Tips for complete removal of dorsal wrist ganglion cyst through open excision
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Ganglion cysts are benign soft tissue masses that are known to occur about any joint in the human body, but most commonly appear at the wrist.
Among these, 60% to 70% develop on the dorsal side, while 20% to 30% develop on the volar aspect. While dorsal ganglion can emerge in various areas on the dorsal aspect of the wrist, the scapholunate ligament is the most frequent point of origin. The etiology of dorsal wrist ganglion cysts is largely unknown. The most proposed theory states that reoccurring joint stress and/or trauma can lead to wrist ganglion generation over time, although it is occasionally seen in children.
Source: M. Lane Moore, MBA; Kevin J. Renfree, MD
On examination of the wrist, ganglion cysts are typically 1 cm to 3 cm in size, non-mobile and compressible on palpation. These are not associated with any warmth or erythema in or around the joint. Diagnosis can be made clinically, especially with transillumination. Imaging studies are not usually required for clinically obvious cysts, although MRI can be helpful for diagnosis of “occult” cysts. Ganglion cysts are commonly asymptomatic; however, some patients may present with pain localized to the wrist with occasional radiation proximally up the arm, decreased grip strength and limited range of motion.
Management of ganglion cysts can be nonsurgical or surgical depending upon the severity of symptoms and impact on the patient’s quality of life. Nonsurgical management includes observation, aspiration of the cyst contents, controlled rupture or injection. Unfortunately, conservative management is associated with a wide range of recurrence rates ranging from 15% to 90%. Accordingly, surgical excision is the gold-standard treatment for patients with symptoms unresponsive to conservative management with severe symptoms.
Surgical approach
Open excision of a dorsal wrist ganglion is commonly performed under general anesthesia or a regional brachial plexus block. The patient is placed supine with the upper extremity of interest resting on a hand table (Figure 1). A deflated tourniquet is placed high on the patient’s arm to minimize intraoperative bleeding. Prior to incision, the dorsal wrist ganglion should be identified and palpated. Next, the incision site can be marked (Figure 2). The upper extremity is then exsanguinated via an Esmarch or Ace bandage (3M), with care taken to avoid direct pressure on the mass to avoid inadvertent rupture, and the tourniquet is inflated.
A longitudinal incision is made over the dorsal wrist. Subcutaneous dissection is performed (Figure 3), and the dorsal sensory branches of the ulnar nerve and radial sensory nerves are bluntly retracted. The posterior interosseous nerve, which commonly appears within the operative field, is typically ligated proximal to the radiocarpal joint (Figure 4). If the cyst is arising from the dorsal scapholunate ligament, the distal 1 cm of the extensor retinaculum is incised over the third dorsal compartment to improve exposure, the extensor pollicis longus and extensor carpi radialis brevis tendons are retracted radially and the extensor digitorum communis and extensor indicis proprius tendons in the fourth dorsal compartment are retracted ulnarly (Figures 5 and 6). A Jacobsen clamp is helpful to separate the capsule from the stalk of the cyst. Once the stalk has been isolated, the cyst is excised completely at the base of the stalk with a small circumferential rim of the dorsal capsule (Figure 7). The senior author prefers to “shave” the stalk off the dorsal fibers of the scapholunate ligament with micro-bipolar electrocautery to prevent inadvertent injury, which could lead to scapholunate instability with time. If the stalk is poorly excised or incompletely identified, then there is an increased risk of ganglion recurrence.
Joint inspection, wound closure
The capsule is not closed to prevent postoperative joint stiffness. Usually, the excision takes place between the biomechanically important dorsal radiocarpal and dorsal intercarpal ligaments, which are preserved. The wound is copiously irrigated and closed with a subcuticular suture. The joint is injected with 0.5% ropivicaine for postoperative analgesia. A volar plaster splint is applied with the wrist in a neutral position and maintained for 72 hours, after which active range of motion to tolerance can be initiated. Patients are usually back to normal activities in 3 to 4 weeks.
Minor complications may include prolonged stiffness following surgery, swelling around the wrist, postoperative pain, wound complications and infection. Major complications following this procedure may include nerve injury to a radial sensory nerve branch, scapholunate interosseous ligament dissociation and instability, and complex regional pain syndrome.
Important tips
During the process of open excision, it is advantageous to locate and determine the stalk of the cyst. This enables removal of the entire ganglion complex, thereby minimizing the chances of recurrence.
The posterior interosseous nerve passes through the fourth dorsal compartment and may be ligated proximal to the radiocarpal joint.
- References:
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- Elahi MA, et al. JBJS Essent Surg Tech. 2023;doi:10.2106/JBJS.ST.21.00043.
- Gude W, et al. Curr Rev Musculoskelet Med. 2008;doi:10.1007/s12178-008-9033-4.
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- Kim JY, et al. Int Orthop. 2016;doi:10.1007/s00264-016-3213-4.
- For more information:
- Muhammad Ali Elahi, BS, and M. Lane Moore, MBA, can be reached at the Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. Jack M. Haglin, MD, MS, and Kevin J. Renfree, MD, can be reached at the department of orthopedic surgery at the Mayo Clinic in Phoenix. Elahi’s email: elahi.muhammad@mayo.edu. Moore’s email: moore.michael1@mayo.edu. Haglin’s email: haglin.jack@mayo.edu. Renfree’s email: renfree.kevin@mayo.edu.
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