It was a big day for fourteen-year-old Melissa who was graduating from eighth grade. The entire family was there for her recognition of straight A’s and winning a number of awards. After the ceremony they all went to Melissa’s house for a party. One of her gifts was a very nice watch from her grandmother. “Try it on dear,” grandmother said. “Model it for us.”
Melissa put it on, held her arm up in the air, and flexed her wrist to highlight the new watch. When she did this, mom gasped upon seeing the large bump or lump on her wrist.
“What is that?” her mom asked in a shocked voice. Melissa said that she had never noticed it before, but it didn’t hurt. It was a large bump about the size of a walnut. It was soft and squishy, but not tender or painful. If she straightened out her wrist and hand it was hardly noticeable at all.
Melissa’s grandmother, who was visiting from the Midwest, looked at the bump and calmly said, “It's just a Bible cyst. Let me smash it with a big book and it will be all gone!” Mom was not so thrilled with this idea and said that she would make an appointment first thing Monday morning.
I did see Melissa on Monday morning, and grandmother was correct. She had a large ganglion cyst. Both mother and daughter were apprehensive and concerned. Melissa was fearful that I was going to get out a large book and smash it as her grandmother had suggested. Her mother was worried that it might be something serious or even cancerous. I assured them both that they did not have a thing to worry about. Mom asked abruptly, “What the heck IS a ganglion cyst?”
Ganglion cysts are benign cysts or swellings on or around the joints or tendons of the wrists, fingers or feet. They arise from the capsule of the joint or from the sheath that covers the tendon. Fluid from the joint, the synovial fluid, fills the cyst which has its own covering making it like a water balloon. The fluid of the cyst is a thick jelly-like liquid. Sixty to seventy percent of ganglia cysts occur on the top of the wrist and are known as dorsal ganglia. The next most common site is on the underside of the wrist between the base of the thumb and the area where one would feel for a pulse. Less common sites are at the base of the finger on the palm side, or at the fingertip just below the cuticle. These are called mucous cysts. They can also occur around the feet.
No one knows the cause of ganglia. However, it is assumed that there is a flaw in the joint capsule or tendon sheath that allows the joint fluid to fill the space. Ganglia cysts are more common in females than males. They are very common in gymnasts. It is felt that they may be exacerbated by overuse or stress. The more active one is in using the wrist, the larger the cyst may become. Regardless, ganglia are NOT cancerous or dangerous.
Melissa’s grandmother referred to it as a Bible cyst. This is because in the old days, it was common for family members to get a large book, such as a bible, and smash the cyst. It would go away…temporarily. If the outer lining of the cyst was not fully removed, the fluid would just re-accumulate over time. Another old school name for these is a Gideon cyst--the obvious reference to the Gideon’s bible.
Ganglia do not often cause problems. In fact, they are not very noticeable unless one flexes the wrist. If the cyst causes discomfort, or if it in any way interferes with joint mobility it can be treated. Treatment options include simple observation since a certain percentage will go away with time. Another treatment option would be to drain the fluid from the cyst with a large needle. This should be followed by injecting the space with a liquid steroid anticipating that this would prevent the fluid from re-accumulating. After aspirating the cyst, often the joint is immobilized for a brief period of time.
If this was unsuccessful, then the cyst could be surgically removed. This should be performed by a surgeon, preferably an orthopedic hand surgeon. The dissection of the cyst can be very involved and there are many delicate structures nearby. Also, if the entire cyst is not properly removed, it is likely to recur. Before surgery is done the surgeon most likely would want some imaging of the cyst to insure that the fluid is not blood from a nearby blood vessel.
I showed Melissa and mom some articles about ganglia. They were relieved and pleased. As it didn’t bother her Melissa felt she would rather watch it over time. I agreed that this was most acceptable. They were given the card of a hand surgeon, should it become problematic. A few days later I got a call from Melissa’s mom begging me to talk with the grandmother. She was insisting on getting out the dictionary to fix it once and for all. It turns out that the dictionary is larger than the bible that they have at home.