Ganglion cysts

Therapy Interventions: Operative for ganglion cysts

*-Bulky dressing X 5 days* -Controlled progression of activity -Edema control Progressive range of motion exercises -Tendon gliding and blocking exercises -The joints that are hardest to move those are the ones you target with blocking exercises (used for force transmission) *-Immobilize skin grafts or flaps X 2 weeks* Scar tissue management -Make sure the tissue is moving as normal as possible

Dorsal wrist ganglion

*Dorsal* presentation more common 60-70% Usually from *scapholunate* joint *Between EPL and EDC* More to the *radial* side of the dorsal aspect

Mucous cyst

Ganglion cyst from *arthritic joint* Most common in *DIP* Palpable mass near a joint, +/- tenderness Close association with *osteoarthritis*

Regarding other tumors and not ganglion cysts

If they are not symptomatic you just watch them If they are growing they go to a physician If its benign they can choose what to do but you might have to give them some padding Identify where their biggest problems are and target them

Carpal boss

Osteoarthritic spur over CMC of 2nd/3rd digits Where ECRL/ECRB insert Firm, non-mobile, tender, and can be observed with wrist flexion (becomes more prominent) *Does not move bc it is a bone spur*

Associated conditions of Ganglion Cysts

de Quervain's tenosynovitis -Immobilize wrist and thumb -Difference from cyst: May not see a cyst, Finkelstein, history Volar flexor tenosynovitis (ie, trigger finger) -Trigger finger will have a bump with it -It will have a catch and lock Pyogenic flexor tenosynovitis -Infection of the flexor sheath Lipomas or other soft tissue tumors -Fatty tumor Dupuytren's disease (contracture) -Does not have a lump/bump but you see dimpling in the palm or hand and they loose movement abililty

Medical Treatment for Ganglion Cysts

Asymptomatic = observation Aspiration (20% recurrence) -Pull the fluid out Excision (<10% recurrence) -Cut it out Put in a *wrist extension splint*. The activities that cause pain are what they should try and change first

Intraosseous Ganglion

Rare Involvement of *scaphoid or lunate* Wrist pain without clear etiology of visible cyst Very deep

Complications of ganglion cysts

Recurrence of ganglion cyst Neuroma develops Stiffness of the wrist and hand

Volar wrist ganglion

Second most common type 15-20% Scapholunate ligament Radial side over FCR *Perform Allen's vascular test* Can be sitting on top of the radial artery so they may not have good blood flow

Summary of ganglion cysts

Strive for improved use of the involved hand without pain Orthotic devices should allow function Educate on flare-ups and how to manage them Begin scar management as soon as sutures are removed Tell them that ganglion cysts can recur

What is a ganglion cyst

Synovial fluid-filled cyst arising from a joint, ligament, or tendon Come about bc of pressure, forceful use, degeneration of soft tissue *Does not involve a nerve* Palpable, mobile mass +/- tenderness; + transillumination *Most common mass seen in the wrist* Some consider it a tumor but it is benign *Due to chronic irritation and connective tissue degeneration* Seen in older ppl but younger ppl can have them as well

Therapy Interventions: Non-Operative for ganglion cysts

Therapy is aimed in the normal use of the hand -Splint to protect it -Self adhesive pads Symptom management -Orthotic devices PRN Gentle home exercise programs -If they are weak strengthen them -Start with the lowest level and gradually increase it *Instruction on heat/cold modalities -This doesn't help a lot * Flares occure -*Rest, orthotic device*, and activity modifications

Occult Ganglion

Unexplained wrist pain and disproportionate tenderness -Tenderness that doesn't make sense Common source of pressure on *posterior interosseous nerve* -PIN palsy -Radial nerve problems- wrist drop, weakness in extensors -*No sensory problem but will have weakness* *May be detected by placing wrist in marked flexion (phalens)*

Volar retinacular cyst Extensor Retinacular Cyst

Volar retinacular cyst: Palpable and symptomatic Involves flexor tendon sheath *Near MCP or PIP joints* Extensor Retinacular Cyst Uncommon Involves 1st extensor compartment *Abductor pollicis longus (APL) and Extensor pollicis brevis (EPB) tendons* *Associated with de Quervain's tenosynovitis*

Orthotic devices for ganglionic cysts

Wear as much as tolerated sleep and bathe in them Wrist extension for ganglino cysts in the wrist DIP gutter for mucous cysts

Therapy assessment of ganglion cysts

Wrist and digital motion (ROM) -If doing the wrist don't forget about supination and pronation Grip and pinch strength Visual analog pain scale Sensory screening and assessment -Even though it may not be right on the nerve it could cause pressure on the nerve -Radial nerve on web space, ulnar on pinky, and median on index finger. If they are normal on this you don't have to do any more ADL measure -Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire