Ganglions

Aetiology

  • A fibrous cystic swelling arising from a tendon sheath or joint filled with mucoid-rich material but with no true epithelial lining
  • Bimodal > young patients with no underlying OA or older with OA
  • Rarely there is a traumatic event

Pathology

  • Wall is made of collagen > no epithelial or synovial lining
  • Histology > mucin-filled ducts and lakes within the stalk that coalesce to form the cyst
  • Mucin is made up of glucosamine, hyaluronic acid, and proteins

Wrist Ganglia

Dorsal

  • 70% of ganglia
  • Scapholunate joint & ligament

Volar

  • 20%
  • STT or radioscaphoid joint
  • Closely associated with radial artery or FCR – beware in dissection
  • Recurrence rate higher

Differential Diagnosis

  • Tenosynovitis – from extensor tendons
  • Synovitis – from underlying OA or RA – diffuse, boggy, tender swelling
  • Extensor tendon ganglia – will move with tendon
  • Tumor, AV malformation, Infection – all rare

Diagnosis

  • Clinical
  • MRI – if it is occult and not visualized on examination

Management

No Treatment Required

  • Reassure patient

Non-Surgical

  • Aspiration

    • 50% recurrence but usually enough to reassure patients

Surgery

Indications

  1. Pain
  2. Neurologic compression
  3. Functional limitation
  4. Aesthetic
  • Arthroscopic or open
  • Pre-operative Allen’s test mandatory for volar ganglions
  • Principle is to excise stalk > take a cuff of capsule and then suture defect
  • Transverse incisions
  • 5% recurrence rate

Other Ganglions

Flexor Sheath (Seed Ganglions)

  • From a weak spot in the A1 or rarely A2 pulley
  • Aspiration helps in 50% but surgery is the treatment of choice
  • Remove a cuff of the A1 pulley
  • Differentiated from Trigger Finger as they don’t move with the tendon

PIPJ/Extensor Tendon Ganglion

  • Remove according to normal principles

Guyon Canal Ganglion

  • Arises from Piso-triquetral joint
  • Presents as a low ulnar nerve palsy
  • Confirm by USS or MRI
  • Surgically excise, taking care not to harm ulnar nerve branches

Mucoid Cyst

  • Related to DIPJ arthritis
  • Underlying osteophyte
  • May cause nail ridging or recurrent infection
  • May be a horseshoe ganglion on either side of the terminal extensor tendon
  • Excision with removal of the osteophyte is the management of choice
  • Skin healing and loss can be a problem
  • Consider local rotational flap or FT skin graft
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