GANGLIA OF THE HAND

(NOT INTRA-OSSEOUS)

Christian Dumontier, MD, PhD

Hand Center, Guadeloupe, FWI
www.diuchirurgiemain.org
I have nothing to disclose
GANGLIA ARE THE MOST FREQUENT HAND
TUMOURS

• Of 1714 hand tumors, 1216

were ganglia

• Wrist > DIP > exor

sheath

• Localisation: Everywhere
a joint is present or a
synovial lining
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 WRIST GANGLIA
• Annual incidence 25/ 100,00 Male vs
43/ 100,000 Females

• Mostly young people (20-40 years),

extremes 3 to 89 years.

• Both hands

• Spontaneous (15% after a trauma or

hypersollicitation) - 2,5 times more
frequent in military vs civilian

• 2/3 dorsal, 1/3 volar and radial,…the

others everywhere around the wrist
WRIST GANGLIA PATHOPHYSIOLOGY

• Intra-ligamentous degeneration

• Under stress, broblasts give off micro-

vacuoles, mucin lled, that merge to
form a ganglion

• Contains gelatinous material with

mainly hyaluronic acid. Different and
thicker than intra-articular synovial uid

• No synovial lining

• Surgical treatment includes capsular

excision
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 DORSAL WRIST GANGLIA

• Arise from the

scapholunate ligament (stress
zone due to differential mobility between
scaphoid and lunate; more frequent in lax
person including females)

• Extend to capsular insertion

• Project dorsally above or

under the dorsal inter
carpal ligament
scaphoid

radius

lunate

• Ulnar sided ganglion

• Sonography has shown the stalk

coming from the SL ligament

• The ganglion was injected with

dye blue. With pressure the
origin of the SL ligament is visible
 VOLAR WRIST GANGLIA
• Arise from the SL ligament, and exit
between RSL and RL ligament

• Some ganglia arise from the STT joint

(1/3 to 1/2 - Rocchi, Angelides) or
CMC1
WRIST GANGLIA CLINICAL PRESENTATION
• Unknown to patients (50%) Bump « problem » in 1/3
of surgically treated patients
• Complains of nothing

• A Bump : unesthetic, psychologically

disturbing, frightening

• Localized pain (wrist extension,

push-ups)

• More diffuse pain (see David Ring

et al. for non-explained pain)
Annoying pain 2/3 of
Westbrook AP et al. Ganglia: the patient’s perception. J Hand Surg.
2000;25(6):566–7. surgically treated patients
Brams JT et al. Factors In uencing Why Children and Their Families Choose
Surgery for Ganglion Cysts J Hand Surg Am. 2021(21)11;S0363-5023
Lowden CM. The prevalence of wrist ganglia in an asymptomatic population. MRI
evaluation. JHS Br 2005; 30B(3)302-306.
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WRIST GANGLIA : NATURAL HISTORY
Volar Dorsal
i l l
l f w
Carp & Stout 1928 h a d 7/12 disappeared
as t a r e
t le p e usly
Mc Evedy 1954 A isap eo 10/21 disappeared within
d tan 10 years
o n
Zachariae 1973
sp 39% disappeared

Rosson & Walker 1989 65% disappeared

45% disappeared within 6 33% disappeared within 6
Burke 2003 (Trent audit)
years years
72% disappeared within 5 42% disappeared within 6
Dias 2003, 2007
years years
63% disappeared within 51% disappeared within
Burke 2003 (Derby audit)
10 years 10 years
 TREATMENT(S)
• Massage / compression (coin,
bullet, edge of a Bible,…)
rubbing the tumor well each morning with fasting saliva and
binding a plate of lead upon it for several weeks successively ...
Others ... prefer a bullet that has killed some wild creature,
especially a stag. (1743)

5 years
• Ponction +/- injection recurrence Volar Dorsal
rate
• Irritating suture through the
ganglion Abstention 48% 55%

Ponction 47% 50%

• Stalk ligation
Surgery 42% 40%
• Open excision

• A°scopic excision Good results published do not differ from

spontaneous evolution (Dias 2007)
Suen M et al. Treatment of Ganglion Cysts. ISRN Orthopedics 2013, Article ID 940615.
WRIST GANGLIA: COMPLICATIONS

• Complication rate 0–56% and is

superior to non-op or reassurance.

• Wound infection, neuroma formation,

hypertrophic scar, median nerve, and
radial artery damage,

• Residual pain, limited range of motion,

and weaken grip (14-25% of patients).

