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Ganglion Cyst of Wrist

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Other Names

  • Bible Cyst
  • Ganglion Cyst

Background

  • This page refers to a ganglion cyst of the wrist, sometimes termed a bible cyst

History
Epidemiology

  • Wrist represents 80% of all ganglion cysts (need citation)
  • Most common hand mass (need citation)

General

Anatomical depiction of dorsal and volar wrist ganglion cyst. Axial section of the wrist through scapholunate joint. 1. First dorsal extensor compartment: abductor pollicis longus, extensor pollicis brevis. 2. Second dorsal extensor compartment: extensor carpi radialis longus, extensor carpi radialis brevis. 3. Third dorsal extensor compartment: extensor pollicis longus. 4. Fourth dorsal extensor compartment: extensor digitorum communis, extensor indicis proprius. 5. Fifth dorsal extensor compartment: extensor digiti minimi. 6. Sixth dorsal extensor compartment: extensor carpi ulnaris. 7. Flexor digitorum profundus. 8. Flexor digitorum superficialis. 9. Flexor pollicis longus. 10. Pisiform recess. 11. Flexor carpi radialis. 12. Flexor carpi ulnaris. 13. Palmaris. 14. Ulnar artery. 15. Radial artery. 16. Superficial branch of the radial nerve. 17. Median nerve. 18. Ulnar nerve. 19. Distal radius. 20. Scaphoid. 21. Lunate. 22. Triquetrum. 23. Ganglion (synovial) cyst(s).[1]
Ganglion Cyst of the Wrist

Etiology

  • Three proposed origins of fluid[2]
    • May originate from within the joint, pumped into the cyst by motion of the wrist
    • From an extra-articular degenerative process resulting in cyst formation and subsequent communication to the joint
    • May originate from mesenchymal cells within the cell wall
    • It is possible that a combination of these mechanisms contribute

Location

Risk Factors

  • Female

Differential Diagnosis

Differential Diagnosis Wrist Pain

Clinical Features

History

  • Swelling of dorsal wrist (most commonly)
  • Onset is typically insidious without a clear injury
  • Can occur from acute injuries

Physical Exam: Physical Exam Wrist

  • Transilluminates (transmits light)
  • Absence of erythema, warmth
  • Firm, well circumscribed, 1-2 cm
  • Typically non-tender

Evaluation

There is a well-defined, thin-walled, lobulated anechoic lesion with the neck appearing to extend between the carpus and ulna[5]

Radiographs

Ultrasound

  • Findings
    • Hypoechoic fluid collection
    • Absence of flow on doppler or color doppler

Classification

  • N/A

Management

Ultrasound-guided Ganglion Cyst Aspiration and Injection

Nonoperative

  • Indications
    • Generally first line treatment
    • In pediatrics, 3/4 will spontaneously resolve (need citation)
    • In adults, about half will resolve spontaneously
  • Closed rupture
    • Home remedy, hence term 'bible cyst'
    • High recurrence rate
  • Aspiration Procedure: Ganglion Cyst of the Wrist Aspiration
    • Ideally, ultrasound guided
    • Approximately half will resolve with this treatment[6]
    • No benefit with repeat aspiration[7]
  • Corticosteroid Injection
    • Somewhat controversial
    • No evidence that this is an inflammatory response
    • One study showed CSI was no better than aspiration alone[7]
  • Splinting
    • No more effective than aspiration, leads to stiffness and loss of range of motion[8]

Operative

  • Indications
    • Severe symptoms, neurovascular injury
    • Failure of conservative measures
  • Technique
    • Resection of stalk, capsule

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Most athletes can play through unless neurovascular symptoms

Prognosis and Complications

Prognosis

  • Study of 219 patients comparing Surgical vs Aspiration/ Injection[9]
    • 8.4% recurrence with non surgical group vs 21.5% recurrence with surgical group
    • Surgical group had more post op pain, stiffness
  • Recurrence
    • Volar ganglion cysts more likely to recur without surgical excision[10]

Complications

See Also

Internal

External

References

  1. ↑ Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  2. ↑ Gude, Warren, and Vincent Morelli. "Ganglion cysts of the wrist: pathophysiology, clinical picture, and management." Current reviews in musculoskeletal medicine 1.3-4 (2008): 205-211.
  3. ↑ Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg. 1976;1(3):228–35.
  4. ↑ Greendyke SD, Wilson M, Shepler TR. Anterior wrist ganglia from the scaphotrapezial joint. J Hand Surg. 1992;17(3):487–90.
  5. ↑ Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 81321
  6. ↑ Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ. Ganglions of the wrist and digits and results of treatment by aspiration and cyst wall puncture. J Hand Surg. 1987;12(6):1041–3.
  7. ↑ 7.0 7.1 Varley GW, Neidoff M, Davis TRC, Clay NR. Conservative management of wrist ganglia: aspiration versus steroid infiltration. J Hand Surg. 1997;22(5):636–7.
  8. ↑ Jacobs LGH, Govaers KHM. The volar wrist ganglion: just a simple cyst? J Hand Surg. 1990;15(3):342–6.
  9. ↑ Paramhans, D, Nayak, D, Mathur, R, Kushwah K. Double dart technique of instillation of triamcinolone in ganglion over the wrist. J Cutan Aesthet Surg. 2010 Jan-Apr;3(1):29–31.
  10. ↑ Gude, W, Morelli, V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):205–211.
Created by:
John Kiel on 3 November 2019 22:55:56
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Last edited:
2 December 2023 17:04:16
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