History and Physical Examination

Most ganglion cysts occur in women in their second, third, or fourth decade of life. The onset is usually insidious, with a progressive increase in size occurring over many years. The ganglion usually manifests as a visible and palpable mass. Patients may relate a traumatic event, such as a wrist hyperextension injury, that occurred before the cyst appeared; however, most cannot recall an event or activity related to the development or appearance of the mass. The masses may be painful, and the symptoms usually are described as an aching discomfort in the region of the mass. Cosmetic dissatisfaction and concern that the mass represents a malignancy are associated complaints. A painless mass is the most frequent presenting complaint.¹² Westbrook’s study of 50 patients indicated that a minority of patients presented with pain, 38% presented because of the cosmetic appearance of the mass, and 28% were concerned that the ganglion was malignant.¹³

The diagnosis is easily made with visual inspection (Fig. 33-3). A 1- to 2-cm, round or ovoid mass usually manifests as a visible fullness in the interval between the FCR tendon and the radial artery. It may be unilobular or multilobular. Palpation reveals a mass that may be slightly tender. The consistency is usually soft and compressible, although chronic lesions may be quite firm. Transillumination with a penlight usually confirms the diagnosis. The differential diagnosis includes vascular lesions of the radial artery, and it is important to determine whether the mass is pulsatile or the pulsations of the radial artery can be distinguished from the mass itself. Despite the relatively easy diagnosis, it is important to exclude other causes of wrist discomfort, such as radiocarpal arthrosis, STT arthrosis, TM arthrosis, DeQuervain’s tendonitis, and FCR tendonitis. Isolated loading and stress testing of the individual joints should not produce any pain if the joint is not arthritic. The result of a Finkelstein maneuver should be negative, and there should be no tenderness of the first dorsal compartment tendons. Resisted wrist flexion should produce no pain over the FCR tendon. In patients with an occult volar ganglion cyst, the only positive physical finding may be fullness in the FCR–radial artery interval and pain with pressure in the region. Exclusion of other potential causes of volar radial wrist pain is essential.

FIGURE 33-3 A volar carpal ganglion cyst (VCG) manifests as a mass on the volar wrist in the interval between the radial artery and the flexor carpi radialis tendon.

Diagnostic Imaging

If the diagnosis is certain and the physical examination presents no confounding findings, imaging is not necessary. Wong and colleagues showed that radiographic abnormalities were diagnosed in only 13% of patients with ganglion cysts, and treatment was affected in only 1% of the cases in their study. They concluded that routine radiographs are not cost-effective.¹⁴ When desired, plain radiographs are usually sufficient as an imaging study to exclude arthrosis of the STT or TM joint. Arthroscopic management of volar ganglions is indicated only for capsular radiocarpal origins; preoperative radiographs that demonstrate arthrosis raise suspicion that the cyst may arise from a location other than the radiocarpal joint. If the nature of the mass is unclear, ultrasound or magnetic resonance imaging is useful. Ultrasound is a cost-effective study that demonstrates the mass as a hypoechoic lesion. Wang and associates were able to localize the stalk-like origin of the ganglion emanating from the volar radiocarpal joint in 7 of 15 cysts. They also found that small cysts can be hypoechoic or anechoic, and not all fulfill the ultrasound criteria for simple cysts.⁵

Indications and Contraindications

Indications for arthroscopic ganglionectomy are relative. Patients desire excision of the ganglion cyst to improve cosmesis, to eliminate pain, and for absolute diagnosis and exclusion of potential malignancy. The procedure is recommended for the typical volar ganglion that manifests in the interval between the FCR and the radial artery and is not located distal to the distal wrist flexion crease. Distal lesions may be associated with the STT or TM joint and therefore not accessible to radiocarpal arthroscopic techniques. The procedure is technically much more challenging than open excision but cosmetically more appealing. Patients should be warned that even small arthroscopy portal incisions can form hypertrophic scar. Theoretically, there is less capsular damage, because the only capsule being excised is that associated with the stalk-like origin of the mass; however, some patients develop significant stiffness that requires extensive rehabilitation despite the arthroscopic approach. If conservative management has failed to bring about symptom resolution or elimination of the mass, surgical treatment is recommended.

