What is a ganglion cyst of wrist?

    The medical term for the so-called ganglion is wrist ganglion. The word “ganglion” is of Greek origin and means “knot of tissue”. A ganglion is perceived as a protrusion on the wrist. Suprabones are benign and by far the most common reason for swelling (tumor) on the hand [1]. A ganglion is a tissue cavity filled with synovial fluid that has a connection with the adjacent joint. The connection to the joint is called a pedicle. The benign growth known as a ganglion contains a viscous, translucent, yellowish fluid. The fluid is composed of hyaluronic acid (hyaluronan), among other substances. Women between the ages of twenty and forty are most commonly affected. At the wrist, ganglions occur on the extensor side in sixty to seventy percent of cases. At this point, a wrist ganglion is also called a dorsal ganglion. If the ganglion is on the flexor side, it is called a palmar wrist ganglion. Occasionally, the misleading terms synovial cyst or ganglion cyst are used. A cyst is a cavity lined with a cell wall. The sheath of a supra-gluteal ganglion is of a different nature and has a filled cavity composed predominantly of collagen. A wrist ganglion is therefore also called a pseudocyst [2]. The term Bible cyst comes from the ancient method of bursting a ganglion by a firm blow with a Bible. Colloquially, a ganglion on the wrist is called a ganglion. Strictly speaking, the term overleg is not correct. Leg is derived from the Germanic word “baina” and means bone (see also shinbone, ivory). In fact, there are also bony prominences on the back of the hand. The bony joint attachments between the metacarpal bones and the carpal bones are called “carpe bossu” or “carpal bossing”.

    What is a ganglion cyst?

    A ganglion can occur at the wrist, among other places, but also at other locations such as the knee or the ankle above the foot. In the case of benign tumours, it must be differentiated whether they occur on the wrist or on the fingers. A fluid-filled swelling of the end joints of the toes, big toes, fingers, or thumbs is a mucoid cyst. A ganglion on the wrist is popularly known as a ganglion. Unlike mucoid cysts, hyperplasia is predominantly found in young adults. Hyperbones most commonly occur at the extensor wrist between the scaphoid and lunate bones (sixty to seventy percent of cases). In rare cases, ganglions are found along the flexor and radius wrist flexor tendon (flexor carpi radialis tendon, in thirteen to twenty percent of cases). The presence of a ganglion near the thumb saddle joint is often associated with joint wear [3]. Ganglia can also occur in the bones. This is called an intraosseous ganglion. Therefore, the treatment recommendations of ganglia differed depending on the place of origin.

    What are the symptoms of a ganglion?

    A ganglion is initially perceived as a bump on the hand or on the back of the hand. The well-defined swelling can sometimes feel hard, sometimes soft. If the ganglion is close to the artery, a pulsation can be felt. The swelling develops over the course of weeks or months. Often the protrusion on the wrist is perceived as unsightly. It is not uncommon for ganglions to be accompanied by pain. In a separate, as yet unpublished study at the University Hospital and BG Clinic in Tübingen, patients with a wrist ganglion gave the following motives for surgery:

    • 77 percent of cases pain
    • 53 percent pain-related movement restrictions
    • 41 percent aesthetic reasons
    • 13 percent fear of a malignant growth

    How is a ganglion detected (diagnosed)?

    A surgeon with the additional designation of hand surgery can usually clearly assign a ganglion. To do this, the hand surgeon examines the ganglion and palpates it. A ganglion can be distinguished from other swellings, e.g. of the tendon sheaths, by careful examination. Fluoroscopy with a flashlight (diaphanoscopy) will brightly illuminate a ganglion. If there is still doubt, then an ultrasound examination may be helpful. A ganglion that cannot be seen externally and is only revealed by an MRI examination is called an occult wrist ganglion. An intraosseous ganglion, which is a fluid-filled cavity of a bone, can be detected by a computed tomography examination.

    Which doctor can help with a ganglion?

