What is a “Ganglion”?
Ganglions are fluid filled cysts arising from a tendon or a joint, they are very common around the hand and wrist.
They can be a sign of inflammation in the underlying joint, ligament or tendon.
There are 4 main types of ganglion:
- Dorsal wrist ganglion
- Volar wrist ganglion
- Pulley or “seed” ganglion
- Mucous cyst
Dorsal wrist ganglion:
Ganglia on the back of the wrist occur most often in young ladies, and may be uncomfortable when bending the wrist backwards, particularly when taking weight, for example, when doing press-ups.
They may also occur in older patients, and can be associated with underlying wrist osteoarthritis.
Volar wrist ganglion:
Ganglia on the front of the wrist occur more often in middle-aged patients and are usually related to mild degeneration in the underlying joints of the wrist or thumb base. They can often be associated with pain.
Pulley or “seed” ganglion:
Ganglia from tendons often occur at the base of fingers, in the palm. They can be uncomfortable when gripping a steering wheel, or holding the handle bars on a bike etc. They may be associated with some stiffness in the finger and occasionally with triggering (see separate information sheet).
Ganglia occurring around the distal finger joints (just below the nails) are related to degeneration in the joint. They may cause pitting in the finger nail, due to pressure on the nail bed. They can sometimes discharge, having been knocked, typically with a clear jelly like substance.
Most ganglia are painless particularly the wrist ganglia, although there may be discomfort from the underlying problem e.g. joint or tendon. The seed ganglion may be tender with gripping and the mucous cyst may be painful if it becomes tense or knocked.
Most ganglia give little in the way of day to day problems but they can be unsightly, especially those on the back of the wrist/hand i.e. the dorsal wrist ganglion and the mucous cyst.
Making the diagnosis
Diagnosis can be made on clinical examination and rarely requires any scans or further investigations.
What are the non-operative treatments?
Ganglions can sometimes resolve over time, but this can take many years, depending on the underlying cause.
If there is significant discomfort, or the ganglion is affecting functional activity, then the ganglion can be drained by aspiration with a needle, or excised with surgery.
Aspiration can be performed in the clinic under local anaesthetic. This has a success rate of approximately 50%, and can be repeated if necessary. If the ganglion is on the volar side of the wrist, then the aspiration is performed under ultrasound guidance, to ensure minimal risk of damage to surrounding nerves and vessels.
Seed ganglia and mucous cysts are usually too small to aspirate, and require excision in theatre under a local anaesthetic.
What does the operation involve?
If aspiration is unsuccessful, and the ganglion and discomfort return, then surgery can be considered.
Dorsal / Volar wrist ganglion:
The operation is typically performed under local anaesthetic or a general anaesthetic depending on the size of the ganglion, and patient choice
A tourniquet, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 10-20 mins or so that it is inflated.
Prior to surgery, the arm and hand are painted with an antiseptic solution. This is used to help minimise the risk of infection. An incision is made over the ganglion, and the ganglion is removed. The skin is then stitched up with absorbable sutures. Sometimes the lining of the ganglion will be sent to the laboratory for analysis to confirm the diagnosis. As the diagnosis is usually so clear it is not typically necessary. A supportive dressing is applied and the patient’s arm elevated. The total time in hospital is usually 1-2 hours.
Recurrence rate of ganglions following surgery is approximately 20-30%.
Pulley or “seed” ganglion:
Seed ganglions can be excised under local anaesthetic, by a small incision made at the base of the affected finger. Recurrence rate is very low.
Mucous cysts are less likely to resolve spontaneously, and are usually excised. The operation is to squally performed under a local anaesthetic, using a small tourniquet at the base of the affected finger.
Depending on the location of the cyst and the size, there are various operative techniques that can be used to ensure the optimum outcome. Mr Murray can explain these options fully at the time of consultation.
What happens in the next few weeks?
The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. The local anaesthetic lasts For approximately 6-12 hours. Patients should start taking painkillers before Any post operative pain sets in i.e. on return home and for at least 24 hours afterwards.
The bandage can be removed after 2-3 days, leaving a sticky dressing beneath. Mr Murray’s hand therapist, or your local district nurse can review the wound and redress if necessary at 7-10 days post operation.
Mr Murray typically uses dissolvable stitches, so they do not require removal
The hand can be used for normal activity after the first few days. Most patients can drive after a 5-7 days. Most patients return to work in 1-5 days, but this varies with occupation; heavy manual work usually takes approx 2-4 weeks.
Are there any risks?
- Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
- The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
- Stiffness may occur, in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness.
- Numbness around the scar can occur but this is rare, and rarely causes any functional problems.
- Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which can often take a long time to resolve fully.
- The ganglion may come back; the rate of recurrence varies depending on the site.
- Dorsal wrist ganglia recur in approximately 25% of cases.
- Volar wrist ganglia can recur in approximately 30-35% of cases.
- Pulley “seed” ganglia rarely recur following surgery.
- Mucous cysts rarely recur
- If the underlying joint is degenerate, this will not be affected by removing the ganglion. Aching may continue and get worse as time goes on.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery, but this is very rare with surgery for ganglions.