Wrist Ganglions

Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

 - Dorsal wrist ganglion ( back of the wrist)
 - Volar wrist ganglion ( front of the wrist)

Who does it affect?

Anyone

Why does it occur?

It is a fluid filled sac, that occurs on the back of the wrist (dorsal) or volar (front). The fluid is clear and quite thick. They are thought to be related to changes in the lining of the joint, but not related to arthritis. Occasionally they communicate with the joint and / or a ligament in the joint.

Symptoms

A painless lump that comes and goes in size. The outline is quite smooth and may feel tense like a small ball or balloon (cystic).

Clinical Examination

A ganglion has quite typical features both in its location and appearance. With the lights turned down and a pen torch is shone through the lump, it transilluminates.

Investigations

Usually none. In unusual situations an ultrasound scan will be helpful.

Non-operative treatment

Ganglions can be aspirated under local anaesthetic. A needle is then introduced into the lump and the fluid sucked away. I then perform multiple wall perforations to help prevent their reoccurrence. A small pressure bandage is applied for a few days afterwards. Here is a short video clip of a ganglion being aspirated (drained). You will see Mike Hayton infiltrating local anaesthetic under the skin, prior to the aspiration. At the end of the video you will see him squeeze the fluid out onto the back of his glove..

Operative treatment

If the lump has reappeared 6 weeks after aspiration I usually recommend surgery. The surgery is a day case procedure usually under local anaesthetic and takes about 20 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

Local anaesthetic is infiltrated under the skin in line with the incision over the lump. Once numb the skin is incised and then the underlying fat is retracted. Care is taken not to injure nerves and blood vessels. At the base of the wound is the ganglion wall. The ganglion is dissected taking care not to puncture it. The base of the ganglion is identified and excised. The photograph below shows a typical ganglion and also the clear jelly like fluid it contains after I have punctured it. The skin is sutured and a bulky dressing is applied.

Post-operative rehabilitation

The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. The sutures are removed at about 10 days.

Return to activities of daily living

It is my advice to keep the wound dry until the stitches are out at 10 days.

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probably advisable to delay returning to driving for at least 7 days or even when the stitches are removed.

Return to work:

Everyone has different work environments. Return to heavy manual labour should be prevented for approximately 4 - 6 weeks. Early return to heavy work may cause tendons ands nerves to scar into the released ligament. Please ask your surgeon for advice on this.

Complications

Overall, greater than 95% are happy with the result. However complications can occur.
There are complications specific to Wrist Ganglion surgery and also general complications associated with hand surgery.

General complications:

 - Infection (Less than 1%)
 - Neuroma (Less than 1%, a coiled painful nerve bundle)
 - Numbness

Reflex Sympathetic Dystrophy - RSD (2% bad reaction to surgery with painful stiff hands - this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

Specific complications:

Recurrence: This is reported between 10 and 40%. We are not sure whether it is the same ganglion recurring or simply another one forming nearby.