    In any examination, consultation and, of course, treatment, among other things, the doctor’s training and experience are of great importance. Hearsay and a friendly approach are equally important. The professional competence is difficult to assess for a medical layman. Therefore, there is the special and protected professional title of hand surgeon. The specialty of hand surgery includes the detection and treatment of diseases, injuries, malformations and tumors of the hand. In technical terms, ganglions are classified as benign tumors of the hand. Specialists in plastic and aesthetic surgery are allowed to obtain the additional designation of hand surgery after further two years of training. Another professional distinction is the certificate of the Federation of European Societies of Surgery of the Hand (FESSH). This certificate is awarded after passing a comprehensive written and oral examination lasting several days.

    How does a ganglion develop?

    It is believed that increased stress on the wrist leads to increased production of synovial fluid (synovia). The fluid leads to an outpouching of the joint capsule (soft synovial membranes) at the wrist at a weak point. The possible causes leading to the development of a ganglion are unclear. Depending on the joint affected, ganglions are readily associated with different causes and different complaints are noted. A ganglion is often observed as a result of injury or overuse, as well as chronic irritation. In some cases it can occur in temporal connection with an arthrosis. There is also a theory that the benign soft tissue tumors known as ganglia develop primarily in people with weak connective tissue. However, the exact causes could not be proven until today. The temporal linkage of two events does not necessarily imply a causal relationship. The observation of a ganglion after an accident, a fall or a contusion is not sufficient to assume with certainty a cause-effect relationship. A causal relationship with pregnancy or rheumatic diseases has not been established. In rheumatism, swelling of the tendon gliding tissue occasionally occurs. This swelling is also called tendon sheath hygroma. There is no association between wrist ganglia and tendon sheath hygromen.

    Treat ganglions without surgery

    Naturally, patients first inform themselves about alternatives to surgery and want to find answers to their questions about possible methods of conservative treatment for a ganglion. On the Internet you can find a large selection of home remedies and cures for the therapy of a ganglion. From an unusual treatment method comes the obsolete term Bible cyst, which was formerly used for wrist ganglia. It is due to the method of bursting a ganglion with the powerful blow of a Bible. However, this is strongly discouraged. The experience should be very painful, with the ganglion very likely to recur in the same place.

    Homeopathic remedies are also offered for the treatment of ganglia. The flowers of the Arnica plant have an anti-inflammatory and analgesic effect. Arnica globules D6 have a potency or dilution of 1:1,000,000. This is equivalent to diluting two Voltaren tablets in a bathtub. Arnica is used in higher concentrations in ointments. The so-called horse ointment contains among other things Arnica. Other ingredients of the horse ointment are camphor, menthol, methyl salicylate (active ingredient similar to aspirin) and rosemary. A common ingredient of traction ointments (ichthammol) is said to positively influence the healing of inflammatory skin diseases. Betonite, the essential active ingredient in healing clays, reduces the harmful effects of mould toxins (aflatoxins). Scientific studies on the effect of homeopathy, ointments, healing earths or a special diet on wrist ganglia have not been published.

    The benefits of applying cold or heat, certain exercises or massages have also not been proven. The same applies to treatment with ultrasound or laser. Bandages, if worn long term, can lead to joint stiffness as well as muscle and bone atrophy. A positive effect of bandages or plasters on overlegs has not been scientifically proven. Studies on syringe treatments such as aspiration or puncture to aspirate filled cysts have already been published. Therefore, it is known that the benefit of injections is far inferior to surgical treatment. The risk of inflammation to the joint when it is treated minimally invasively with an injection is not insignificant. Inflammation of the joints is difficult to treat. Permanent movement restrictions and mild to severe pain are often the result of joint inflammation.

    What really helps? Comparison with all conservative therapies and other non-surgical treatments shows that ganglions are least likely to recur after surgical removal. After careful removal through a small skin incision, those affected usually experience a significant relief of symptoms.

    How is a ganglion cyst removed?

