Ganglion cysts, also known as synovial cysts or ganglia, are
the most common soft tissue tumors of the wrist and hand.1 They
are a common reason for patients to present to the Emergency Department.
Their chief complaint is usually a mild pain or ache exacerbated
by movement and localized to a 1 to 2 cm mass on the wrist or hand.
Patients may also present with concern about a painless “lump.” Acute trauma
prior to presentation is uncommon, though patients often give a
history of repetitive motion at the site. The mass usually increases
in size progressively over time or, occasionally, may grow rapidly
over a short period. Patients presenting to the Emergency Department
with ganglia may have already attempted one of several popular home
remedies, including homeopathic medications or striking the cyst
firmly with a large book or hammer.
Ganglion cyst aspiration is a relatively simple procedure that
may be performed by the Emergency Physician. However, cysts recur
in many cases. There are reports of up to and even greater than
50 percent recurrence postaspiration.2,3 The practice of
Emergency Department aspiration has been challenged because of the
high recurrence rate.4 However, the procedure usually alleviates
presenting symptoms, is occasionally curative, and is more cost-effective
than referring all patients for surgical treatment.5
Ganglia are benign synovial cysts that arise from a joint capsule
or tendon sheath. It is unclear whether they are formed by herniation
of the tendon sheath, myxomatous degeneration of connective tissue,
or some other mechanism. Contained within the cyst is a viscous,
jelly-like fluid. Ganglia often connect with the underlying synovial
cavity or tendon sheath by a stalk. Hyaluronic acid makes up all
or part of the mucoid fluid.6
Ganglia are usually encountered on the dorsum of the wrist, in
particular over the scapholunate ligament (Figure 88-1). They may
also be found on the palmar surface of the wrist, the lateral surface
of the wrist, or on the hand itself. Ganglia of the foot and ankle,
while less common, are also seen.7 Ganglia are occasionally
encountered in other areas such as the shoulder, hip, elbow, knee (including
the anterior cruciate ligament), the lumbar spine, temporomandibular
joint, or even the odontoid process of the cervical spine.8–10
Oblique view of the wrist demonstrating a ganglion
cyst overlying the scapholunate joint.
Ganglia present as fixed or slightly movable masses that are
usually solitary. Frequently characterized as smooth and “rubbery,” cysts
may become more noticeable with wrist flexion. They vary in size
from barely palpable to 3 cm in diameter (smaller than 1.5 cm being
the norm). Tenderness is sometimes but not invariably present. Ganglion
cysts will transilluminate, as they are fluid-filled.
Diagnosing a ganglion is usually not difficult. However, ganglia
of the foot, ...