The volar wrist ganglion: Just a simple cyst?

THE

VOLAR

WRIST

GANGLION:

L. G. H. JACOBS

JUST

A SIMPLE

CYST?

and K. J. M. GOVAERS

From the Department of Orthopaedic and Accident Surgery, University Hospital, Nottingham

The results of operation on 71 volar wrist ganglia are reported. The recurrence rate was 28x, occurring between 1 and 144 months (median: 5 months). The highest risk of recurrence is in a male patient, under 30 years of age, in a manual occupation, operated on by a junior surgeon. The use of a post-operative plaster slab seemed to be followed by significant wrist stiifness. 28% of the patients had evidence of damage to the paimar cutaneous branch of the median nerve. It is suggested that this could be avoided by positive identification of this nerve at operation. Journal of Hand Surgery (British Volume, 1990) 15B: 342-346 The volar wrist ganglion is the second most common ganglion around the hand and wrist, constituting l&20% of ganglia in this region (Angelides, 1987). It presents on the radial side of the palmaris longus tendon, at the level of the wrist skin-creases, in an area well known for its important anatomical structures. These are vulnerable at operation, but the few published reports have concentrated on the recurrence rate after operation (Zachariae and Vibe-Hansen, 1973; Greendyke et al., 1989). A search of the literature has not revealed any papers giving details of complications after surgery. A retrospective survey was therefore conducted to discover post-operative complications and to investigate what factors affected recurrence. Patients and methods The operating records of Harlow Wood Orthopaedic Hospital (1972-1989) and of the Day Case theatre unit at the University Hospital, Nottingham (1982-89) were examined. All patients who had undergone excision of a volar wrist ganglion by one consultant hand surgeon and his team were requested to attend for a review consisting of three parts. 1. Pre-operative details. These included the dominant hand, occupation, manual hobbies, the nature and length of symptoms and treatment and a history of any wrist injury or surgery. 2. Operative and immediate post-operative details. These were obtained from the patient’s medical records. 3. Present assessment (a) Present wrist symptoms were recorded along with details of any recurrence and its management. @I The length and maximum width of the scars were measured. The direction of the scar was described as: longitudinal (along the axis of the forearm), transverse (perpendicular to the axis of the forearm) or combined. The appearance of the scar was classified according to defined criteria (see below) devised by the authors, as there was no comparable system in the literature. 342

The range of movements (flexion, extension, radial and ulnar deviation) of both wrists were measured with a goniometer. Any alteration in sensation distal to the scar and over the hand was noted. Allen’s test (Conolly, 1980) was performed to assess patency of both radial and ulnar arteries. Features suggesting carpal tunnel syndrome were noted: a history of typical nocturnal symptoms, sensory loss over the median nerve distribution to the hand and Phalen’s test. Finally, the grip strength of both hands was assessed using a hand dynamometer (JAMAR 2A@-Asimov Engineering Company, USA). The patients’ maximally sustained grip strength was measured three times, alternating between hands. The mean of the three measurements was then calculated as the grip strength in kilograms. Analysis was performed using the chi square, Student’s t test and regression analysis programmes of the Statistical Package for the Social Sciences (SPSS-X@) software package. The level of statistical significance was set at pKO.05.

Results 78 patients underwent excision of a volar ganglion during the study period. One patient had died and seven could not be contacted because they had moved or emigrated. Thus 70 patients with 71 ganglia were reviewed. The age range at operation was from 3 to 66 years (mean 35 years): 45 (64%) were women. 42 (59%) had right-sided ganglia; one woman had bilateral ganglia excised under one general anaesthetic. 47 (67%) patients were employed in manual occupations at the time of operation. Table 1 shows the pre-operative symptoms. 25% of patients who complained of pain also said they had aching over the base of the thumb and parasthesiae over the thumb and thenar eminence. Only 14% of patients had a history of injury to the volar aspect of the wrist before the ganglion appeared. The duration of symptoms before operation ranged from 1 to 96 months (median 18 THE JOURNAL

OF HAND

SURGERY

VOLAR WRIST GANGLION Table 1-Pre-operative

Patients were reviewed between 3 and 220 months (median 70 months, i.e. nearly six years) after their operation.

symptoms

Complaints

Number of ganglia (%)

29 (41) 22 (31) 20 (28)

Pain only Pain and cosmetic Cosmetic only

Recurrences

n=71

months). 32 (45%) patients had been treated by aspiration and injection of local steroid on at least one occasion. Since their operation, no patient had sustained any wrist or forearm injury, nor had they undergone any hand surgery, other than that relating to their volar ganglion. All operations were performed under tourniquet, the policy at this site being to release it before closure to detect bleeding from small branches of the radial artery. Table 2 shows operative details of the 71 operations. Table 3 shows the sites of origin of the ganglia. A plaster slab was worn for between 7 and 18 days (mean 13 days) after 46 (66%) operations. 50 (71%) patients had 1 to 14 weeks (median 2.5 weeks) off work afterwards but no patient became unemployed as a result of the operation.

