A ganglion cyst is a very common bump in the hand and wrist. This type of cyst comes from a joint or tendon in the hand and wrist. The most common location is the back of the wrist (see image below). A ganglion cyst can occur in people of all ages. The cause of a ganglion cyst is unknown in most cases. One theory is that the cyst arises from joint fluid which has leaked from a small opening in the joint. The cyst is filled with a thick, jelly-like fluid and usually has a connection with a joint or tendon below.

What are the symptoms? Many people notice that the cyst fluctuates in size. In some cases the cyst can go away on its own. In many cases the cyst is not painful but in other cases, the cyst can cause pain and limited range of motion. Now you know what a ganglion cyst is. What is the best ganglion cyst treatment? Please read on.

Most ganglion cysts are diagnosed by history and physical exam by a trained physician. Since ganglion cysts are fluid-filled, a light shined directly on the mass will light up the cyst. X-ray, ultrasound, and MRI testing are not usually required to make the diagnosis in typical cases. Hand surgeons are experts in diagnosis of ganglion cysts in the hand and wrist.

What are the treatments available? There are three common ganglion cyst treatment options:

OBSERVATION:   Also known as watch and wait. Since ganglion cysts are benign (not cancer), surgery is not required to remove them. Cysts which are not painful and do not interfere with function can be left alone and monitored. Some cysts can go away on their own. If the cyst becomes larger, painful, or interferes with function, further options should be discussed.

ASPIRATION:   Also known as drainage with a needle. The cyst can be punctured and the thick fluid removed using a needle under sterile conditions. This is a quick procedure which is performed in the office. There is a high chance that the cyst comes back, however. There is a small risk of bleeding, pain, and infection from this procedure. Do NOT try this at home!

SURGICAL EXCISION: Finally, surgery is ganglion cyst treatment option. This surgery requires an incision and it is performed in the operating room. During surgery, the cyst is removed including the base which goes down to the joint. Removing the connection to the joint reduces the chance of cyst recurrence. Gardeners realize that the roots of the weed need to be removed, or else it will grow back.  

In the past, some physicians have recommended simply popping the cysts by hitting them with a heavy book or Bible. For this reason ganglion cysts have been called “Bible cysts.” This is not recommended since damage can be done to the surrounding area, and most cysts recur with this technique.

What is the recovery from ganglion cyst excision surgery? Ganglion cyst excision is performed on an outpatient basis. Most people can return to light duty work in a few days as the pain and swelling subside. Hand therapy is sometimes helpful after this procedure to improve range of motion and strength. Patients should avoid forceful use of the hand for approximately 4 weeks after surgery. Normal use of the hand is resumed as comfort allows. Complications from surgery include cyst recurrence (5-10%), wrist stiffness, scar tissue, and infection.

The ganglion cyst images are copyright Dr John Erickson and the cyst aspiration drawing is copyright AAOS OrthoInfo. The video is courtesy of American Society for Surgery of the Hand.

What is a boxers fracture? A boxers fracture is a very common hand injury. The typical cause is punching a wall with the fist. These injuries are most common in young adult males. They can also occur in a variety of ways such as a fall, sports injury, or car accident. A “boxer’s fracture” is defined as a fracture of the 5^th metacarpal neck. “Fracture” is simply the medical term for “broken bone.” See the picture below

There are five metacarpals — one for each finger and the thumb. The 5^th metacarpal is at the base of the pinkie. Bruising, swelling, pain, and finger stiffness are common symptoms at first. The knuckle may look abnormal or out of place as well.

The recommended treatment of this injury depends on the alignment of the fracture on the x-rays and the patient’s medical condition and activity level. Most patients have a boxer’s fracture with mild to moderate angulation. Therefore, they do not require surgery. Angulation is measured in degrees and this defines how “crooked” the bone is. A firm “bump” is often noticed at the fracture site during healing. This is composed of new bone formation, the body’s normal response to heal the fractured bone. This bump can be seen on x-ray and is called the “fracture callus.”

Mild to moderate angulation in a boxer’s fracture typically results in a good long-term hand function. Our hands can naturally compensate for this deformity and still function very well due to the motion at the base of the 5^th metacarpal. This is because the joint at the base of the 5^th metacarpal has a high degree of mobility. Treatment in these cases is typically rest and protection in a splint or cast for a few weeks. Ice, compression, elevation and oral NSAIDs are helpful to reduce hand swelling. Follow-up x-rays are obtained in clinic to evaluate how the fracture is healing. Hand therapy is often helpful to improve finger range of motion and hand strength.

If the fracture angulation is excessive, or the metacarpal alignment is poor, the bone can be re-aligned with manipulation. This procedure is called a “closed reduction” and is performed in the office with local anesthesia numbing medicine. These patients can be treated without surgery and achieve a good result.

