Ganglion Cyst of the Wrist and Hand
Ganglion Cyst | Denver, Colorado
Ganglion cysts are a common condition of the hand and wrist I see in my hand surgery practice in the Denver metropolitan area.
Ganglions are small fluid-filled cysts that often occur in the fingers, hand, or wrist. They originate from a joint, and a portion of the joint fluid becomes trapped outside the joint in the surrounding tissues. They are not dangerous (ie, they are not a cancer) and do not spread through the body.
The most common place to find them is on the back of the wrist, where they can become quite large.
Ganglion Cyst Diagnosis & Treatment
Figure 1 - Depicted here is a fluid-filled ganglion cyst arising from the joint space between two bones. These can occur in the wrist, hand, or finger and can also be associated with tendon sheaths.
Diagnosing a ganglion cyst is straightforward if it is large. These are fluid-filled cysts that are easy to palpate and have defining characteristics such as their tendency to rapidly grow and shrink. Additional imaging is typically only needed if the cyst is adjacent to an important blood vessel or nerve, or if the cyst is small and difficult to identify on physical examination.
For better or worse, treatment is quite straightforward: do nothing or have it excised surgically. Because these are not dangerous, it is perfectly acceptable to live with them if that is consistent with your goals. There is a middle ground that involves draining the cyst with a needle, but the cyst typically recurs 75-80% of the time. Most of my patients are unwilling to have a needle drainage with such a high failure rate.
Ganglion Cyst Excision Surgery
Many patients ultimately choose to have their cysts removed, whether for cosmetic or functional reasons.
Surgery to remove a ganglion cyst involves a surgical incision slightly larger than the cyst. This allows me to protect any nerves, blood vessels, or tendons that may be near the cyst. I will then go all the way down to the joint level where the cyst originates and excise the stalk through which the fluid is traveling from the joint. The cyst is removed in its entirety.
Typical recovery from this surgery occurs over 4-6 weeks. I use absorbable sutures that do not need to be removed. You will wear a post-operative splint for the first week, followed by progressive mobilization and strengthening as your soft tissues heal.
Additional Information
If you’d like more information on ganglion cysts, please continue reading through the frequently asked questions below. You can also access my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to ganglion cysts and their treatment.
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The Basics
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A ganglion cyst is a fluid-filled cyst attached to a joint through a one-way valve. This allows joint fluid to escape the joint and enlarge the cyst. They can occur at any joint, though I most commonly see them on the back of the wrist and in the fingers.
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The highly unsatisfying answer here is that we don’t really know what causes ganglion cysts. Many theories have been postulated over the years, without any reliable conclusions.
About 10% of cysts are associated with a memorable trauma to the region, indicating that injury could play a role in the development of ganglion cysts.
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Ganglion cysts have been reported in children and the elderly. They are most common beginning in the teenage years through the fourth decade of life. This finding supports the theory that these cysts are not necessarily degenerative in nature.
Ganglion Cyst Symptoms & Diagnosis
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Ganglion cysts often act in a characteristic fashion. They may appear suddenly and can rapidly grow, shrink, and grow again. When they are large, they are soft and slightly mobile. While the cysts are not inherently painful, if they are closely adjacent to nerves or become pinched between bones with movement, they can elicit pain. Many patients do not like the cosmetic appearance of the cysts, particularly when large.
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A large ganglion cyst is easily diagnosed by your physician. I say that with one caveat: the only way to truly diagnose a cyst is to excise it, look at it under the microscope, and have a pathologist confirm the findings.
But there are several clues in the workup of a ganglion cyst. We discussed the typical symptoms and feel of the cyst above. An additional examination technique is that of ‘transillumination.’ To do this, a dark room is needed. A flashlight is then used to shine directly on the cyst. If the entire cyst lights up, this is considered a positive test and makes the diagnosis of a ganglion more likely.
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Large ganglion cysts do not require additional imaging.
In my practice, I obtain additional imaging in the form of MRI or ultrasound if the cyst is closely adjacent to an important nerve or vessel. This assists with preoperative planning for safe surgical excision.
Additionally, if a cyst is very small or the diagnosis is uncertain, imaging can cement the diagnosis. This allows me to effectively counsel the patient so we can make a shared decision about treatment.
