Ganglion Cysts: What Retail Clinicians Should Know

Patients presenting with bumps on their hands and wrists likely have benign ganglion cysts.

Ganglion cysts are firm, knobby masses under the skin that are filled with clear fluid or gel but don’t move with palpation. They’re most commonly located on the top of the wrist, the palm side of the hand, the base of the finger on the palm side, and the top of the end joint of the finger.

Notably, 60% of all bumps on patients’ hands are classified as ganglion cysts. These cysts are colloquially referred to as “Bible Bumps” because a folk remedy was to smash them with the heaviest book in the patient’s house (often the Bible), which ruptured the cyst. Although the cyst’s contents usually drained away into the lymphoid tissue afterward, the risk of infection, scarring, and restricted movement remained high.

It’s unclear how or why ganglion cysts develop, but degeneration of the mucoid connective tissue (collagen) probably contributes to them. Some researchers believe that joint stress may compromise the joint capsule and allow synovial fluid to escape into the periarticular tissue. The impact is joint instability, weakness, and limited range of motion.

Although most ganglion cysts are painless, some tumors can be acutely painful if they compress nerves, and they can sometimes cause parasthesias. They may also change in size over time.

For clinicians, recognizing the cyst is the most important step in diagnosis. Ganglion cysts have very typical presentations, and a simple search in an image library will provide dozens of typical pictures for clinicians.

Clinicians and patients have some treatment choices. If the cyst isn’t painful or causing problems, one option is to do nothing. The cyst may resolve spontaneously over time, which many do.

Another option is for clinicians to refer the patient to a surgeon for removal. After careful assessment, surgeons may aspirate if the cyst seems uncomplicated and its contents haven’t thickened. Ganglion cysts recur after aspiration in about 50% of patients.

Larger or more complicated cysts may need more extensive surgery and recurrence is less likely than when aspiration is used. Approximately 15% of patients have significant residual pain and functional limitation after excision of wrist ganglions. Splints and anti-inflammatory medications can be prescribed to decrease this pain.

It’s important for clinicians and patients to handle ganglion cysts with care. Surgery in the office may lead to infection, and joint infections are notoriously difficult to treat.