Occasionally, surgery is recommended to fix the boxer’s fracture with metal implants such as pins, screws, or a plate. Surgery is most beneficial if there is significant angulation or if the finger is mal-rotated (twisted). Surgery has the potential complications of infection, stiffness, scar tissue formation, and need for removal of the metal implants.

Your doctor will explain the options to you and recommend individual treatment based on your specific type of hand injury. All Raleigh Hand to Shoulder Center doctors are members of the American Society for Surgery of the Hand.

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper extremity. It results from increased pressure on the median nerve at the wrist, within the carpal tunnel.  Symptoms such as numbness, tingling, weakness, and pain can result if the nerve is compressed or “pinched.”

The word “carpus” is derived from the Greek word karpos, which means “wrist.” The carpal tunnel is a passageway in the wrist through which the median nerve and tendons of the hand travel. The carpal tunnel is a narrow, confined space: the floor of the tunnel is made up by the carpal bones of the wrist, and the roof is created by the transverse carpal ligament. The median nerve is at risk for compression within this tunnel. If there is abnormal swelling, altered wrist anatomy, or injury to this area, the function of the median nerve may be affected. 

What causes carpal tunnel syndrome? 

In most cases, the cause of CTS is unknown. Thyroid disorders, rheumatoid arthritis, pregnancy, vitamin deficiencies, diabetes, fluid retention, and trauma can be associated with CTS. Women are more commonly affected than men. Repetitive, forceful gripping and heavy use of vibratory tools may increase a person’s risk of CTS.

How do I know if I have carpal tunnel syndrome?

Patients with CTS commonly report “numbness” or “tingling” in the fingers. Some patients feel that the fingertips are “asleep” or report “poor circulation” in the hands. Symptoms are often worse at night and people tend to shake their hands for relief. Some patients report increased symptoms while gripping a steering wheel.  Dropping objects, clumsiness with the hands, or a weak grip are also common complaints. Some people also report pain in the forearm, wrist or fingers. In severe cases, the muscles at the base of the thumb (thenar muscles) can become weak and atrophy, sometimes permanently. 

Often the diagnosis can be made on the basis of your symptoms, medical history, and physical examination. An electrodiagnostic study (nerve conduction study and/or electromyogram) can be ordered to confirm the diagnosis.

What are the treatment options?

Not everyone with carpal tunnel syndrome needs surgery. Fortunately, many people with CTS improve with non-operative treatment. Wearing a wrist brace at night supports the wrist in neutral alignment and takes pressure off the median nerve. Avoiding prolonged wrist flexion and forceful or repetitive gripping may also help. Corticosteroid injections provide an anti-inflammatory effect and can be effective in many patients. 

Should these measures fail to improve the condition, or if nerve compression is severe, surgery may be recommended. A carpal tunnel release (CTR) is performed to decrease pressure on the median nerve. During this procedure, the “roof” of the carpal tunnel (the transverse carpal ligament) is divided. Cutting the transverse carpal ligament increases the size of the carpal tunnel and provides more room for the median nerve. 

The length and type of incision varies among surgeons; however, the common goal is to reduce pressure on the median nerve. The length of incision used for CTR has decreased in size since the procedure was invented decades ago due to advancement in surgical techniques. Open CTR and endoscopic CTR are two surgical options. The recommended procedure will be discussed with you in the clinic. 

What is the recovery from surgery?

The surgery is performed as an outpatient under local anesthesia. Oral or intravenous sedation medication may also be used. Patients may use their hands for light activities soon after the surgery. Many people can return to light duty work in a few days. Patients should avoid heavy use of the hand for approximately 3-4 weeks after surgery. As the pain from surgery subsides, normal use of the hand is resumed.

What are the results from carpal tunnel surgery?

Most patients are very satisfied with their outcome after CTR surgery. Many patients report dramatic improvement in their symptoms in just a few days, but others may take longer. Some patients do not have complete relief of symptoms, especially in severe or long-standing cases. Temporary soreness or tenderness in the palm can occur. There is less than 5% recurrence rate after CTR surgery.

What are the complications from surgery?

Complications from carpal tunnel release surgery are uncommon. Possible complications include persistent symptoms, pain, bleeding, infection, stiffness, and damage to the median nerve. 

Dr. George Edwards III discusses treatment of metacarpal fractures of the hand at WakeMed orthopedic hand conference on August 24, 2020. Diagnosis, non-operative treatment, modern surgical techniques, and rehabilitation programs are discussed.

