Patients › Hand
Ganglio en la vaina del tendón flexor
A benign, fluid-filled cyst arising from the flexor tendon sheath – often painless, but can cause clicking or limited finger movement.
Qué está sintiendo¶
Tiene un bulto pequeño y firme en la palma de la mano, generalmente cerca de la base de un dedo. Se encuentra sobre el túnel tendinoso que permite el movimiento de flexión del dedo. Ese bulto es un quiste ganglionar: un saco lleno de líquido que se forma a partir del revestimiento de dicho túnel tendinoso. Puede sentirse como un guisante bajo la piel.
El bulto puede doler, especialmente al agarrar o apretar algo. Presionarlo resulta incómodo. Las actividades que obligan a doblar el dedo contra el bulto también causan dolor; por ejemplo, agarrar el volante del coche, llevar bolsas de la compra o sostener una herramienta. En algunas personas, el bulto se vuelve más evidente tras utilizar mucho la mano.
Un bulto en esta zona puede confundirse fácilmente con otras afecciones. El dedo en gatillo, en el que el dedo se atasca o “clic” al doblarse, produce síntomas similares. También lo es la enfermedad de Dupuytren, en la que bandas de tejido tiran de los dedos hacia la palma. Su cirujano examinará el bulto para determinar cuál de estas condiciones padece. Estudios como la ecografía pueden ayudar a confirmar su naturaleza.
Los quistes ganglionares suelen evolucionar con el tiempo. Muchos se reducen por sí solos, aunque esto puede tardar años. Algunos permanecen del mismo tamaño o crecen lentamente. Se puede extraer el líquido del bulto mediante una aguja; esto suele aliviar los síntomas durante un tiempo, pero el quiste suele reaparecer. La cirugía para extirparlo por completo reduce considerablemente la probabilidad de recurrencia.
Si el bulto le causa dolor o le dificulta las actividades diarias, existen buenas opciones de tratamiento. En primer lugar, se suele intentar la aspiración del líquido. Cuando el problema persiste, la extirpación quirúrgica del quiste también constituye una solución eficaz.
¿Qué está ocurriendo realmente?¶
El dedo se dobla gracias a un tendón, una cuerda resistente que va desde el antebrazo, a través de la palma de la mano, hasta el dedo. Este tendón se desliza por un túnel ajustado llamado vaina tendinosa. El revestimiento de dicho túnel produce una pequeña cantidad de líquido que actúa como aceite en una bisagra, permitiendo que el tendón se desplace sin fricción.
Un ganglio se forma cuando parte de ese revestimiento se abulta y se llena de un líquido espeso y transparente. Es algo similar a la formación de una pequeña ampolla en la pared del túnel. La bolsa permanece conectada al túnel, motivo por el cual extraer el líquido con una aguja no siempre soluciona el problema; mientras persista esa conexión, la bolsa puede volver a llenarse.
El bulto en sí es inofensivo, pero ocupa un espacio que escasea en esa zona. Por eso, agarrar o apretar objetos puede causar dolor: la bolsa hinchada ejerce presión sobre los tejidos circundantes. Esta misma compresión explica por qué un bulto en este lugar puede situarse cerca de las estructuras responsables de que el dedo “chasquee” o se trabe, y por qué el cirujano debe determinar con precisión qué condición padece el paciente.
La mayoría de estos bultos evolucionan de forma estable con el tiempo. Alrededor del 40 % disminuyen de tamaño durante los primeros 6 años tras su diagnóstico. Algunas personas son simplemente más propensas a desarrollarlos; además, las muñecas con mayor laxitud articular parecen favorecer la aparición de ganglios. Si se extirpa quirúrgicamente, hay aproximadamente un 10 % de probabilidad de que vuelva a formarse en el mismo lugar.
Lo más importante es saber qué no es este bulto: no es cáncer ni se propaga a otras partes del cuerpo. Se trata simplemente de una acumulación de líquido proveniente de un revestimiento ya presente en la mano. Comprender esto puede hacer que las decisiones futuras parezcan menos intimidantes: observar y esperar, drenarlo o extirparlo.
