Ganglion cyst

Last updated
Ganglion cyst
Other namesGanglia, synovial cyst, [1] Gideon's disease, Olamide's cyst, Bible cyst, Bible bump [2]
Ganglion-cyst.jpg
Cyst on dorsum of left hand close to the wrist
Specialty Plastic surgery, orthopedic surgery, hand surgery
Symptoms Small soft bump associated with a joint or tendon sheath [3]
Complications Only with operative treatment
Usual onsetAny age
Diagnostic method Typically based on signs [4]
Differential diagnosis Lipoma, extensor tenosynovitis [4]
Treatment Watchful waiting, splinting the affected joint, needle aspiration, surgery [3]
Prognosis Not serious [3]
Frequency~3 per 10,000 per year (wrist and hand) [5]

A ganglion cyst is a fluid-filled bump associated with a joint or tendon sheath. [3] It most often occurs at the back of the wrist, followed by the front of the wrist. [3] [4]

Contents

The cause is unknown. [3] The underlying mechanism is believed to involve an outpouching of the synovial membrane. [4] Risk factors include gymnastics activity. [3] Diagnosis is typically based on examination with light shining through the lesion being supportive. [4] Medical imaging may be done to rule out other potential causes. [3] [4]

Treatment is not necessary. Options for treatment include needle aspiration or surgery. [3] About half the time, they resolve on their own. [4] About three per 10,000 people newly develop ganglion of the wrist or hand a year. [5]

Presentation

The average size of these cysts is 2 centimetres (0.79 in), but excised cysts of more than 5 centimetres (2.0 in) have been reported. [6] The size of the cyst may vary over time. Between 50 and 70% of all masses on the hand and wrist are ganglion cysts. [7] [8]

Wrist

They commonly are found near the wrist joint, especially at the scapholunate area. [9]

Common wrist ganglions include:

In a 2007 study of patients in Glasgow whose foot lumps were removed surgically, 39 of 101 cases were ganglion cysts. The study replicated earlier findings that no ganglion cysts were found on the sole or heel. The authors wrote, "Although lumps in these areas may be ganglia, the surgeon should probably consider other diagnoses in the first instance." The researchers noted a preponderance of occurrence among females (85%) and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery. [13]

Ganglion cysts are not limited to the hands and feet. They may occur near the knee, commonly near the cruciate ligaments, but they may occur at the origins of the gastrocnemius tendon, and anteriorly on Hoffa's infrapatellar fat pad. [14] At the shoulder, they typically occur at the acromioclavicular joint or along the biceps tendon. [15]

Other

From their common origin at a joint or tendon, ganglion cysts may form in a wide range of locations. Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue. [6] [16] Rare cases of intramuscular ganglion cysts in the gastrocnemius muscle of the calf have been reported. [17] [18] It is possible for a cyst to be considerably displaced from the joint. In one extreme case, a ganglion cyst was observed to propagate extensively via the conduit of the common peroneal nerve sheath to a location in the thigh; in such cases surgery to the proximal joint to remove the articular connection may remove the need for a riskier, more extensive surgery in the neural tissue of the thigh. [19] The cysts may intrude into the spine, which may cause pain and dysesthesia in distant extremities. [20]

Cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, has been proposed recently to occur by an articular mechanism, with a conduit leading from the joint, similar to the development of ganglion cysts, that spreads within the peroneal nerve. [21]

Cysts that were compressing one or more nerves and causing bone erosions have been reported to occur near the shoulder joint. [22]

Causes

The most commonly accepted probable cause of ganglion cysts is the herniation hypothesis, by which they are thought to occur as an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath. This description is based on the observations that the cysts occur close to tendons and joints. The microscopic anatomy of the cyst resembles that of tenosynovial tissue. The fluid is similar in composition to synovial fluid. Dye injected into the joint frequently ends up in the cyst. Dye injected into the cyst rarely enters the joint, however, which has been attributed to the apparent formation of an effective and one-way "check valve", allowing fluid out of the joint, but not back in. [6]

In synovials, post-traumatic degeneration of connective tissue and inflammation have been considered as causes. Other possible mechanisms for the development of ganglion cysts include repeated mechanical stress, facet arthrosis, myxoid degeneration of periarticular fibrous tissues and liquefaction with chronic damage, increased production of hyaluronic acid by fibroblasts, and a proliferation of mesenchymal cells. [20] [23]

Diagnosis

Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining Ganglion Cyst, Hand.jpg
Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining

Ganglion cysts are diagnosed easily, as they are visible and pliable to touch.

