Advances in diagnosing and treating ganglion cysts and other wrist bumps
Dr. Laith Jazrawi and Dr. Nader Paksima of NYU Langone Orthopedics discuss everything you want to know about wrist bumps. From common ganglion cysts to rare tumors, they cover how to diagnose, treat and rehab from wrist lumps and bumps.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Dr. Laith Jazrawi: We are continuing our podcast called Bone Whisperers. Today we have a great guest on - Doctor Nader Paksima, Professor of Orthopedic Surgery and Hand Surgery, and also Chief of the Hand Center here at NYU Langone Health. And today we're going to talk about, what is that bump on my wrist? And I'm Laith Jazrawi, Chief of Sports Medicine here at NYU Langone Health, moderating this discussion. Good morning.
Dr. Nader Paksima: Good morning.
Dr. Laith Jazrawi: So the first thing and the first question that people ask when they see a bump on their wrist is, could this be cancer? And Nader, how do you respond to that? And is that even a possibility?
Dr. Nader Paksima: Well, good morning, Laith. And it's great to be here. People are concerned when they see a bump anywhere. One of the things that can run through their minds is it's cancerous. And the answer, 99.99% of the time, is it's not. Benign growths around the wrists are really common. They're usually not cancerous, but it is a legitimate concern. And people come in and we run tests and do examinations to make sure that it's not.
Dr. Laith Jazrawi: So when you have a patient that comes into your office that has a bump, where do you typically see it, in either the hand or the wrist. And what are the possibilities? I guess, to kind of put people, their mind at ease that it's not this cancerous thing or some weird growth. What is the differential diagnosis, as we would say in medicine?
Dr. Nader Paksima: Sure. So typically, as we're talking about specifically on the wrist, there's bumps that grow on the back of the wrist, on the back surface, and they can also grow on the palm side. And the most common thing that we see are ganglions. But we break it down into bony and soft tissue growths. And things that can grow from a bony perspective are arthritis - you can get arthritic spurs. If you've had a previous wrist fracture, you can have a bump that grows on the back of the wrist. Specifically, there's a bone called scaphoid, which many times can break and people don't know they have scaphoid. And then years later, they get arthritis, and they present with this thing called slack wrist or snack wrist, and that can present with a bony bump. And then on the other side, we have soft tissue growths. And the most common soft tissue growth is a ganglion, which is a jelly fluid filled cyst. And, um, there can also be other things, like tendinitis. Tendinitis can present with a large bump on the back of your wrist and we call that tenosynovitis, which is teno means tendon, and synovium is the lining of the tendon. And then itis just means inflammation. So tenosynovitis is inflammation of the lining of the tendons. And those can appear with or without a cyst. So we categorize those bony growths and soft tissue growths, and usually, after doing a physical examination and x-ray, we have a pretty good idea which one they are.
Dr. Laith Jazrawi: And circling back to that dreaded “C” word, the cancer word that people are so fearful about and are so rare in the hand and wrist, what is the most common bone tumor that you see in the hand or wrist? And then what is the most common soft tissue tumor?
Dr. Nader Paksima: Bone tumors are rare in the hand and wrist, but the most common one would be something called an enchondroma, which is a benign growth of cartilage. And the most common soft tissue tumor is the ganglion, which is, you know, a benign tumor, basically.
Dr. Laith Jazrawi: So people shouldn't be worried when they see these bumps on their wrists. These are things that could be taken care of by someone like you.
Dr. Nader Paksima: That's right.
Dr. Laith Jazrawi: Okay, so I guess the next question is, I need an MRI doc. For me, as a sports medicine specialist, this is the number one thing. Patients want MRIs before they even want me to examine them. So is this something in the hand and wrist? Are we getting an MRI on all patients, or is it the routine? Do we get an x-ray and then an MRI?
Dr. Nader Paksima: Yeah, that's a great question. So many patients, by the time they come to see me, they've already had an MRI, because they went to see their family physician, and they ordered an MRI. And MRIs are great. They're great diagnostic tools, and they can really give us a lot of answers. But when I see someone fresh with a bump on their wrist, we always start with an x-ray. And x-rays are important because there are bony reasons why you can have a bump on your wrist and those show up on an x-ray better than on MRI. So you do need an x-ray. And people will ask me, why do I need an x-ray if it's a soft tissue mass? And that's the reason. Also, when we get the x-ray, we get these things called stress views. And stress views are where we position the wrist in different positions to put stress on the bones to make sure that the bones are moving together in the right way. When you have a ligament injury, you can't see that on an x-ray, but you can see if the bones don't move properly together, and that's really important information. So we always start with an x-ray and we get these stress views. And then if, uh, the x-rays are negative, which is a good sign, then either an ultrasound or an MRI can be performed. Each has an advantage. Ultrasound is great for identifying things that have fluids in them, like cysts. And MRI is great because it can identify the mass and also tell us about the ligaments underneath. So, generally, the progression is an x-ray and either an ultrasound or MRI, depending on what the clinical exam shows.
