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Wrist ganglia

 

Clinical bottom line

In most cases wrist ganglia can safely be left alone, in the knowledge that they will fade away.


Reference


1. FD Burke et al. Primary care referral protocol for wrist ganglia. Postgrad Med J 2003 79: 329-331.


Bandolier has a wrist ganglion in its midst: it comes and goes (more or less) and causes mild to moderate pain from time to time, but only occasionally interferes with life. What can, or should, be done about it?

It is said that in olden days the standard treatment was to hit it with the family bible (the size of the book is probably more important than the content), but in the absence of good quality studies of this approach, Bandolier looked further afield. There are several small randomised controlled trials and observational studies, but no systematic reviews. There is, however, an excellent review from Derby [1], which although it does not claim to be systematic, does cover the important studies.


Background

Ganglia are benign fluid-filled lumps, formed when synovial fluid escapes from a joint and collects in the superficial layers. The ganglion capsule is formed from compressed stroma, with no cellular lining, and may be linked to the underlying joint capsule by a narrow channel acting as a one-way valve. Their cause is unclear, and only a small minority give a history of previous trauma. They are the most common swellings of the wrist, occurring more often in women than men, and in these aged 20 to 50 years. Many untreated ganglia resolve spontaneously, with 50% of patients "ganglion free" at six years. Higher rates of spontaneous resolution (70 to 80%) are reported for ganglia in children. Despite this, a large number are referred to hand surgeons for advice and treatment. Patients seek advice mainly for cosmetic reasons, or because of concern about malignancy, or pain.

Diagnosis in a primary care setting is usually straightforward. Wrist ganglia are site-specific: they overlie the scapholunate ligament on the dorsal surface, or the radiocarpal or scaphotrapezoal joints on the volar (ventral) surface, adjacent to the radial artery. Transillumination shows clear fluid, except where the ganglion is very deep or small, or where the skin is dark. Ultrasound is effective for demonstrating ganglia that are too small to palpate. A questionnaire survey of GPs in South Derbyshire showed that 90% of responders (179 GPs) felt that ganglia were fairly easy to diagnose, although the majority would not undertake any form of invasive treatment in primary care, and many would welcome a checklist to aid referral (see below).

GP referral letter for patients with wrist ganglia (from Burke et al 2003).

All boxes in Section A should be ticked, along with the relevant boxes in Section B.
I have assessed my patient using the Derby Ganglion Referral protocol and wish to refer the patient because:
Section A
1.  The ganglion transilluminates
2.  The patient is aware that most ganglia resolve spontaneously with the passage of time
3.  The patient is aware of the complications of ganglion excision (30% recurrence and 15% scar tenderness or numbness. Persistent wrist stiffness may also occur)
Section B
1.  The patient's ganglion is painful and restricts work and hobbies
2.  The patient remains concerned by the risk of malignancy, despite aspiration and reassurance
3.  The patient has failed to respond to aspiration of the ganglion
4.  The ganglion is ugly
5.  Other reasons; please specify:

 

Treatment options

Comment

Bandolier is reassured that, in common with most wrist ganglia, this one should be left alone. It is always good to find a condition where the best treatment for most people is the simplest and cheapest: reassure and let nature take its course.