Most of the masses that appear in the hand and wrist are benign. One such mass that is commonly seen in the wrist is a ganglion cyst. A ganglion cyst is a fluid-filled sac filled with joint fluid. It may be located on the back (dorsum) of the wrist or on the palmar (lower) side of the wrist.

The Development of a Cyst

These cysts develop in relation to the lining of the wrist joint. Sometimes, a small weak spot or hernia develops in this lining. The weak spot then allows joint fluid to escape and form a small cyst. 

The cyst is connected to the wrist joint by a long tube-like stalk, and is labeled according to its location:

  • A dorsal ganglion typically originates from the wrist near the scapholunate joint
  • palmar or volar ganglion typically originates from the radiocarpal joint or wrist joint. 

A ganglion cyst may develop after repetitive flexion or use of the wrist, as the repeated activity may weaken the joint lining (also referred to as the joint capsule). It also has been noted to develop after trauma to the wrist.

The Symptoms of a Cyst

Ganglion cysts may be symptomatic or asymptomatic, depending on the nature of each cyst. 

  • In some cases, the cyst may be small and located underneath the wrist tendons, where it is noticeable only as a diffuse swelling of the wrist, with some tenderness or tendinitis present. This is known as an occult ganglion. Diagnosis of an occult ganglion cyst requires suspicion of its presence after exam and confirmation with an MRI.
  • In most cases, the ganglion cyst has expanded to the surface and is easily visible as a firm cystic mass. The mass may change in size with more intensive or less intensive wrist use. The stalk functions as a partial one-way valve to allow joint fluid to pump into the cyst with wrist use. This type of ganglion cyst may be painful itself, due to its presence causing irritation by displacing the tendons and other structure.

The Treatment of a Cyst

Treatment of the cyst may be conservative (i.e. with lifestyle changes and observation only) if it is small and asymptomatic. Aspiration or draining the cyst is usually not recommended in these cases, since the recurrence rate is 100% and there is a risk of infection. Hitting it with a bible or breaking it (as was suggested for such “preachers nodes”) is also not suggested; the recurrence rate is very high, and the trauma and scar tissue that results makes later excision difficult. 

If conservative treatment does not work (or if the cyst is too large and causes too many symptoms to attempt conservative treatment), the next step in care is surgical excision of the ganglion. During this surgery, local standby or twilight anesthesia is used.

  • An incision is made over the top of the ganglion; the cyst is exposed and the surrounding tissues and tendons are pulled aside, exposing the stalk all the way down to the wrist capsule. 
  • The abnormal section of the joint capsule is removed together with the cyst and the capsule is repaired. 
  • The skin is closed and a small dressing and splint are removed. 
  • The skin sutures are removed at two weeks postop. A wrist splint that allows finger motion is used for two to 6 weeks after surgery, depending on the amount of abnormal capsule. The splint will help to reduce the rate of recurrence.

Risks with this surgery. include anesthesia-related risks, wound healing problems or infection, and possible recurrence of the cyst (which occurs in 3 to 5% of cases involved in national studies). 

Note that a ganglion cyst may occur less commonly at other joints in the hand as well. Treatment is similar.