    Before the ganglion surgery, we will again make sure that all your questions from A-Z have been answered. Before each operation, the surgeon makes sure that the best possible conditions for open surgery are met. In the hand, important and fine structures such as vessels, nerves and tendons are very close together. Optimal visual conditions are the most important basic requirement for ganglion surgery, especially in hand surgery. The procedure uses the method of draining the blood. The blood void prevents blood from obstructing the view and minimizes blood loss. For this purpose, a rubber bandage (Esmarch bandage) is wrapped from the fingertips to the upper arm before the operation. Then a blood pressure cuff inflates to prevent blood from flowing back after the rubber band is removed. To prevent the pressure on the upper arm from being felt as an unpleasant tingling or numbness sensation, the brachial plexus is given a local anaesthetic. This ensures that you do not feel any pain. General anesthesia is not necessary for the surgical procedure.

    The skin is disinfected several times with an alcohol solution before the surgical treatment. Sterile drapes ensure that the entire area remains germ-free. With magnifying glasses, the plastic surgery specialist sees the tissue in two to four times magnification. The small skin incisions required for such operations (usually only one precise incision is sufficient) are chosen to be as small as possible and as large as necessary so that nothing is overlooked. The orientation of the section takes into account the direction of the anatomical structures of the respective region. The incision must be chosen in such a way that the scar that forms later does not impair the mobility of the wrist, even when large ganglia are removed. For planning purposes, the incision is occasionally drawn on the skin with a pencil before the operation. Smaller vessels are welded with special tweezers through which an alternating current flows. Nerves and vessels are freed from the ganglion and its connection to the joint using gentle microsurgical techniques. After the bulge is completely removed, the joint and the wound are carefully closed again with fine sutures.

    After the wrist has been bandaged, you can relax in our rest room. There you will be told what to look out for in the following days and appointments will be made for check-ups. You will be given a letter to take with you, in which all the details of the operation are listed. In case of emergency, the surgeon is always available after the operation. The procedure takes about twenty minutes. Taking into account the preparation and subsequent aftercare, you should allow two to three hours.

    Can a ganglion be removed arthroscopically (through arthroscopy)?

    Yes, ganglions can be removed using the keyhole technique (arthroscopy, joint endoscopy). This involves making four small incisions on the back of the hand through which fine instruments are inserted. For comparison, in the conventional method, the ganglion is removed with a scalpel through an incision about two centimeters long. Since the skin incisions of the keyhole technique are each four to five millimeters long, the procedure does not help to reduce scarring. However, the technical and time requirements of the keyhole method are far greater (Pang EQ, et al., 2017, J Hand Surg Am.). The likelihood of a supra-leg recurring and the risks of both procedures do not differ (Crawford C, et al. 2018, J Hand Surg Eur Vol).

    What are the risks of removing a ganglion?

    Potential complications of wrist surgery include vascular and nerve injury, impaired wound healing, hematoma, inflammation, or complex regional pain syndrome (CRPS). Complication rates of previously published studies range from 0 to 17 percent for surgical removal of ganglions (Kang, L., et al. 2008. J Hand Surg Am, Dias, J. J., et al. 2007, J Hand Surg Eur Vol). In a separate study conducted at the University and BG Clinic in Tübingen, Germany, not a single complication occurred in 70 patients.

    How can you prepare for surgery on a wrist overbone?

    • All your questions about possible complications and alternative treatments should be answered before the operation.
    • Keep nicotine and alcohol consumption to a minimum.
    • Blood-thinning medication (e.g. ASS, Thomapyrin®) must be discontinued at least ten days before the operation after consultation with your doctor.
    • Vitamin preparations (A, E) and dietary supplements (omega-3 fatty acids, St. John’s wort preparations, etc.) must be stopped four weeks before the operation.
    • Surgery limits the ability to travel by air. Therefore, do not plan any professional or private air travel during the four weeks following the operation.
    • At home, prepare ice cubes or cooling pads to cool your skin after the operation.

    What do you need to watch out for after removing a ganglion?

    • Your well-being and the outcome of the operation will be monitored regularly.
    • The elevation and cooling of the hand during the first three days promotes swelling reduction and wound healing.
    • Perform complete fist closure and finger extension exercises several times per hour.
    • From the third postoperative week onwards, several daily circular massages for a few minutes, along and across the course of the scar with oily creams (e.g. Bepanthen® ointment or Linola® fat) help to create inconspicuous scars.
    • The skin threads are removed after ten to fourteen days.

    Can an excess leg return after an operation?

    In a specially carried out follow-up examination of 70 patients at the University and BG Clinic Tübingen, the excess leg came up again in eight percent of the patients. The probability that an excess leg will recur fluctuates in scientific studies between eight and ten percent (Crawford C, et al. 2018, J Hand Surg Eur Vol).

    Tumors on hand and fingers

    Soft tissue tumors on the hand are frequent and usually benign. The hand is a fine clockwork with many structures in a very small space: muscles, tendons, tendon sheaths, ligaments, skin, blood vessels and nerves. In all these tissues cells can multiply unchecked. Both hands correspond to two percent of the total body surface. The hands make up only 1.2 percent of the total body weight. However, fifteen percent of all soft tissue tumors of the body are found on the hand.

    What are giant cell tumors?

    Giant cell tumors are painless swellings of the hand or fingers near tendon sheaths. Affected patients are usually between thirty and fifty years old. The tumour can spread to the joints and bones. Then it is very difficult to remove the tumor completely. In case of suspicion, x-rays and magnetic resonance examinations should be performed. The operation is the treatment of first choice. The removed tissue is typically yellow-brown to grey-white in colour with a flap-like and soft structure.

    What are vascular malformations?

    Vascular malformations are malformations of the vessels that can occur throughout the entire body. The vascular malformations are subdivided according to the flow velocity of the blood flow. Vascular malformations with a high flow velocity transport oxygen-rich arterial blood from the heart. Malformations with a low flow velocity transport oxygen-poor venous blood to the heart. Most vascular malformations are partly arterial and partly venous. At the body surface, malformations are noticeable by a bluish discoloration of the skin. Arterial vascular malformations are characterized by a palpable pulsation and possibly a flow noise. Vascular malformations mainly affect children and adolescents.

    What are schwannomas?

    Schwannomas are benign tumors of the nerve sheaths. The swelling is caused by the uninhibited growth of cells surrounding the nerves. They occur in middle-aged adults. They cause pain or numbness. Touching them can cause an electrifying pain. Schwannomas can be removed from the affected nerve by surgery.

    What are glomus tumors?

    The glomus tumor is a benign malformation of the glomus corpuscle. Glomus corpuscles serve to regulate the skin temperature on the hands and are mainly located under the nails. Five and seventy percent of glomus tumors occur in the hand under the fingernails. Glomus tumors make up only one percent of all hand tumors. They are more common in women between the ages of thirty and fifty and occur spontaneously. Glomus tumors typically manifest themselves through pain that is limited in places and sensitivity to cold. Discoloration of the nail bed is visible under the nail. Occasionally, nail deformations also occur.


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    The author

    Dr. med. Stéphane Stahl

    “We provide you with extensive expert knowledge so that we can work with you to select the best possible treatment path.”

    Dr. med. Stéphane steel is the former director of the Clinic for Plastic, Reconstructive and Aesthetic Surgery / Hand Surgery at the Lüdenscheid Clinic. Dr. Stahl studied medicine at the Universities of Freiburg and Berlin. In 2011 he passed the European and 2012 the German specialist examination for plastic and aesthetic surgery. Further specialist qualifications and additional qualifications followed (including quality management, medical didactics, physical therapy, emergency medicine, laser protection officers, hand surgery) as well as prizes and awards. In 2015 he completed his habilitation in plastic and aesthetic surgery in Tübingen. He is an experienced microsurgeon, a sought-after expert and a regular speaker at specialist congresses. After a multi-stage selection process, Stéphane Stahl became a member of the American Society for Aesthetic Plastic Surgery (ASAPS), one of the world’s largest and most influential specialist societies for aesthetic surgery. His authorship includes numerous articles in respected peer review journals and standard surgical textbooks.


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