A Patient's Guide to Ganglions of the Wrist
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Introduction
A ganglion is a small, harmless cyst, or sac of fluid,
that sometimes develops in the wrist. Doctors don't know exactly
what causes ganglions, but a ganglion that isn't painful and
doesn't interfere with activity can often be left untreated
without harm to the patient. However, treatment options are
available for painful ganglions or ones that cause problems.
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This guide will help you understand
• what part of the wrist is involved
• how doctors diagnose the condition
• what treatment options are available
Anatomy
What part of the wrist is involved?
The anatomy of the wrist joint is extremely complex--probably the
most complex of all the joints in the body. The wrist is actually
a collection of many joints and bones. These joints and bones let
us use our hands in lots of different ways. The wrist must be extremely
mobile to give our hands a full range of motion. At the same time,
the wrist must provide the strength for heavy gripping.
The wrist is made of eight separate small bones, called the carpal
bones. The carpal bones connect the two bones of the forearm,
the radius and the ulna, to the bones of the hand.
The metacarpal bones are the long bones that lie underneath
the palm.
View close-up of wrist joint.
Ligaments connect and hold all these wrist bones together. The
ligaments allow the bones to move in all directions. These ligaments
meld together to form the joint capsule of the wrist. The joint
capsule is a watertight sack of tissue that surrounds the wrist
bones. Inside the wrist capsule are the joints themselves containing
a small amount of lubricant, called synovial fluid, that
allows the bones to move together easily. The many tendons required
to move the fingers run just outside the joint capsule.
View joint capsules.
Ganglions are generally attached by a stalk of tissue to a nearby
joint capsule, tendon, or tendon sheath. Wrist ganglions are attached
to the wrist joint capsule. Typically only one ganglion appears,
often in a location that is predictable to doctors. However, ganglions
have been seen in almost every joint in the hand and wrist.
Sixty to seventy percent of wrist ganglions are dorsal wrist
ganglions. A dorsal wrist ganglion is found on the back of the hand,
often centered over the wrist, though it can appear in any number
of areas along the wrist. A dorsal wrist ganglion may be not be
visible from the outside. Doctors refer to this type of ganglion
as occult, or concealed.
View dorsal ganglion.
A volar wrist ganglion typically appears on the palm side
of the wrist in the wrist crease just below the thumb. This is the
second most common type of wrist ganglion.
View volar ganglion.
Causes
Why do I have this problem?
Doctors don't know why ganglions develop. In some cases, the wrist
has been injured previously. Repetitive injuries, such as those
that can occur from playing tennis or golf frequently, seem to play
a role in ganglion development as well.
Doctors also don't understand exactly how ganglions form. One theory
suggests that wrist ganglions are formed when connective tissue
degenerates, or is damaged by wear and tear. The damaged tissue
forms a weakened spot in the joint capsule--just like a weak spot
on a car tire that allows the inner tube to bulge through. The joint
fluid may escape through this weakened area and begin to collect
in a sack, or cyst outside the joint. Over time this cyst grows
larger. The joint fluid seems to move out of the wrist joint into
the ganglion, but not the other way. In the end, a clear, sticky
fluid fills the cyst. The fluid is a mix of chemicals normally found
in the joint.
Symptoms
What does a ganglion feel like?
A patient with a dorsal wrist ganglion may feel a bump or mass on
the back of the wrist. With a volar wrist ganglion, the bump is
felt on the wrist crease below the thumb. The mass may appear suddenly,
or it may develop over time. The ganglion may occasionally increase
or decrease in size.
The wrist may ache or feel tender. The ganglion may also interfere
with activities. A volar wrist ganglion may compress the median
or ulnar nerve, causing trouble with sensation and movement. An
occult dorsal wrist ganglion may be quite painful and tender, even
though it is smaller than other ganglions. Typically the symptoms
from a ganglion are not harmful and do not grow worse. These cysts
will not turn into cancer.
Diagnosis
How do doctors diagnose the problem?
Your doctor will ask for a history of the problem and examine your
hand and wrist. Usually, this is all that's required to diagnose
a ganglion. An occult dorsal wrist ganglion, however, may be more
difficult to locate because of its small size.
Treatment Options
What can be done for a ganglion?
Treatment for dorsal and volar wrist ganglions may be either surgical
or nonsurgical. The relative risks and benefits of any ganglion
treatment should be considered carefully.
Nonsurgical Treatment
Dorsal Wrist Ganglions
In the past, dorsal wrist ganglions were treated by breaking them
without rupturing the skin. This was done with a mallet (or Bible)
or simply with firm pressure. However, because ganglions often reappeared
after this type of treatment, it is no longer used.
Observation is often sufficient "treatment" for wrist
ganglions. Ganglions typically are harmless and do not grow worse
over time. Nor do they usually cause damage to the tendons, nerves,
or the joint as a whole. Additionally, as many as 50 percent of
wrist ganglions may eventually go away by themselves.
Beyond observation, closed rupture with multiple needle punctures
is another nonsurgical treatment option for dorsal wrist ganglions.
In this procedure, the cyst wall is punctured with a needle, and
anti-inflammatory and numbing drugs are injected into the cyst.
This treatment can shrink the cyst and alleviate symptoms. However,
the ganglion is likely to reappear.
View graphic of treatment.
Volar Wrist Ganglions
Observation is the most common nonsurgical treatment for volar
wrist ganglions.
Surgery
Surgery is recommended when the patient feels significant pain
or when the cyst interferes with activity. It is also recommended
if the ganglion is compressing nerves in the wrist, since this can
cause problems with movement and feeling in the hand. Surgery is
usually done using regional anesthesia, which means only the arm
is put to sleep, but it can be done under a general anesthesia is
well.
Dorsal Wrist Ganglion
Doctors have two options to surgically treat dorsal wrist ganglions.
The first is cyst puncture and aspiration. (Aspiration means
drawing the fluid out with suction.) However, this procedure has
less than a 50 percent success rate.
Excision, or removal, of the cyst is the second option. Removing
the cyst is usually effective if the stalk that connects the cyst
to the joint capsule and a bit of the surrounding capsule are removed.
Usually only a single incision is made, but depending on the location
of the ganglion, a second incision may be necessary.
To remove a dorsal wrist ganglion, a small incision is made in
the back of the wrist. The tendons that run across the back of the
wrist and into the fingers are retracted (or moved) out of the way.
This allows the surgeon to see the ganglion and follow it down to
where it attaches to the wrist capsule. Once the surgeon locates
this stalk, the entire ganglion is removed including the area where
it attaches to the joint capsule. The joint capsule may or may not
need to be repaired with sutures. Finally, the skin incision is
closed with sutures.
View graphic of treatment.
Volar Wrist Ganglion
Puncture and aspiration is not recommended for volar wrist ganglions
located in certain areas because of the possibility of nerve and
blood vessel damage. In other areas, needle puncture has a better
success rate.
Excision is the most common surgery for a volar wrist ganglion.
Removing the cyst is usually effective if the stalk that connects
the cyst to the joint capsule and a bit of the surrounding capsule
are removed. The surgical procedure is basically the same, except
the volar ganglion is usually very close to the radial artery (the
artery in the wrist used to feel someone's pulse). In some cases,
the volar ganglion even winds around the artery. This makes removing
the ganglion a bit more difficult. The surgeon must be careful to
protect the artery, while at the same time removing the cyst down
to the joint capsule--just like with the dorsal ganglion.
View graphic of treatment.
Both of these procedures have risks. Even after excision surgery,
a ganglion may reappear, though this is uncommon. There is a slight
risk of infection with both procedures. Excision can sometimes result
in decreased motion, instability, and nerve or blood vessel damage.
Removing a volar ganglion has a greater risk of nerve and blood
vessel damage. However, the vast majority of people have two arteries
that travel into the hand. If one is injured, the other is sufficient
to provide and adequate blood supply to the hand.
Rehabilitation
What should I expect after treatment?
After surgery, a bulky dressing is applied to the wrist and forearm.
You will be encouraged to move your fingers and wrist soon after
surgery. Stitches are removed after two weeks. Physical therapy
exercises should be continued until you can move your wrist normally.
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