What is a “ganglion”?
A “ganglion” is a cyst of excess fluid from a tendon or a joint, and is extremely common around the hand and wrist. It is a sign of some inflammation in an underlying joint, ligament or tendon. The underlying problem is usually mild. There are 4 main types of ganglion: dorsal wrist ganglion; volar wrist ganglion; pulley or “seed” ganglion; and mucous cyst.
Dorsal wrist ganglion:
Ganglia on the back of the wrist occur most often in young ladies, and may be uncomfortable when bending the wrist back particularly when taking weight, for example, when doing press-ups. They come from a ligament, and are more common in patients who are “loose-jointed”. They may also occur in older patients associated with underlying wrist osteoarthritis. Typical dorsal wrist ganglia in adolescence or young adulthood do not go onto wrist arthritis.
Volar wrist ganglion:
Ganglia on the front of the wrist occur more often in the middle-aged, and are related to mild degeneration in some of the joints of the wrist or thumb base. There may be aching related to those joints
Pulley or “seed” ganglion:
Ganglia from tendons often occur at the base of fingers, in the palm. They can be uncomfortable when gripping a steering wheel etc. They may be associated with some stiffness in the finger and very occasionally with triggering (see separate information sheet).
Mucous Cyst:
Ganglia just behind the nails come from the last joint in the finger, and again are related to degeneration in the joint. They may cause a furrow in the finger nail, due to pressure on the nail bed. They may discharge having been knocked typically with a clear jelly like substance.
Most ganglia are painless particularly the wrist ganglia, although there may be discomfort from the underlying problem e.g. joint or ligament inflammation. The seed ganglion may be tender with gripping and the mucous cyst may be painful if it becomes tense. This is often shortly before it bursts. Most ganglia give little in the way of day to day problems but they are unsightly especially those on the back of the wrist/hand i.e. the dorsal wrist ganglion and the mucous cyst
Why does it occur?
The pathology i.e. the abnormality is inflammation in an underlying joint, ligament or tendon. Normally in joints and around ligaments and tendons there is a thin film of fluid that helps lubricate the joint, ligament or tendon. In response to the underlying abnormality the body produces extra fluid which becomes concentrated as a clear jelly. This forms the contents of the cyst. The body limits the spread of the jelly by containing the jelly in a capsule or lining and so a cyst is formed. Quite why it occurs in some people and not in others is unclear. It does NOT imply any sinister or worrisome problems.
What happens if nothing is done?
(This is referred to as the natural history i.e. what happens if Nature runs its own course.)
For wrist ganglia and seed ganglia many will resolve spontaneously i.e. on their own. This is usually a gradual process but can be sudden with the cyst bursting particularly if it is hit suddenly (hence the old advice to hit the ganglion with a family bible – this is no longer recommended!). In particular dorsal wrist ganglia may resolve over 5 years. Why they can resolve so late is unclear. Mucous cysts tend to resolve less commonly but all ganglia can settle on their own. Some ganglia will gradually enlarge becoming more of a nuisance. Their behaviour is unpredictable.
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at the wrists and hands. They may shine a small torch at the ganglion which should light up the swelling evenly if it is a cyst (rather than a solid lump). Typically the diagnosis will be obvious to an experienced clinician. The main alternative is a solid lump (see information sheet).
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
Usually the diagnosis will be obvious and no tests will be required. Sometimes a wrist X-ray will be taken particularly in older patients but not usually for younger patients.
Treatment:
What are the non-operative treatments?
Most ganglia are not more than mildly uncomfortable. They often disappear with time (up to 5 years) and usually should be left alone. If there is significant discomfort then the best treatment is to remove the thick ganglion fluid with a needle called aspiration. This is sometimes combined with a steroid injection into the joint or tendon sheath. This can be done in the clinic room, with local anaesthetic. This has a success rate of approximately 50%, and can be repeated if necessary. The relief of discomfort is even more successful. Seed ganglia are usually too small to aspirate (suck out) and instead they are burst with an injection of local anaesthetic. By sucking out the fluid (or bursting the seed ganglion) the diagnosis is confirmed. Many patients will be happy with this even if the ganglion does return.
What does the operation involve?
If this is unsuccessful, and the ganglion and discomfort return persistently, then the surgeon may recommend surgically removing the ganglion. The results are more reliable for some ganglia than others and this will guide your Hand specialist in advising you.
Dorsal wrist ganglion:
These mostly resolve, and recur in significant numbers (up to 25%) that most specialists will advise against surgery if the symptoms are not great. The operation is called excision of dorsal wrist ganglion. The operation is typically performed under local anaesthetic/general anaesthetic largely depending on the surgeon’s experience. A band, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 10-20 mins or so that it is inflated (this happens just before the surgeons starts the operation). Before that the arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection. The surgeon makes a transverse incision (i.e. across the back of the wrist) over the ganglion, and removes it. The “neck” of the ganglion sac is widened out to reduce the chance of it recurring. The skin is then stitched up with absorbable stitches. Sometimes the lining of the ganglion will be sent to the laboratory for analysis to confirm the diagnosis. As the diagnosis is usually so clear it is not typically necessary. A supportive dressing is applied and the patient’s arm elevated. The total time in hospital is usually 1-2 hours.