A mucous cyst is a fluid-filled sac that occurs on the finger joint closest to the nail. The fluid is clear, thick, sticky, similar to mucous. The cyst may thin the skin and may cause a groove to form in the nail. Most patients who develop a mucous cyst have wear and tear arthritis (osteoarthritis) of the involved joint. The cyst has a stalk that is connected to the joint. It is thought that underlying bone spurs from the arthritis weakens the joint lining allowing the cyst to form. See blow for pictures of mucous cyst in finger.

How is a mucous cyst diagnosed?

The mucous cyst typically has a characteristic appearance, and the diagnosis is straight-forward for most hand specialists. Radiographs are usually ordered to confirm underlying arthritis of the joint and associated bone spurs (also known as osteophytes).

Does the mucous cyst need to be treated?

Most mucous cysts are not painful. If they are not causing pain or hand dysfunction, they do not require treatment. In these cases, observation for changes in the cyst is all that is needed. Some cysts can go away on their own. If a patient develops pain, recurrent drainage, or nail deformity, surgery may be recommended. Even if not painful, diagnosis should be confirmed by a physician, as other diseases may mimic a mucous cyst or ganglion cyst. These cysts should not be drained at home with a needle because a serious infection in the joint can occur. See images below for examples:

Pictures of mucous cyst in finger

Images from Dr John Erickson

Raleigh Hand to Shoulder Center doctors are members of the American Society for Surgery of the Hand.

Nerves are fragile and can be injured in many ways — including compression, lacerations, or blunt trauma. Compression is caused by prolonged pressure on a nerve, such as in carpal tunnel syndrome. Nerve lacerations are caused by a sharp object such as a knife or broken glass. A cut nerve in the finger will make it feel constantly numb often with tingling and electric pain. A nerve can also be injured by a sudden blunt force or “contusion” such as the thumb being hit with a hammer.

Treatment of a nerve injury depends on the type of injury, timing of the injury, and specific nerve involved. Nerves which are contused due to blunt trauma will often recover function gradually on their own, if the nerve injury is not too severe.

Surgery is recommended for most cut nerves in the hand in order to improve function and decrease the chance for neuroma formation. Without surgery, the two ends of the nerve have difficulty joining together and the numbness can be permanent. A neuroma is a thickened end of a cut nerve which can be hypersensitive to touch.  Nerve repairs in the hand are common procedures performed by hand specialists.

During nerve repair surgery, the nerve ends are brought back together and the nerve sheath is repaired using fine sutures. This is known as a “primary repair.” Magnification improves the ability to see the nerve and its tiny internal bundles called fascicles. Injured tendons are also repaired if needed. This surgery is ideally performed within a few days of the injury. 

If there has been a delay in treatment or if the nerve has been injured over a wide area, it may not be possible to bring the ends of the nerve back together. In this case a “nerve graft” can be used for nerve reconstruction to bridge the gap. There are many available sources for nerve graft reconstruction.  The three most common ways to bridge the gap are:

1. Autografts: An autograft is a nerve graft obtained from the same patient’s body using another skin incision. Some numbness can be expected from the donor site, depending on the location of the graft.
2. Allografts: An allograft is a nerve obtained from a person who has donated their body tissues. The grafts are cleaned and prepared carefully for this purpose. There is a very small risk of both disease transmission and graft rejection with use of allografts, but they do not require a second incision on the patient. These are commonly used today.
3. Synthetic tubes: Synthetic hollow tubes are designed to guide the reconnection of nerve gaps. They do not require nerve harvesting from the patient but there is a small risk of graft rejection with any manufactured material.

Nerve repair surgery is not a “quick fix.” Recovery of the nerve is slow and can take 6-12 months for the feeling to come back. Recovery time varies among patients, depending on the severity of the injury, patient age, possible complications, and medical history of the patient. Not all patients regain full function after a nerve repair or reconstruction.

Dr. George Edwards, III of Raleigh Hand to Shoulder Center will be discussing congenital hand problems at WakeMed UNC orthopedic resident conference on Monday, February 3rd. This talk includes a discussion of various birth abnormalities involving the hand including treatment options.

Dr. Terry Messer of Raleigh Hand to Shoulder Center and Dr. William DeAraujo of Goldsboro Orthopaedics recently traveled to Leon, Nicaragua for a medical mission trip.  They worked with the Resident and Attending doctors at HEODRA Hospital where they saw approximately 100 patients and performed more than 25 surgeries during the week.  Several doctors from RHSC have participated in medical mission trips to Nicaragua in recent years.

Dr. George Edwards III discussed treatment options for broken wrists, also known as distal radius fractures, at WakeMed UNC orthopedic hand conference.

Dr. Terry Messer gave a talk entitled “Thumb Collateral Ligament Injuries in the Athlete” at the 2019 North Carolina Orthopedic Association, Annual Meeting on Saturday, October 12, 2019.