Dr. Laith Jazrawi: Yeah, I think that's very important. x-rays get a bad name, but really, you can get your answer with the x-ray and be done with it, and then not tax the healthcare system by getting MRIs - more co pays, more deductibles. And you bring up a good point - a good clinician with a well done x-ray, you can answer the question about “what is that on that patient's wrist?” Or is it another reason? And oftentimes you can miss something if you just get the MRI and don't have the x-ray. Correct?
Dr. Nader Paksima: That's right. Yeah. You can actually miss pathology if you don't get the x-ray and just go straight to the MRI. So that's a really important point.
Dr. Laith Jazrawi: So I think that's very important. Now, do all these need surgery? That's the first thing. “Do I need surgery, doc?” Or can we just aspirate these or put a needle in it? Once you've sort of come down to that diagnosis, yeah.
Dr. Nader Paksima: So most people, by the time they come to see me, it's bothering them, and they want to get rid of it. And I always tell them, look, once we've established a diagnosis, we know it's not cancerous, and we know it's a benign ganglion, then options are to just do nothing and watch it. If it's not bothering them, you can just observe it and re-examine it in a few months. Um, aspiration is a great option for fluid-filled structures like ganglion. And then surgery for when aspiration fails or if it's recurred or if it's a solid type tumor. So the way aspiration works is once we've established that the mass is fluid-filled or jello filled, we can numb up the skin, and this can be done right in the office. We numb up the skin, and we put a needle directly into the area of the swelling, the lump, and aspirate it. Pull back on the needle and see if we can get some of the jello out. And you can combine that with a cortisone injection or just an aspiration. And, uh, it works about 30% to 50% of the time. Sometimes you put the needle directly into the mass and nothing comes out. So why does that happen? Either the lump isn't one big balloon, but it's a bunch of septated balloons. So I always make the analogy - either it's a grapefruit or it's a cluster of grapes. And so if it's one big grapefruit, you can put the needle in and drain the fluid out. But if it's a cluster of grapes, you're not going to be able to hit all those little pockets. And then the other reason that, um, the aspiration can fail is if the jello has become too solidified or the diagnosis was incorrect and it was really a solid tumor, because there are rare solid tumors that grow on the back of the wrist, like a lipoma, a fatty tumor, and those kinds of things. So if I put a needle into the mass and I don't get the typical clear, gelatinous fluid, then I recommend the surgery because we can remove the mass and do a biopsy at the same time.
Dr. Laith Jazrawi: Circling back to the most common reason to have a mass on your wrist, these ganglion cysts, these fluid filled structures. Is there a reason why people get them? I mean, what's the theory behind them? Or they just come out de novo or just out of the blue?
Dr. Nader Paksima: Yeah. Usually people don't remember a particular injury, but they're typically related to some kind of ligament irritation. So the most common ligament is the scapholunate ligament between the scaphoid bone and the lunate bone. And that ligament sees a lot of strain when you go into a hyperextension, push up type position. So, um, if you're doing things like yoga or Pilates, or planks or pushups, you can cause a minor injury to the ligament, and either the ligament heals itself with some inflammation, or it can undergo some degeneration. And when it becomes degenerated and breaks down a little bit, one of the reactions is that it can form a cyst. So the theory with these cysts are that they're mostly caused by a minor ligament injury which then went on to become degenerative.
Dr. Laith Jazrawi: So it seems like it's a fairly common thing in the wrist. It seems like a lot of people don't like them. They want to get him out - these masses. And I'm focusing more on the ganglion cyst, which seems to be the most common thing. So now that you've decided that the patient wants surgery. One of the questions that comes up is, doctor, what's the risks of taking it out? Is this a simple surgery? Is this a big deal? What are your thoughts on that?
Dr. Nader Paksima: Yeah, that's a great question, because people always ask me, is it? And I never say a surgery is a simple surgery, because when you have surgery on your hand, it's never simple. We use our hands for everything. So there are risks associated with any surgery. And so those same things would apply. Like, you're going to have a scar, uh, there's a possibility of an infection, there's little nerves in the skin that have to be moved around, so there's possibility of numbness or nerve damage. And, uh, the cyst can certainly come back and you may need more m surgery. But probably the most common thing that can happen is stiffness after a surgery on your wrist. So we always talk about the need for postoperative exercises, which you can do yourself or go to a rehab place with a hand therapist to regain your range of motion. But the risks of this type of surgery are relatively low, and it's a very safe operation.
Dr. Laith Jazrawi: The next question that patients ask is, can I be awake during this type of surgery? Do I need a general anesthetic? Can it only be done under local? And then can it be done under local with no sedation? Are these all possibilities?