• 8% of patients get worse (Dias),

21% were no better or worse
after surgery (Clay)

Faithful DK, Seeto BD. The simple wrist ganglion - more than a minor surgical procedure , Hand Surg 2000;5(2):39-43
Jacobs LGH, Govaers KJM. The volar wrist ganglion : Just a simple cyst ? J Hand Surg 1990 ; 15-B : 342-346.
 WRIST GANGLIA: A°SCOPIC TREATMENT

• 1987 (Osterman): incidental

cure of a patient’s ganglion
during an arthroscopy

• Many reports claiming less

scarring, less loss of motion,
earlier RTW,…

• Same principles apply:

excision of the pathological
zone
 COMPARISON BETWEEN THE TWO TECHNIQUES ?

• Kang (2008): 72 dorsal ganglia,

1 year FU, no difference, Recurrence Complications
10-15% still complaining,
recurrence 10,7% (A°) vs
8,7% (open) A° 6 % 4 %

• Rocchi (2008) volar ganglia: 30 Open 21 % 14 %

open vs 30 A° : No
Aspiration 59 % 3 %
difference, more
complication (open) Head et al. Wrist Ganglion Treatment: Systematic Review
and Meta-Analysis. J Hand Surg Am. 2015;40(3):546-553.

Rocchi L, et al. Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. A prospective randomised study. Scand J
Plast Reconstr Surg Hand Surg 2008;42(5):253–9.
Kang L, et al.. Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg
Am 2008;33(4): 471–5.
Fernandes CH et al. A systematic review of complications and recurrence rate of arthroscopic resection of volar wrist ganglion. hand Surg 2014 ;19(3):475-80.
 MUCOUS CYSTS
• 2nd in frequency

• 1st description (Hyde-1882)

• Mostly females (70%), 5th to 7th

decades (12 to > 100 years)

• 90% at the DIP (10% on toes)

• More frequent at the index and

middle nger

• Frequent association with DIP

arthritis (72% - Kleinert; 74% -Chaise;
84% - Roulet; 93%)
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 MUCOUS CYST:
PATHOPHYSIOLOGY
• Unclear

• Mucoid degeneration of the dermis (Gross 1937,

Woodburne 1947) is abandoned

• Theory of the synovial hernia (Kleinert 1972,

Newmeyer 1975, Eaton 1973): Frequent
communication with the joint, sometimes a small
conduit is visible,…But no lining cells are present in
the cyst, …

• Theory of the broblastic metaplasia is

preferred (Ledderhose 1893, Ritschel 1895, Carp
& Stout 1928, Johnson 1965, Angélides 1976).
Secondary to various trauma (osteophytes, articular
hyperpressure), capsular broblasts secrete mucines
in the peri-articular tissues
Eaton RG, Dobranski AI, Littler JW. Marginal osteophyte excision in treatment of
mucous cysts. J Bone Joint Surg Am. 1973;55(3):570-4.
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MUCOUS CYST : CLINICAL PRESENTATION

• Soft-tissue tumor (≈ 0,5 cm

diameter)

• Around the DIP, most often between

the joint line and the proximal nail wall

• Independent from the skin but

progressive thinning of it

• Fixed to the underlying structures

Node
Cyst
• Usually slightly lateralized

• May be confused with Heberden’s

nodes
MUCOUS CYST AND NAIL INVOLVEMENT
• Anderson (1947) reported nail
deformity with mucous cysts
• 20-40% of cases
• Pressure of the cyst over the
nail matrix
• The cyst may not be visible, only
the nail dystrophy (especially if
the cyst goes under the matrix)
• MRI may be helpful
 MUCOUS CYST : NATURAL HISTORY AND NON-
OPERATIVE TREATMENTS
• Few report of spontaneous
regression

• Progressive increases in size with

thinning of the skin

• Spontaneous rupture

• Many non-operative treatment

Recurrence rate Complications
with high recurrence rate Repeated needling 28-50% 2-3% infection
Steroid/sclerosant injections 30-70% Skin atrophy
Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the
ngers; a review of 134 cases with minimum 2-year follow-up Cryosurgery 14-44% Signi cant scarring, nail
evaluation. J Hand Surg Am. 2003;28(3):519- 524. dystrophy
Dodge L, Brown RL, Niebauer JJ, McCarroll R. The treatment of Carbon Dioxide Laser 33 % Injury nail matrix
mucous cysts: Long- term follow-up in sixty-two cases. J Hand Infrared coagulation 14-22% Blistering, pain
Surg Am. 1984;9(6):901-904.
Li K, Barankin B. Digital mucous cysts. Journal of Cutaneous Radiotherapy
Medicine and Surgery, 2010;14(5):199–206 Simple excision > 25%
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MUCOUS CYST: SURGICAL TREATMENT

