Wrist Ganglia Aspiration and Injection

Anne Boyd, MD and Scott Wissink, MD
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Subject: Wrist Ganglia Aspiration and Injection

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Introduction

Ganglion cysts are common soft tissue tumors that arise from joint capsules or synovial sheaths of tendons. They can be mobile and vary in size. Ganglia occur at all ages, but roughly 70% appear in women between the ages of 20 and 40 years, with only approximately 15% in patients younger than 20 years. Women are affected three times as often as men. No predilection exists for the right or left hand, and occupation does not appear to increase the risk of ganglion formation. The dorsal and volar aspects of the wrist are the most common sites. 
Ganglion cysts may be single- or multilobulated. They are smooth walled, translucent, and white. The content within a ganglion is clear and highly viscous mucin that consists of hyaluronic acid, albumin, globulin, and glucosamine. The cyst wall is made up of collagen fibers, and multilobulated cysts may communicate through a network of ducts. Ganglia may be obvious or occult. Obvious ganglia may slowly enlarge or develop suddenly after trauma. These ganglia often appear as firm, nontender, pea- to marble-sized lesions beneath the skin. Occult ganglia may compress superficial nerves and cause dull aching. Ganglia may also produce weakness and altered range of motion in the wrist and fingers. Imaging modalities such as ultrasonography or magnetic resonance imaging may help to identify suspected or occult ganglia. 
Striking a dorsal wrist ganglion with a large Bible to rupture the cyst was a treatment used for centuries. Once the cyst ruptures, the body absorbs the fluid, and the lesion can be cured in approximately a third of individuals. This “Bible technique,” however, carried with it a high recurrence rate as well as a significant risk of fracture and other injury to surrounding tissues. Today, a more controlled technique of aspiration with or without steroid injection has become the most commonly performed nonsurgical intervention for ganglia. A large-bore needle is placed within the ganglion to remove the thick, viscous fluid. Simple aspiration is associated with high rates of recurrence (>50%). Injection of corticosteroid after aspiration can help to shrink or resolve the lesions and reduces recurrences to between 13% and 50%. 
Surgical intervention may be needed for recurrent or symptomatic lesions, but even surgical excision has recurrence rates >5% to 10%. Most ganglia in children resolve without intervention. The rate of spontaneous resolution in adults is not as high as that seen in children but is still significant enough to counsel patients about the option of observation. 

Equipment

  • Needle (25 gauge, 1 inch long) on a 3-mL syringe with 2 mL of 1% lidocaine with epinephrine (for anesthesia)

  • Needle (18 gauge, 1.5 inches long) on a 5 mL syringe (for aspiration)

  • Methylprednisolone acetate (Depo-Medrol; 0.4 mL [10 mg]) and 1.6 mL of 1% lidocaine without epinephrine in a 3-cc syringe (for injection)

Ganglion cysts are best aspirated with 18-gauge, 1.5-inch needles. A hemostat may be used to exchange the injection syringe for the aspiration syringe. Needles, syringes, and ace wraps may be ordered from local surgical supply houses. Hemostats may be ordered from instrument dealers. A suggested tray for performing soft tissue aspirations and injections and ordering information are listed in Appendix I. Skin preparation recommendations appear in Appendix E

Indications

  • Ganglia over the wrist that cause limitation of motion, pain, weakness, or paresthesias

  • Externally draining ganglia or infectious concerns (no injection of steroid if suspect infection)

  • Ganglia for which patients select nonsurgical intervention for cosmetic reasons

Contraindications (Relative)

  • Uncooperative patients

  • Ganglia overlying artificial joints

  • Coagulopathy or bleeding diathesis

  • Presence of septic arthritis or bacteremia

The Procedure

Step 1

After informed consent is obtained, hands are washed, materials are prepared, and gloves are applied. Position the patient so that the ganglion is exposed with the wrist supported. Swab the patient’s skin with iodine or 70% ethanol (see Appendix E). Do not touch the injection site after swabbing. 
  • PITFALL: The location of the radial artery is particularly important in the assessment of volar wrist ganglia because they may be intimately associated with or adjacent to this vessel.

Step 2

Insert a 25-gauge, 1-inch needle on a 3-mL syringe, and inject approximately 2 mL of 1% lidocaine with epinephrine subcutaneously to create a small, superficially raised wheal. 
  • PEARL: Insertion of a large-bore needle for aspiration later in this procedure is painful. This pain is alleviated by prior intradermal injection of 1% lidocaine at the site where the aspiration needle is to be inserted.

Step 3

Enter the ganglion using an 18-gauge, 1.5-inch needle on a 5-mL syringe at an angle that provides optimal access to the cyst and comfort for the patient. Aspirate once in the cyst. The aspirating syringe will fill with thick, gel-like material. 

Step 4

If, after aspirating, the provider chooses to inject a steroid solution, a hemostat or finger grasp can be used to stabilize the hub of the 18-gauge needle, which is already in place. Remove the gel-filled aspirating syringe from the needle, and attach the steroid-filled injecting syringe. 
  • PITFALL: Movement of the large needle when replacing syringes can make the procedure very uncomfortable and may dislodge the needle tip from inside the cyst.

  • PEARL: Keep the needle tip immobile by maintaining a firm grasp on the needle hub, and by bracing (anchoring) the hand or hemostat holding the needle on the patient’s wrist or forearm.

Step 5

Inject 0.4 mL (10 mg) of methylprednisolone acetate (Depo-Medrol) and 1.6 mL of 1% lidocaine without epinephrine through the 18-gauge needle into the ganglion. Apply pressure with a 4- × 4-inch gauze pad, clean the area with 70% ethanol, and apply a sterile bandage. Have the patient rest in the office for 20 to 30 minutes postinjection to ensure patient tolerability of the procedure and to review postprocedure instructions. 
  • PITFALL: Care must be taken to avoid the radial artery during injection of a volar wrist ganglion because injury to this vessel may potentially compromise circulation to the hand.

Complications

  • Ganglion recurrence is the most common complication following treatment.

  • Infection, bleeding, nerve and tendon injury, scarring, and vascular injury are possible.

  • Joint stiffness and decreased range of motion may also occur.

  • Skin and fat atrophy and thinning, as well as hypopigmentation are possible because of the superficial position of ganglia.

  • Depending on anatomic location, injury to the superficial sensory branch of the radial nerve is a potential complication following dorsal ganglion injection, whereas injection of a volar ganglion can cause a radial artery injury.

Pediatric Considerations

This condition rarely occurs in pediatric patients. 

Postprocedure Instructions

Splinting and compression are advised after aspiration and injection. For the first 3 to 5 days, an elastic wrap may be used in combination with a volar splint to reduce pain and swelling. Mobilization is initiated after several days, and range-of-motion exercises are encouraged to restore wrist and finger mobility. The patient should return for re-evaluation within 1 week so the clinician can assess for re-accumulation of the fluid, any persistent drainage, or any signs of infection. 

Coding Information and Supply Sources

ICD-9 Codes

Bibliography

Griffin YG, ed. Essentials of Musculoskeletal Care, 3rd ed. Rosemont, IL: AAOS;  2005:362–367.
Ho PC, Griffiths J, Lo WN, et al. Current treatment of ganglion of the wrist. Hand Surg. 2001;6:49–58. [View Abstract]
Hollister AM, Sanders RA, McCann S. The use of MRI in the diagnosis of an occult wrist ganglion cyst. Orthop Rev.  1989;18(11):1210–1212. [View Abstract]
Pfenninger JL, Fowler GC. Procedures for Primary Care, 2nd ed. St. Louis (MO): Mosby;  2003: 1473–1499.
Rouzier P. The Sports Medicine Patient Advisor: Ganglion Cyst and Ganglionectomy, 1st ed. Amherst, MA: HBO & Company;  1999:251–254.
Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am.  2001(26):599–602.
2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
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