Arthroscopic management of volar ganglions is contraindicated for masses that may be coming from locations other than the radiocarpal joint capsule, such as the STT joint or the FCR sheath. Wrists that have sustained prior trauma or are excessively stiff and may present difficulty in visualization of the volar extrinsic ligaments should have their ganglia excised in an open fashion. Unusual or atypical masses that are likely not ganglions should also be treated by open excision. Recurrent ganglion cysts should be treated in an open fashion, although some surgeons have reported success in treating recurrent lesions arthroscopically.³

Conservative Management

Conservative treatment of symptomatic volar ganglion cysts is somewhat limited. Historically, conservative treatment of ganglions has included external pressure with a variety of topical agents and mechanical devices, external rubbing or massage, and closed rupture with the use of digital pressure or more violent means, such as striking the mass with a heavy book, which accounts for the designation Bible cyst. These techniques are associated with recurrence rates as high as 64%.^6,15 Spontaneous resolution of ganglia occurs in approximately 50% of patients but can take many years.¹⁶ Cysts that have developed acutely or after an identifiable traumatic event should be treated with a period of splint immobilization, because the initial symptoms and the mass may resolve. More frequently, patients present with a cyst of insidious origin with a duration of many months or even years, and splinting is not an effective treatment.

Aspiration of wrist ganglia has a success rate of only 30% to 50%. The poorest results for aspiration are associated with volar ganglion cysts, and most surgeons caution against aspiration because of the risk of injury to adjacent neurovascular structures such as the radial artery and the palmar cutaneous branch of the median nerve.^12,17,18 A 47% recurrence rate after aspiration was reported in Dias and Buchs’ study, but recurrence did not correlate with patients’ satisfaction with treatment.¹⁶ Aspiration is offered to patients who desire cyst resolution but want to avoid a more involved surgical procedure. Physicians should be certain that adjacent neurovascular structures are separate from the mass and that there is no possibility that the volar mass represents a lesion of vascular origin. Patients should be warned that the failure rate with aspiration is high and that recurrence is likely.

Arthroscopic Technique

Arthroscopic excision of volar ganglion cysts starts with a standard arthroscopic setup. The arm is exsanguinated, and a proximal tourniquet is used. Traction is applied by means of sterile finger traps (Fig. 33-4). The method used to provide traction should not interfere with the ability to convert to an open procedure. A sterile traction tower offers full access to the dorsal and volar wrist, and if the need to convert to open ganglionectomy arises, the tower can be removed and an open procedure performed without compromising sterility.

FIGURE 33-4 The hand is supported in an arthroscopy tower. The distraction facilitates instrument manipulation within the radiocarpal joint. Sterile access to the entire hand facilitates localization of the ganglion and conversion to an open procedure if necessary.

After traction is applied, standard arthroscopic portals are marked (Fig. 33-5). The outer margins of the volar ganglion should be palpated and marked (Fig. 33-6). The skin landmarks are outlined to confirm that the mass has been eliminated and decompressed.

FIGURE 33-5 Standard arthroscopic portals are used for the procedure. Marking is done after traction is applied. The surgeon’s thumb is on Lister’s tubercle.

FIGURE 33-6 The outline of the ganglion is marked. This facilitates localization of the mass during the procedure and confirmation that the mass has been adequately decompressed.

This procedure is commonly performed with the 3-4 portal as a viewing portal and a 4-5 portal as an operative portal. In cadaver experiments, this combination was identified as being most effective for access to the volar capsular origin of the cyst (Fig. 33-7), and it was safest in regard to injury to neurovascular and tendon elements volar to the wrist capsule (Vella and Greenberg, unpublished data).