Ultrasonography (US) may be used to increase diagnostic confidence in clinically suspected lesions or to view smaller "occult" cysts as a cause of dorsal wrist pain with forceful extension.

Treatment

At least 33% resolve without treatment within six years, and 50% within 10 years. [24]

Surgical excision is the primary discretionary, elective treatment option for ganglion cysts. Alternatively, a hypodermic needle may be used to drain the fluid from the cyst (via aspiration). [25] The recurrence rate is about 50% following aspiration of a ganglion cyst.

Complications

Complications of treatment may include joint stiffness and scar formation. [25] Recurrence of the lesion is more common following excision of a volar ganglion cyst in the wrist. Incomplete excision that fails to include the stalk or pedicle also may lead to recurrence, as will failing to execute a layered closure of the incision. [26]

Prognosis

Recurrence rate is higher in aspirated cysts than in excised ones. [27] Ganglion cysts have been found to recur following surgery in 12% [28] to 41% [29] of patients.

A six-year outcome study of the treatment of ganglion cysts on the dorsal wrist compared excision, aspiration, and no treatment. Neither excision nor aspiration provided long-term benefit better than no treatment. Of the untreated ganglion cysts, 58% resolved spontaneously; the postsurgery recurrence rate in this study was 39%. [30] A similar study in 2003 of ganglion cysts occurring on the palmar surface of the wrist states: "At 2- and 5-year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated, or left alone." [31]

Etymology

Being a misnomer that has persisted into modern times, [32] the ganglion cyst is unrelated to the neural "ganglion" or "ganglion cell"; its etymology traces back to the ancient Greek γάγγλιον, a "knot" or "swelling beneath the skin", [33] which extends to the neural masses by analogy. Generally, Hippocrates is credited with the description of these cysts. [6] [34]

Bible cyst

The term "Bible cyst" (or "Bible bump") is derived from an urban legend or historical effort to hit the cyst with a Bible. [35] [36] Trying to treat the lesion by hitting it with a book, though, is discouraged. [4]

A historical method of treatment for a ganglion cyst was to strike the lump with a large and heavy book, causing the cyst to rupture and drain into the surrounding tissues. Historically, a Bible was the largest or only book in any given household, and was employed for this treatment. This led to the nickname of "Bible bumps" or "Gideon's disease" for these cysts. [2] [37] This treatment risks injuring the person and thus is not recommended. [38]

See also

Related Research Articles

<span class="mw-page-title-main">Wrist</span> Part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

<span class="mw-page-title-main">Lumbricals of the hand</span> Muscles in the central compartment of the hand

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<span class="mw-page-title-main">Pilonidal disease</span> Skin infection between the buttocks

Pilonidal disease is a type of skin infection which typically occurs as a cyst between the cheeks of the buttocks and often at the upper end. Symptoms may include pain, swelling, and redness. There may also be drainage of fluid, but rarely a fever.

<span class="mw-page-title-main">Pisiform bone</span> Bone in the wrist

The pisiform bone, also spelled pisiforme, is a small knobbly, sesamoid bone that is found in the wrist. It forms the ulnar border of the carpal tunnel.

<span class="mw-page-title-main">Baker's cyst</span> Medical condition

A Baker's cyst, also known as a popliteal cyst, is a type of fluid collection behind the knee. Often there are no symptoms. If symptoms do occur these may include swelling and pain behind the knee, or knee stiffness. If the cyst breaks open, pain may significantly increase with swelling of the calf. Rarely complications such as deep vein thrombosis, peripheral neuropathy, ischemia, or compartment syndrome may occur.

<span class="mw-page-title-main">Dupuytren's contracture</span> Disease with gradual bending of the fingers due to scar tissue build-up within the palms

Dupuytren's contracture is a condition in which one or more fingers become permanently bent in a flexed position. It is named after Guillaume Dupuytren, who first described the underlying mechanism of action, followed by the first successful operation in 1831 and publication of the results in The Lancet in 1834. It usually begins as small, hard nodules just under the skin of the palm, then worsens over time until the fingers can no longer be fully straightened. While typically not painful, some aching or itching may be present. The ring finger followed by the little and middle fingers are most commonly affected. It can affect one or both hands. The condition can interfere with activities such as preparing food, writing, putting the hand in a tight pocket, putting on gloves, or shaking hands.

<span class="mw-page-title-main">Thyroglossal cyst</span> Medical condition

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<span class="mw-page-title-main">Smith's fracture</span> Medical condition

A Smith's fracture, is a fracture of the distal radius.

<span class="mw-page-title-main">Plantar fibromatosis</span> Medical condition

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<span class="mw-page-title-main">Flexor retinaculum of the hand</span> Thickened fascia over the carpal tunnel

The flexor retinaculum is a fibrous band on the palmar side of the hand near the wrist. It arches over the carpal bones of the hands, covering them and forming the carpal tunnel.

<span class="mw-page-title-main">Deep transverse metacarpal ligament</span> Ligament that connects the palmar surfaces of the heads of the second to fifth metacarpal bones

The deep transverse metacarpal ligament connects the palmar surfaces of metacarpophalangeal joints of all the fingers of the hand except the thumb.

<span class="mw-page-title-main">Extensor retinaculum of the hand</span> A thickened fascia holding the tendons of the hand extensor muscles in place

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<span class="mw-page-title-main">Triangular fibrocartilage</span> Anatomical feature in the wrist

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<span class="mw-page-title-main">Calcifying odontogenic cyst</span> Medical condition

Calcifying odontogenic cyst (COC) is a rare developmental lesion that comes from odontogenic epithelium. It is also known as a calcifying cystic odontogenic tumor, which is a proliferation of odontogenic epithelium and scattered nest of ghost cells and calcifications that may form the lining of a cyst, or present as a solid mass.

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The hand is a very complex organ with multiple joints, different types of ligament, tendons and nerves. Hand disease injuries are common in society and can result from excessive use, degenerative disorders or trauma.

<span class="mw-page-title-main">Carpal tunnel surgery</span>

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a nerve decompression in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

<span class="mw-page-title-main">Trapeziometacarpal osteoarthritis</span> Medical condition

Trapeziometacarpal osteoarthritis (TMC OA) is, also known as osteoarthritis at the base of the thumb, thumb carpometacarpal osteoarthritis, basilar (or basal) joint arthritis, or as rhizarthrosis. This joint is formed by the trapezium bone of the wrist and the metacarpal bone of the thumb. This is one of the joints where most humans develop osteoarthritis with age. Osteoarthritis is age-related loss of the smooth surface of the bone where it moves against another bone (cartilage of the joint). In reaction to the loss of cartilage, the bones thicken at the joint surface, resulting in subchondral sclerosis. Also, bony outgrowths, called osteophytes (also known as “bone spurs”), are formed at the joint margins.

<span class="mw-page-title-main">Wrist arthroscopy</span>

Wrist arthroscopy can be used to look inside the joint of the wrist. It is a minimally invasive technique which can be utilized for diagnostic purposes as well as for therapeutic interventions. Wrist arthroscopy has been used for diagnostic purposes since it was first introduced in 1979. However, it only became accepted as diagnostic tool around the mid-1980s. At that time, arthroscopy of the wrist was an innovative technique to determine whether a problem could be found in the wrist. A few years later, wrist arthroscopy could also be used as a therapeutic tool.