Qué podemos hacer al respecto¶
El Dr. Kieran Hirpara, cirujano de extremidades superiores en el Mater Private Hospital Rockhampton, comienza con las opciones menos invasivas que se adapten a su condición. Por lo general, los pacientes son derivados a nuestra clínica por su médico de cabecera; si un fisioterapeuta le ha sugerido consultarnos, igualmente necesitará una derivación de su médico de cabecera para poder acceder al reembolso de Medicare. En su primera visita, tomamos un historial clínico detallado, examinamos el bulto y, si es necesario, programamos una ecografía para confirmar su naturaleza.
Como ya se mencionó, muchos de estos bultos desaparecen por sí solos. Si el suyo no le causa dolor ni le dificulta las actividades diarias, quizás optemos simplemente por vigilarlo. Modificar la forma en que agarra o sostiene objetos puede reducir la presión sobre el bulto. La terapia de la mano busca mantener el movimiento de los dedos sin molestias y aliviar el dolor al usar la mano.
Con frecuencia, lo primero que se intenta es extraer el líquido con una aguja. Esta drena el líquido espeso del saco, lo que reduce temporalmente el tamaño del bulto. Sin embargo, la conexión con el túnel tendinoso suele permanecer abierta, por lo que el bulto a menudo vuelve a formarse. Discutimos este procedimiento con usted antes de la cirugía, ya que para algunas personas evita la necesidad de una operación.
Si el bulto sigue siendo problemático tras estos pasos, hablamos sobre la posibilidad de extirparlo mediante cirugía. La operación consiste en retirar todo el saco y su conexión con el túnel tendinoso, lo que disminuye el riesgo de que reaparezca. No obstante, toda intervención quirúrgica deja una cicatriz y conlleva ciertos riesgos de complicaciones, los cuales analizamos con usted. En algunos casos, la cirugía no alivia el dolor ni mejora el funcionamiento de la mano tanto como dejar el bulto tal cual; por eso evaluamos esta opción juntos. Si su trabajo o sus pasatiempos requieren un agarre fuerte con la muñeca doblada hacia atrás, hablaremos sobre la posibilidad de que persistan el dolor y la rigidez tras la cirugía en la parte dorsal de la muñeca.
Qué esperar¶
La mayoría de estos bultos evolucionan de forma tranquila. Algunos mantienen el mismo tamaño, y unos pocos crecen lentamente. El dolor suele aparecer y desaparecer según el uso que haga de la mano.
Si deja el bulto sin intervención, hay una buena probabilidad de que desaparezca por sí solo, aunque eso puede tardar años. Extraer el líquido suele aliviar los síntomas durante un tiempo, pero la mayoría de los quistes ganglionares vuelven a aparecer después. La extirpación quirúrgica del bulto reduce la probabilidad de recurrencia; quienes se someten a esta operación refieren una mejor función de la mano y menos dolor a las 6 semanas. No obstante, la cirugía no garantiza que la mano quede completamente libre de dolor, y en algunas personas no resulta más eficaz que dejar el bulto tal cual.
Si el bulto se extirpa y no vuelve a aparecer, la mayoría de las personas retoman su vida normal. La cicatriz se va suavizando con el paso de los meses. No obstante, algunos bultos vuelven a crecer en el mismo lugar incluso tras una extirpación cuidadosa; por eso revisaremos esa zona en sus visitas de seguimiento. En tal caso, usted y su cirujano podrán decidir cuál es el siguiente paso a seguir.
