The patient’s unmet needs (PUNs)
A 36-year-old woman complains of an uncomfortable swelling on the back of her wrist. It has been present for three months and is slowly enlarging. Examination reveals a cystic, slightly tender lesion which the patient has correctly self-diagnosed as a ganglion. She says: ‘I know it’s not going to go, so I’d like to see a surgeon to have it removed.’ You’re not convinced of the need for surgery and are unclear on current local referral policies.
The doctor’s educational needs (DENs)
What are wrist ganglions and how common are they?
Wrist ganglions are fluid-filled cysts that arise from the capsuloligamentous structures of the wrist. Around 70% arise on the dorso radial aspect of the wrist and 20% on the volar radial aspect. Other locations account for the remaining 10%. Dorsal ganglions tend to occur in younger patients aged between 20 and 40 years, while volar ganglions are more likely to occur in patients aged between 50 and 70 years. Histological examination of ganglions reveals a cyst wall of fibrillated connective tissue with sparse mesenchymal cells.
The central area is filled with a clear necrotic jelly. The annual incidence is approximately 30 per 100,000 and they are more common in women than men, with a ratio of around 8:1.
What is the natural history of a ganglion? In particular, what is the likelihood of spontaneous resolution?
Ganglions often arise spontaneously with an insidious onset, although occasionally they can appear more suddenly. In one study the presenting complaints of patients in an outpatient setting were studied in 50 consecutive patients with a wrist ganglion. The reported complaints were cosmetic (38%), fear of malignancy (28%), pain (26%) or loss of hand and wrist function (8%).1
In a six-year prospective study, 33% of dorsal and 45% of volar wrist ganglions spontaneously resolved.2
Are any investigations needed to make a diagnosis?
Most ganglions are obvious from their history, anatomical location and appearance. But occasionally further investigations may be required.
Simple transillumination in clinic will show the lump to be fluid filled. Ultrasound is a simple, cheap and non-invasive investigation that will accurately diagnose ganglions. MRI scans will also clearly demonstrate the exact location of a ganglion and may give a clue to the origin of the stalk. Ultrasound and MRI are both equally sensitive in diagnosing wrist ganglions. Plain radiographs should be performed if the patient has any suggestion that underlying degenerative joint disease or previous trauma could be a primary cause of the ganglion.
Red-flag signs for the lump being malignant and not a ganglion include:
- unusual location
- a progressive increase in size
- pain (and night pain)
- dry aspiration and negative squeeze test (remember that some ganglions are very viscous) – in cases of dry aspiration refer for an urgent ultrasound scan
- tethering of surrounding structures
- associated distal nerve symptoms
- systemic features, such as weight loss
- axillary lymph nodes.
What are the typical current referral policies?
There is no general consensus of opinion on referral policy. Cosmetic worries are often disregarded as an indication for referral, but the prominent location of the ganglion may be distressing for some patients and should not be dismissed. Concern about malignancy can often be resolved in the outpatient setting through history and clinical examination, and later confirmed by aspirating a clear, jelly-like substance. Reassurance that the ganglion is a non-malignant condition has been shown to settle concerns in around a quarter of patients. Pain and lack of function as a consequence of the ganglion are strong indicators for treatment.
What are the treatment options, and is there any value in deliberate rupture or aspiration? If appropriate, who should attempt this and how?
Simple aspiration is usually effective and may need to be repeated. Multiple wall perforation is my preferred technique although there is no evidence that this is more effective than a simple single puncture. There is no data to suggest that either steroid or hyaluronidase injections improve the results. Care must always be taken with steroid injections in superficial locations as it’s possible to cause skin and subcutaneous atrophy. As a rule, I never inject more than 10mg of triamcinolone into the hand and wrist.
There does appear to be value in aspirating wrist ganglions to alleviate symptoms. Dorsal ganglions are very simple to localise and aspirate effectively. But volar wrist ganglions may be more difficult because of their proximity to the adjacent radial artery. Aspiration should be performed under aseptic conditions.
A small amount of local anaesthesia may be infiltrated under the skin prior to aspiration. Care should be taken to prevent ballooning the skin leading to an inability to accurately palpate the ganglion. Any suitably trained clinician should be able to reliably aspirate ganglions in the outpatient setting. If inadvertent arterial puncture occurs, the procedure should be abandoned and pressure applied for a timed five minutes. Occasionally the aspirate is so thick it is unable to be aspirated into the syringe. In these circumstances, manual pressure will force the ganglion jelly out through the skin puncture site.
From personal experience, I would strongly recommend that all ganglion aspirations should be performed in a well-ventilated room with the patient lying supine in case of syncope and fainting.
Surgery may be performed on symptomatic ganglions that don’t respond to these conservative methods – but this should always be regarded as the last resort. Reassurance, aspiration and repeat aspiration should have been attempted before surgery. Surgery is often performed under general anaesthetic to clearly trace the stalk to its origin at the wrist capsule and ligamentous origin.
Dorsal wrist ganglions are thought to arise from the dorsal scapholunate ligament, and volar ganglions from the volar wrist capsule and ligaments around the radioscaphoid region and the scaphotrapezial joints. The ganglion and its stalk are carefully excised with a small surrounding area of capsule. The capsule is left open and the skin sutured.
Surgery carries risks of scarring, tenderness, stiffness and recurrence. There is also a risk – though minimal – of inadvertent injury to surrounding structures including tendons, ligaments and neurovascular structures. The recurrence rates after surgery have been reported to vary from 4-40%3 and this does not appear to be related to size, location or chronicity.
- The aetiology of ganglions is unknown.
- The annual incidence is approximately 30 per 100,000 and they are more common in women than men, with a ratio of approximately 8:1.
- Ganglions often arise spontaneously with an insidious onset, although occasionally they can appear more suddenly.
- Pain is a feature in only a quarter of patients.
- Around 10% have loss of hand and wrist function.
- Around a third of dorsal and 45% of volar wrist ganglions spontaneously resolve.
- Reassurance that this is a non-malignant condition has been shown to settle around a quarter of patient complaints.
- Pain and lack of function as a consequence of the ganglion are strong indicators for treatment.
- Simple aspiration is usually effective and may need to be repeated.
- Surgery should be regarded as the last resort.
Mr Mike Hayton is a consultant orthopaedic surgeon at Wrightington, Wigan and Leigh NHS Foundation Trust
Go to www.mikehayton.com for further information on a wide range of hand conditions plus videos of several hand operations.
1 Westbrook AP, Stephen AB, Oni J et al. Ganglia: the patient’s perception. J Hand Surg Br 2000;25: 566-7
2 Dias J, Dhukaram V and Kumar P. The natural history of untreated dorsal wrist ganglia and patient-reported outcome six years after intervention. J Hand Surg Eur Vol 2007;32:502-8
3 Zachariae L and Vibe-Hansen H. Ganglia. Recurrence rate elucidated by follow-up of 347 operated patients. Acta Chir Scand 1973;139:625-28