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Ganglion cyst

ganglion cyst, ganglion cyst wrist
A ganglion cyst is a fluid filled lump associated with a joint or tendon sheath3 They most often occur at the back of the wrist followed by the front of the wrist34 Onset is often over months4 Typically there are no further symptoms3 Occasionally pain or numbness may occur3 Complications may include carpal tunnel syndrome4

The cause is unknown3 The underlying mechanism is believed to involve an outpouching of the synovial membrane4 Risk factors include gymnastics3 Diagnosis is typically based on examination with light shining through the lesion being supportive4 Medical imaging may be done to rule out other potential causes34

Treatment options include watchful waiting, splitting the affected joint, needle aspiration, or surgery3 About half the times they resolve on their own4 About 3 per 10,000 people newly develop ganglion of the wrist or hand a year5 They most commonly occur in young and middle aged females3 Trying to treat the lesion by hitting it with a book is discouraged4


  • 1 Signs and symptoms
    • 11 Sites
  • 2 Cause
  • 3 Diagnosis
  • 4 Treatment
    • 41 Complications
  • 5 Prognosis
  • 6 Etymology
  • 7 See also
  • 8 References
  • 9 External links

Signs and symptomsedit

The average size of these cysts is 20 cm, but excised cysts of more than 5 cm have been reported6 The size of the cyst may vary over time and, may increase after activity


These cysts most frequently occur around the dorsum of the wrist and on the fingers A common site of occurrence is along the extensor carpi radialis brevis, as it passes over the dorsum of the wrist joint Although most commonly found in the wrist, ganglion cysts also may occur in the foot7

Ganglion cysts are "commonly observed in association with the joints and tendons of the appendicular skeleton, with 88% 'in communication with the multiple small joints of the hand and wrist' and 11% with those of the foot and ankle"6 They commonly are found near the wrist joint, especially at the scapho-lunate area8

In a 2007 study of patients in Glasgow whose foot lumps were being removed surgically, 39 of 101 cases were ganglion cysts The study replicated earlier findings that no ganglion cysts were found on the sole or heel of the foot; the authors wrote that "Although lumps in these areas may be ganglia, the surgeon should probably consider other diagnoses in the first instance" The researchers also noted a marked preponderance of occurrence among females 85% and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery9

Ganglion cysts are not limited to the hands and feet They may occur near the knee, commonly near the cruciate ligaments, but also they may occur at the origins of the gastrocnemius tendon and, anteriorly, on Hoffa's infrapatellar fat pad10 At the shoulder, they typically occur at the acromioclavicular joint or along the biceps tendon11

From their common origin at a joint or tendon, ganglion cysts may form in a wide range of locations Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue612 Very rare cases of intramuscular ganglion cysts in the gastrocnemius muscle of the calf have been reported1314 It is possible for a cyst to be displaced considerably from its connection to the joint In one extreme case, a ganglion cyst was observed to propagate extensively via the conduit of the common peroneal nerve sheath to a location in the thigh; in such cases surgery to the proximal joint to remove the articular connection may remove the need for a riskier, more extensive surgery in the neural tissue of the thigh15 The cysts may intrude into the spine, which may cause pain and dysesthesia in distant extremities16

It has been proposed recently that cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, may occur by an articular mechanism, with a conduit leading from the joint, similar to the development of ganglion cysts, that spreads within the peroneal nerve17

Cysts that were compressing one or more nerves and causing bone erosions have been reported to occur near the shoulder joint18


The most commonly accepted probable cause of ganglion cysts is the "herniation hypothesis", by which they are thought to occur as "an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath" This description is based on the observations that the cysts occur close to tendons and joints, the microscopic anatomy of the cyst resembles that of the tenosynovial tissue, the fluid is similar in composition to synovial fluid, and dye injected into the joint capsule frequently ends up in the cyst, which may become enlarged after activity Dye injected into the cyst rarely enters the joint, however, which has been attributed to the apparent formation of an effective and one-way "check valve", allowing fluid out of the joint, but not back in6

In synovials, posttraumatic degeneration of connective tissue and inflammation have been considered as causes Other possible mechanisms for the development of ganglion cysts include repeated mechanical stress, facet arthrosis, myxoid degeneration of periarticular fibrous tissues and liquefaction with chronic damage, increased production of hyaluronic acid by fibroblasts, and a proliferation of mesenchymal cells Ganglion cysts also may develop independently from a joint1619


Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining

Ganglion cysts are diagnosed easily, as they are visible and pliable to touch

Radiographs in AP and lateral views should be obtained to exclude any more serious underlying pathology20 Ultrasonography US may be used to increase diagnostic confidence in clinically suspected lesions or to depict occult cysts,21 because intratendinous ganglia are readily distinguished from extratendinous ganglia during dynamic ultrasonography, as microscopically, ganglionic cysts are thin-walled cysts containing clear, mucinous fluid7


Besides the frequent choice to leave the cyst in place, surgical treatments remain the primary elective option for treatment of ganglion cysts The progression of ganglion surgery worldwide is to use an arthroscopic or mini-opening method22 Alternatively, a hypodermic needle may be used to drain the fluid from the cyst via aspiration and a corticosteroid may be injected after the cyst is empty;21 however, if the fluid has thickened, owing to the passage of time, this treatment is not always effectivecitation needed There is a recurrence rate of approximately 50% following needle drainage via aspiration of ganglion cysts

One common and traditional method of treatment for a ganglion cyst was to strike the lump with a large and heavy book, causing the cyst to rupture and drain into the surrounding tissues Historically, a Bible was the largest or only book in any given household, and often was employed for this treatment This led to the former nickname of "Bible bumps" or "Gideon's disease" for these cysts223 This treatment risks injuring the patient


Complications of treatment may include joint stiffness and scar formation21 Recurrence of the lesion is more common following excision of a volar ganglion cyst in the wrist Incomplete excision that fails to include the stalk or pedicle also may lead to recurrence, as will failing to execute a layered closure of the incision24


Recurrence rate is higher in aspirated cysts than in excised ones20 Ganglion cysts have been found to recur following surgery in 12%25 to 41%26 of patients

A six-year outcome study of the treatment of ganglion cysts on the dorsum back of the wrist compared excision, aspiration, and no treatment Neither excision nor aspiration provided long-term benefit better than no treatment Of the untreated ganglion cysts, 58% resolved spontaneously; the post-surgery recurrence rate in this study was 39%27 A similar study in 2003 of ganglion cysts occurring on the palmar surface of the wrist states: "At 2 and 5 year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated or left alone"28


Being a misnomer that has persisted into modern times,29 the ganglion cyst is unrelated to the neural "ganglion" or "ganglion cell"; its etymology traces back to the ancient Greek γάγγλιον, a "knot" or "swelling beneath the skin",30 which extends to the neural masses by analogy Generally, Hippocrates is credited with the description of these cysts631

The term "Bible cyst" or "Bible bump" is derived from an urban legend that the historical treatment consisted of hitting the cyst with a Bible32 Trying to treat the lesion by hitting it with a book is however discouraged4

See alsoedit

  • Ganglioneuroma


  1. ^ "National Library of Medicine - Medical Subject Headings MeSH - Ganglion Cyst" Retrieved August 27, 2013 
  2. ^ a b "E-handcom The Electronic Textbook of Hand Surgery" The American Society for Surgery of the Hand asshcom Retrieved April 12, 2014 
  3. ^ a b c d e f g h i j k l m "Ganglion Cyst of the Wrist and Hand-OrthoInfo" orthoinfoaaosorg March 2013 Retrieved 10 June 2017 
  4. ^ a b c d e f g h i j k l Ferri, Fred F 2014 Ferri's Clinical Advisor 2015 E-Book: 5 Books in 1 Elsevier Health Sciences p 472 ISBN 9780323084307 
  5. ^ a b Cooney, William P 2011 The Wrist: Diagnosis and Operative Treatment Lippincott Williams & Wilkins p 1089 ISBN 9781451148268 
  6. ^ a b c d e Craig A Camasta, DPM 1993 "excision of the ganglion cyst" PDF Podiatry Institute 
  7. ^ a b McNabb, J W 2005 Practical Guide to Joint and Soft Tissue Injection and Aspiration Lippincott Williams & Wilkins pp 62–65 ISBN 9780781753630 
  8. ^ "Ganglion cysts" The British Society for Surgery of the hand BSSH Retrieved April 6, 2017 
  9. ^ Duncan JM Macdonald; et al August 2007 "The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years" Annals of the Royal College of Surgeons of England 89 3: 272–275 PMC 1964714  PMID 17394713 doi:101308/003588407x168235 
  10. ^ Jon Arthur Jacobson 2007 Fundamentals of Musculoskeletal Ultrasound Elsevier Health Sciences 
  11. ^ Arend CF Ultrasound of the Shoulder Master Medical Books, 2013 Sample chapter available on acromioclavicular joint ganglion
  12. ^ Muir B, Kissel JA, Yedon DF December 2011 "Intraosseous ganglion cyst of the humeral head in a competitive flat water paddler: case report" J Can Chiropr Assoc 55 4: 294–301 PMC 3222705  PMID 22131566  includes MRI images
  13. ^ Jae Jeong Park; et al 2010 "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle" Korean Journal of Dermatology 
  14. ^ Soonchan Park MD, et al October 2009 "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: Sonographic appearance" Journal of Clinical Ultrasound 37 8: 478–481 doi:101002/jcu20609 
  15. ^ Robert J Spinner; et al 2012 "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" PDF Turkish Neurosurgery pp 527–528 
  16. ^ a b Sang Woo Kim; et al April 2011 "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen" J Korean Neurosurg Soc 49 4: 237–240 PMC 3098430  PMID 21607185 doi:103340/jkns2011494237  original source cites eight additional references for the quoted paragraph
  17. ^ R J Spinner; et al 2012-08-29 "Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected" Clin Anat 26 2: 267–81 PMID 22933403 doi:101002/ca22152 
  18. ^ Field, Larry D 2003 MasterCases: Shoulder and Elbow Surgery Thieme p 241 ISBN 9780865778733 
  19. ^ Ribes, Ramón 2010 Learning Musculoskeletal Imaging Springer p 197 ISBN 9783540880004 
  20. ^ a b Pocket Guide to Musculoskeletal Diagnosis Springer 2005 p 63 ISBN 9781597450096 
  21. ^ a b c The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1 Gale 2003 p 560 ISBN 9780787677213 
  22. ^ Bismil MSK, Bismil QMK The wide awake approach to hand and wrist ganglia: Ten-year experience, technical tips and review of macroscopic pathology and outcomes of 300 cases OA Case Reports 2013 Nov 15;213:129
  23. ^ Dacombe, PJ; Robinson, J Mar 27, 2012 "Falling Up the Stairs: the Equivalent of 'Bashing it with a Bible' for an ACL Ganglion Cyst of the Knee" BMJ Case Reports 2012 PMC 3316796  PMID 22605799 doi:101136/bcr0120125591 
  24. ^ Camasta, Craig A, DPM, Excision of the Ganglion Cyst, podiatryinstitutecom, update 1993, 1993 33 pdf, pages 181–5
  25. ^ Gallego S, Mathoulin C 2010 "Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years" Arthroscopy 26 12: 1675–1682 PMID 20952152 doi:101016/jarthro201005008 
  26. ^ Lidder S, Ranawat V, Ahrens P 2009 "Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction" Orthop Rev 1 1: e5 PMC 3143961  PMID 21808669 doi:104081/or2009e5 
  27. ^ Dias JJ, Dhukaram V, Kumar P Oct 2007 "The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention" J Hand Surg Eur 32 5: 502–8 doi:101016/jjhse200705007 
  28. ^ Dias J, Buch K Apr 2003 "Palmar wrist ganglion: does intervention improve outcome A prospective study of the natural history and patient-reported treatment outcomes" J Hand Surg Br 28 2: 172–6 doi:101016/s0266-76810200365-0 
  29. ^ JC Segen 1992 The Dictionary of Modern Medicine  see the entry for aneurysmal bone cyst, which "like pyogenic granuloma and ganglion cyst, a misnomer that has withstood the sands of time and the dint of logic"
  30. ^ "Etymology of the Greek word ganglion γάγγλιον" 
  31. ^ See Hippocrates' "On the Articulations" part 40 at Wikisource
  32. ^ http://wwweatonhandcom/hw/hw013htm

External linksedit

  • ICD-10: M674
  • ICD-9-CM: 7274
  • MeSH: D045888
  • DiseasesDB: 31229
External resources
  • eMedicine: orthoped/493

  • MRI showing a ganglion cyst of the knee
  • American Academy of Orthopaedic Surgeons - Ganglions cyst of the wrist
  • Canadian Centre for Occupational Health and Safety - Ganglion cyst

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