Volar wrist ganglion:
These often resolve partly or completely, and recur following surgery in significant numbers (up to 30-40%) that most specialists will advise against surgery if the symptoms are not great. The operation is called excision of volar wrist ganglion. The operation is typically performed under local anaesthetic/general anaesthetic largely depending on the surgeon’s experience. A band, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 10-20 mins or so that it is inflated (this happens just before the surgeons starts the operation). Before that the arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection. The surgeon makes a longitudinal incision (i.e. along the line of the front of the wrist) over the ganglion, and removes it. The “neck” of the ganglion sac is widened out to reduce the chance of it recurring. The skin is then stitched up with absorbable stitches. Sometimes the lining of the ganglion will be sent to the laboratory for analysis to confirm the diagnosis. As the diagnosis is usually so clear it is not typically necessary. A supportive dressing is applied and the patient’s arm elevated. The total time in hospital is usually 1-2 hours.
Pulley or “seed” ganglion:
Seed ganglia resolve in 50% of cases with bursting. In a technique that we have pioneered up to 85% satisfaction is achieved with a release of the underlying pulley with a needle through the skin. This is a small operative procedure that can be performed in the outpatient’s clinic. Open surgery is thus rarely required. If it is it is called excision of seed ganglion. The operation is performed under local anaesthetic. A band, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 10 mins or so that it is inflated (this happens just before the surgeons starts the operation). Before that the arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection. The surgeon makes a transverse incision (i.e. across the palm/finger) over the ganglion, and removes it. The “neck” of the ganglion sac is widened out to reduce the chance of it recurring. The skin is then stitched up with absorbable stitches. Sometimes the lining of the ganglion will be sent to the laboratory for analysis to confirm the diagnosis. As the diagnosis is usually so clear it is not typically necessary. A simple elastoplast dressing usually suffices.
Mucous Cyst:
Mucous cysts are less likely to resolve, and are usually excised. Moreover in our experience recurrence is rare (<1%). If it is it is called excision of mucous cyst. The operation is performed under local anaesthetic. The arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection. A small band is placed at the base of the finger to provide a bloodless field. As the finger is numb the patient does not feel it. The surgeon makes an oblique incision (i.e. diagonal) over the ganglion, and removes it. The “neck” of the ganglion sac is widened out and any local spurs of bone removed to reduce the chance of it recurring. Sometimes the skin over the ganglion there is very thin, and it is necessary to move skin along the finger to let the wound heal properly. The skin is then stitched up with absorbable stitches. Sometimes the lining of the ganglion will be sent to the laboratory for analysis to confirm the diagnosis. As the diagnosis is usually so clear it is not typically necessary. A supportive dressing is applied and the patient’s arm elevated. The total time in hospital is usually 1-2 hours.
What happens in the next few weeks?
The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
The bandage can be removed after 2-7 days, leaving a sticky dressing beneath. The patient or GP practice nurse can do this. If well healed at that stage then the wound can be left open (exposed). If in doubt it can be covered with a light dressing for a few more days. The patient is reviewed in clinic between 2-4 weeks following the operation. Typically dissolvable stitches are used so they should not require to be removed.
The hand can be used for normal activity after the first few days. Most patients can drive after a 5-7 days. Most patients return to work in 1-5 days, but this varies with occupation; heavy manual work usually takes about 6 weeks. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked a Physio may be organised to help reduce the scar tenderness but this is rarely required. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful.
What are the results of the operation?
Wrist ganglia
Approximately 80-90% of patients with wrist ganglia say they have a good result following this operation, with relief of the discomfort and the lump. If the ganglion recurs many patients are still satisfied as it is often smaller. Nonetheless the ganglion can recur larger which then gives both a scar and a more unsightly swelling.
Seed ganglion
The percutaneous treatment of seed ganglia the we have pioneered gives around 85% satisfaction.
Mucous cyst
Excision of mucous cysts is even more successful with satisfaction of 90-95%. And in our experience recurrence of <1%.
Are there any risks?
All interventions in medicine have risks. In general the larger the operation the greater the risks. For these operations the risks include:
- Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
- The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
- Aching occurs in a few cases long-term mainly in the wrist.This is primarily due to the underlying abnormalities in the joint or ligament. Grip strength can take some months to return to normal.
- Stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below)
- Numbness around the scar can occur but this rarely causes any functional problems.
- Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which very slowly improve but often does not resolve fully..
- The ganglion may come back; the rate of recurrence varies depending on the site.
- Dorsal wrist ganglia recur in approximately 25% of cases.
- Volar wrist ganglia recur in approximately 30-40% of cases.
- Pulley “seed” ganglia rarely recur following open surgery but this is usually not required.
- Mucous cysts rarely recur
- If the underlying joint is degenerate, this will not be affected by removing the ganglion. Aching may continue and get worse as time goes on.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery. This is rare for CTS.