From the Guidelines
The most appropriate next step is to aspirate the mass (option B). This patient presents with a classic case of a ganglion cyst, which is a benign fluid-filled sac that commonly occurs near joints or tendon sheaths, particularly at the wrist. The clinical features supporting this diagnosis include the fluctuating size, location on the volar aspect of the wrist near the radial styloid, transillumination, and increased prominence with extension. Aspiration is the recommended initial intervention as it is minimally invasive, can provide immediate relief, and confirms the diagnosis by revealing the characteristic viscous, clear fluid.
Key Considerations
- While cortisone injection may be considered after aspiration, it is not the first step, as noted in various guidelines 1.
- Excision is more invasive and typically reserved for recurrent cases after aspiration has failed.
- An MRI is unnecessary given the classic clinical presentation, although it could be considered if the diagnosis is unclear or if there are suspicions of other conditions, as suggested by the American College of Radiology 1.
- Simple reassurance without intervention would not address the mass, which may continue to cause discomfort or cosmetic concerns for the patient.
Diagnostic Approach
- Ultrasound (US) of the wrist is also a useful diagnostic tool for examining extra-articular soft tissues, such as suspected ganglion cysts, with accuracy similar to that of MRI 1.
- US can guide therapeutic intra-articular and other soft-tissue injections, providing an additional diagnostic and therapeutic option.
Treatment Priorities
- The primary goal is to provide relief from symptoms while minimizing invasive procedures, prioritizing the patient's quality of life and minimizing potential morbidity.
- Aspiration, being minimally invasive, aligns with these priorities, making it the most appropriate initial step in managing this patient's condition.
From the Research
Diagnosis and Treatment Options
The patient presents with a 3-week history of a bump on her right wrist, which fluctuates in size and is not associated with pain. Examination reveals a 2-cm mass on the volar aspect adjacent to the radial styloid, which transilluminates and becomes more prominent with extension. Based on these symptoms, the likely diagnosis is a ganglion cyst.
Treatment Considerations
- Aspiration followed by intralesional steroid injection is a common treatment option for ganglion cysts, as seen in studies 2, 3, 4, 5.
- However, a study 6 found that surgical excision had a higher success rate (92.5%) and lower recurrence rate (7.5%) compared to aspiration and steroid injection (success rate: 64.3%, recurrence rate: 35.7%).
- Another study 4 found that aspiration followed by intralesional steroid injection was better managed than surgical excision, with a success rate of 86.8% compared to 83.3% for surgical excision.
- A study 5 found that aspiration and steroid injection reduced the volume of the cyst, but the effect waned off over time, with only 10% of patients experiencing complete disappearance of the cyst.
Next Steps
Based on the evidence, the most appropriate next step would be to:
- Aspirate the mass to confirm the diagnosis and potentially treat the condition, as supported by studies 2, 3, 4, 5.
- Consider surgical excision if aspiration and steroid injection are not effective, as supported by study 6.
- The other options, such as administering a cortisone injection, excising the mass, obtaining an MRI of the wrist, or reassuring the patient, may not be the most appropriate next steps based on the current evidence.