GANGLION

OF THE
WIRST AND
HAND
WITANTRA DHAMAR HUTAMI

SUPERVISOR

DR. DR. WAHYU WIDODO, SPOT (K)

 EPIDEMIOLOGY ANATOMY AND PATHOPHYSIOLOGY
PATHOLOGY

OUTLINES

CLINICAL MANAGEMENT CONCLUSION

FEATURES
 EPIDEMIOLOGY

Represents 60% of hand and wrist tumor

A common reason for Orthopaedic consultation

Women: men = 3: 1

Can affect all age groups, but most common occur in young adult

Usually located adjacent to joint and tendons

Common sites
• Dorsal wrist (dorsal wrist ganglion)
• Volar-radial wrist (volar carpal ganglion)
• Dorsum of the DIP joint (mucous cyst)
• Proximal digital flexion crease (volar retinacular ganglion cyst)
Etiology is unknown
 ANATOMIC & Often multilobulated
PATHOLOGIC
CONSIDERATION OF
THE GANGLION Wall
CYST
• Outer wall: several layer of
collagen fibers  Relatively
acellular, with few fibroblasts and
mesenchymal cells among collagen
fibers (lack of epithelial lining)
• Inside: clear, viscous mucin
containing glucosamine, albumin,
globulin, and hyaluronic acid
 PATHOPHYSIOLOGY

Unclear, there are many theories:

• Ganglions are formed by herniation of the synovial lining
in which a one-way valve mechanism is created
• Benign tumor of synovial origin
• There is a rent in the joint capsule or tendon sheath 
allows leakage of synovial fluid  irritates surrounding
tissue  local tissue reacts by forming a pseudocapsule and
subsequent ganglion, reaction between this tissue and the
synovial fluid produces the ganglion fluid
• Mucoid degeneration of connective tissue  breakdown
products of collagen collecting in pools  coalesce to form
large cysts
• Recurrent stress and microtrauma at the synovial capsular
interface may stimulate mucin production by mesenchymal
cells or fibroblasts
 Symptoms
CLINICAL • Aching in the wrist that may also radiate up the
patient’s arm
FEATURES • Pain with activity or palpation of the mass
• Decreased range of motion and decrease grip strength
• Volar ganglia may also cause paresthesias from
compression of the ulnar or median nerves or their
branches
• The clinical
presentation is usually
adequate for diagnosis
Signs
• X-ray evaluation is • 1–2 cm cystic structures, feeling much like a firm
rarely indicated  rubber ball that is well tethered in place by its
attachment to the underlying joint capsule or tendon
except in the case of
sheath
‘‘occult wrist • There is no associated warmth or erythema
ganglion’’ where MRI • Readily transluminate
is needed to make a
diagnosis
 1–2 cm cystic structures,
feeling much like a firm rubber
CLINICAL FEATURES ball
 Reassurance
• Many may not opt for any treatment if they are
reassured of the benign nature of the disease
• Even for painful ganglions, they cause less pain
compared to other common orthopaedic problems,
like carpal tunnel syndrome and osteoarthritis
• The spontaneous resolution rate of untreated
ganglion ranged 40–58%
MANAGEMEN
T
 Aspiration
• Simplest way of treatment
• High recurrence rate (> 50% of cases)

Steroid injection

MANAGEMEN • Research showed that injection of steroid has no benefits

• The potential complications are fat atrophy and skin
T depigmentation
CONSERVATIV Sclerotherapy
E TREATMENT • Sclerosant was injected into ganglion sac to damage the
intimal lining and cause fibrosis to reduce the recurrence
rate
• The failure rate is as high as 94%
• Since there is communication between ganglion and
synovial joint, sclerosant might pass from ganglion to the
joint and tendon and cause damage to them
MANAGEMENT
CONSERVATIVE TREATMENT

Immobilizatio
• Has the potential adverse effects of inconvenience,
n following economic repercussions, and stiffness
aspiration

• Technique: wo sutures were passed through the ganglion

Threat at right angles to each other, and each was tied in a loop,
and the contents of ganglion were expelled by massage
technique at interval
• Complete resolution only 50%
MANAGEMENT
SURGERY

 Surgical excision remains the gold standard for treatment of ganglion cysts
 The surgical techniques that include excision of the entire ganglion complex,
including cyst, pedicle, and a cuff of the adjacent joint capsule, recurrence rates
have improved significantly
 The recurrence rates for dorsal wrist ganglia as low as 1–5% and as low as 7%
for volar wrist ganglia
CONCLUSION

 Taking into account that nearly half of the ganglion

would resolve spontaneously, with such a high
failure rate, nonsurgical treatment of ganglion was
generally ineffective.
 Nonsurgical treatment can be considered to be an
alternative way for symptomatic relief if the patients
do not want surgery. Another advantage of
conservative treatment is that aspiration of ganglion
contents confirms a benign diagnosis and allays the
patients’ fear and desire for further treatment.
FURTHER READING

 Gude W. Ganglion cysts of the wrist: pathophysiology, clinical picture, and

management. Ganglion cysts of the wrist: pathophysiology, clinical picture, and
management