92: Excision of a Dorsal Wrist Ganglion

Procedure 92 Excision of a Dorsal Wrist Ganglion



Sandeep J. Sebastin, Kevin C. Chung


imageSee Video 68: Treatment of Dorsal Wrist Ganglions



Indications




image Patient concern about appearance or malignancy (Fig. 92-1)


image Ganglion with associated pain


image

FIGURE 92-1



Examination/Imaging



Clinical Examination




image Patients are usually asymptomatic, and a specific history of antecedent trauma is available only in 10% of patients. Patients with pain or history of trauma should be examined for evidence of scapholunate (SL) instability. This includes tenderness at the SL joint, the Watson scaphoid shift test, and the resisted finger extension test. The resisted finger extension test is done by asking the patient to extend the index and middle fingers against resistance with the wrist partially flexed. These tendons pass over the SL joint, and if there is inflammation of the SL joint with synovitis, resisted extension compresses the area of synovitis, resulting in pain.


image Pain associated with a ganglion may not go away after excision of the ganglion, and patients must be appropriately counseled.


image The clinical diagnosis of a ganglion is relatively simple and can be confirmed by transillumination. The differential diagnosis for swellings on the dorsum of the hand includes extensor tendon ganglion (moves with the tendon), extensor tendon tenosynovitis (diffuse and moves with the tendon), lipoma, and sebaceous and epidermal cysts (do not transilluminate).



Imaging




image A preoperative radiograph is not required in all dorsal wrist ganglions and needs to be ordered if patients complain of pain or history of antecedent trauma.



Surgical Anatomy




image A dorsal wrist ganglion typically arises from the SL joint and usually presents on the dorsum of the hand over the SL joint (1 to 2 cm distal to Lister tubercle). However, depending on the course of the ganglion and the length of the stalk, it may present anywhere on the dorsum of the hand. Irrespective of anatomic location of the ganglion on the dorsum of the hand, it must be presumed that it is arising from the SL joint and incisions planned accordingly.



Positioning




image The patient is positioned supine, and the procedure is done under tourniquet control.



Exposures




image A transverse incision is preferred because it is more aesthetic and the most common indication for excision of the ganglion is appearance. For dorsal wrist ganglions that present in the typical location over the SL joint, the incision is made directly over the ganglion. However, if the ganglion is not located directly over the SL joint, one must plan the incision in such a manner that the ganglion can be dissected and the stalk followed to the SL joint. Occasionally this may need two transverse incisions or a single longitudinal incision. If a clinical diagnosis of a ganglion is doubtful, a longitudinal incision is preferred because it can easily be extended.

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 92: Excision of a Dorsal Wrist Ganglion

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