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Introduction

Ganglions, soft, mucin-filled cysts, account for 50-70% of all soft-tissue tumors of the hand. Malignancy has never been reported. Ganglions respond poorly to conservative therapy, but they can subside with rest or disappear spontaneous. With proper excision, recurrence is rare.

Related Anatomy

  • Scapholunate ligament
  • Radiocarpal joint
  • Scaphotrapeziotrapezoid joint

Incidence and Related Conditions

  • More prevalent in women (3:1); ~70% occur in people aged 20-49
  • Less common ganglions often associated with bossing of second and third carpometacarpal joints, DeQuervain’s syndrome and Heberden’s nodes of the distal interphalangeal joint

Differential Diagnosis

  • Lipoma
  • Extensor tenosynovitis
  • Extensor Brevis Manus muscle
  • Other hand tumors
ICD-10 Codes
  • GANGLION (WRIST, HAND, FINGERS)

    Diagnostic Guide Name

    GANGLION (WRIST, HAND, FINGERS)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    GANGLION CYST    
    - WRIST M67.432M67.431 
    - HAND AND FINGER(S) M67.442M67.441 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Dorsal Carpal Ganglion
    Dorsal Carpal Ganglion
  • Dorsal Carpal Ganglion
    Dorsal Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
  • Volar Carpal Ganglion
    Volar Carpal Ganglion
Symptoms
New lump on the top, side or bottom of the wrist
Pain usually only with pressure on the lump
Pain at rest or with use (intracapsular small nonviable ganglion)
Lump fluctuates in size - gets larger but sometimes smaller
Paresthesias when ganglion presses on a nerve.
Typical History

A 16-year-old female cheerleader is complaining about a sore lump on the top of her left wrist.  It has been present for 2-3 months.  There is no history of trauma or night pain.  The patient notes that the lump fluctuates in size.  A week ago it was quite big until she bumped it. Following this minor injury it was temporarily much smaller but now is getting larger.  The lump’s appearance troubles her considerably.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Ultrasound showing an anechoic ganglion of the wrist
    Ultrasound showing an anechoic ganglion of the wrist
  • MRI showing ganglion in Guyon's canal
    MRI showing ganglion in Guyon's canal
Treatment Options
Conservative
  • Reassurance/observation
  • Aspiration with/without corticosteroid injection
  • Aspiration followed by 3 weeks of casting with short arm cast.
Operative

 

  • Surgical excision For ASSH's Hand-e Surgical Video of an open ganglion excision by Benheim:

    For ASSH's Hand-e Surgical Video of an arthroscopic dorsal ganglionectomy by Kakar:

Treatment Photos and Diagrams
  • Excision of Dorsal Carpal Ganglion
    Excision of Dorsal Carpal Ganglion
  • Excision of Dorsal Carpal Ganglion
    Excision of Dorsal Carpal Ganglion
  • Excision of Dorsal Carpal Ganglion
    Excision of Dorsal Carpal Ganglion
  • Dorsal Capsule after ganglion excision with extensor tendons retracted.
    Dorsal Capsule after ganglion excision with extensor tendons retracted.
  • Extensor Tendons after ganglion excision
    Extensor Tendons after ganglion excision
  • Volar Carpal Ganglion with palpable pulse
    Volar Carpal Ganglion with palpable pulse
  • Volar Ganglion adherent to radial artery
    Volar Ganglion adherent to radial artery
  • Volar Ganglion being dissected off radial artery
    Volar Ganglion being dissected off radial artery
  • Excised Volar Ganglion with intact radial artery
    Excised Volar Ganglion with intact radial artery
CPT Codes for Treatment Options

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Common Procedure Name
Ganglion excision wrist
CPT Description
Excision of ganglion, wrist (dorsal or volar), primary
CPT Code Number
25111
Common Procedure Name
Excision finger ganglion
CPT Description
Excision of lesion of tendon sheath or capsule hand (cyst or ganglion)
CPT Code Number
26160
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Complications
  • Aspiration: high recurrence rates (>50%)
  • Steroid injection: skin depigmentation, subcutaneous fat atrophy
  • Hyaluronidase: high recurrence rates (>70%), allergic reaction

Volar ganglion excision:

  • stiffness
  • wound infection
  • neuroma
  • hypertrophic scar
  • nerve injury
  • radial artery injury
Outcomes
  • Conservative treatment provides symptomatic relief with higher rates of recurrence
  • Operative treatment reduces recurrences rates but increases complications
YouTube Video
Ganglion Cyst
Key Educational Points
  • The majority of ganglion cysts will resolve spontaneously without recurrence, hence observation
    is indicated.
  • Ganglions have recurrence rates of up to 43% with aspiration.
  • There is significant risk to the radial artery with aspiration in this area.
  • Surgical excision can have recurrence rates of up to 35%.
  • Needle biopsy is not necessary with the history and exam
    consistent with a ganglion.
References

New Articles

  1. Kim JP, Seo JB, Park HG, Park YH. Arthroscopic excision of dorsal wrist ganglion: factors related to recurrence and postoperative residual pain. Arthroscopy 2013;29(6):1019-24. PMID: 23726108
  2. Korkmaz M, Ozturk H, Amanvermez Senarslan D, Erdogan Y. Aspiration and methylprednisolone injection to the cavity with IV cannula needle in the treatment of volar wrist ganglia: New technique. Pak J Med Sci 2013;29(1):103-6. PMID: 24353517

Reviews

  1. Thommasen HV, Johnston S, Thommasen A. Management of the occasional wrist ganglion. Can J Rural Med 2006;11(1):51-2. PMID: 16454973
  2. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Phys2003;67(4):745-50. PMID: 12613728

Classics

  1. Dostal GH, Lister GD, Hutchinson D, et al. Extensor digitorum brevis manus associated with a dorsal wrist ganglion: a review of five cases. J Hand Surg Am 1995;20(1):35-7. PMID:  7722261
  2. Dellon AL, Seif SS. Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain. J Hand Surg Am 1978;3(4):326-32. PMID: 681715
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