Ganglion cysts of the hand and wrist

1. Ganglion cysts are the most common soft-tissue mass of the hand and wrist, accounting for roughly 50–70% of all hand masses.

True

Ganglions are tumour-like lesions rather than true neoplasms and are by far the most frequent mass of the hand and wrist, outnumbering giant cell tumour of tendon sheath and epidermal inclusion cysts. Standard reviews place them at 50–70% of all hand and wrist masses. Most sit on the dorsal wrist, with volar wrist, flexor-sheath and distal interphalangeal (mucous cyst) sites accounting for the remainder.

• Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin. 2004;20(3):249-60, v. PMID 15275684
• Zoller SD, Benner NR, Iannuzzi NP. Ganglions in the Hand and Wrist: Advances in 2 Decades. J Am Acad Orthop Surg. 2023;31(2):e58-e67. PMID 36580047

2. The wall of a ganglion cyst is lined by synovial cells.

False

Scanning electron microscopy shows a ganglion wall made of multidirectional layers of collagen fibres with no cellular lining, which is why a ganglion is a pseudocyst rather than a true cyst. Synovial membrane and adventitious bursae, by contrast, do have a cellular lining. The lumen contains viscous mucin rich in hyaluronic acid, biochemically distinct from and much thicker than synovial fluid.

• Psaila JV, Mansel RE. The surface ultrastructure of ganglia. J Bone Joint Surg Br. 1978;60-B(2):228-33. PMID 659471
• Gude W, Morelli V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008;1(3-4):205-11. PMID 19468907

3. Dorsal wrist ganglia most commonly arise from the scapholunate joint, with a one-way, valve-like communication from the joint into the cyst.

True

Angelides and Wallace traced the pedicle of dorsal wrist ganglia to the scapholunate joint and, on microdissection, demonstrated a one-way valve-like duct system between the joint and the cyst; arthrography shows contrast passing from joint to cyst but not in reverse. The pedicle can arise elsewhere on the dorsal capsule, so 'most commonly' rather than 'always' is the accurate wording. The stalk is excised with a cuff of capsule while the scapholunate interosseous ligament itself is preserved.

• Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am. 1976;1(3):228-35. PMID 1018091
• Elahi MA, Moore ML, Pollock JR, Haglin JM, Lai C, Hinckley NB, et al.. Open Excision of Dorsal Wrist Ganglion. JBJS Essent Surg Tech. 2023;13(2). PMID 38274143

4. Recurrence after aspiration of a dorsal wrist ganglion is below 20%.

False

In the 2015 systematic review and meta-analysis by Head and colleagues (35 studies, 2,239 ganglions) the mean recurrence was 59% after aspiration, 21% after open excision and 6% after arthroscopic excision, and in randomised trials excision reduced recurrence by 76% compared with aspiration. Dias and colleagues reported 58% recurrence after aspiration in a prospective cohort. Aspiration remains useful to confirm the diagnosis and reassure, but it is not a low-recurrence treatment; flexor-sheath ganglia respond better than wrist ganglia.

• Head L, Gencarelli JR, Allen M, Boyd KU. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015;40(3):546-53.e8. PMID 25708437
• Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007;32(5):502-8. PMID 17950209

5. Mucous cysts of the distal interphalangeal joint are associated with osteoarthritis, and excision combined with joint debridement carries a low recurrence rate.

True

Mucous cysts are dorsal ganglia of the osteoarthritic distal interphalangeal joint and frequently present with nail ridging. In Rizzo and Beckenbaugh's series of 134 cysts there were no recurrences after excision with joint debridement, compared with a 40% recurrence rate after aspiration and injection, and Roulet and colleagues reported 1.5% recurrence after excision with osteophyte resection. Surgery itself can occasionally produce a new nail deformity, so patients should be counselled accordingly.

• Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am. 2003;28(3):519-24. PMID 12772114
• Roulet S, Marteau E, Bacle G, Laulan J. Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection: Results in 68 cases at a mean 6.63 years' follow-up. Chir Main. 2015;34(4):197-200. PMID 26188999