Ganglion Cyst Treatment
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If you read much about ganglion cysts, you’re sure to come across ‘Bible smashing.’ In medieval times, doctors would take a heavy object (the heaviest around at the time was often the Bible) and smash the cysts. This would cause them to rupture.
We don’t typically advocate for this anymore. Nearly all cysts ruptured in this way will come back. Not to mention the associated pain with this method.
The mainstay of nonoperative treatment is acceptance and monitoring. A ganglion cyst is not dangerous. It is acceptable to do nothing and live with the cyst. However, because a diagnosis can only be confirmed after excision, it is important to monitor the cyst for unusual behavior that could indicate the presumed cyst is actually a different type of mass or even a tumor.
When cysts arise and patients come to see me quickly, I often recommend several months of watchful waiting. Many cysts will spontaneously disappear on their own with time.
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Unfortunately, no protocols of therapy, bracing, or other nonoperative treatments have reliably shown any impact on ganglion cysts.
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A treatment technique known as aspiration-injection is an option for some ganglion cysts. I typically will not offer this if the cyst is near a nerve or artery, so as to prevent collateral damage.
In this technique, a needle is pierced through the cyst and the fluid is drained. A steroid is then injected into the cyst to facilitate resolution. Unfortunately, this technique has about a 20% success rate. Because of the high recurrence rate, most patients choose to skip this treatment option.
Ganglion Cyst Excision Surgery
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The most reliable treatment for a ganglion cyst is surgical excision. In this procedure, an incision just larger than the cyst is made. This allows me to protect the surrounding tendons, nerves, and blood vessels. Once these are protected, I work all the way down to the joint and cut off the stalk through which the cyst has appeared. The cyst is then completely removed.
Once the cyst is removed I then close your skin with all absorbable sutures and place your wrist in a postoperative splint for rest.
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Ganglion cyst excision surgery is a day surgery typically performed in an outpatient surgery center. In most cases, a light anesthetic is required.
The exception is for ganglion cysts of the fingers. In this case, the procedure can be done simply with numbing medicine injected into their finger (like the dentist) and remain wide awake for the 20-minute procedure.
For all other ganglions of the hand and wrist, an anesthesiologist will administer a ‘twilight’ sedation (similar to a wisdom tooth extraction or colonoscopy procedure). With this anesthesia, you will feel asleep but will be breathing on your own without the need for a breathing tube.
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Following ganglion cyst excision surgery, you will be placed into a post-operative splint. All my patients have a visit with a Certified Hand Therapist within a week or so of surgery. At this visit, the splint is removed and some gentle exercises are begun.
I will then meet with you approximately 3 weeks after surgery to evaluate your healing process. The sutures I use are absorbable, so they will not need to be removed in the office.
The next stage of healing is variable. Some patients have regained their wrist range of motion rapidly and are ready to return to most activities at 3 weeks. Others take a little more time to heal, and we support them with continued therapy and intermittent bracing. The majority of patients feel 80-90% recovered by 6 weeks.
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Restrictions are fairly simple after ganglion cyst excision surgery. The surgical dressing and splint must stay on and dry until your post-op visit with our hand therapists. Finger movement and light to moderate use of the hand is allowed and encouraged, beginning the day of surgery.
The goal of your postoperative healing window is to allow the joint capsule to heal and then regain your wrist range of motion.
If you remember that ‘pain is your guide’ throughout your healing, you will be appropriately adhering to your restrictions. If it hurts, don’t do it! Some patients continue to use a splint intermittently through the recovery process to achieve this goal.
Most patients begin strengthening their wrist around 3 weeks and the majority resume full activity by 6 weeks.
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding tendons/nerves/vessels, anesthesia risks, or failure of the procedure.
The most common risk of ganglion cyst excision surgery is wrist stiffness. Because some of the surgical work is done at the level of the joint, the joint capsule is involved in the healing process after the cyst is removed. As it heals, the tissues contract and naturally cause some stiffness. Most patients work through this over the first 4-6 weeks after surgery. Occasionally, it can take even longer.
The other important risk to understand with this surgery is recurrence of the cyst. Please see below for additional information about this risk.
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An important risk to understand following ganglion cyst excision is recurrence.
Ganglion cysts can recur after surgery about 5-10% of the time. While this rate is far lower than that following cyst drainage, it is an unfortunate reality to consider prior to electing for surgery.
If your cyst recurs, you could require a second surgery to remove the cyst again.
