Fig.1Dorsal wrist ganglion
Fig.2Site of the surgical scar
What is a Wrist Ganglion?
A ganglion is a type of liquid-filled structure that most commonly occurs at the wrist. It is most common on the back of the wrist but may occur on the palm-side of the wrist.A ganglion is due to degeneration of fibres in a wrist ligament that allow fluid from the joint to collect causing the cyst-like structure, which is not normally present. It originates from the level of the wrist bones and not just under the skin as it would first appear, so the surgery does go quite deep to the level of the wrist bones.
Wrist ganglions are entirely benign. Many patients are concerned that the lump may be cancerous but this is not the case and they are not dangerous.
The symptoms of wrist ganglion are usually that there is an obvious lump on either the front or the back of the wrist. This may cause discomfort and aching in the wrist. This may be worse with activity or when doing things that force the wrist back such as press-ups or pushing up out of the bath.
Ganglions may be present for months or years and may increase or decrease in size. They are rarely more than 2cm in diameter and usually less than 1.5cm. Many of them disappear on their own with time.
Ganglions on the front of the wrist (volar wrist ganglions) have a particular problem for surgery in that they sit directly under one of the main wrist arteries. If your surgeon finds (by doing a simple test in clinic) that the two wrist arteries are not joining freely and your symptoms are not too bad, he may advise you not to have surgery as there is a small risk of damage to the artery, which may be a problem afterwards.
Occult wrist ganglion
This is a small dorsal wrist ganglion that does not case an obvious lump on the wrist but can be quite painful. The diagnosis is usually confirmed with an MR or ultrasound scan.
Operations for wrist ganglion
Three main treatments are routinely performed for wrist ganglions:
- Needle aspiration. This is the simplest procedure in which a needle is placed, often several times into the ganglion and the fluid is drawn off.
- Open removal. In this procedure the ganglion is surgically removed through a cut in the skin, which is usually cross-wise but may be long-wise or zig-zag for a volar ganglion to find and protect the artery. The incision is usually around 2cm long.
- Arthroscopic removal. Your surgeon my recommend having a dorsal ganglion removed by a keyhole operation.
After your surgeon has recommended an operation to help your ganglion, you will be placed on a waiting list for surgery. The vast majority of these operations are done under a general anaesthetic (with you asleep) or under a regional block (a numbing injection around the shoulder which freezes the arm and you are awake for the surgery). It is also usually done as a day case operation. That means you will normally only have to be in the hospital for half a day and not over night. Do not drive to the hospital yourself. You will need a responsible adult to pick you up after your surgery. Rarely, people are admitted to the hospital over night. This is usually planned before the surgery and is for medical or social reasons. You will be given a gown to wear on the ward before the operation is carried out. It is recommended that you wash your hands with soap and water before the operation. Make sure your nails are clean. You will be taken to the anaesthetic room, just off the operating theatre, where the anaesthetist will give you the anaesthetic. You will then have a tourniquet placed around your upper arm. This is blown up when the operation starts so that the wound does not bleed and the surgeon can see what he is doing. The surgery usually takes between 20 and 40 minutes.
After the Operation
You will find that there is a large bandage on your wrist. It is important to move your arm including the shoulder, elbows and hand after the operation to stop them stiffening. The bandage is removed along with the stitches after 2 weeks (or sometimes earlier) and you will be asked to start massaging the scar with a moisturiser. If you have an arthroscopic removal, there may not be any stitches to remove.
You may get back to driving after that and can consider going back to work although people doing heavy manual jobs may need up to 6 weeks off.
Risks of Surgery
Generally, these procedures are considered to be effective and low risk. However some people may have problems. The commonest of these is discomfort around the wrist, which may last for a couple of months after surgery. Other problems are swelling and stiffness of the hand, which if severe and accompanied by pain, is called “reflex sympathetic dystrophy.” It is rare. Infection is also rare. Occasionally the ganglion returns after a period of time. There will be a visible scar from surgery but this will fade aver the course of a year. The scar for a volar wrist ganglion is more visible. Occasionally a pool of blood called a haematoma may collect under the wound, which can slow wound healing and, rarely, the radial artery may be injured in volar ganglion surgery. Occasionally small nerve branches may ball up in the scar and cause scar tenderness.
Please be aware that you will not fully be able to use the operated hand for a short while after surgery. Make life easy for yourself at home by planning ahead, particularly if you are alone at home or if you will be alone at home for long periods in the day. Get enough shopping in to last for a week or two after your surgery, as you will not be able to drive. Loosen the tight caps of jars; don’t forget the contents will go off more quickly! You may wish to eat ready-meals for a few days after surgery or do some cooking beforehand and freeze it. Wear slip-on shoes so you don’t have to tie laces etc.