What’s This Lump On My Wrist? 6 Quick Facts About Ganglion Cysts
Welcome back to another article covering the basics of hand & upper extremity conditions.
Let’s review a common growth on the hands and wrist, a lump known as a ganglion cyst. I’ll teach you the top 5 things you need to know about ganglion cysts in under 5 minutes.
1.Ganglion cysts are usually painless - but not always
A ganglion cyst is a type of growth that typically occurs on the back or the front of the wrist. It can also occur in the hand or in other joints in the body.
It is still a little bit unclear why each cyst develops. But we do know that the cyst itself is joint fluid that has escaped from the joint. We think this may occur from a small injury, a genetic predisposition, or some accumulation of degeneration over time.
Either way, a small pouch of fluid pushes its way out of the joint (Figure below). Over time, the joint will continue to generate more and more fluid, and the cyst can grow and grow. If this goes on long enough, the cyst can make its way all the way to the level of your skin — and that’s typically when you notice it.
The good news?
These are usually painless — and certainly not dangerous. They do not cause any long-term damage. It is not a cancer and will not spread elsewhere. However, if they are in just the wrong spot, they can cause discomfort or limitations.
2. We gather clues for a diagnosis, but there is always some uncertainty
With any mass or growth in the body, it is important to remember the only way to truly know what it is (ie, diagnosis) is to remove it and have a pathologist look at it under the microscope. Anything short of that is really just collecting clues to guess at the most likely diagnosis.
In the case of a ganglion cyst, we rely on five main clues.
Location
As I said before, these cysts are most common over the back of the wrist and, somewhat less commonly, on the palm side of the wrist.
Growth
It is common for ganglion cysts to randomly grow and shrink day to day or week to week. This particular detail is a classic finding in a ganglion cyst that does not occur in other masses.
Appearance
If they are very large, we can do something called transillumination. For this test, I shine a light through the mass. If it appears to transmit the light and glow, that is consistent with a ganglion cyst.
Feel
The larger ganglion cysts have a classic feel to them. They are soft and somewhat ‘bouncy’ when you push on them. They oftentimes will easily slide around a little bit. Again, think back to the drawing above and imagine how a water balloon connected to a deep stalk might feel if you pushed it around.
MRI
Finally, in some settings, we will get an MRI. This is most helpful when planning for surgery if the cyst is on the palm side of the wrist. An MRI helps us locate where the cyst is relative to important structures such as nerves and blood vessels on the palm side of the wrist. An MRI will also give us clues as to how the cyst looks and where it is coming from to tell us whether it is most likely a ganglion cyst or something else. But again, even an MRI does not confirm the diagnosis. This is why, for most of these cysts, an MRI is not advised.
3. Your chosen treatment must align with your goals and symptoms
Always keep this in mind. Because these cysts are not dangerous, you really do not have to do anything. You must make sure that whatever treatment you choose is aligned with your goals and your symptoms.
If the cyst does not bother you that much, then don’t have surgery!
If your cyst is particularly painful, please realize that is outside the normal bounds for this type of cyst.
It may be that it is just in the wrong spot causing all your pain. But it may also be that something else is going on with your wrist that is resulting in your wrist pain. Or alternatively, your growth is not a cyst at all but instead is a different type of painful mass.
It is important to keep this in mind if you have decided to proceed with surgery to remove the cyst. There is a small but real chance that removing the cyst does nothing to resolve your pain.
4. I can drain these cysts - but I wouldn’t recommend it
Most patients who see me for this cyst will naturally assume that I can or will drain it. While this is technically true, these days, I rarely recommend this as a course of treatment.
Studies over the years have shown that drainage of a ganglion cyst is highly unlikely to be successful. The most recent studies show that only 20-30% of cysts are successfully treated with aspiration [1,2]!
This makes sense when you remember the anatomy. The problem that created the cyst exists deep down at the joint level. If all we are doing is ‘popping’ the cyst and sucking out the joint fluid, as soon as that small hole heals over, the balloon will just reinflate with more joint fluid.
Instead, we have to address the underlying pathology to cure the condition for good. While there are some situations where it makes sense to drain the cyst (for instance somebody with a painful cyst and a lot of other medical problems who would not be a good candidate for safe surgery), I typically steer patients away from this.
Joint fluid is thick and requires a large needle to drain. Drainage is not comfortable and does carry a small risk of infection.
And if it does not typically work, then why go through this?
So this leaves the (somewhat unsatisfying) treatment options of observation or surgery.
Keeping an eye on these cysts is perfectly safe. They often shrink on their own and can even resolve spontaneously.
5. Surgery is your surest bet. But cysts can still come back.
If you grow tired of the cyst or it bothers you too much, surgery is your most reliable option. However, it is crucial to understand that even with perfect surgery, about 5 to 10% of ganglion cysts can recur after surgery.
Remember, these cysts are extremely common at baseline and while surgery treats the cause of one cyst, the factors that came together to cause it in the first place can easily recur.
As alluded to above, in a ganglion cyst excision surgery, I will move the cyst out of the way and work my way all the way down to the joint level. There is usually a small stalk through which the cyst is emanating from the joint (see drawings above). This stalk needs to be excised in its entirety in order to best prevent cyst recurrence.
This is typically done under ‘twilight’ anesthesia with some medicine to numb your arm. I keep my patients in a wrist splint for a week following surgery before initiating range of motion. This makes it less likely for the area of stalk excision to reopen and cause a cyst recurrence.
Many patients rapidly recover at this point and resume all activities once out of the splint. Depending on the person, a smaller percentage of patients are actually quite stiff after this week of immobilization and require a little bit of therapy to regain their wrist function.
The majority of patients feel about 80 to 90% of their former selves by 6 weeks after surgery.
Wrapping up
So there you have it. The basics to understanding everything you need to know about a ganglion cyst.
As always, I hope this gives you the knowledge you need to empower you to take charge of your own health. If you have a growth on your hand or wrist that does not seem to be following the patterns that I described above, it is safest to get yourself to a physician as soon as possible to make sure you do not have anything dangerous growing on your wrist.
If you happen to be in Denver, Colorado, and would like consultation on your ganglion cyst, I would always be happy to see you.
References:
[1]: Kurkis, Gregory, et al. "Ultrasound-guided aspiration does not reduce the recurrence rate of ganglion cysts of the wrist." Journal of Wrist Surgery 8.02 (2019): 100-103.
[2]: Stephen AB, Lyons AR, Davis TR. A prospective study of two conservative treatments for ganglia of the wrist. J Hand Surg [Br]. 1999;24:104–105.
