Ganglion/Myxoid Cysts

This guideline applies to adults aged 18 and over.

Ganglia are common atthe wrist and next to the small joints of the foot. 

 

• Solid swellings that do not transilluminate
   
• Features consistent with sarcoma, including:
  • recurrence at the site of a previously excised tumour
  • larger than 4.3cm
  • swellings that are increasing in size and/or painful
• Sarcomatous swellings can be superficial or deep to the fascia
   
• Epithelioid sarcoma can present as an innocuous nodule on the dorsal aspect of the foot

 

 

 

• Nature and location of the lump and pain
   
• Function, work and leisure activities affected
   
• Transilluminate to determine ganglia from solid lesions
   
• Assess for nerve compression
   
• Exclude red flags

 

 

 

 

Adopt a shared decision making approach with the patient

For typical ganglia with no suspicious features of sarcoma, explain to the patient that ganglia are benign, can gradually enlarge to 1 to 2cm and if not causing symptoms, they can be left alone.  Up to 50% may resolve without treatment.
 

Traumatic rupture is not recommended.

 

Conservative Measures

• Advise to modify activities and avoid loading the wrist in end-range positions.
• Splints or soft wrist supports can help.

• Aspiration can be performed using a green needle.  Recurrence rates after aspiration can be as high as 63%. Dorsal digital ganglion aspiration is not recommended due to the high risk of joint infection.

 

 

For red flag pathology

• Solid swellings that do not transilluminate
• Features consistent with sarcoma including recurrence at the site of a previously excised tumour, larger than 4.3cm, swellings that are increasing in size and/or painful.  Sarcomatous swellings can be superficial or deep to the fascia.
• Epithelioid sarcoma can present as an innocuous nodule on the dorsal aspect of the foot

 

Refer all suspected sarcoma lesions on the 2WW Sarcoma pathway

 

Urgent orthopaedic referral criteria

Evidence of nerve compression (numbness, paraesthesiae, or motor impairment)

Routine orthopaedic referral criteria

Significant persistent pain, i.e. pain without spontaneous resolution within 1 to 2 years, or detailed significant functional impairment and the patient would like to proceed with surgery.

Explain to the patient that ganglia surgery has a 1 to 2% risk of complications, such as injury to neighbouring structures, e.g. nerves, arteries.  After surgery, 10% of dorsal wrist and dorsal digital ganglions recur and 30% of palmar wrist ganglions recur.  The recurrence rate for flexor sheath ganglions is minimal.

 

 

No formal advice and guidance service is available.

 

For professionals:

For patients:

NHS Ganglion Cyst https://www.nhs.uk/conditions/ganglion/

References

 

BSSH Evidence for Surgical Treatment 1 Wrist Ganglion http://www.hands2elbowsurgeon.co.uk/uploads/1/5/6/1/15615196/ganglion.pdf

 

Ganglions Treatment & Management. Author: Valerie E Cothran, MD; Chief Editor: Harris Gellman et al.

 

 

 

 

Review date	11/03/2024
Next review date	11/03/2026
Clinical editor	Dr Rebecca Hopkins
Contributors	Dr Rebecca Hopkins, GP Guidelines Lead Referral Management Service, Cornwall and IoS ICB Mr Rob Poulter, Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust