Wrist ganglions

by Neil Kruger, Pieter Jordaan & Duncan McGuire

Learning objectives

  1. A ganglion is a benign mass.
  2. The diagnosis is clinical.
  3. If you are not certain of the diagnosis, rather refer or send for further investigations.
  4. They are usually pain free, but occasionally cause discomfort or pain.

Definition

A ganglion is a fluid filled sac whose wall is made up of a lining that has no cells. It usually originates from a joint.

Background

Wrist ganglions are common, occurring predominantly on the dorsum of the wrist. They vary in size. They may also wax and wane (get bigger and then smaller again). They have been described originating from every joint in the hand, but the most common origin is from the dorsal scapholunate joint.

They may occur volarly where they usually originate from the radiocarpal joint. These are often intimately related to the radial artery.

Diagnosis

The diagnosis is mainly a clinical one.

History

A typical history is of a non-painful mass which may increase and decrease in size over time. Occult ganglions on the dorsum of the wrist are small and usually present with pain on wrist extension. They are usually not visible due to their small size. Pain is due to impingement or posterior interosseus nerve irritation.

Examination

The mass is well defined, fluctuant, non-tender and trans-illuminates. Flexion of the wrist can sometimes unmask a small dorsal wrist ganglion. Wrist movement should be checked and compared to the opposite side. Extension may be slightly decreased depending on the size of the ganglion, but flexion is usually normal.

Special investigations

Investigations are usually unnecessary but, if there is doubt about the diagnosis, an ultrasound or MRI may be performed.

Classification

The classification is based on location - either dorsal or volar.

Management

Dorsal ganglions

No treatment is required as ganglions often resolve on their own and are usually asymptomatic except for the cosmetic aspect. Aspiration may be attempted but the recurrence rate is high. Surgical excision may be done but there is a recurrence rate of around 5%.

Volar ganglions

Again, usually no treatment is required. Aspiration should not be attempted due to the risk of injury to the radial artery. The recurrence rate after excision is about 10%.

Complications

Pitfalls

References

Hammert WC, Calfee RP, Bozentka DJ, Boyer MI; 2010; ASSH Manual of Hand Surgery; Lippincott, Williams and Wilkins (Wolters Kluwer); Philadelphia, USA.

Miller MD; 2008; Review of Orthopaedics, 5th edition; Elsevier; Philadelphia, USA.

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS; 2017; Green’s Operative Hand Surgery, 7th Edition; Elsevier; Philadelphia, USA.

Assessment

A 22-year-old female patient presents with a mass on the dorsum of the wrist that has been there for years, without a history of trauma. Since starting CrossFit, it causes discomfort when she does press-ups. Your most likely diagnosis is:

  1. Scapholunate interosseus ligament tear
  2. Scaphoid fracture
  3. Osteochondroma
  4. Giant cell tumour
  5. Dorsal wrist ganglion

The correct answer is (E), dorsal wrist ganglion.