References

  1. ↑ "National Library of Medicine - Medical Subject Headings (MeSH) - Ganglion Cyst". Archived from the original on March 10, 2016. Retrieved August 27, 2013.
  2. 1 2 "E-hand.com The Electronic Textbook of Hand Surgery". The American Society for Surgery of the Hand assh.com. Archived from the original on March 9, 2014. Retrieved April 12, 2014.
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  4. 1 2 3 4 5 6 7 8 Ferri FF (2014). Ferri's Clinical Advisor 2015 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 472. ISBN   9780323084307. Archived from the original on 2017-09-10.
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  11. ↑ Kirk Watson H, Sorelle J (2010-01-01), Slutsky DJ (ed.), "CHAPTER 45 - Dorsal Wrist Syndrome and Rotatory Subluxation of the Scaphoid", Principles and Practice of Wrist Surgery, Philadelphia: W.B. Saunders, pp. 487–491, ISBN   978-1-4160-5646-1 , retrieved 2020-10-24
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  13. ↑ Duncan JM Macdonald, et al. (August 2007). "The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years". Annals of the Royal College of Surgeons of England. 89 (3): 272–275. doi:10.1308/003588407x168235. PMC   1964714 . PMID   17394713.
  14. ↑ Jon Arthur Jacobson (2007). Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences. ISBN   978-1416035930. Archived from the original on 2014-07-04.
  15. ↑ Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Sample chapter available on acromioclavicular joint ganglion Archived 2014-05-18 at the Wayback Machine .
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  17. ↑ Jae Jeong Park, et al. (2010). "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle". Korean Journal of Dermatology. Archived from the original on 2013-06-17.
  18. ↑ Park S, Jin W, Chun YS, Park SY, Kim HC, Kim GY, Park JS, Ryu KN (October 2009). "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: sonographic appearance". Journal of Clinical Ultrasound. 37 (8): 478–81. doi:10.1002/jcu.20609. PMID   19618443. S2CID   20586520.
  19. ↑ Robert J. Spinner, et al. (2012). "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" (PDF). Turkish Neurosurgery. pp. 527–528. Archived (PDF) from the original on 2013-10-14.
  20. 1 2 Sang Woo Kim, et al. (April 2011). "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen". J Korean Neurosurg Soc. 49 (4): 237–240. doi:10.3340/jkns.2011.49.4.237. PMC   3098430 . PMID   21607185. (original source cites eight additional references for the quoted paragraph)
  21. ↑ R. J. Spinner, et al. (2012-08-29). "Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected". Clin. Anat. 26 (2): 267–81. doi:10.1002/ca.22152. PMID   22933403. S2CID   37986961.
  22. ↑ Field LD (2003). MasterCases: Shoulder and Elbow Surgery. Thieme. p. 241. ISBN   9780865778733.
  23. ↑ Ribes R (2010). Learning Musculoskeletal Imaging. Springer. p. 197. ISBN   9783540880004.
  24. ↑ "Clinical treatments for wrist ganglia" (PDF). ROYAL AUSTRALASIAN COLLEGE OF SURGEONS. Archived from the original (PDF) on 27 March 2018.
  25. 1 2 The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1. Gale. 2003. pp.  560. ISBN   9780787677213.
  26. ↑ Camasta, Craig A., DPM, Excision of the Ganglion Cyst Archived 2013-11-01 at the Wayback Machine , podiatryinstitute.com, update 1993, 1993 33 pdf, pages 181–5
  27. ↑ Pocket Guide to Musculoskeletal Diagnosis. Springer. 2005. p. 63. ISBN   9781597450096.
  28. ↑ Gallego S, Mathoulin C (2010). "Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years". Arthroscopy. 26 (12): 1675–1682. doi:10.1016/j.arthro.2010.05.008. PMID   20952152.
  29. ↑ Lidder S, Ranawat V, Ahrens P (2009). "Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction". Orthop Rev. 1 (1): e5. doi:10.4081/or.2009.e5. PMC   3143961 . PMID   21808669.
  30. ↑ Dias JJ, Dhukaram V, Kumar P (October 2007). "The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention". The Journal of Hand Surgery, European Volume. 32 (5): 502–8. doi:10.1016/J.JHSE.2007.05.007. PMID   17950209. S2CID   21853864.
  31. ↑ Dias J, Buch K (Apr 2003). "Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes". J Hand Surg Br Vol. 28 (2): 172–6. doi:10.1016/s0266-7681(02)00365-0. PMID   12631492. S2CID   44865301.
  32. ↑ J.C. Segen (1992). The Dictionary of Modern Medicine. CRC Press. ISBN   9781850703211. Archived from the original on 2017-09-10. (see the entry for aneurysmal bone cyst, which "like pyogenic granuloma and ganglion cyst, a misnomer that has withstood the sands of time and the dint of logic")
  33. ↑ "Etymology of the Greek word ganglion (γάγγλιον)". Archived from the original on 2013-10-06.{{cite web}}: CS1 maint: unfit URL (link)
  34. ↑ See Hippocrates' "On the Articulations" (part 40) at Wikisource
  35. ↑ "Ganglions". Archived from the original on 2009-04-15. Retrieved 2009-05-27.
  36. ↑ Hammond C. "Should you bash a 'bible bump'?" . Retrieved 24 November 2018.
  37. ↑ Dacombe PJ, Robinson, J (Mar 27, 2012). "Falling Up the Stairs: the Equivalent of 'Bashing it with a Bible' for an ACL Ganglion Cyst of the Knee". BMJ Case Reports. 2012: bcr0120125591. doi:10.1136/bcr.01.2012.5591. PMC   3316796 . PMID   22605799.
  38. ↑ Hammond C. "Should you bash a 'bible bump'?" . Retrieved 2018-08-09.
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