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Ganglions are the most common soft tissue lumps in the hand. They are generally innocent lumps that form a particular route at a joint or a tendon sheath. They are much more common in ladies (three to one). The vast majority occur in young adulthood.
There are four common sites for ganglions
- The dorsal wrist ganglion - A lump that occurs on the back of the wrist a little bit more towards the thumb side than the little finger side.
- Mucous cyst - This occurs at the base of the nail and is common in arthritic fingers. Sometimes these do cause a groove on the nail.
- Volar wrist ganglions - These are at the front of the wrist, just over the position where you would take someone's pulse.
- Seed ganglions - These are hard, tiny ganglions present at the base of the finger. You generally cannot see these but you can feel them, particularly when gripping the steering wheel.
Why ganglions occur is unknown. They generally occur from damaged joints where the amount of fluid in the joint increases and is extruded through a weakness in the joint capsule, forming a ganglion. They can also occur when there are damaged ligaments and defects in tendon sheaths.
There are four treatments for ganglion
- Nothing - Nobody ever died from a ganglion. They can sometimes disappear by themselves. The only real reason for treating a ganglion is if it pressing, or obstructing a nerve.
- The religious treatment - The age-old treatment of hitting it with a bible. (Obviously it is not necessary to use a bible!) One can apply simple pressure and burst them, as one can do a spot!
- Aspiration - This is drawing off of the fluid with a needle. After the aspiration can be injected with some steroid and this slightly reduces the recurrence rate.
- Surgery - Unfortunately ganglions tend to recur. Recurrence after bursting it (with whatever means!) is about 90%. Recurrence straight after aspiration is some 50% or 60%. The recurrence rate, even after surgery, is recorded as being 25%.
General or regional anaesthetic.
- Dorsal wrist ganglionscan be removed by two means.
- Arthroscopic
- Open technique - The ganglion is approached by a transverse incision over the back of the wrist. The ganglion identified and it's root is dissected down to the ligament between the scaphoid and the lunate and a small area of that degenerate ligament is excised. The wound is closed using nylon sutures.
- Mucus cysts
Incision is an 'H' incision. The ganglion is excised. Also these ganglions are generally associated with arthritis at the end joint of the finger (DIPJ) and arthritis involves extra overgrowth of bone (osteophytes). These are removed from either side of the extensor tendon. The wound is closed with 5-0 nylon.
- Volar wrist ganglion
An incision is made longitudinally over the ganglion. It may have a zigzag extension as it goes over the wrist. The radial artery is identified and the ganglion's root is identified. (Often this goes down to the scapho-trapezoid joint). The wound is closed with 5-0 nylon.
- Seed Ganglion
These are excised using a V-incision at the base of the finger. The nerves are identified either side of the ganglion. The ganglion is excised with a small piece of the tendon sheath and then closed with 5-0 nylon.
- A bulky bandage applied with a slight pressure dressing. The bulky bandage should be maintained for a week and the patient goes home in a high sling for two days. After two days the sling is removed. After one week the bulky dressing is removed leaving a sticky dressing on the back of the wrist which needs to be maintained for two weeks.
- There is a finger stall dressing applied. The patient goes home with a hand on the opposite shoulder with a high arm sling. This is removed after two days. The finger stall is left intact until the patient is seen in Outpatients in two weeks when sutures are removed.
- A sticky dressing is applied over the wound. A pressure dressing is then applied over that. The patient is discharged with the hand on the opposite shoulder in a high arm sling. The pressure dressing is maintained for a week and then removed by the patient. The sticky dressing is then left intact for a further week until the stitches are removed. You can drive a car once the bulky bandage has been removed at one week, as long as you feel safe.
- Post operatively a sticky dressing is applied over the wound. A bulky dressing is then applied on top of that. The patient is sent home with a hand on the opposite shoulder with a high arm sling. The sling and dressing are removed after 48 hours, leaving the sticky dressing on for a period of two weeks until the patient is seen in Outpatients for removal of sutures.
1. Infection - These can occur after any operation but hand operations are generally less likely to have post op infections. If present they can be treated with antibiotics.
2. Nerve damage - Nerves go either side of the ganglion and they are potentially vulnerable to damage. This can result in a painful area, or neuroma or some loss of feeling in the hand.
3. Scar - There will be tenderness over the scar for six to eight weeks. This can be helped with desensitising exercises, given at the two-week period.
4. Recurrence
Clinical recurrence rate of ganglions following surgery is 25% when performing the surgery it is important to get the root of the ganglion. The root of the ganglion is the most difficult to get in the volar wrist ganglions and it is these type of ganglions that have the highest recurrence rate in Mr Field's hands although it is not 25%. The lowest rates of recurrence in Mr Field's hands are the seed ganglions and mucous cyst and Mr Field has 4 known recurrence of the dorsal wrist ganglion (in 12 years).
Nail changes - Occasionally the mucus cyst can infect the growth of the nail and give you a grooved nail.
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