Dr. Nader Paksima: These are all possibilities. So it really depends on the person. So the most common way this is done is with a little anesthesia, a little sedation, so it's like having a colonoscopy. You come in, you get an IV, you get a little sedation, and while you're sedated, your arm is made numb with an injection, and then you have the surgery. But you can have it done under just local anesthesia. I've done it plenty of times, and it works out fine. But the patient has to be able to tolerate being awake during the surgery, and most people can. The surgery doesn't take long. It takes 15 or 20 minutes. So usually there's a tourniquet that's involved, and so you have to be able to put up with the tourniquet being on your arm. It's just like a tight blood pressure cuff. And so for the straightforward surgery, a local anesthetic is fine. Sometimes we have to combine a surgery with an arthroscopy. Like, let's say the reason you have a ganglion is for a partial ligament tear. And at the same time that we want to remove the ganglion, we also want to address the partial ligament tear. So then that surgery is a little more involved because it involves putting a camera into your wrist joint to clean out the torn parts of the ligament and then making an incision to remove the cyst. So, for that type of thing, generally a light anesthetic is, um, what most people go with.
Dr. Laith Jazrawi: And what is the typical recovery after taking these masses out?
Dr. Nader Paksima: Yeah. So it's done as an outpatient. You go home the same day, and you'll have a bandage on your wrist, which is kind of a bulky bandage, for a week. After a week, the bulky bandage is removed, then you start doing exercises. I like to keep the wound dry for two weeks, not submerging it in water. And then you start doing exercises, and most people are back to sports by six weeks. But you can go back to work probably the next day after the surgery, as long as you're limiting the use of your hand.
Dr. Laith Jazrawi: The other question that patients asked, you mentioned it - this thing called the arthroscopy or the scope, can this be done with a minimally invasive procedure? I know the incision can be quite small for these things, but is there any benefit for taking these masses out via a small camera or even smaller incisions?
Dr. Nader Paksima: Yeah, we do that all the time. You can make small little incisions and put in a tiny camera into the wrist joint and take a look at the root of where the cyst comes from. And if you eliminate the root, then usually it goes away. But generally, because we want to also get rid of the lump, we do the arthroscopic portion to get rid of the root, and we make a small incision to get rid of the balloon.
Dr. Laith Jazrawi: And are there any other things that patients should know when they come to see a hand surgeon like yourself with a mass on their wrist.
Dr. Nader Paksima: Yeah. People come in with a story about the Bible bump, and that's sort of the nickname for these things, because the old fashioned treatment for it was to whack it with a heavy book.
Dr. Laith Jazrawi: It's funny.
Dr. Nader Paksima: Basically, rupture the cyst. So, I tell them, you know, instead of hitting it with a heavy book, now we just put a needle in it, which accomplishes the same thing. The other thing is, one of the most common reasons I see this is from people doing yoga and push ups and things like that. And that's really important to people who are practicing yoga or who are, uh, push ups as part of their routine. They don't want to give that up. So a simple preventative thing is to, instead of putting your wrist in that hyperextended pushup position, is to do the push ups on your knuckles or using a push up bar or using dumbbells to keep the wrist in a neutral position. Because if the wrist is in a neutral position, the weight and strain go through the bones, as opposed to when your wrist is at 90 degrees, the weight and strain go through the ligaments, which can exacerbate, uh, the symptoms and cause a lot of pain. There's a little nerve on the back of the wrist, and these ganglion cysts tend to grow right near it. It's called the posterior interosseous nerve, the P.I.N. And for some reason, the small ganglions seem to hurt most. So when you have these tiny little ganglions the size of a pea, they seem to cause a lot of pain. You can't actually see them, but they're there. And somehow, when they get larger, it seems like they go past the nerve, and now they're more superficial, they don't hurt as much.
Dr. Laith Jazrawi: And the last question is, can we live with these things? Is there any reason that it needs to come out?
Dr. Nader Paksima: Well, if they're not causing pain and you've established a diagnosis and you know exactly what it is, you can just observe them. But most people don't like living with them because they're cumbersome, they get in the way, they prevent your wrists from bending back as much as you would normally, so there's no danger in watching one of them. Most people don't put up with them for too long.
Dr. Laith Jazrawi: Okay, well, this has been Bone Whisperers that you've been listening to, and we've been chatting with Doctor Paksima, Professor of Hand Surgery and Orthopedic Surgery, as well as head of the Hand Center here at NYU Langone. Health. I'm Laith Jazrawi, chief of sports medicine and professor of orthopedic surgery, and we just discussed what's that bump on my wrist? It's been a pleasure having you listening to this, and make sure you listen to the rest of the Bone Whisperers podcast. Thank you.
Narrator: The Bone Whisperers is a co-production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.