Treatment of Dorsal Wrist Ganglions : Wheeless' Textbook of Orthopaedics

- Open Resection:
- short transverse incision directly over the mass;
- dorsal ganglions are often located between the EPL and EDC tendons;
- retinaculum is incised between the 2nd and 4th extensor compartments (EPL tendon sheath need not be incised);
- main cyst and its pedicle are mobilized down to joint capsule;
- w/ wrist in volar flexion, the joint capsule is opened along border of radius and proximal pole of scaphoid;
- to ensure complete ganglion excision, a trianglular portion of capsule is removed between the dorsal oblique radiotriquetral
              ligament and the dorsal transverse scaphotriquetral ligament:
- capsule is retracted distally, exposing capsular attachments of the scapholunate ligament; (see dorsal wrist ligaments);
- ganglion & its capsular extension are excised off scapholunate ligament;
- resection of involved portion of dorsal scapholunate ligament will show degenerative changes;
- this resection should be tangential, and should be proximal to the distal 2-3 mm of dorsal scapholunate interosseous ligament;
- do not excise scapholunate interosseous ligament, since this could potentially cause SLD;
- PIN is identified as it runs past 4th dorsal compartment (nerve may be resected proximally over radius);
- in the study by Loh YC, et al (1999), several patients were identified who had developed a neuroma of the PIN following
                  ganglion excision;
- whether or not the nerve is resected, the surgeon should have a clear plan for its management;
- ref: Neuroma of the distal posterior interosseous nerve. A cause of iatrogenic wrist pain.
    - post op care:
- need active wrist flexion to avoid contractures;
- outcomes:
- in the study by Steinberg and Kleinman (1999), 16 out of 21 patiens who underwent excision of an occult ganglion had an
                     excellent outcome;
            - Occult scapholunate ganglion: a cause of dorsal radial wrist pain.