A ganglion is a harmless cyst, which presented as a sac of fluid, that develops around joints and/or tendons. Wrist joint is commonly affected. We often do not identify exact cause, but we know that ganglions nature is benign, often self-limiting and only handful need active surgical input. Treatments are usually required when ganglions are long standing, increasing in size, painful and regularly interfering with activities of daily living.

All joints are surrounded, wrapped by tough, watertight sac called the joint capsule. Joints contain certain amount of viscous fluid that acts as a lubricant, called synovial fluid. It allows tendons and bones within the joint to move easily, glide against each other. Wrist ganglions are attached to the wrist joint capsule and appear at the back of the wrist (dorsal side) in approximately 60 -70 % of cases. They can appear on the palm side of the wrist (volar side) too, usually towards the base of the thumb (20-30% of wrist ganglions). Please refer to Gallery below where pictures illustrate diversity in ganglion appearance and location and their, often deep origin.

Causes are poorly understood. In some cases, the wrist has been injured previously so the weakening of the joint capsule allows ‘escape’ of the joint fluid. Most patients are therefore asked about possible trauma in the past.

Other theory suggests that wrist ganglions are formed when connective tissue degenerates or is damaged by wear and tear, strenuous repetitive movements, again allowing weak spots within the capsule to open up. Over time, especially with manual work, the cyst grows larger. The joint fluid seems to move out of the wrist joint into the ganglion, but not the other way. More the hand and wrist are being used, bigger the cysts become and vice versa. Patients commonly report temporary decrease in ganglions size during rest, holidays, pause from sports etc. Ganglions commonly “come and go”, but, except for truly acute ones, they rarely properly disappear.

First complain is often only cosmetic – annoyance with visible and palpable bump at the back of the wrist. Ache or tenderness often follows, but most patients are able to do everything. Occasionally, ganglions are not visible or palpable at all and are therefore called occult. Those are usually very small, seated deeply within the wrist joint and only detected by special imaging after patient complains of long standing wrist pain.

Ganglions are often considered to be a “top of the iceberg” – they appear because of the underlying arthritis of ligament injury (Picture 1, Gallery). All of these should be excluded prior to treatment or addressed during surgery in order to achieve good outcome.

Most ganglions do not require treatment! They are typically harmless and many would disappear on their own. They do not cause damage to the tendons, nerves, or the joint as a whole. Clinical assessment should be critical in order to prevent premature and harmful interventions. No surgery is without risk, so when benign abnormalities are considered for treatment, caution is advisable.

Aspiration – content of the ganglion is simply aspirated through a needle and lesion deflated. Benefit is usually short lived and commonly used only as a temporary measure. Intervention is feasible in outpatient setting. Personally, I very rarely aspirate ganglions: intervention does not resolve the underlying problem, can be unpleasant for the patient, can often fail as sac content is too thick to be aspirated even through a thick needle, aspiration can introduce infection, induce scarring which is unfavorable in case of subsequent surgery. In my practice, ganglion aspiration is reserved for symptomatic patients with frail health, for whom attendance to a day surgery list would be of significant inconvenience.

Surgery is recommended when the patient feels significant pain or when the cyst has been interfering with daily activities over prolonged period of time (several months rather then weeks).

It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:

• Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
• Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery
• Plan your time off school / work / sports
• Allow at least few weeks after surgery before considering travel

Operation is usually carried out on day care basis using regional or general anesthesia. Tourniquet needs to be applied during surgery for a period of time longer then awake patient is able to tolerate hence local anaesthetic is usually avoided.

Excision (removal) of the ganglion requires removal of entire stalk, inspection of the underlying joint ligaments and sometimes their reinforcement, repair of the joint capsule and protection of all surrounding tendons and nerves (Picture 1, Gallery). Incisions are usually placed within the existing wrist skin creases (Picture 5, Gallery). Either dissolving or non-absorbable sutures can be used to close the wound. Wrist is bandaged and kept elevated. I only put a cast (Plaster of Paris) if more radical surgery has been carried i.e. internal wrist ligaments have been repaired or reinforced at the time of ganglion excision.

Recovery is straight forward and without major restrictions. Bandage is removed and wound checked at one week. You are encouraged to move fingers straight after surgery – make a fist and fully extend fingers several times a day, whilst keeping hand and wrist elevated (above elbow level). Stitches are removed at 2 weeks.

You will be shown how to massage the scar and operated area in order to help body disperse local tissue fluid and oedema. Scar and wrist may remain firm and feel stiff up to 3-4 months. Healing process continues to change the scar properties up to 8 months after surgery. During that time, scar tissue will eventually soften, fade and become more pliable. Patients should not be discouraged by a rather slow scar maturation, but continue moving the wrist fully 2-3 weeks after operation.

Things to look out for after operation and contact us earlier than planned:

• Disproportionate swelling and pain in your hand
• Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
• Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
• Increased skin temperature in the scar area
• Offensive wound smell

Complications are rare, but as with any surgical procedure, there are well recognised general and wrist surgery specific risks which patients should be aware of:

General complications:

• Adverse reaction to the general anaesthetic
• Skin/wound infection
• Stiffness
• Hypertrophic (lumpy and itchy) scarring
• Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery with painful and stiff hands – this can occur with any hand surgery from a minor procedure to a complex reconstruction)

Specific complications:

•  Implant dislocation (if implant is used)
• Nerve injury resulting in either: Numbness or Neuroma (painful nerve lump extremely sensitive to touch)
• Joint infection
• Recurrence (reported rates are between 10-35%)
• Tendon and nerve damage