FIGURE 33-7 In cadaveric experiments, the combination of the 3-4 portal as a viewing portal and the 4-5 portal as a working portal was safest in terms of relative distance from neurovascular and tendon structures on the volar aspect of the wrist. The 4-5 portal provided good shaver access to the stalk of the mass for decompression and resection.

The joint is insufflated with saline through the 3-4 portal. During insufflation of the joint, the needle used to inject the joint should mimic the path of the arthroscope. The angle should reflect the volar inclination of the distal radius. Portal incisions are made through the skin, and spreading of soft tissue with a hemostat exposes the joint capsule. The scope is placed gently into the wrist to avoid articular cartilage injury. A 4-5 portal is established by direct arthroscopic visualization. The angle of the portal is of paramount importance, because a portal that is placed too proximal or too distal will make access to the volar capsular origin of the cyst very difficult. Initially, diagnostic arthroscopy of the radiocarpal joint is performed to rule out or assess additional pathology. In most cases, diagnostic arthroscopy reveals no additional pathology. Occasionally, there is synovial proliferation, and a synovectomy is necessary to enable visualization.

After the diagnostic portion of the procedure is completed, a full-radius resector is introduced into the 4-5 portal. The shaver is used to remove any proliferative synovium that is present. Frequently, the ligamentous interval between the RSC and LRL ligaments is obscured by the vascular leash known as the radioscapholunate ligament or ligament of Testut. The shaver is used to resect this vascular leash so that the volar capsule can be easily seen (Fig. 33-8).

FIGURE 33-8 The ligament of Testut or radioscapholunate (RSL) ligament is a vascular leash that may obscure visualization of the capsular origin of the cyst. It should be resected so that the origin of the cyst can be seen.

At this point, a lobular structure representing the origin of the ganglion is visualized (Fig. 33-9). This is usually in the ligamentous interval on the volar capsule. Xanthomatous changes consistent with degeneration or mucinous changes may be present. If the cyst is not obvious, external pressure on the volar mass usually produces an outpouching that can be dynamically seen entering the joint in the RSC and LRL interval. This is especially true in cases of occult volar ganglion cysts.

FIGURE 33-9 The origin of the ganglion emanates from the extrinsic ligament interval as a volar outpouching into the radiocarpal joint.

After the origin is identified, the full-radius resector is used to carefully resect the capsular origin of the mass (Fig. 33-10). As the cyst base is removed, a distinct fluid blush is seen as the ganglion fluid decompresses into the radiocarpal joint (Fig. 33-11). This fluid movement can be enhanced by external pressure on the cyst. Resection continues until a window measuring approximately 1 × 1 cm is created (Fig. 33-12). The flexor pollicis longus tendon is visualized. A blunt probe can be passed through the created capsular defect into the cyst body and can be palpated. Passage of an instrument along this course safely avoids neurovascular structures.

FIGURE 33-10 A full-radius resector introduced through the 4-5 portal has excellent access to the origin of the ganglion cyst.

FIGURE 33-11 Frequently, a fluid blush of yellowish liquid can be seen entering the radiocarpal joint as the sac of the ganglion decompresses its contents into the joint.

FIGURE 33-12 A capsular defect is created after resection of the origin of the volar ganglion. The flexor pollicis longus (FPL) tendon can be visualized through this defect.

After the cyst is decompressed, the procedure is complete. Arthroscopic equipment is removed. Portal incisions are closed with nonabsorbable suture. A dressing is applied to place compression on the volar radial wrist. The postoperative dressing and splint are removed at 2 weeks postoperatively. Range-of-motion exercises and modalities to control edema are initiated, with resumption of activities as tolerated. Most patients are back to full, unrestricted use at 6 weeks postoperatively.

Postoperative Rehabilitation

Patients remove their postoperative dressing and start gentle range-of-motion exercises as tolerated. Suture removal is performed at 10 days postoperatively. Patients who demonstrate excessive stiffness or swelling during this time should start a supervised therapy program that emphasizes range-of-motion exercises and edema control. Most patients require minimal supervised therapy. The level of patient satisfaction with the outcome of the procedure is typically high.^3,7,20,21