Review of Ganglion Cyst
Ganglion cysts are found throughout the body and can arise from joints, tendons, and ligaments (8). The most common location for a ganglion cyst of the upper extremity is the dorsal wrist above the scapholunate ligament (1, 9). The dorsal wrist cysts account for 70% of all upper extremity cysts (1). A ganglion cyst is a mucin filled soft tissue collection that has a stalk to the joint surface (2). The outer wall of the cyst is made of collagen fiber and the cyst does not have an epithelial lining (6). The etiology of a ganglion cysts is unknown. There are theories that vary from a herniation of the synovial lining to local leakage of synovial fluid (6). Ganglion cysts are seen more commonly in females and patients between the ages of 20-40 years old (2).
Most patients with a ganglion cyst will not complain of pain and the cyst will be asymptomatic. However, due to location and size of the cyst, pain and paresthesias are possible (1). Diagnosis is typically made clinically, but an MRI can be done to help visualize the soft tissue structure (4). The differential for a wrist ganglion cyst includes an arterial aneurysm vs. intraneural cyst (6).
In a study looking at the accuracy of MRI to identify a ganglion cyst, they found that of 25 MRIs with surgically diagnosed cysts, only 19 of the studies mentioned a ganglion cyst on the radiology report (4). They found that physicians who wrote on the order to evaluate for a ganglion cyst had a higher likelihood of having the radiologist mention a cyst on the report (4).
In addition to MRI, ultrasound can also be used to evaluate for a ganglion cyst. A ganglion cyst on ultrasound will be anechoic and typically ovular in shape with a thin wall (5). However, the cysts are sometimes multiloculated (9). Ultrasound has a sensitivity of 88% and specificity of 85% for diagnosis of ganglion cysts (5).
Ultrasound of an AC joint ganglion cyst
Over half of the ganglion cysts seen in practice disappear with no intervention (1). For those patients with pain, an aspiration can be considered (3). Using ultrasound guidance for an aspiration can help avoid incidental artery or nerve damage (5). The color doppler setting on an ultrasound will help differentiate an artery from a cystic structure (5). There is no evidence for injection of corticosteroids following aspiration (6). Another study looked at repetitive cyst wall puncture during an aspiration, but found that the risk of recurrence was just as high in the repetitive puncture group as the single aspiration group (7).
Surgery can also be considered for elimination of the ganglion cyst. Unfortunately, there is a high risk of cyst return after surgery. Open surgery has led to cyst recurrence up to 50% of the time and arthroscopic surgical removal leads to recurrence up to 30% of the time (1). Pediatric ganglion cysts have also been found to come back following surgical excision at a higher rate than adults (2).
Ganglion cysts are thin walled mucin filled soft tissue collections found commonly in the wrist, hand, and foot (8). They are typically diagnosed clinically and confirmed with MRI or ultrasound. Treatment is typically nonoperative with aspiration, but they can be surgically removed.
By Gregory Rubin, DO
Wrist MRI of a ganglion cyst.
1) Cluts, Landon M., and John R. Fowler. “Factors Impacting Recurrence Rate After Open Ganglion Cyst Excision.” Hand (New York, N.Y.), vol. 17, no. 2, Mar. 2022, pp. 261–65. PubMed, https://doi.org/10.1177/1558944720921477.
2) Meyerson, Joseph, et al. “Pediatric Ganglion Cysts: A Retrospective Review.” Hand (New York, N.Y.), vol. 14, no. 4, July 2019, pp. 445–48. PubMed, https://doi.org/10.1177/1558944717751195.
3) Bram, Joshua T., et al. “Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children.” The Journal of Hand Surgery, vol. 46, no. 12, Dec. 2021, p. 1122.e1-1122.e9. PubMed, https://doi.org/10.1016/j.jhsa.2021.02.026.
4) Versteeg, Gregory, and Kanu Goyal. “Radiologist Identification of Occult Dorsal Wrist Ganglion Cysts on MRI.” Journal of Wrist Surgery, vol. 8, no. 4, Aug. 2019, pp. 276–79. PubMed, https://doi.org/10.1055/s-0039-1683847.
5) Starr, Harlan M., et al. “Ultrasonography for Hand and Wrist Conditions.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 24, no. 8, Aug. 2016, pp. 544–54. PubMed, https://doi.org/10.5435/JAAOS-D-15-00170.
6) Thornburg, L. E. “Ganglions of the Hand and Wrist.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 7, no. 4, Aug. 1999, pp. 231–38. PubMed, https://doi.org/10.5435/00124635-199907000-00003.
7) Gant, Jonathan, et al. “Wrist Ganglions.” The Journal of Hand Surgery, vol. 36, no. 3, Mar. 2011, pp. 510–12. PubMed, https://doi.org/10.1016/j.jhsa.2010.11.048.
8) Achar, Suraj, et al. “Soft Tissue Masses: Evaluation and Treatment.” American Family Physician, vol. 105, no. 6, June 2022, pp. 602–12
9) Zhang, Andrew, et al. “Sonography of Wrist Ganglion Cysts: Which Location Is Most Common?” Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, vol. 38, no. 8, Aug. 2019, pp. 2155–60. PubMed, https://doi.org/10.1002/jum.14912.