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Ganglion Cyst of the Wrist Aspiration

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Other Names

  • Ganglion Cyst in the Wrist Aspiration and Injection
  • Bible Cyst Aspiration Injection

Background

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]

Key Points

  • Most commonly seen in the dorsal wrist
  • Injection: 21-25 gauge, 1-1.5 inch needle; Aspiration: 18 gauge, 1-1.5 inch needle
  • Recommend to be performed with high frequency, linear transducer
  • Surgery and percutaneous management have similar recurrence rates
  • Optimal treatment involves, aspiration and injection followed by trephination, rupture

Anatomy of Ganglion Cyst of Wrist

  • Ganglion cysts are soft tissue tumors which most commonly occur at the wrist
  • Dorsal is most common (70%), involving the scapholunate joint
  • Flexor tendon sheaths represent about 10% of ganglion cysts[2][3]

Palpation Guidance vs Ultrasound Guidance

  • This procedure can be performed with ultrasound guidance or palpation guidance
  • There are no studies comparing treatment with palpation versus ultrasound guidance
  • We recommend the use of ultrasound if possible
    • This helps ensure that it is a ganglion cyst and not something else (abscess, lipoma, neuroma, etc)

Indications


Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Uncertainty in diagnosis
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Ganglion Cyst of the Wrist
Needle and transducer for dorsal approach[1]
Ultrasound appearance of dorsal ganglion cyst. Blue arrow represents hypoechoic debris, white arrow represents needle vector.[1]

Equipment

  • Sterile including chloraprep, chlorhexadine, iodine
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Common ultrasound findings include[4]
    • Cystic mass with sharply defined borders
    • Contents are hypoechoic or anechoic fluid
    • May or may not have loculations
    • Should not have any flow under doppler interrogation
    • Compressible

In-Plane Technique

  • Patient position
    • Seated or supine
    • Hand resting comfortably on table, palm down
  • Transducer position
    • Optomize transducer over best approach of cyst
  • Needle Orientation and Approach
    • In plane
    • Approach is subjective to optimize access to cyst
  • Target
    • Middle of cyst
  • Pearls and Pitfalls
    • Confirm cyst in two planes, use color doppler to ensure diagnosis
    • Consider using a larger needle for aspiration
    • Consider fenestration technique to help cyst rupture, can use manual pressure

Aftercare

  • Place patient in cock up wrist splint
    • Duration typically a few days
    • Helps reduce movement at wrist and distortion of the deflated cyst

Complications

  • Intravascular injection
  • Nerve injury
  • Local trauma

See Also


References

  1. 1.0 1.1 1.2 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  2. 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.
  3. 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.
  4. Nguyen V, Choi J, Davis KW. Imaging of wrist masses. Curr Probl Diagn Radiol. 2004;33(4):147-160. doi:10.1016/j.cpradiol.2004.01.002
Created by:
John Kiel on 2 December 2023 16:31:55
Authors:
Last edited:
11 December 2023 03:29:16
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