retinaculum over the ganglion is excised, and the extensor carpi radialis longus and brevis are isolated and retracted radialward. The extensor digitorum communis to the index finger is then retracted with the remaining extensor tendons ulnarward. The mass is identified and mobilized in a circumferential fashion. Surgical treatment should focus on removing the ganglion cyst and all material between the radiotriquetral ligament and dorsal intercarpal ligament. The ganglion is excised with all of its attachments to the joint capsule and scapholunate ligament (Fig. 84—3). Capsular closure is not recommended. The lesion should be inspected on the back surgical table to verify diagnosis and sent to pathology for definitive histologic analysis. The wound is irrigated, hemostasis is obtained, and the skin is closed.
Postsurgical treatment consists of a soft bulky dressing and immobilization with a splint for 10 days. The patient is encouraged to initiate active digital motion. The patient returns for a dressing change and suture removal, and is referred to a hand therapist for scar management and progressive range-of-motion exercises.
Wrist stiffness, injury to the dorsal sensory branch of the radial nerve, and recurrence are the most common complications after surgical excision. The recurrence
rates after surgery are reported as high as 10%, although in our practice we never had a recurrence. Recurrences are due to inadequate excision, often the result of inadequate anesthesia.
Other forms of treatment include closed rupture and aspiration. Closed rupture by direct pressure is painful and has a 33% recurrence rare. Richman et al reported that aspiration with multiple needle punctures, when combined with 3 weeks of splint immobilization, has a 60% failure rate. Without immobilization, the cure rate has been reported to be as low as 13%. An injection of a corticosteroid into the area after aspiration has not been shown to alter recurrence rates in our experience.
Other Ganglions of the Hand
The second most common site for a ganglion is the volar wrist. These cysts arise from the radiocarpal capsule in the scaphotrapezial (ST) joint. The ganglion often wraps itself around the radial artery. Aspiration must be avoided because of possible injury to the radial artery.
For surgical excision of a volar scapholunate ganglion, a triangular type Brunner zigzag incision is made. Deep flaps are lifted and tied back. The radial artery is identified. The ganglion is excised coming from ulnar to radial underneath the radial artery. The ganglion is excised in one piece all the way down to the wrist capsule (Fig. 84—4). The palmar cutaneous branch of the median nerve is visualized at all times. Meticulous hemostasis is obtained and the wound is irrigated and closed. The patient is instructed to see an occupational hand therapist in 10 to 12 days postoperatively to avoid the most common complication, which is stiffness. Other complications of this type of excision include injury to the radial artery, lateral ante-brachial cutaneous, and volar branches of the superficial radial nerve. Recurrence rates are often higher for volar ganglion because of timid dissection.
Cysts of the flexor tendon sheath account for 7% of ganglions in the wrist. These ganglions are noted to arise at the A1 pulley of the flexor tendon sheath. The mass
Figure 84—4. Excision of volar wrist ganglion. Note relationship of radial artery.
can vary in size from 4 to 10 mm in diameter and is often palpated by patients. Patient's symptoms include the inability to grip objects (as well as pain from the mass). Two-point discrimination should be tested to verify that the cyst has not encased itself in the digital nerve. Aspiration and injection of steroids can be effective, but cyst involvement with the digital nerve relies on surgical intervention as the mainstay of treatment (Fig. 84-5).
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