Introduction

A ganglion is a small, harmless cyst, or sac of jelly-like fluid, that sometimes develops in the wrist. Doctors don't know exactly what causes ganglions, but a ganglion that isn't painful and doesn't interfere with activity can often be left untreated without harm to the patient. However, treatment options are available for painful ganglions or ones that cause problems. 

Anatomy

Ligaments connect the wrist bones allowing them to move in some directions while restricting their movement in others and assuring stability. The joint capsule is a watertight sack of tissue surrounding the wrist bones. Inside the wrist capsule are the joints themselves containing a small amount of lubricant, called synovial fluid, which allows the bones to move together easily. The many tendons required to move the fingers run just outside the joint capsule. 

Ganglions are generally attached by a stalk of tissue to a nearby joint capsule, tendon, or tendon sheath. Wrist ganglions are attached to the wrist joint capsule. Typically, only one ganglion appears. Although, ganglions have been seen in almost every joint in the hand and wrist.

Most wrist ganglions are found on the back of the hand (dorsal side), often centered over the wrist. Though, it can appear in any number of areas along the wrist. A dorsal wrist ganglion may be not be visible from the outside. Doctors refer to this type of ganglion as occult, or concealed. 

A volar wrist ganglion typically appears on the palm side of the wrist in the wrist crease just below the thumb. This is the second most common type of wrist ganglion.

Causes

Doctors don't know why or how ganglions develop. In some cases, the wrist has been injured previously. Repetitive injuries, such as those that can occur from playing tennis or golf frequently, seem to play a role in ganglion development. Defects or weaknesses in the joint capsule or wrist ligaments may also contribute to the development of ganglions.

Symptoms

A patient with a dorsal wrist ganglion may feel a bump or mass on the back of the wrist. With a volar wrist ganglion, the bump is felt on the wrist crease below the thumb. The mass may appear suddenly, or it may develop over time. The ganglion may occasionally increase or decrease in size.

The wrist may ache or feel tender. The ganglion may also interfere with activities. An occult dorsal wrist ganglion may be quite painful and tender, even though it is smaller than other ganglions. Typically the symptoms from a ganglion are not harmful and do not grow worse.

Diagnosis

The doctor will ask for a history of the problem and examine your hand and wrist. Usually, this is all that's required to diagnose a ganglion. An occult dorsal wrist ganglion, however, may be more difficult to locate because of its small size.

Treatment 

Treatment for dorsal and volar wrist ganglions may be either conservative (non-surgical) or surgical.

Conservative Treatment

Observation is often sufficient "treatment" for wrist ganglions. Ganglions typically are harmless and do not grow worse over time. Nor do they usually cause damage to the tendons, nerves, or the joint as a whole. Many wrist ganglions eventually go away by themselves.

Beyond observation, closed rupture with multiple needle punctures is another nonsurgical treatment option for dorsal wrist ganglions. In this procedure, the cyst wall is punctured with a needle, and anti-inflammatory and numbing drugs are injected into the cyst. This treatment can shrink the cyst and alleviate symptoms. However, the ganglion is likely to reappear.  

Observation is the most common nonsurgical treatment for volar wrist ganglions.

Surgery

Surgery may be recommended when the patient feels significant pain or when the cyst interferes with activity. It may also be recommended if the ganglion is compressing nerves in the wrist causing problems with movement and feeling in the hand. Surgery is usually done using regional anesthesia, which means only the arm is put to sleep, but it can be done under a general anesthesia as well.

Doctors have two options to surgically treat dorsal wrist ganglions. The first is cyst puncture and aspiration. (Aspiration means drawing the fluid out with suction.) However, this procedure has less than a 50 percent success rate.

Excision, or removal, of the cyst is the second option. Removing the cyst is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed. Usually a single incision is made, but depending on the location of the ganglion, a second incision may be necessary.

To remove a dorsal wrist ganglion, a small incision is made in the back of the wrist. The tendons that run across the back of the wrist and into the fingers are retracted (or moved) out of the way. This allows the surgeon to see the ganglion and follow it down to where it attaches to the wrist capsule. Once the surgeon locates this stalk, the entire ganglion is removed including the area where it attaches to the joint capsule. The joint capsule may need to be repaired with sutures. Finally, the skin incision is closed with sutures.  

Excision is the most common surgery for a volar wrist ganglion. Removing the cyst is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed. The surgical procedure is basically the same, except the volar ganglion is usually very close to the radial artery (the artery in the wrist used to feel someone's pulse). In some cases, the volar ganglion even winds around the artery. This makes removing the ganglion a bit more difficult. The surgeon must be careful to protect the artery, while at the same time removing the cyst down to the joint capsule. 

Both of these procedures have risks. Even after excision surgery, a ganglion may reappear, though this is uncommon. There is a slight risk of infection with both procedures. Excision can sometimes result in decreased motion, instability, and nerve or blood vessel damage. Removing a volar ganglion has a greater risk of nerve and blood vessel damage. However, the vast majority of people have two arteries that travel into the hand. If one is injured, the other is sufficient to provide an adequate blood supply to the hand.
 
Rehabilitation

After surgery, a dressing is applied to the wrist and forearm. You will be encouraged to move your fingers and wrist soon after surgery. Stitches are removed after two weeks. Physical therapy exercises may need to be continued until normal wrist movement returns.