Table 2-Qwrative

20 (28%) ganglia recurred after operation, and one of these recurred despite a second operation. The recurrences occurred from 1 to 144 months (median 5 months) after surgery. Tables 3 and 4 show the frequency of recurrence in relation to the origin of the ganglia and the surgeon’s seniority. The management of the recurrences is shown in Table 5. Table 4-Recurrences

Consultant Senior registrar Registrar Senior house officer

26 9 11 5

6 (19) 4 (31) 7 (39) 3 (38)

51

Total

20

(x2=2.81; p>O.O5; 3 D.F.)

management of recurrences

Management

Number of ganglia (%)

Number of ganglia

Nothing Re-explored* Steroid injection Steroid then re-explored

Operator

Consultant Senior Registrar Registrar Senior House Officer Ganglion adhering to radial artery Difficulty with dissection

Recurrences (% of surgeonk total)

No recurrence

Surgeon

Table 5-The

details

in relation to the experience of operating surgeon

32 (45) 13 (18) 18 (25) 8(ll) 38 (54) 11 (16)

Total

14 4 1 1 20

*I ganglion was explored twice

Radial artery

Preserved Ligated Not stated Volar capsule excised Tourniquet released Before closure

59 (83) 5 (7) 7 (10) 45 (63) 52 (73)

Operation scars

The length ranged from 1.4 cm to 9.9 cm (median 3.0 cm). The length of the scar was not related to its direction. Table 6 shows that 20 (28%) had an unsatisfactory outcome. Table 7 shows that longitudinal scars healed with a significantly (p < 0.001) worse cosmetic result than transverse scars.

n=71

Table 3-O&&

of the voiar ganglia

Origin

Number of ganglia (%)

Recurrences

25 (35) 13 (18) 11 (16) 8(ll) 7 (10)

9 3 2 2 1

: (10)

3

Table 6-Appearance

Radio-scaphoid joint Scapho-lunate joint Distal scaphoid surface Flexor tendons Scapho-trapezia1 joint Extensor tendons Not stated Total

71

of operation scars

Quality

Width

Sensitivity

Number of ganglia (%)

Excellent Good Fair Poor

2mm Any width Any width

None None Mild Marked*

38 (54) 13 (18) 18 (25) 2 (3)

20 *Denotes extreme sensitivity of a scar associated with a neuroma.

VOL. 15B No. 3 AUGUST 1990

343

L. G. H. JACOBS AND K. J. M. GOVAERS Table 7-Widtb

of zxar ia relatioa to its directiaa

Width

Direction of scar Longitudinal

5mm (x2=30.18;p<

3 12 2

Transverse Combination 42 I

3 2

<0.001;4D.F.)

Sensory changes 20 (28%) patients had developed some sensory disturbance following surgery (Table 8). The occurrence of sensory disturbance in the area of supply of the palmar cutaneous branch of the median nerve was significantly (p < 0.05) related only to the surgeon’s seniority (Table 9). Table g-Poshperative

sensory disturbance

Sensory disturbance

Anaesthesia

Ganglia (%)

None 1-2 cm distal to scar P.C.N. distribution P.C.N. distribution

None Slight Slight Marked

51 (72) 5 (7) 13 (18) 2*

P.C. N. : palmar cutaneous branch of the median nerve *One patient had hyperaesthesia in the area supplied by the palmar cutaneous branch and the other patient is illustrated in Figure 1.

Table %Iqjnry to the palmar cutaaeoas bra& relation to seniority of the operating surge00

Surgeon

Consultant Juniors (all grades)

of tbe median nerve in

Nerve not damaged

Injury topalmar cutaneousnerve

27 24

3 12

(x1=3.71; p
The most severe example of damage to the palmar cutaneous branch in this series was a patient who had complete anaesthesia over the thenar eminence and proximal half of the palmar surface of the thumb, with hyperaesthesia from the operation scar to the distal wrist crease (Fig. 1). There was also evidence of a neuroma in the scar. She had developed a recurrence which was operated on and the sensory disturbance followed the second operation. However, she was coping with a demanding manual job packing sterile supplies in a hospital. The last two patients in Table 8 were the only patients who had noticed their sensory disturbance before this review. 344

Fig. 1 The hand of the patient who had the most severe neurological symptoms following damage to the palmar cutaneous branch of the median nerve. N = neuroma in the operation scar; A = area of anaesthesia; H = area of hyperaesthesia.

