Q & A: GANGLIONS OF THE HAND

by Lorenzo G. Walker, M.D.

Surgery of the Hand and Upper Extremity

QUESTION: Over the past 2-3 years, I have noticed a large lump on the back of my wrist. Initially, it did not bother me, but over time it has begun to hurt when I use my wrist a lot. The lump gets bigger and then smaller, and some people say that if I hit it with a book, it will go away. What is this growth?

ANSWER: Over 70% of the "lumps and bumps" of the hand are ganglions. A ganglion has a well-defined, smooth surface and is a firm, cyst-like lesion that actually comes from the joint below it. It can develop on the palm side of the hand, the back of the hand, or near the finger joints. It is three times more common in women than in men, and equally common in the young and the elderly.

There are four sites where ganglions are most commonly found. The most common site is on the back of

the hand, at the wrist level. These make up approximately 60-70% of all ganglions. The next most common is at the wrist level also, but on the palm side of the hand, close to the radial artery. This is where a nurse would check your pulse. Ganglions can also occur at the finger level coming from the small joints of the hand, the third most common location. Ganglions which are found out at the tips of the fingers are called mucous cysts. These occur close to the nail, and are a result of arthritis involving the last joint in the finger.

Ganglions generally occur after a physically traumatic event. This even may not be recalled by the patient, and may have occurred quite a long period of time before the ganglion actually appears. A small hole is created in the joint capsule lying beneath the ganglion, and some of the cells which line this capsule are pushed out into the soft tissues over the joint. These cells continue to produce joint fluid and eventually form a fairly large, stalked, mushroom-like mass which is the ganglion. On the back of the hand, symptoms usually worsen when the ganglion presses on a small nerve which crosses the wrist at that point.

Evaluation of hand masses should be done by an experienced surgeon; although malignant tumors of the soft tissue and bone of the hand are rare, they can occur and should be investigated. Some patients desire excision of the ganglion for cosmetic reasons, and this is understandable.

The old remedy of hitting the ganglion with a Bible or other book in an attempt to burst it is not recommended in the current era, where quality of medical treatment is readily available. Needle aspiration of masses on the back of the hand can be performed with a 30-50% success rate. However, recurrence after aspiration is not uncommon and this should be understood. If recurrence occurs, surgical excision of ganglion cysts is performed on an outpatient basis, with a recovery time of approximately 2-4 weeks. After treatment, most patients are highly satisfied with the degree of pain relief and improved cosmetic appearance.