Ganglion cysts commonly affect the hands. They appear as firm lumps in the hand and wrist. They are cysts which grow out from joints or tendons and they fill with viscous colourless gel. They are not dangerous but they can be a nuisance, unsightly or cause pain. They can settle spontaneously and treatments are available if they are persistent.
Understanding The Condition – What is a Ganglion Cyst?
A ganglion is a gel-filled cyst that arises from a joint capsule or tendon sheath. It is the most common soft tissue lump found in the hand and wrist, accounting for approximately 70% of all hand and wrist swellings. Despite their sometimes alarming appearance, ganglions are entirely non-dangerous.
They may fluctuate in size, perhaps related to activity levels and sometimes can sometimes disappear altogether. They may stretch adjacent ligaments or small nerves causing pain. Ganglions arising deep in the wrist may cause pain without showing a visible lump and are discovered by scans.
The exact cause is not fully understood, but they are thought to arise from a degenerative change or minor injury to the joint capsule or tendon sheath, causing a localised outpouching that fills with fluid. They can occur in adults of all ages.
Common Symptoms – What to Expect
- A smooth, rounded lump on the back or front of the wrist, or over a finger joint or tendon
- The lump feels firm or rubbery
- It may fluctuate in size.
- Aching or discomfort, particularly with repetitive wrist movements or after activity
- Transillumination – the lump glows when a light is shone through it , confirming it is fluid
- Finger tip ganglions (aka Mucous cysts) may cause a ridge or groove in the fingernail
- Finger tip ganglions may be fragile and burst open at times
Types of Ganglion – Where Do Ganglions Occur?
Ganglions arise in several characteristic sites in the hand and wrist. Knowing the type helps guide investigation and treatment planning.
Dorsal Wrist Ganglion
This arises from the back of the wrist; it is the commonest location. Usually these are 1-2 cm in size. They can cause pain in the wrist and they are a nuisance especially for fitness exercises like press-ups and planks.
Finger-tip (DIP Joint) Ganglion or Mucous cyst.
These are also very common. Typically these arise due to arthritis in the underlying joint and there may be arthritic bony lumps immediately adjacent. The ganglion sits just between the nail fold and the joint.
Volar Wrist Ganglion
These are less common. The ganglion arises on the palm side of the wrist adjacent to the base of the thumb.
Flexor Sheath Ganglion
Also called a “seed ganglion”, this is a small firm lump which is found in the palm immediately at the base of a finger. It is like a seed or a small pea stuck under the surface and patients typically find this uncomfortable when they try to grasp objects.
Other sites
Ganglions can arise from other parts of the hand, wrist and fingers.
Managing Ganglion Cyst?
There is no absolute need to treat ganglions as they are not dangerous but often they can be uncomfortable or a source of inconvenience or concern.
Studies suggest that at least 40% of ganglions may disappear without treatment over the course of a year or so; and they may return after treatment in 10-20% of cases.
Therefore it is probably best to give ganglions a good chance to settle on their own unless they are particularly troublesome or if there is any doubt about diagnosis.
Investigations
It is not usually necessary to investigate ganglions and they can be diagnosed based on clinical features.
Ultrasound may be helpful of diagnosis is unclear. Xr-ays may also be helpful in order to understand whether there is any arthritis in the adjacent joints.
Aspiration – Needle drainage of the cyst – Non-surgical
Aspiration involves emptying the ganglion cyst using a needle and syringe, sometimes with ultrasound guidance. Steroid is often introduced to the cyst once it has been emptied.
The procedure takes only a few minutes and requires no incision or stitches.
Aspiration is straightforward and can provide immediate relief of symptoms. However, because the stalk connecting the cyst to the joint or tendon sheath is not removed, the ganglion fluid re-accumulates in many cases (50-75%).
Aspiration is a reasonable first-line option for patients who wish to avoid surgery, or as a temporary measure. It is particularly useful for tense, painful cysts where immediate relief is desirable. It is generally not recommended for volar wrist ganglions, where the proximity of the radial artery makes blind aspiration less safe.
Surgical Excision
This is the most reliable way of eradicating ganglions because the ganglion, its capsule and the stalk connecting it to the underlying joint or tendon sheath are completely removed through a carefully planned incision. Removing the stalk at its origin is the key step in preventing recurrence.
For dorsal wrist ganglions, a transverse incision is made over the cyst on the back of the wrist. The ganglion is carefully dissected free and the stalk traced back to its origin and cauterised.
For fingertip ganglions, excision of the cyst is combined with removal of the underlying bony lumps (osteophytes) in order to minimise recurrence.
The type of anaesthetic and the recovery time depends on the location and size of the ganglion but typically gentle activity will be allowed straight away after surgery.
Frequently Asked Questions
Is a ganglion cyst dangerous or could it be cancer?
Ganglion cysts are entirely benign — they are non-cancerous and pose no risk of becoming malignant. However, any new or changing lump in the hand or wrist should be assessed by a doctor to confirm the diagnosis, as other conditions — including lipomas, inclusion cysts and, rarely, soft tissue tumours — can occur in similar locations. Transillumination and, where needed, an ultrasound scan will confirm the diagnosis reliably in the vast majority of cases.
Can a ganglion go away by itself?
Yes — at least 40% of ganglions resolve spontaneously without any treatment over a year or so. For this reason, if a ganglion is not causing significant symptoms, observation is recommended in most cases and treatment for ganglions which persist for many months.
Why might a ganglion change in size?
The size of a ganglion cyst often fluctuates because it is connected to the underlying joint or tendon sheath by a stalk, through which fluid can move in and out under pressure. Activity, repetitive use of the wrist and changes in intra-articular pressure can all affect the size of the cyst. It is common for patients to notice their ganglion feels larger after activity and smaller after rest.
What is the chance of the ganglion coming back after surgery?
After careful surgical excision particularly where the stalk is traced to its origin and removed with a cuff of joint capsule recurrence rates for dorsal wrist ganglions may be 10-20%. For mucous cysts the recurrence rate tends to be less than 10%.
Will surgery leave a visible scar?
All surgical procedures leave a scar. For dorsal wrist ganglions, the transverse incision is placed in a natural skin crease on the back of the wrist and tends to heal inconspicuously. The scar will initially be pink and slightly raised, but should settle to a fine, pale line over 6–12 months.
Is surgery performed under general anaesthetic?
Finger tip ganglions and seed ganglions are removed under local anaesthetic control. Wrist ganglions may be removed under local anaesthetic or general anaesthetic surgery, depending a bit upon size and complexity.
What happens if I leave my ganglion untreated?
In most cases, leaving a painless, non-enlarging ganglion untreated is entirely safe. The cyst may persist, grow, shrink or resolve spontaneously. Ganglions do not become cancerous and do not cause permanent damage to surrounding structures. Treatment is recommended primarily when the ganglion is painful, interfering with function or causing concern or inconvenience.
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