, size and symptoms. Physical examination is sufficient in making a diagnosis. A ganglion is usually not mobile and it frequently has bounce to touch. However, in an attempt to identify an underlying cause such as arthritis and exclude other explanations, X-rays may be necessary.

Non-Operative Treatment

A person who notes a lump but is not experiencing pain or limitation as a result of the lump has choices. She may observe the lump and do nothing. The lump may be struck to try and pop it in hope that it scars down and does not recur. This is unpredictable. The other option is surgical removal (excisional biopsy). If the lump is large enough to be ugly or is bothersome it may need to be removed surgically.

An attempt at withdrawing the jelly-like fluid from the ganglion with a needle is largely unsuccessful; usually the cyst will recur. Some physicians have reported good results from cortisone injection, but in my experience there is a high recurrence rate after injection. There is no good physiological reason why corticosteroids should have any effect on this problem.

In the case of mucus cysts involving the finger or thumb distal interphalangeal joint, it's necessary to remove osteophytes (bone) from the underlying joint in addition to the soft tissue sac. A small 1/2" incision is made to remove the cyst. The semi-line prevents the scar from pulling tightly across the finger. Nail deformity coming from pressure against the growth area will then correct itself as the nail regrows.

Traditional Surgery (Wrist Ganglion):

Ganglion removal is best done using a small 1/2" transverse incision. The ganglion is exposed down to the joint and cut out along with a small wedge of the joint capsule.

Arthroscopic Surgery:

There is an arthroscopic technique for removing a wrist ganglion. It is straightforward and requires two small puncture wounds in the wrist. It is as equally effective as open ganglion removal only it leaves an even smaller incisional scar and it costs a lot more due to use of elaborate equipment. For the person determined to absolutely minimize the size of the scar and for whom "money is no object" - there aren't many of those around - arthroscopic removal of a ganglion is a safe, straightforward outpatient procedure. Surgical removal of ganglia in general is quite effective. However, in order to obtain a good result one must do the surgery in an operating room. This prevents injury to associated structures such as the superficial nerves and arteries and minimizes incision size. It decreases the chance of recurrence by allowing careful dissection down to the base of the ganglion and excision of the entire ganglion with its origin.

Physical or Occupational Therapy

It's rare for a person who undergoes ganglion removal to require hand therapy afterwards if treated at Nebraska Hand & Shoulder Institute, P.C. There is usually minimal discomfort after surgery. Since there are no restrictions necessary, the patient is allowed to move her fingers and wrist immediately. Significant stiffness develops only if the patient babies herself and refuses to do simple exercises. Total ganglion removal provides 85-90% chance of permanent cure. Surgery achieves difinitive tissue diagnosis and treatment in one sitting. If the specimen appears classical for a benign (non cancerous) ganglion, it may not be necessary to send it to a pathologist and incur an additional charge, though hospital regulations may mandate having the pathologist look at the specimen. Having an absolute tissue diagnosis often provides an unparalleled measure of confidence in a person by eliminating the fear of an undiagnosed cancer.