¿Cuándo consultar a un especialista?¶
La mayoría de los bultos de este tipo son inofensivos y pueden esperar a una consulta rutinaria. Acuda a su médico de cabecera si el bulto le duele, está creciendo o le dificulta agarrar objetos o realizar sus tareas diarias. Solicite una evaluación especializada si al doblar el dedo este se traba o hace “clic”, o si sus dedos se desvían hacia la palma de la mano; estos síntomas pueden indicar otra afección que requiere un tratamiento distinto. Acuda a urgencias si la mano se vuelve caliente, roja e hinchada, o si aparece fiebre, ya que una infección necesita atención inmediata. Busque atención urgente si nota entumecimiento, hormigueo o debilidad nueva en el pulgar o los dedos, pues un bulto que comprime un nervio puede provocar problemas permanentes si no se trata a tiempo.
En mayor profundidad¶
Esta sección profundiza más de lo necesario para que usted tome decisiones sobre su propio tratamiento. El ganglio en la vaina del tendón flexor merece ser leído con atención, ya que se trata del bulto más pequeño en cirugía de mano que, de manera constante, provoca síntomas desproporcionados; además, lo que lo une a otras estructuras determina tanto el motivo del dolor como el porqué los tratamientos sencillos no surten efecto.
Un bulto del tamaño de un guisante que duele de forma desproporcionada¶
Estos quistes, también denominados quistes retinaculares o gangliones retinaculares volares, se originan en la vaina fibrosa que mantiene los tendones flexores adheridos a los huesos de los dedos [1]. Se localizan en la base del dedo, en la palma de la mano; suelen medir solo unos pocos milímetros de diámetro y son firmes en lugar de blandos.
El síntoma es característico y se explica fácilmente una vez que se comprende la anatomía: dolor al agarrar objetos duros y estrechos, como un volante, un palo de golf, el manillar de una bicicleta o el asa de una bolsa de compras. El quiste queda atrapado entre el objeto y el hueso subyacente, y no hay tejido blando que lo amortigue, ya que la vaina está adherida directamente a la falange.
Por eso la relación entre el tamaño del quiste y los síntomas es tan débil. Un bulto grande y blando en el dorso de la muñeca puede ser indoloro, mientras que una lesión mucho más pequeña en la base de un dedo puede llegar a limitar seriamente la movilidad.
La misma regla que para cualquier otro ganglio¶
Su comportamiento depende de a qué estructura está conectado. Este quiste se origina en la vaina tendinosa y se llena a partir de ella; por lo tanto, su mecánica es idéntica a la de los ganglios de muñeca y los quistes mucosos: el saco quístico es solo la manifestación visible del problema, no su origen.
En consecuencia, puncionar o aspirar el quiste soluciona el hinchazón, pero no el origen de la fuga de líquido. Es frecuente que el quiste reaparezca tras un drenaje simple; el tratamiento definitivo consiste en extirpar el quiste junto con la porción afectada de la vaina tendinosa de la que proviene.
¿Por qué la operación parece menor de lo que parece, pero no es trivial?¶
La escisión es un procedimiento breve que se realiza mediante una incisión pequeña en la base del dedo, y generalmente resulta curativa. Dos características anatómicas justifican la necesidad de extremar el cuidado en esa zona.
Los nervios digitales discurren justo al lado de la vaina flexora, uno a cada lado; en la base del dedo, estos nervios se encuentran en una posición superficial y cercana a las estructuras mediolaterales que se van a extirpar. La aparición de una zona entumecida a lo largo de uno de los bordes del dedo es un riesgo conocido de cualquier operación pequeña en esta zona.
En segundo lugar, solo se puede extirpar la porción redundante de la vaina. Las poleas que mantienen los tendones adheridos al hueso son estructuras que soportan carga; si se pierde una de ellas, el tendón tiende a separarse del dedo, lo que debilita la capacidad de agarre. Por ello, la escisión se limita deliberadamente al segmento de la vaina que no cumple esa función.
¿Cuándo dejarlo sin tratar?¶
Dado que esta lesión es benigna y no crece indefinidamente, el tratamiento se decide únicamente en función de los síntomas. Una quiste que es visible pero no causa dolor durante el agarre diario no requiere ninguna intervención. Cuando sí se trata, es porque una actividad específica y repetida resulta afectada; esto constituye un indicador más claro que la mayoría de los demás, ya que la forma de agarre que provoca el problema suele ser fácil de identificar para la persona afectada.
