A 16-year-old male came to clinic with a 2 week history of a mass on the inside of his wrist. He had noticed it when he was keyboarding. He denied pain, irritation, redness, warmth or limitation of motion of the wrist. He also thought that it wasn’t getting larger but wasn’t going away. The past medical history and review of systems was non-contributory.
The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters. There was a ~10 mm round, mobile mass along the lateral, palmer aspect of the wrist. It was non-tender without changes in the overlying skin. He had complete range of motion that did not elicit tenderness. The mass transilluminated. The diagnosis of a ganglion cyst was made. The natural history of this potentially becoming larger or receding was discussed. Potential future options such as aspiration or surgery were also discussed but the family was told that they could often recur. The patient wanted to wait and watch.
Lumps and bumps in the pediatric age group are most often benign. They can be from unwitnessed/unrecognized trauma (e.g. leg bruise, Osgood-Schlater disease, insect bites), normal pubertal changes (e.g. gynecomastia, testicular enlargement, acne) or normal variants (e.g. prominence of mastoid or occipital process). Some are often uncomplicated but need appropriate treatment (e.g. early abscess formation, inguinal hernia, dermoid cyst). Prominent lymph nodes are a very common reason for parents to come to the physician. Patients and families are often distressed by these masses and seek help because “they weren’t there before” or “they’re not going away.” They are often surprised to find out that the mass is benign or normal but are happily reassured.
Ganglion cysts (GC) are cystic masses that can overlying a tendon, ligament, joint and occasionally a bone. They are benign but because of size or location may need treatment. GC are not considered true cysts as they do not have an epithelial cell lining. The etiology is unclear but the walls are made up of smooth muscle cell variants and there is mucinous fluid within. They can be solitary or multilobulated. Often they are not palpable and are found secondary to evaluation for other problems. GC can occur anywhere in the appendicular skeleton but wrists are a very common location and are the most common cause of wrist soft tissue masses in the general population. The incidence in the pediatric population is not known. Adults have more lesions on the dorsal surface and adolescents have more on the palmar surface. They can occur at any age in the pediatric age group and are more common in adolescents. In the pediatric age group, females have them more than males.
GC usually has low morbidity with potential spontaneous resolution and unfortunately a relatively high recurrence rate after various interventions. Evaluation may including imaging with ultrasound or magnetic resonance imaging (MRI) and both have equal effectiveness but ultrasound is significantly more cost effective. In a study of pediatric patients who had MRI imaging of their wrist, ~ 1/3 had a GC. Many had pain (82.9%), swelling (20%) or a palpable mass (11.4%). Most also had other significant wrist abnormalities and it was difficult to ascertain if these wrist symptoms were due to GC or GC was an incidental finding.
Interventions include aspiration, puncture rupture, steroid injection, open or arthroscopic excision. In a prospective study of adults with GC, 70 months after reassurance or treatment, the GC often did not resolve (58%) and 39% had recurrence after intervention. Patients who had intervention were more satisfied overall than patients who were reassured though. Surgical complications were 7.7%. Treatment costs obviously increased with intervention because of radiology, pathology and surgery costs.
GC are sometimes called “bible bumps” because laypeople would take the largest book they had in the house (i.e. a bible or similar book) and smash the lesion to treat it. This form of treatment is NOT recommended.
Questions for Further Discussion
1. What are common benign and malignant bone masses in adolescents?
2. What are indications for referral for a mass to a surgeon?
- Disease: Ganglion Cyst | Wrist Injuries and Disorders
- Symptom/Presentation: Mass or Swelling
- Specialty: General Pediatrics | Orthopaedic Surgery and Sports Medicine | Surgery
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Wrist and Hand Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007 Oct;32(5):502-8.
Gant J, Ruff M, Janz BA. Wrist ganglions. J Hand Surg Am. 2011 Mar;36(3):510-2.
Bracken J, Bartlett M. Ganglion cysts in the paediatric wrist: magnetic resonance imaging findings. Pediatr Radiol. 2013 Dec;43(12):1622-8.
O’Valle F, Hernandez-Cortes P, Aneiros-Fernandez J, Caba-Molina M, Gomez-Morales M, Camara M, Paya JA, Aguilar D, del Moral RG, Aneiros J. Morphological and immunohistochemical evaluation of ganglion cysts. Cross-sectional study of 354 cases. Histol Histopathol. 2014 May;29(5):601-7.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital