Injection Technique for Ganglion Cysts of the Wrist and Hand

Indications and Clinical Considerations

The dorsum of the wrist is especially susceptible to developing ganglion cysts ( Fig. 98.1 ). These cysts are thought to form as a result of herniation of synovial-containing tissues from joint capsules or tendon sheaths ( Fig. 98.2 ). This tissue may then become irritated and begin producing increased amounts of synovial fluid, which can pool in cystlike cavities overlying the tendons and joint space. A 1-way valve phenomenon may cause these cystlike cavities to expand because the fluid cannot flow freely back into the synovial cavity. Ganglion cysts may also occur on the volar aspect of the wrist ( Fig. 98.3 ).

FIG. 98.1, A typical dorsal wrist ganglion.

FIG. 98.2, Dorsal wrist ganglion. Longitudinal ultrasound image demonstrating large dorsal ganglion cyst arising from the radio-lunate joint.

FIG. 98.3, A ganglion on the volar aspect of the wrist.

Activity, especially extreme flexion and extension, makes the pain worse; rest and heat provide some relief. The pain is constant and is characterized as aching. It is often the unsightly nature of the ganglion cyst, rather than the pain, that causes the patient to seek medical attention. The ganglion is smooth to palpation and transilluminates with a penlight in contradistinction to solid tumors, which do not transilluminate. Palpation of the ganglion may increase the pain.

Plain radiographs of the wrist are indicated for all patients with ganglion cysts to rule out bony abnormalities, including tumors. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the wrist is indicated if the cause of the wrist mass is suspect ( Fig. 98.4 ).

FIG. 98.4, A, Coronal fast spin-echo ( FS ) T2-weighted magnetic resonance ( MR ) image of the dorsal compartment of the wrist. A ganglion cyst with high signal intensity ( SI ) arises between the extensor tendons. B, The axial T1-weighted MR image shows the low SI cyst (white arrows) lying superficial to the scapholunate joint and deep to the extensor carpi radialis brevis and longus tendons (asterisks). C, The cyst has high SI on the comparative axial FS T2-weighted MR image and is partially loculated. L, Lunate; S, scaphoid.

Clinically Relevant Anatomy

Ganglion cysts usually appear on the dorsum of the wrist, in the area overlying the extensor tendons or the joint space, with a predilection for the joint space of the lunate or from the tendon sheath of the extensor carpi radialis ( Figs. 98.5– 98.7 ). Occasionally, ganglion cysts can surround or compress other anatomic structures, including nerves, arteries, and veins ( Fig. 98.8 ).