Los quistes relacionados en la articulación de la punta del dedo y en la muñeca se tratan en sus propias páginas; el principio común a los tres casos es que es el tallo del quiste, y no la propia bolsa, lo que determina si el problema volverá a aparecer.
Referencias¶
[1] Foret AL, Chhabra AB. Gangliones del retináculo volar. J Hand Surg Am. 2012;37(3):566-7. https://doi.org/10.1016/j.jhsa.2011.05.013
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview¶
- Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath [1].
- Percutaneous puncture is a practical option for managing flexor tendon sheath ganglions given its low cost, lack of downtime, and low recurrence rate [2].
- No recurrences were observed after a second puncture in the cohort assessed for percutaneous puncture of flexor sheath ganglions [2].
- Endoscopic ganglionectomy via flexor carpi radialis tendoscopy is a minimally invasive approach that offers better cosmesis, less soft tissue trauma, and the ability to manage concomitant FCR tendon pathology [3].
- Endoscopic ganglionectomy via flexor carpi radialis tendoscopy carries risks of recurrence and nerve or vessel injury [3].
- Pediatric ganglions are more commonly found on the volar surface of the hand and wrist compared to adults [4].
- Pediatric ganglions more commonly have tendon sheath origin compared to adults [4].
- There is no consensus within the literature regarding the best management of pediatric wrist ganglia [9].
- No single treatment modality confers a particular advantage or disadvantage over another for pediatric wrist ganglia [9].
- Current best evidence suggests that about 40% of lesions decrease over the first 6 years after evaluation by a hand surgeon [18].
- Current best evidence suggests that most ganglions recur after aspiration [18].
- Current best evidence suggests that surgical intervention has about a 10% recurrence rate [18].
- Surgical intervention for ganglions leaves scars and has some risk for adverse events [18].
- Operation-related complications after arthroscopic volar wrist ganglionectomy are associated with anatomical location distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer [21].
Anatomy & Pathophysiology¶
Anatomical Location and Origin¶
- Volar wrist ganglia tend to arise in the interval between the first extensor compartment and the flexor carpi radialis (FCR) tendon sheath, just proximal to the wrist flexion crease [7].
- Approximately two thirds of anterior wrist ganglions reportedly arise from the radiocarpal joint [7].
- One third of anterior wrist ganglions reportedly arise from the scaphotrapezial joint [7].
- Ganglion cysts that arise from the FCR sheath are often located slightly more medially, either just radial or palmar to the sheath [7].
- Ganglions arising from the FCR sheath are typically less mobile than ganglions arising from the wrist joint [7].
- Ganglions arising from the first extensor compartment tend to adhere to the sheath (extensor retinaculum) and are less mobile [7].
- Ganglions are defined as cystic swellings closely connected to joints or tendon sheaths which contain mucinous material [64].
Clinical Presentation and Physical Characteristics¶
- Volar wrist ganglia typically appear to be 1 to 2 cm in size but may be significantly larger at the time of surgical dissection [7].
- Patients with volar wrist ganglions often present with a mass that has been present for a number of months or years and is typically asymptomatic [7].
- Patients with volar wrist ganglions often note discomfort when the mass is "bumped" [7].
- Clinically, volar wrist ganglia are compressible, slightly mobile, nontender, and visible when transilluminated [7].
- Volar wrist ganglia are nonpulsatile but are often intimate with the radial artery, which is palpable alongside the lesion [7].
- Most patients with intraneural ganglions are aged 30 to 50 years, though occurrence in children has also been reported [11].
- Most patients with intraneural ganglions present with a painless mass [11].
- Some patients with intraneural ganglions present with symptoms of nerve irritation or entrapment neuropathy [11].
Pathogenesis and Etiology¶
- The etiology of ganglions is unknown [64].
