GANGLION CYST

Presenter: Aida Batrisyia Binti Abd Rahim

Supervisor: Dr Ashwin
Ganglion Cyst

• Benign, smooth, mucin-filled synovial cysts

• Single/multiloculated
• Leakage of synovial fluid on or near a joint or tendon sheath
• Most common swelling in the wrist (60-70%)
- most common in women
- 20-40 y/o
• No true epithelial lining (not a true cyst!)
• Clinical Diagnosis
• Causes:
- trauma
- mucoid degeneration (OA at DIP)
- synovial herniation
 Types
• Dorsal carpal (70%)
- originate from SL articulation

• Volar carpal (20%)

- originate from radiocarpal or STT joint

• Volar retinacular flexor sheath (10%)

- originate from herniated tendon sheath fluid (A1, A2
Pulley)

• Occult Ganglion cyst

- Small cyst, compression of the deep (muscular)
branch of the ulnar nerve.

• Dorsal DIP joint

- mucous cyst, associated with Heberden's nodes

• Lower extremity
- most commonly about the knee /ankle
Clinical Presentation
SYMPTOMS
• Usually asymptomatic
• Pain/discomfort (trauma)
• Cosmetics issues
• Activity limitations/weakness
• Severe: neurovascular
manifestations
• Median/ulnar nerve
compressions (volar carpal)
• Hand ischaemia (volar carpal)
PHYSICAL EXAMINATION
LOOK
- swelling/mass
- size (initially pea –sized)
- location
FEEL
- firm, well circumscribed
- Fixed to deep tissues, not overlying skin
- Non-tender
MOVE
- Mild pain upon ROM
- Prominent upon flexion (dorsal carpal)
- Does not move with tendons

SPECIAL TESTS
- Transilluminative
- Allen’s test (volar carpal)
TRANSILLUMINATION TEST
• Transmission of light through a
swelling
• Roll of X-ray or paper is held on 1 side
and observed while the light is held
on the other side of the swelling
• Transillumination – POSITIVE in
swellings containing clear fluid and
thin transparent walls
• Transillumination- NEGATIVE if wall is
thick, or turbid fluid is present (blood,
pus, lymph)
• Has to be done in dark room
Differential Diagnosis

• Lipoma
• Carpal tunnel syndrome
• Extensor Tenosynovitis
• Giant cell tumor of the tendon sheath
• Pseudoaneurym (Volar carpal)
• Osteoarthritis of hand
Imaging
ULTRASOUND

X-RAY MRI
Management
CONSERVATIVE SURGICAL
• Observe
• Excision biopsy of cyst
- no neurovascular compromise
• Higher rate of resolution but
recurrence is possible
• volar ganglions have higher
recurrence after resection than dorsal
ganglions (15-20% recurrence)

• Technique:
- requires adequate exposure to
identify origin and allow resection
of stalk and a portion of adjacent
capsule
- at dorsal DIP joint: must resect
underlying osteophyte
Complications

• Due to ganglion cysts: rare

• Due to surgery:
• Infection
• Stiffness
• Instability
• Neurovascular injury
• Injury to scapholunate interosseous ligament
Case
54 y/o, Malay, Lady
Housewife
Left hand dominant
U/L: HPT (on KK follow up)
Left hand examination:
- Swelling on dorsal aspect of wrist,
1. Swelling x7/12 2x2cm
-above wrist joint - Firm, no tender
-painless - Mobile
-Noted increasing in size - ROM wrist full
- No wrist drop
-able to carry out daily activities
- Sensation intact
- CRT<2 secs all fingers
Otherwise,
- Radial, ulna pulses palpable
No trauma
No procedures done
Patient opted for op in view of
cosmetic reason
Done Excision Biopsy of Left Wrist Ganglion Cyst
under LA on 31/7/2022

IOF:
- ganglion cyst over dorsal aspect of wrist , extending
towards wrist joint - removed
- once removed, no pus discharge
- able to extend fingers post removal of ganglion cyst

HPE (31/7/2022): shows ganglion cyst

• Typically, insidious onset with no predisposing
conditions.
• Usually only a cosmetic problem but local pain and
neurovascular compression may occur.
• Conservative management usually suffices if no
neurovascular compromise.
• Surgical excision has a higher rate of resolution but
recurrence is possible.
• No reported malignant transformation.
References

• Orthobullet – Ganglion Cysts

https://www.orthobullets.com/hand/6086/ganglion-cysts
• Apley’s & Solomon’s System of Orthopaedics and Fractures
• Essential Orthopaedics
• BMJ Best Practice
https://bestpractice.bmj.com/topics/en-us/984#:~:text=Ganglion%20cysts%20are%20smooth%2C
%20soft,viscous%2C%20sticky%2C%20mucinous%20fluid.