Ortho Dx: A mass on the wrist - Clinical Advisor

Ortho Dx: A mass on the wrist

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A 51-year-old woman presents with a 2-month history of a mass on her right wrist. The mass is not painful but seems to be growing over the last few months. On examination, the mass is firm, not tender to palpation, and located between the radial artery and the flexor carpi radialis tendon. The mass becomes prominent with wrist extension. The patient denies any numbness or tingling in the hand, and light touch sensation is intact throughout the hand and wrist. She is concerned about the growth and seeks advice on what the best treatment option may be. 

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants. 

The patient presents with a volar ganglion cyst of the right wrist. Ganglion cysts are the most common hand and wrist mass. Ganglion cysts arise from tendon sheaths or joints of the wrist and are usually asymptomatic. The etiology is unclear....

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The patient presents with a volar ganglion cyst of the right wrist. Ganglion cysts are the most common hand and wrist mass. Ganglion cysts arise from tendon sheaths or joints of the wrist and are usually asymptomatic. 

The etiology is unclear. However, it is believed that ganglion cysts are an out-pouching of the joint capsule or tendon sheath. Most occur on the dorsum of the wrist joint (70%) and arise from the scapholunate joint. Volar cysts are less common (20%) and arise from the radiocarpal or scaphotrapeziotrapezoidal (STT) joint. 

Women are 3 times more likely than men to have hand and wrist ganglion cysts. The cyst is usually firm, fixed to the deep tissue, and transilluminates. An Allen’s test should be performed to ensure radial and ulnar arterial flow is intact to differentiate a cyst from a radial or ulnar aneurysm.1,2 

Observation is the first-line treatment for all asymptomatic volar ganglion cysts. Patient education on the benign nature of ganglion cysts and the potential for spontaneous resolution is essential. Aspiration and/or injection of volar ganglion cysts is generally avoided due to the risk of injury to the radial artery or the palmar cutaneous branch of the median nerve. Recurrence rates are also high after aspiration and injection, with rates between 57% to 83%. Surgical indications include persistent pain, interference with daily activities, and nerve palsy. The recurrence rate after surgical excision is higher in volar ganglion cysts (approximately 30%), compared to dorsal ganglion cysts.1 

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA). 

References

  1. Thornburg LE. Ganglions of the hand and wrist. J Am Acad Orthop Surg. 1999;7(4):231-238. 
  2. Day M. Ganglion cysts. http://www.orthobullets.com/hand/6086/ganglion-cysts. Updated August 29, 2015. Accessed May 27, 2016. 
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