- Many hypotheses have been advanced for the pathogenesis of ganglions, including retention cyst, herniation of tendon or capsular synovia, bursal transformation, neoplasia, and mucinous degeneration of fibrous tissue [64].
- Carp and Stout reported that a ganglion does not initially connect with the joint and that communication occurs secondary to degeneration of the capsule which then ruptures [64].
- Injections of contrast material into ganglions usually fail to show a communication into the joint [64].
- Injections of contrast material into the wrists of patients have demonstrated communications into the ganglions [64].
- In forty of fifty-nine patients with ganglions in the study by Andrén and Eiken, contrast medium passed from the joint into the ganglion through a tortuous narrowed duct [64].
- The articular (synovial) theory has gained worldwide acceptance as a scientifically proven explanation for the formation of intraneural ganglions [11].
- The pathogenesis of intraneural ganglion cysts remains unclear, though trauma has been proposed as a possible reason [77].
- The theory of articular unification is mainly accepted as the cause for intraneural ganglion cysts [77].
Nerve Involvement¶
- Involvement of the peripheral nerves of the upper extremity by intraneural ganglion is rare [11].
- The ulnar nerve is the most commonly involved nerve in the upper extremity by intraneural ganglion [11].
- Almost any other nerve in the vicinity of a joint can be involved by intraneural ganglion [11].
- Intraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves [77].
Classification¶
- Volar wrist ganglia tend to arise in the interval between the first extensor compartment and flexor carpi radialis (FCR) tendon sheath, just proximal to the wrist flexion crease [7].
- Ganglion cysts that arise from the FCR sheath are often in a slightly more medial location, either just radial or palmar to the sheath [7].
- Ganglions arising from the first extensor compartment tend to adhere to the sheath (extensor retinaculum) [7].
- Ganglions arising from the first extensor compartment tend to be quite firm and are less mobile [7].
- The proposed classification of ganglia helps minimize the area of resection required [50].
Clinical Presentation¶
General Characteristics¶
- Volar wrist ganglia are typically asymptomatic masses that have been present for months or years [7].
- Patients with volar wrist ganglions often report discomfort when the mass is bumped [7].
- Clinically, volar wrist ganglions are compressible, slightly mobile, nontender, and visible when transilluminated [7].
- Volar wrist ganglions are nonpulsatile but are often intimate with the radial artery, which is palpable alongside the lesion [7].
- Ganglion cysts arising from the flexor carpi radialis (FCR) sheath are often located slightly more medially, either just radial or palmar to the sheath [7].
- Ganglions arising from the first extensor compartment tend to adhere to the sheath, are quite firm, and are less mobile [7].
Epidemiology and Demographics¶
- Women are significantly more likely to be diagnosed with a volar wrist ganglion, regardless of age or military status [6].
- Pediatric ganglions more commonly have a tendon sheath origin compared to adults [4].
- In children aged less than 10 years, ganglion cysts present on the volar aspect of the wrist [15].
- In patients aged greater than 10 years, ganglions resemble those in the adult population and present on the dorsal aspect of the wrist [15].
- Ganglions in pediatric populations demonstrate a female predilection [26].
Imaging and Diagnosis¶
- Routine wrist radiography is not cost-effective in the evaluation of patients with a wrist ganglion due to a low prevalence of therapeutically significant findings [16].
- MRI provides relatively good reliability in establishing the diagnosis of an occult dorsal wrist ganglion, with a sensitivity of 83% when using intra-operative findings as the standard [27].
- MRI is an excellent diagnostic modality to evaluate rapidly growing upper extremity masses and distinguish ganglions from malignant processes [20].
- The 3-dimensional FSE extended echo train MRI sequence (cube) provides better visualization of intraneural ganglions and articular connections to the cyst [11].
Investigations¶
- Radiologists are less likely to identify occult dorsal ganglion cysts on MRI if the cyst is smaller or if the requisition form does not mention a cyst [63].
- Recent advances in MRI technology, specifically the 3-dimensional FSE extended echo train sequence called cube, have revolutionized the visualization of intraneural ganglions and the articular branches that connect them to the joint [11].
- High-resolution MRI techniques have the potential to improve patient outcomes by allowing better preoperative planning and more accurate surgical intervention [11].
- Routine wrist radiography is not cost-effective in the evaluation and treatment decision-making process for patients with a wrist ganglion due to a low prevalence of therapeutically significant findings [16].
- Sonography-guided wrist arthroscopy provides visualization of the ganglions and ganglion stalk, as well as of the arthroscopic shaver and adjacent structures such as nerves, vessels, and tendons [54].
- Sonography-assisted arthroscopic resection is a safer and more reliable method for treating volar wrist ganglia [30].
- A careful physical examination is essential to direct care and future testing if indicated, as diagnostic tests such as imaging can be expensive, time consuming, and often nonspecific [23].
Non-Operative Management¶
- Nonsurgical treatment is largely ineffective in treating ganglion cysts, though it may be considered for symptomatic relief in patients who do not want surgery [55].
- No recurrences were observed after a second puncture in the cohort assessed for percutaneous puncture of flexor tendon sheath ganglions [2].
- Most ganglions recur after aspiration [18].
- There is no consensus within the literature regarding the best management of pediatric wrist ganglia, and no single treatment modality confers a particular advantage or disadvantage over another [9].
Operative Management¶
- Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions [62].
- Surgical intervention has about a 10% recurrence rate, leaves scars, and has some risk for adverse events [18].
- Arthroscopy allows for the simultaneous treatment of ganglions and other pathologies [10].
- The outcomes, recurrence, and complications rates after 4 years of follow-up support the use of arthroscopy as a treatment for dorsal wrist ganglion [12].
- At 12 months follow-up, the rates of recurrence with arthroscopic dorsal ganglion excision are comparable with and not superior to those of open excision [17].
- Arthroscopic resection is an effective treatment strategy for intra-articular synovial ganglions refractory to conservative measures, providing complete resolution of symptoms and functional recovery with minimal soft tissue damage [51].
- Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia [52].
- Recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection [22].
- In patients with the clinical diagnosis of wrist ganglion cyst, the quality of care would not be compromised by abandoning the practice of routine submission of surgical specimens for pathological examination after excision of the ganglion cyst [13, 25].
Outcomes and Complications¶
- Recurrence of the wrist ganglion cyst occurred in five patients (9%) in a cohort of 53 patients undergoing arthroscopic resection [49].
- PRWE scores were significantly higher in patients with a recurrence (30 vs. 12, p = 0.002) following arthroscopic resection [49].
- Patients initially presenting with a new ganglion cyst had fewer recurrences at final follow-up compared with patients initially presenting with recurrence (4 vs. 15%, respectively) [49].
- Three of the 53 patients (6%) had a complication following arthroscopic resection of wrist ganglion cysts [49].
- One patient experienced neuropraxia of the radial superficial nerve, which resolved spontaneously [49].
- One patient developed extensor carpi ulnaris (ECU) tendinitis which was successfully treated with splinting [49].
- One patient experienced painful scar tissue, which was successfully removed surgically [49].
- Worse hand function was associated with recurrence following prior surgery, worse baseline hand function and lower treatment credibility [28].
Complications¶
- Surgical excision of flexor tendon sheath ganglions is considered a safe method with no specific complications reported in the cited study [1].
- Percutaneous puncture of flexor tendon sheath ganglions has a low recurrence rate, with no recurrences observed after a second puncture in the studied cohort [2].
- Volar wrist ganglions arising from the first extensor compartment or flexor carpi radialis (FCR) sheath may be difficult to distinguish from anterior wrist joint ganglions [7].
- Ganglion cysts arising from the FCR sheath are typically less mobile than ganglions arising from the wrist joint [7].
- Ganglions arising from the first extensor compartment tend to adhere to the sheath and are less mobile [7].
- Operation-related complications after arthroscopic volar wrist ganglionectomy are associated with the anatomical location of the cyst, specifically when it is distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer [21].
- Surgical intervention for wrist ganglions has a recurrence rate of approximately 10% [18].
- Surgical intervention for wrist ganglions leaves scars and carries some risk for adverse events [18].
- Open dorsal wrist ganglion excision in patients whose occupation or activities require forceful wrist extension is associated with a considerable risk of residual pain and functional limitations [70].
- Arthroscopic resection of dorsal wrist ganglions has recurrence and complication rates that support its use as a treatment option [12].
Recovery¶
- Surgical excision of a painful ganglion of the digital flexor tendon sheath is a simple, safe, and effective method [1].
- Percutaneous puncture for flexor tendon sheath ganglions has a low recurrence rate, with no recurrences observed after a second puncture in the studied cohort [2].
- Endoscopic ganglionectomy via flexor carpi radialis tendoscopy offers better cosmesis and less soft tissue trauma compared to other approaches [3].
- In children with a wrist ganglion, if the cyst resolves spontaneously, it usually does so within 18 months [14].
- In children aged <10 years, volar wrist ganglions are generally amenable to observation with spontaneous regression [15].
- Open surgical excision for pediatric wrist ganglions demonstrates a relatively low recurrence rate with minimal complications [15].
- Approximately 40% of wrist ganglion lesions decrease over the first 6 years after evaluation by a hand surgeon [18].
- Surgical intervention for wrist ganglions has about a 10% recurrence rate [18].
- Surgical intervention for wrist ganglions leaves scars and has some risk for adverse events [18].
- Routine midcarpal joint exploration during arthroscopic excision of dorsal wrist ganglions appeared to reduce recurrence at 1 year without negatively impacting patient outcomes [29].
- Complete resection of the ganglion stem and complete closure of the joint capsule is the most important step to avoid recurrences [71].
Key Evidence¶
- [L4] Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath. [1] (10.1007/s11552-007-9028-4)
- [L4] Percutaneous puncture is a practical option for managing flexor tendon sheath ganglions given its low cost, lack of downtime, and low recurrence rate, with no recurrences observed after a second puncture in this cohort. [2] (10.1177/17531934221115983)
- [Paper] Endoscopic ganglionectomy via flexor carpi radialis tendoscopy is a minimally invasive approach that offers better cosmesis, less soft tissue trauma, and the ability to manage concomitant FCR tendon pathology, though it carries risks of recurrence and nerve or vessel injury. [3] (10.1016/j.eats.2017.06.002)
- [L4] Pediatric ganglions are more commonly found on the volar surface of the hand and wrist and more commonly have tendon sheath origin compared to adults. [4] (10.1007/s11552-008-9122-2)
- [L3] Women are significantly more likely to be diagnosed with a volar wrist ganglion, regardless of age or military status. [6] (10.1016/j.jhsa.2016.08.008)
- [L5] [7] (10.1016/j.hcl.2004.03.015)
- [L4] There is no consensus within the literature regarding the best management of pediatric wrist ganglia, and no single treatment modality confers a particular advantage or disadvantage over another. [9] (10.1177/1558944720966716)
- [L4] Arthroscopy allows for the simultaneous treatment of ganglions and other pathologies. [10] (10.1016/j.jhsa.2012.04.042)
- [L4] [11] (10.1016/j.jhsa.2015.05.025)
- [L4] The outcomes, recurrence, and complications rates after 4 years of follow-up presented in this study support the use of arthroscopy as a treatment for dorsal wrist ganglion. [12] (10.1177/1558944717743601)
- [L4] In patients with the clinical diagnosis of wrist ganglion cyst, the quality of care would not be compromised by abandoning the practice of routine submission of surgical specimens for pathological examination after excision of the ganglion cyst. [13] (10.1016/s0363-5023(10)60107-4)
- [L4] In a child with a wrist ganglion, if the cyst ultimately resolved, it usually did so within 18 months. [14] (10.1016/j.jhsa.2019.10.032)
- [L4] [15] (10.1016/j.jhsa.2021.12.015)