• Simple excision

• Surgical excision + ligature

of its pedicle

• Osteophytes removal

• En bloc excision with the

skin + ap or skin graft
reconstruction

• DIP arthrodesis
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 Recurrence rate

Constant 1969, Dodge

Simple excision 25 %
1984, Crawford 1900
Excision with ligation of
6 % De Berker, 2001
the stalk
Osteophytes removal
without cyst or skin excision 1,5 % Roulet 2015

Osteophytes removal Gingrass 1995 Rizzo

without skin excision 2003
Osteophytes + cyst + Crawford 1990, Chaise
0-8 % 1994, Kleinert 1972, Blanc
skin removal + Flap 2004
Osteophytes + cyst +
3 % Constant 1969
skin removal + Skin graft
MUCOUS CYST: COMPLICATIONS
11 years excellent outcome

• Recurrence (up to 8%)

• Postoperative pain from underlying DIP

joint arthritis (up to ?)

• Soft tissue defect

• Infection (up to 3%)

• Joint stiffness-extension lag (up to 20%)

• Nailbed injury/deformity (up to 40%)

• Damage to the extensor tendon

Fritz GR et al. Complications following mucous cyst excision . J Hand Surg 1997;222B(2):222-225
 DIGITAL SHEATH GANGLIA
• 5-15% of all hand ganglia

• Etiology unknown - Lack of synovial lining

• Mostly female 2,6 : 1

• Mean age ≈ 40 yrs

• Mostly middle nger

• 1/4 have also triggering

• 50% come from A1, 36% from A2 and 12%

in between.
Jebson PJ, Spencer EE. Flexor tendon sheath ganglions: results of surgical excision. Hand 2007;2:94-100
Al-Khawashki H, Hooper G. The distribution of brous exor sheath ganglions. J Hand Surg 1997;22B:226-7.
Abe Y et al. Flexor tendon sheath ganglion. Analysis of 128 cases. Hand Surgery, 2004 ;9(1):1–4
Jang S et al. Ganglion cysts developed from the exor tendon sheath in the ngers: Clinical and sonographic features. J Clin
Ultrasound. 2019;1–5.
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 DIGITAL SHEATH GANGLIA
• Spontaneous disappearance in 13
out of 20 pts

• Cyst aspiration or dispersal ≈ 50%

recurrence. Improved results
under sonography ? May be cost
effective

• Surgical excision: Few recurrences,

high patients satisfaction, some
nerve injuries reported

Bittner JG et al. Management of Flexor Tendon Sheath Ganglions: A Cost Analysis. J Hand Surg 2002;27A:586–590
Forster B, Forster I. Aspiration of exor tendon sheath ganglion guided by ultrasonography. An alternative to blind aspiration or surgery?
Handchir Mikrochir Plast Chir. 2009 Feb;41(1):56-7.
Finsen V et al. Surgery for ganglia of the exor tendon sheath. Ortho Rev 2013; 5: 27-28
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 PIP GANGLIA
• From the joint capsule

• Usually pierce the oblique

bers between the central slip
and lateral band.

• May interfere with joint motion.

• Surgical excision
includes the dorsal
capsule
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 CARPAL BOSS GANGLION
• Associated with carpal boss
in 30% of cases

• May favor extensor tendon

dislocation

• Non-operative
management

• Surgical excision alone +/-

carpal boss removal
 INTRA-TENDINOUS GANGLIA
• 1st report by Lecene (1927)

• Rare, mostly 4th compartment

(EPL, EPB, manus have also
been described)

• Middle-aged patients

• May be associated with

tenosynovitis (with recurrence)

• Surgical excision may fragilise

the tendon
Lecene MP: Trois cas de dégénérescence gelatineuse pseudokystique du tissu conjonctif juxta-articulaire et du tissu tendineux, Bull Mem Soc
Nat Chir 53:2, 1927
Seidman GD, Margles SW. Intratendinous ganglia of the hand. J Hand Surg 1993; 18A:707-710.
 CONCLUSIONS
Th
• Frequent and benign lesions an
k yo
• Most (not including mucous cyst) will
u
spontaneously disappear

• If a surgical treatment is indicated, good results can

usually be obtained, but…

Primum non nocere: Hippocrate: 410 bc de ned the goal of medicine : « to have, facing diseases, two goals:
be useful or at least do not harm » (« ἀσκέειν, περὶ τὰ νουσήματα, δύο, ὠφελέειν, ἢ μὴ βλάπτειν »).
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