Ganglion cysts are the most common soft tissue tumours in the hand. They can be thought of as a herniation of joint or tendon sheath fluid outside the normal confines of the joint capsule or tendon sheath. They are attached to the structures from which they originate by a stalk, which acts as if it has a one-way or two-way valve. This concept helps to explain the variation in size of ganglion cysts over time.

Common types of ganglion cysts include dorsal or volar carpal (wrist) ganglion cysts, retinacular (tendon sheath) cysts and mucous (small finger joint) cysts. They tend to arise in common and predictable locations. Ganglion cysts can however arise from any joint in the hand, and when suspected ganglion cysts are seen in unusual locations, alternate diagnoses may need to be considered. Further investigation and treatment options will be based on the careful assessment of your history and physical examination findings by Dr Tolerton.

Investigations may include x-rays, ultrasound and/or magnetic resonance imaging (MRI). Non-surgical treatment include observation, activity modification, nonsteroidal anti-inflammatories drugs (NSAIDs), splinting and hand therapy. A trial of aspiration and/or corticosteroid injection may be recommended. Surgical treatments include excision of the ganglion cyst, using open or endoscopic (keyhole) techniques.

Dorsal or Volar Carpal (Wrist) Ganglion Cysts 

If the findings of the physical examination strongly support the diagnosis of ganglion cyst, the management of asymptomatic dorsal or volar carpal ganglion cysts may involve a simple watch and wait approach. If this is not the case, further investigation may be necessary. Non-surgical treatments for dorsal carpal ganglion cysts include aspiration +/- injection of corticosteroid. Recurrence may exceed 50% following aspiration. Open or endoscopic (keyhole) excision reduces the risk of recurrence to approximately 5%. Symptomatic volar carpal ganglion cysts can be treated similarly, although the close proximity of the radial artery and sensory nerve branches increases the risk of complications.

Retinacular (Tendon Sheath) Ganglion Cysts

Small, asymptomatic or minimally symptomatic retinacular ganglion cysts may be observed as long as physical examination findings are characteristic. While certain symptomatic lesions may be amenable to aspiration with occasional recurrence, surgical treatment in the form of marginal excision is generally recommended.

Mucous (Small Finger Joint) Ganglion Cysts

It is reasonable to observe small, asymptomatic and non spontaneously-draining mucous ganglion cysts. Large or symptomatic lesions may be aspirated, however recurrence is frequent. Surgical excision also carries a substantial risk of recurrence as the underlying cause (osteoarthritis) remains. The degree of debridement of the underlying joint pathology is inversely proportional to the rate of recurrence, but conversely increases the risk of skin and wound-healing problems. Skin coverage may need to be considered in cases complicated by size or infection.