- [L4] The study concludes that routinely performing wrist radiography is not cost-effective in the evaluation and treatment decision-making process for patients with a wrist ganglion due to a low prevalence of therapeutically significant findings. [16] (10.1007/s11552-007-9032-8)
- [L1] At 12 months follow-up, the rates of recurrence with arthroscopic dorsal ganglion excision are comparable with and not superior to those of open excision. [17] (10.1016/j.jhsa.2008.01.009)
- [L5] Current best evidence suggests that about 40% of lesions decrease over the first 6 years after evaluation by a hand surgeon, that most ganglions recur after aspiration, and that surgical intervention has about a 10% recurrence rate, leaves scars, and has some risk for adverse events. [18] (10.1016/j.jhsa.2010.11.048)
- [L4] MRI is an excellent diagnostic modality to evaluate rapidly growing upper extremity masses and distinguish ganglions from malignant processes. [20] (10.1007/s11552-007-9083-x)
- [L3] The operation-related complications after arthroscopic volar wrist ganglionectomy are associated with its anatomical location: distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer. [21] (10.1186/s12891-025-08766-x)
- [L4] Ganglion cysts also have a high association with certain interosseous laxities, and recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection. [22] (10.1016/j.jhsa.2008.11.025)
- [L3] This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. [25] (10.1016/j.jhsa.2010.03.021)
- [L2] Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. [26] (10.1016/j.jhsa.2021.02.026)
- [L3] MRI scans provide relatively good reliability in establishing the diagnosis of an occult dorsal wrist ganglion, with a sensitivity of 83% when using intra-operative findings as the standard. [27] (10.1177/1753193408092041)
- [L2] Worse hand function was associated with recurrence following prior surgery, worse baseline hand function and lower treatment credibility. [28] (10.1177/17531934231153029)
- [L3] Routine midcarpal joint exploration during arthroscopic excision of dorsal wrist ganglions appeared to reduce recurrence at 1 year without negatively impacting patient outcomes. [29] (10.1177/17531934251405730)
- [Paper] This method is safer and more reliable for treating volar wrist ganglia. [30] (10.1016/j.eats.2011.12.007)
- [L4] [49] (10.1055/s-0040-1716509)
- [L4] The proposed classification of ganglia helps minimize the area of resection required. [50] (10.1054/jhsb.2001.0620)
- [L4] Arthroscopic resection is an effective treatment strategy for intra-articular synovial ganglions refractory to conservative measures, providing complete resolution of symptoms and functional recovery with minimal soft tissue damage. [51] (10.1016/j.jhsg.2024.05.007)
- [L4] Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia. [52] (10.1016/j.arthro.2009.08.021)
- [L4] Sonography-guided wrist arthroscopy provides several advantages for surgeons, including visualization of the ganglions and ganglion stalk, as well as of the arthroscopic shaver and adjacent structures such as nerves, vessels, and tendons to perform surgery safely. [54] (10.1016/j.jhsa.2012.04.012)
- [L4] Nonsurgical treatment is largely ineffective in treating ganglion cysts, though it may be considered for symptomatic relief in patients who do not want surgery. [55] (10.1155/2013/940615)
- [L1] Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions. [62] (10.1016/j.jhsa.2014.12.014)
- [L3] Radiologists are less likely to identify occult dorsal ganglion cysts on MRI if the cyst is smaller or if the requisition form does not mention a cyst. [63] (10.1055/s-0039-1683847)
- [L4] [64] (10.2106/00004623-197254070-00009)
- [L4] Patients whose occupation or activities require forceful wrist extension should be counseled on the considerable risk of residual pain and functional limitations that may occur after open dorsal wrist ganglion excision. [70] (10.1016/j.jhsa.2015.05.030)
- [L4] Complete resection of the ganglion stem and complete closure of the joint capsule is the most important step to avoid recurrences. [71] (10.1007/s001670050073)
- [L5] [77] (10.1186/s12883-018-1229-7)
References¶
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