Intra-articular Cystic Stalks

In the current literature, the exact roles of intra-articular cystic stalks are somewhat vague. Earlier reports implied, but did not specifically state, that identification and surgical excision of the stalk are paramount when standard arthroscopic techniques are used for ganglion excision. However, the presence of this important structure has been variably reported in the literature. Osterman and Raphael¹ identified a stalk in two thirds of their patients undergoing arthroscopic ganglion excision. Although one third of their patients had no identifiable stalk, ganglions were successfully excised with no recurrences. Other studies have reported a stalk incidence as low as 10%.^2–4 Despite vastly different reports on stalk identification, the importance of such pathology must be questioned. Rather than a cystic stalk, Edwards and Johansen⁴ described intra-articular cystic material and redundant capsular tissue in most of their patients with ganglion cysts. This finding, which was more consistently evident than the stalk, was the focus of their resection.

The intra-articular limitations of arthroscopic viewing may explain the paucity of stalk identification. The radiocarpal and midcarpal joints are separated by the extrinsic capsular ligaments. At this separation, the dorsal capsular reflection is adherent to the interosseous scapholunate ligament. It is possible for a ganglion stalk to travel toward the scapholunate ligament within the substance of the dorsal capsular reflection, rather than through the radiocarpal or midcarpal spaces, and the stalk may never be visualized by arthroscopy. Certain observations during arthroscopic resections may support this theory. On several occasions, extravasations of cystic fluid were observed during débridement of the dorsal capsular reflection between the radiocarpal and midcarpal joints when stalks had not been visualized in either compartment. In other words, the stalk might have been hidden within the dorsal capsular extrinsic ligaments.

Intra-articular Associations

The dorsal ganglion may be an overt sign of intra-articular pathology. Povlsen and Peckett⁵ found intra-articular abnormalities in 75% of patients with painful ganglia. They concluded that, like the popliteal cyst in the knee, the dorsal ganglion was a marker of joint abnormality. Osterman and Raphael¹ found abnormalities in 42% of their cases, predominately findings at the scapholunate ligament (24%), the triangular fibrocartilage (8%), and the lunatotriquetral ligament (3%) and significant chondromalacia. Despite the fact that only the ganglion was treated, wrist pain resolved in all cases. Edwards and Johansen⁴ elaborated on this notion by showing that most ganglia are associated with type II and III scapholunate and type III lunatotriquetral laxity (Table 23-1). Although it is reasonable to propose that increased intercarpal laxity may contribute to ganglion formation, the actual significance is unclear, given that the natural incidence of these ligamentous laxities in the general population is not known.

TABLE 23-1 Classification of Intracarpal Instability

Adapted from Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78:357-365.

History and Physical Examination

The first question to answer when a patient presents with a mass is whether it is a cyst or a tumor. Many elements of the history and physical examination are not conclusive. Occurrence, progression, size, shape, texture, presence or absence of pain, and association with traumatic or repetitive activities provide little more than suggestions either way. One element of history, however, can be quite helpful in determining whether the lesion is cystic. Cysts and tumors get larger, but only cysts get smaller. There are rare exceptions to this rule, such as some vascular tumors that involute over a period of months to years, but cysts can decrease in size as quickly as overnight. On physical examination, transillumination can be helpful to differentiate a cyst from a tumor. This is performed by holding a penlight up against the lesion. A cystic lesion allows the light to transmit through its fluid medium, whereas the solid tissue of a tumor prevents any propagation of light.

Occasionally, cysts may herald a more dubious underlying pathology, such as a scapholunate ligament injury. The history and physical examination should focus on any recent or remote trauma. Often, patients have incompetent scapholunate ligaments that remain clinically unapparent until the manifestation of an associated ganglion cyst. Palpation of the dorsal portion of the scapholunate ligament, a positive Watson scaphoid shift test, or a positive straight finger resistance test may suggest scapholunate ligament pathology. Cysts may resemble other pathologies, such as gouty tophus, tenosynovitis, and rheumatoid pannus. A careful history and physical examination should suffice to differentiate these conditions.

Diagnostic Imaging

MRI and ultrasonography remain the imaging modalities most commonly used to differentiate fluid-filled cysts from solid tumors. Although both perform this task with equal reliability, MRI may suggest an etiology of a solid tumor, whereas ultrasonography cannot. Nevertheless, there has been a shift toward ultrasonography as the preferred technique, given its lesser comparable cost. Very small ganglions, although clinically significant, can be readily overlooked by both types of imaging. Surgeons should keep a high index of suspicion for these lesions even if the face of a negative reading.

Nonoperative Management

Although there is no consensus about the best nonoperative treatment for ganglion cysts, restriction of wrist activity seems to be well accepted. The efficacy of anti-inflammatory medications is more controversial. Some believe that reducing inflammation is helpful for patients with painful cysts, whereas others believe that these medications may make the cystic fluid less viscous and possibly more likely to spontaneously decompress. Neither belief has been substantiated in the literature. Needle aspiration seems to be relatively safe for dorsal ganglion cysts, but volar ganglions place neurovascular structures at particular risk with blind aspiration. Patients need to understand that recurrences after aspiration can be high. In summary, nonoperative treatments for dorsal ganglion cysts are unpredictable, and the evidence to support such measures is largely anecdotal. However, most surgeons attempt a trial of nonoperative treatment before committing the patient to surgical excision.

Indications and Contraindications

Indications and contraindications for arthroscopic dorsal wrist ganglion resection are still evolving. Ho and colleagues²