CHAPTER 191 Ganglion Treatment
The most common tumor of the hand or wrist is the ganglion, which has a propensity for women. A ganglion can occur at almost any location adjacent to a joint or tendon sheath. The most common site is the dorsal wrist (Fig. 191-1), accounting for about 65% of ganglions; for this location the scapholunate ligament and joint are usually the source or root of the pathology (Fig. 191-2). Volar cysts account for about 20% to 25% of ganglions and typically originate from the scaphotrapezial or trapeziometacarpal joints (Fig. 191-3). Another site of origin is the palmar fibro-osseous flexor tendon sheath, which accounts for about 10% of ganglions. A ganglion at this location normally presents as a hard, small or pea-sized, painful lesion at the proximal interphalangeal flexion crease (Fig. 191-4). Ganglion cysts can be seen at other body sites, with the foot and ankle being common locations (Figs. 191-5 and 191-6). Occasionally they can even be found intraosseously.
Figure 191-6 Ganglion inferior to malleolus of ankle.
(Courtesy of The Medical Procedures Center, Midland, Mich.)
Identification and Characteristics
Patients usually present with an obvious mass and sometimes complain of pain and weakness. Ganglion cysts are usually easy to identify by their appearance. The most consistent characteristic is their location, as noted previously. The cyst is often rubbery, but it is sometimes firm. Occasionally a ganglion will allow fluid to be compressed from one septate area to another. The ganglion may transilluminate if it is of sufficient size. Seldom is it necessary to order additional studies to confirm the diagnosis; rather, confirmation is usually made by aspiration, which yields a viscous mucoid fluid (Fig. 191-7). A differential diagnosis includes extensor tenosynovitis, lipoma, sebaceous cyst, or other hand tumors.
Figure 191-7 Typical thick, honey-like consistency of ganglion mucin.
(Courtesy of The Medical Procedures Center, Midland, Mich.)
NOTE: A close “cousin” of the ganglion cyst is the mucous (or mucinous) cyst. Both are nearly identical histologically, but the mucous cyst often involves a more ominous process. Mucous cysts arise from an arthritic distal interphalangeal (DIP) joint (i.e., the cyst is a direct drainage conduit to the DIP joint; Fig. 191-8). Unfortunately, as these cysts enlarge with time, they will commonly erode into the germinal nail matrix, causing discomfort and nail distortion. (Nail distortion is a hallmark of this type cyst.) Past treatments have included sclerosis, steroid injection, electrical or chemical cautery, cryotherapy, and simple incision and drainage. The thinned local subcutaneous tissue may rupture spontaneously, leading to a septic joint or osteomyelitis. These lesions are particularly difficult to manage, even by skilled hand surgeons. Aspiration or injection of mucous cysts can be attempted judiciously, but the risk of causing a septic joint must be appreciated. If such treatment is implemented, the patient needs to be aware of the signs of infection.
Preprocedure Patient Preparation
Ganglion cysts of the volar wrist near the distal radius are near the radial artery (Fig. 191-9). In fact, excision of a cyst in this region often requires dissecting scar tissue off the radial artery. Theoretically, incision and drainage of a ganglion in this area might predispose the patient to an arteriovenous malformation; however, a cyst that spontaneously ruptures in this area or is surgically removed may also predispose the patient to such a lesion.
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