“When you have eliminated the impossible whatever remains, however improbable, must be the truth”
Sherlock Holmes from The Sign of Four by Sir Arthur Conan Doyle
Lumps and bumps, masses and growths in the hand, are one of the most common reasons patients come to see hand surgeons. Fortunately malignant ,or cancerous, lesions in the hand and wrist are very, very rare, so much so that a hand surgeon may go through his entire career and never treat a malignant lesion. A good hand surgeon is always on the lookout for malignant tumors, but the vast majority of hand lesions are benign growths that can be either observed or removed without too many problems.
By far and away the most common hand tumor is a growth called a ganglion cyst. Ganglions are fluid filled cysts that usually arise from joints or from other areas such as the sheaths of tendons. No one has any idea how these lesions arise. A fair number of them will come and go seemingly as they please. A great number of people live with these lesions and they never cause them trouble. I have a couple of ganglions on my fingers, and when I show them to patients who have them most people choose to live with them rather than to have them removed.
What is a ganglion like? It’s usually a solid lesion that you can move around a bit. You can usually feel around the mass and get the feeling that the mass is separated from the surrounding tissues. If you shine a light through it the light will usually pass through, or trans-illuminate the lesion. The cysts have a fairly thin wall and inside they contain a viscous fluid that looks more like hair gel than anything else I can come up with. They can grow to some degree, but I’ve not seen a ganglion in the hand or wrist that got as big as a ping pong ball. Ganglions can grow up around the other structures in the hand, but only very rarely do they cause a problem. My sense is that ganglions are like balloons, in that they can only grow and fill up to a certain size.
There are four common locations for ganglions in the hand and wrist, although they can occur in other locations. I’ll talk about each location separately.
The most common location is on the back of the wrist. Ganglions can start as very small growths, the size of a pea, that arise from the wrist joint and grow bigger and become more noticeable. Some people get pain in the back of their wrist from the ganglion, especially when they’re doing things like a push up. About 30% of ganglions go away on their own. An option for treatment, especially on the back of the wrist, is to pop the cyst with a needle after numbing the skin over the cyst. You can draw out the jelly inside the cyst, and this gets rid of 50-60% of the ganglions. The last option is surgery, which can result in some stiffness in the wrist. Even with surgery I would estimate 2-3% of ganglions recur.
The second most common site is on the bottom of the wrist near where your pulse is. These arise from the wrist joint as well. These cysts will grow up towards the radial artery, which is your pulse, but they will never choke off or constrict the artery. Because the artery is so close to these cysts I’m not very fond of trying to aspirate these cysts. I usually recommend either living with the cyst or have it removed with surgery if it’s bothering you. The surgery is a little harder than taking those out on the back of the wrist because of the location of the artery, but the cyst can be safely removed in an operating room.
The most common location in the fingers is just in front on the nail. These small cysts arise from the last joint of the finger called the distal inter-phalangeal joint, or DIPJ. A lot of patients have some underlying arthritis at the joint. The skin is really thin over this joint, and sometimes these cysts can grow and actually pop through the skin. I’ve patients try to pop these on their own, as well as some physicians, and I don’t seem to have much luck trying to pop, or aspirate them. Again I advise folks to live with the cyst or have it taken out. I remove almost all of these in my office under local anesthesia and most of the patients do very well. Like ganglions in other locations, these can recur after surgery.
The last spot that ganglions occur is in the palm of the hand at the base of the finger. These ganglions arise from a tendon sheath rather than a joint, and they are usually very firm and not as mobile as ganglions in other locations. I have a couple of these in my right hand that have been there for years and not caused me any problems. In some people the cyst can get tender and cause problems grasping objects so they want something done about it. You can occasionally succeed in popping the cyst with a needle after numbing the skin with local anesthetic or you can have the cyst removed with surgery.
If you have a ganglion there is no harm in living with it. They won’t grow and cause problems by wrapping themselves around nerves or tendons. In most cases you can pop, or aspirate the cyst, which has around a 50/50 chance of working or you can have the cyst removed with surgery. 2-3% of cysts can come back after surgery.