Pediatric Surgical Treatment of a Wrist Ganglion Cyst in a Resource-Limited Setting

Abstract

Ganglion cysts are benign, mucinous-filled swellings that overly tendons and joints. They are the most common soft tissue mass found in the hand and wrist but also commonly encountered in the knee and foot. Presenting as a palpable knot, the cyst is asymptomatic until it impinges on local neurovasculature causing pain, numbness, tingling, and/or motor deficits. Pediatric ganglion cysts have different epidemiological characteristics than adults, with the majority found on the volar aspect on the wrist. Treatment of ganglion cysts is most often observation due to the 50% chance of resolution over time. Activity causes the cyst to increase in size, and thus more aggressive treatment is often desirable. If the cyst recurs or symptoms are not relieved with observation alone, a more aggressive treatment is often desirable. Surgical excision, while more invasive, has a lower rate of recurrence.^1, 2 Here, we present a female pediatric patient undergoing surgical excision of a large ganglion cyst on the dorsum of her right wrist. With the treatment options explained to her, she chose excision for the lower rate of recurrence.

Case Overview

Background

Ganglion cysts are mucin-filled cysts that are most commonly found on the dorsum of wrists. They arise from trauma and/or mucoid degeneration of the periarticular structures that present as a firm, well circumscribed knot.¹ Ganglion cysts are distinguished from synovial cyst due to the lack of communication with the joint cavity or the synovial membrane. The size of the cyst increases with activity and can impinge on local nerves, resulting in motor and/or sensory loss. Diagnosis of ganglion cyst is usually clinical and can be determined with transillumination. First-line treatment for most patients is observation, as over 50% resolve gradually; however, aspiration and excision can relieve impingement on neurovascular structures, improve joint pain and decrease rate of recurrence.²

Focused History of the Patient

This 13-year-old female pediatric patient arrived at the clinic with a senior family member as an escort. She complained of a firm, smooth, unilateral ganglion cyst on the dorsum of her right wrist, which had been present for about a year. The treatment options, strategies, possible outcomes, and complications including the possible hypertrophic scarring and keloid formation were discussed with the patient and her family member. The decision was made to proceed with surgical intervention due to the lower chance of recurrence. There were no known allergies or contraindications for the procedure.

Imaging

No imaging was performed to confirm the diagnosis due to its limited availability in the rural settings. However, clinical assessment and transillumination of the cyst provided sufficient confidence for diagnosis.

Natural History

Ganglion cysts are the most common soft tissue hand masses.¹ They are thought to result from the mucoid degeneration causing herniation of connective tissue from the tendon sheaths, ligaments, joints capsules, bursae, and menisci with no true overlying epithelial lining. This swelling contains a gelatinous fluid that overlies the joint and can be found anywhere in the body.¹ Though this patient has a dorsal ganglion, pediatric ganglions are more commonly found on the volar surface of the hand and wrist, whereas they are most commonly dorsal in the adult population.³ Recurrence of ganglion cyst is approximately 60–95% with aspiration and 20% with excision surgery.^{5 6}

Options and Rationale for Treatment

The patient and her family member were given the options for her treatment and were informed about possible outcomes and complications before her procedure took place. As she had a cyst approximately 2 cm in diameter that was causing her pain and an unpleasant cosmetic presence, observation deferred. Surgical intervention was ultimately chosen due to the lesser chance of recurrence. Observation is typically the first-line treatment for ganglion cyst as 50% of the time they regress over time with no intervention.² Aspiration and excision is often turned to when the cyst recurs after a period of observation and fails to regress. Aspiration, while far less invasive than excision of the cyst, does have a much higher recurrence rate of 60–95%.⁵ With a higher chance of complications from a more invasive procedure, the recurrence rate is far lower at 20% with excision.⁶ Further research is needed to determine the recurrence rates after ganglion cyst marsupialization. Although this patient had a dorsal wrist ganglion cyst, volar wrist cyst has a greater complication rate and a higher recurrence rate due to the complexity of the volar wrist’s neurovasculature. If symptomatic relief is the patient’s primary concern, a conservative method is preferred, while surgical intervention will decrease the likelihood of recurrence.

Special Considerations

No special considerations were indicated for this patient.

Discussion

The procedure was performed under local anesthesia in a sitting position. Although the supine position is preferred for such surgical procedures under local anesthesia to minimize the risk of collapse, the sitting position was chosen to alleviate the discomfort and anxiety of the pediatric patient. An option to convert to the Trendelenburg position was available in case of a collapse. Next, 1.5 mL of 1% lidocaine was injected on top and around the ganglion, with an incision made on top of the cyst, taking precautions not to penetrate it. A mosquito hemostat was used to bluntly dissect around the ganglion as much as possible. Since the ganglion cyst penetrated deeper between the tendons of the wrist, the decision was made to incise the cyst and evacuate the gel-like synovial fluid. This was done to avoid injury to the structures underneath and allow the extraction of the cyst wall while dissecting out the inferior border adjacent to the underlying tendons. Mosquito hemostats were attached to both sides of the incision on the cyst to ensure a point of reference with the cyst wall during dissection. Electrocautery was used throughout the procedure to separate the cyst wall from surrounding soft tissue. Since the cyst extended deeper into the underlying tendons, a marsupialization procedure was performed as an alternative technique. Surgical excision was deemed unfeasible in a resource-limited setting and posed a risk of complications. Marsupialization involved suturing the cyst wall to the surrounding soft tissue, creating a continuous surface from the exterior to the interior of the cyst. This allowed the cyst to remain open and drain freely. Due to unavailability of an electrocautery device with a low collateral thermal damage, hydrogen peroxide was used inside the incision for its hemostatic properties, although it may negatively affect the wound healing process. The overlying skin was closed with subcuticular sutures, with precautions taken not to close the cyst wall due to the increased risk of recurrence.

The procedure, as typical, took 10–15 minutes and was performed in an outpatient setting, with patients discharged soon after. The prognosis for ganglion cyst excision is excellent, providing immediate pain relief and cosmetic improvement. Potential complications of surgery include infection, tendon injury, decreased range of motion in the affected joint, and neurovascular injury. The timeframe for another ganglion cyst varies from patient to patient; some experience recurrence within months, while others may go years without another occurrence. In rural settings, procedures like these can significantly improve the quality of life for patients who may otherwise have to wait several months for simple elective procedures.

Equipment

Minimal equipment is necessary for ganglion cyst excision:

• Antiseptic cleansing solution
• Local anesthesia in syringe
• Scalpel
• Sterile supplies: bandages, drapes, gauze, gloves
• Small-tipped hemostats (Mosquito)
• Suture supplies 

Disclosures

Nothing to disclose.

Statement of Consent

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.