Ganglions

What is a ganglion

 

Ganglions are benign lumps that can appear at various locations over the body. They are not cancer and are caused by a different and more localised problem. 

Lumps and bumps can understandably cause anxiety. If you are unsure about the cause of your lump you should seek medical attention for a diagnosis.

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A ganglion is an outpouching or hernia of a joint or tendon. They are very common in the hand as the joints and tendons are close to the skin and it is therefore easy to feel small lumps and bumps that are present. They can occur in any joint in the hand and wrist and can vary in size from a few millimetres to several centimetres in diameter. 

Ganglions are one of the most common lumps seen in the hand and wrists. They are around two to three times more common in females than in males and are seen most commonly in patients between the age of 20-50.

Many of these ganglions will disappear on their own, given enough time. Previous research from the 1970's suggested that 40% of ganglions will disappear on their own within 6 years of onset. 

What causes a Ganglion

 

Ganglions can be formed in response to an injury but more often they just occur spontaneously. They are commonly seen in joints with arthritis.
Our joints and many of our tendons are surrounded by a lining. This lining has two important roles;

1. To add structural support
The outer structure or joint capsule is tough. It supports the joint or tendon and allows movement to occur in the desired direction but prevents unwanted movements.

2. To lubricate the joint or tendon.
The inner synovial lining produces a lubricant (synovial fluid) which helps to allow frictionless movement. This fluid also provides nutrition to the cartilage and tendons.

A ganglion is formed when the outer lining has a small defect and allows the inner layer to bulge (or herniate) through. Synovial fluid then can enter this bulge but cannot get back into the joint as a one way valve has been created. Over time the fluid becomes thicker and the increasing pressure makes the hernia bigger. 

What are the signs and symptoms of a Ganglion

 

Ganglions can cause a variety of symptoms and many of these are due to the physical effect of the ganglion exerting pressure onto surrounding structures.

 

Pain

Ganglions in themselves are not usually painful due to the absence of nerve fibres. Ganglions can however exert pressure onto structures that do have pain receptors and therefore result in pain. They can also physically get trapped in a joint during movement which may cause pain.

Lump

Ganglions often cause a physical lump to appear. Some patients find the lump unsightly.

 

Diagnosis 

The diagnosis of a Ganglion is often made through a simple history and examination.

It is common for patients to describe suddenly noticing a lump. These lumps do not usually grow significantly but may fluctuate in size. Often there is a history of a cycle where the lump appears, then disappears a few months later, only to reappear once again.

A fluctuant (fluid filled) lump is often felt. The lumps are commonly seen on the back or front of the wrist. Small 'flexor sheath' ganglions can be felt on the flexor tendon at the front of the finger where the digit meets the palm.

Ganglions are also commonly seen around the distal interphalangeal joints (DIPJ), these are the last joints in the finger just below the nails. When seen in this location they are known as 'mucoid cysts'.

Ganglions often become more or less prominent depending on the position of the joint. For example ganglions on the back of the wrist look larger when the wrist is flexed (bent forwards). This is due to the increased pressure within the ganglion cyst during movement. 

Example of mucoid cyst

Example of volar ganglion

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Transillumination

As ganglions are filled with a clear fluid they have the unusual findings of transillumination. Transillumination is, "the passing of a strong beam of light through a part of the body for medical inspection".

A solid lump will not allow light to pass through it whereas a ganglion, being liquid filled, will allow the passage of light. This causes the ganglion to "light up" when a torch is pressed onto the lump. Try it for yourself.

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Example of dorsal ganglion

Investigations

As mentioned, ganglions are usually diagnosed from a careful history and examination. Occasionally special tests are used to either help confirm the diagnosis or to confirm the location that the ganglion has originated from.

Ultrasound scans are a useful, quick and cheap test that can be used to confirm the presence of a ganglion if there is diagnostic doubt. It can differentiate between ganglion cysts and solid growths. 

If necessary, MRI scans can locate the precise location that the stalk of the ganglion has originated from. This can help establish whether key- hole surgery is appropriate.

Treatment


No treatment
Given the fact that ganglions are completely benign lesions they do not require any form of treatment.  The natural history of this condition his that many will resolve on their own over time and will not deteriorate and cause any long-term damage.

Needle aspiration
if the ganglion is causing pain, affecting function or is cosmetically distressing there is an option to use a needle to remove the thickened fluid or rupturing the ganglion under local anaesthetic.  This is a very low risk procedure however the down side is a high recurrence rate.  This can be done either in the clinic at your initial visit or via referral to an ultrasound guided procedure under the care of the radiologists. the recurrence rates are between 80- 90% following this procedure.

Surgical excision
We would normally recommend trying to avoid surgery unless absolutely required.  If the ganglion has been there long time, is causing significant pain or functional limitation and has failed  non-surgical measures for example a needle aspiration then surgical excision is an option.

Either an open procedure or a keyhole procedure can be used depending on the location of the ganglion.  During the procedure it is important not only to remove the actual swelling (ganglion sac ) but more important is the removal of the origin of the ganglion as it enters either the tendon sheath or joint.  The removal of the origin of the ganglion is a crucial part in reducing the recurrence rates following this procedure.

Recurrence rates following surgical excision should be less than 5% in experienced hands.


 The risks of surgery include;​ 

  1. Infection

  2. Nerve injury

  3. Scar sensitivity

  4. Stiffness

  5. Recurrence

  6. Chronic pain

  7. Failure to fully improve

Recovery

 
 
 
 

 As mentioned previously it is perfectly reasonable to leave a ganglion alone as many will resolve on their own over time.  If you decide to leave it alone then you can resume all of your normal activities, hobbies and sports.  You will not cause any damage by doing these activities but if the ganglion was causing some discomfort it may continue to do so.
 
If you undergo a needle aspiration of your ganglion you may find that it is more painful than normal for a few days up to a couple of weeks. During this time you should rest the arm and perform gentle exercises to maintain movement. You may need to take simple painkillers if you find it uncomfortable.  After a few days or a week or 2 you should be able to return to your normal activities.
 
If you were to undergo surgery then it may take longer to fully recover.
A keyhole procedure to excise a wrist ganglion will have a quicker recovery than an open procedure  but it will still be a few weeks before wrist is comfortable  enough to perform most activities.
 
Following an open procedure the wrist is often placed into a plaster cast for 5 days and then rehabilitation exercises commence.  It will take roughly 2 weeks for the wounds to be fully healed and 6-8 weeks to return to full function.

It is important that  the diagnosis of a simple ganglion is made by a medically qualified individual.  Often it is extremely obvious that it is a simple ganglion but there are other more serious lumps and bumps that can occur that might need treatment.  Cancers of the hand and wrist are extremely rare but do occur. If any doubt exists please consult your GP or feel free to make an appointment to see our hand Specialist.


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Devon Hand Surgery aims to give you an early diagnosis, rapid treatment (which can often be non-surgical) and perform any necessary surgery when required. We will also supervise your rehabilitation to ensure you have the best chance of restoring function, getting back to work and improving your quality of life.