Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

without neurovascular compromise

1st line – observation

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ACUTE
|
without neurovascular compromise
1st line – 

observation

Given that ganglia are the most common benign tumors of the hand and the wrist with no reported cases of malignant degeneration, the most appropriate initial line of treatment is observation.[11][25]

Conservative treatment can lead to spontaneous resolution in up to 58% of adults and up to 93% of children over a 9- to 12-month period.[26][27][28]

Consider – activity modification + analgesia

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ACUTE
|
without neurovascular compromise
Consider – 

activity modification + analgesia

Treatment recommended for SOME patients in selected patient group

For activity-related pain, patients may benefit from activity modification. Compressive wraps or wrist supports worn during activities that exacerbate discomfort can also help.

Discomfort or aching, especially after activity, can usually be alleviated by nonsteroidal anti-inflammatory drugs.

Primary options

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required, maximum 150 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

2nd line – cyst aspiration ± corticosteroid injection

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ACUTE
|
without neurovascular compromise
2nd line – 

cyst aspiration ± corticosteroid injection

Cyst puncture and drainage, with or without corticosteroid injection, is the primary form of closed management of dorsal ganglia and can be curative as well as diagnostic. Aspiration of volar ganglion cysts is not recommended due to the potential risk of injury to the radial artery.[22]

While aspiration can be done in the office, caution must be utilized given the direct extension of the cyst stalk into the wrist joint. Septic arthritis is a rare, but possible, complication of this procedure.

The success rate of single aspiration of dorsal ganglion cysts can be increased by approximately 27% if the wrist is splinted for 3 weeks afterward.[29]

Evidence suggests that simple aspiration yields similar success rates (33%) to aspiration and injection of corticosteroid.[31] Injection of corticosteroid may reduce inflammation and increase the success rate, but definitive benefit has not been demonstrated.[32] 

Needling of dorsal cysts can lead to overall decompression and multiple needling of the base or stalk of the cyst can increase the rate of resolution to 42%.[26] Multiple needling can be painful or uncomfortable and injection with local anesthetic may be warranted.

One systematic review of studies that reported treatment outcomes for adult wrist ganglions found that 59% of patients who underwent aspiration experienced recurrence.[33] Aspiration was not associated with a significant reduction in recurrence compared with reassurance.

Primary options

triamcinolone acetonide: 10 mg into affected area as a single dose

and

lidocaine: (1%) 1-2 mL into the affected area as a single dose

3rd line – surgical resection

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ACUTE
|
without neurovascular compromise
3rd line – 

surgical resection

Cysts that are recalcitrant to conservative management may be addressed surgically if they are painful or cosmetically unpleasing and the patient desires excision of the mass.

Prior to surgery patients should be advised that they will be trading cosmetic masses for surgical scars, and that complete excision may be prevented if the cyst encapsulates neurovascular structures.

Options include a formal open excision versus arthroscopic decompression and resection.

Dorsal ganglion recurrence is reduced when a cuff of normal tissue is removed along with the stalk of the ganglia. However, care must be taken to avoid overaggressive resection of the scapholunate interosseous ligament or a resultant scapholunate diastasis may develop.

Volar wrist ganglia often intimately surround, or are attached to, the radial artery and have a slightly higher rate of recurrence. A cuff of the ganglion may remain after surgery in these patients to avoid injury or arteriotomy of the artery.

Wrist immobilization following surgery may help to reduce the rate of recurrence, but motion should be initiated relatively soon postoperatively to reduce the risk of stiffness.

The risk of recurrence following open surgery varies. Typically, dorsal ganglia have a 3% to 9% recurrence rate and volar ganglia have a recurrence rate of 7% to 19%. Open surgical excision offers a significantly lower chance of recurrence compared with aspiration.[33] In pediatric patients with wrist ganglia, the patient’s age is an important factor in recurrence, with teenagers having higher recurrence rates.[34]​ 

Arthroscopic debridement offers the benefit of treating any other intra-articular pathology that may be noticed on examination. Recurrence rate following arthroscopic resection is 7% to 11%.[7][36][37][38][39]​ Two systematic reviews of arthroscopic excision of ganglion cysts conclude that arthroscopic excision and open excision have comparable outcome profiles, including recurrence and complication rates.[35][40]

with neurovascular compromise

1st line – surgical resection

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ACUTE
|
with neurovascular compromise
1st line – 

surgical resection

Patients with neurovascular compromise related to ganglia are typically treated with surgical resection. Completely devascularized fingers/hand are not typical presentations of ganglia, so surgical intervention can usually be performed in a nonemergent but timely manner.

Options include a formal open excision versus arthroscopic decompression and resection.

Dorsal ganglion recurrence is reduced when a cuff of normal tissue is removed along with the stalk of the ganglia. However, care must be taken to avoid overaggressive resection of the scapholunate interosseous ligament or a resultant scapholunate diastasis may develop.

Volar wrist ganglia often intimately surround, or are attached to, the radial artery and have a slightly higher rate of recurrence. A cuff of the ganglion may remain after surgery in these patients to avoid injury or arteriotomy of the artery.

Wrist immobilization following surgery may help to reduce the rate of recurrence, but motion should be initiated relatively soon postoperatively to reduce the risk of stiffness.

The risk of recurrence following open surgery varies. Typically, dorsal ganglia have a 3% to 9% recurrence rate and volar ganglia have a recurrence rate of 7% to 19%. Open surgical excision offers a significantly lower chance of recurrence compared with aspiration.[33] In pediatric patients with wrist ganglia, the patient’s age is an important factor in recurrence, with teenagers having higher recurrence rates.[34]​ 

Arthroscopic debridement offers the benefit of treating any other intra-articular pathology that may be noticed on examination. Recurrence rate following arthroscopic resection is 7% to 11%.[7][36][37][38][39]​ Two systematic reviews of arthroscopic excision of ganglion cysts conclude that arthroscopic excision and open excision have comparable outcome profiles, including recurrence and complication rates.[35][40]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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