Allen’s test Two operation scars were too sensitive to perform the test satisfactorily. Table 10 shows a comparison between the state of the radial artery at the end of the operation and Allen’s test at review. No patient complained of cold intolerance in their hand after surgery. Table 10-A comparisoa of the state of the radial artery from the operation aote aad its pateacy as assess4 by Allen’s test at review

Allen’s test

Radial artery

Preserved Ligated Not stated

Positive

Negative

58 3 3

0 1 4

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VOLAR

WRIST

Carpal tunnel syndrome

Carpal tunnel syndrome was present in five patients at review but one of these was pregnant. The symptoms in the remaining four patients were not severe enough to need operation. Statistical analysis No single factor in the management of these ganglia was found to significantly affect their recurrence after surgery by chi square testing. Multivariate discriminant analysis showed that the following factors (ranked in decreasing order of importance) combined to increase the chance of recurrence : a less experienced surgeon and a patient less than 30 years old with a manual occupation and of male sex. However when this statistically-derived discriminant function was used to predict a recurrence, it was only able to predict 13 (65”/$ of the actual recurrences. Recurrence did not significantly affect the grip strength or range of movement in the wrist by Student’s t test. The grip strength was decreased in two patients who had evidence of neuromata in their operative scars, but this was not amenable to statistical analysis. Student’s unpaired t test showed a statistically significant (0.05 >p>O.Ol) decrease in the arc of wrist movement from full flexion to full extension in patients treated with a plaster slab after operation. The same was true when the total range of radial and ulnar deviation was compared for the two groups (0.05 > p > 0.01). Discussion The recurrence rate of 28% in this series compares favourably with others (Zachariae and Vibe-Hansen, 1973; Greendyke et al., 1989) but confirms that one cannot be confident that surgical treatment of volar ganglia will be successful. Greendyke et al. (1989) attributed this to the number of different origins of these ganglia (which was also shown in our series): “Surgical excision and capsulotomy of the radio-scaphoid joint for treatment of a ganglion which actually arises from the scapho-trapezia1 joint may be more likely to result in recurrence because the joint of origin has been left intact.” They found that one in three volar wrist ganglia arose from the scapho-trapezia1 joint, a frequency very similar to the rate of recurrence for these lesions. However in our series only seven (10%) recurrences arose from the scapho-trapezia1 joint. With such a variety of possible origins from around the scaphoid, it would seem that the volar surface of the scaphoid should be carefully explored to determine the origin of the ganglion. However, only five of our 20 patients with recurrence had enough symptoms from it to want another operation. Angelides (1987), and Rosson and Walker (1989) rightly emphasise the risk of damage to the radial artery. VOL. 15B No. 3 AUGUST

1990

GANGLION

Lister and Smith (1978) describe a useful method of preserving the radial artery at operation, whereby that part of the ganglion wall closely adherent to the radial artery is left attached during excision of the ganglion. This piece of ganglion wall can then be used, where necessary, to retract the artery with safety. There is also a considerable risk to the palmar cutaneous branch of the median nerve after operations on this area of the wrist, as reported by Carroll and Green (1972) and Das and Brown (1976). Hobbs et al. (1990) have recently given a comprehensive description of the anatomy of this branch of the median nerve from dissections in fresh cadavera. They have shown it to be a constant feature, arising from 3 to 21.5 cm (mean 8.4 cm) proximal to the proximal wrist crease. It runs deep to the ante-brachial fascia between the tendons of palmaris longus and flexor carpi radialis, with very few subbranches proximal to the wrist. Since in our series 15 (21%) patients had evidence of injury to the nerve, its identification and protection during operations for volar wrist ganglia is mandatory. If it is damaged, Carroll and Green (1972) suggest it be resected to a point away from the wound to prevent the morbidity associated with neuroma formation in the operative scar. Application of a plaster-of-Paris slab made no difference to the recurrence rate of these ganglia. It was not possible to assess post-operative pain relief accurately in ‘our patients in relation to the use of a plaster slab. No patient complained specifically about decreased movement of the wrist, but in the light of the statistically significant decrease in the range of wrist movements, it would seem that there is little to be gained from using a plaster slab.

Conclusions The results of surgical management of volar wrist ganglia in our patients fell short of the ideal outcome expressed by Angelides (1987) that: “A cosmetically acceptable scar, with full range of motion and no complications, should be the goal in all cases.” We therefore recommend that : Patients are warned before the operation of the high recurrence rate, especially in the young male manual worker. This operation should be performed or supervised by an experienced surgeon who is able to explore the area around the volar surface of the scaphoid with confidence. The radial artery and the palmar cutaneous branch of the median nerve should be positively identified and protected. The use of a plaster slab post-operatively could be abandoned and be replaced by a wool and crepe bandage. 345

L. G. H. JACOBS AND K. J. M. GOVAERS

Acknowledgment The authors would like to thank Mr N. J. Barton for inviting us to review his patients and for his help with the preparation of this paper. We would further like to thank the medical secretaries and the medical records staff at Harlow Wood Orthopaedic Hospital and University Hospital, Nottingham for their help with obtaining patients’ medical records.

ANGELIDES, A. C. Ganglions of the Hand and Wrist. In: Green D. P. (Ed.) Operariw Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: Vol3: 2281-2299. CARROLL, R. E. and GREEN, D. P. (1972). The Significance of the Palmar Cutaneous Nerve at the Wrist. Clinical Orthopaedics and Related Research, 83 : 24-28. CONOLLY, W. B. A Colour Atlas of Hand Conditions London, Wolfe Medical Publications, 1980: 25. DAS, S. K. and BROWN, H. G. (1976). In search of complications in carpal tunnel decompression. The Hand, 8 : 3 : 243-249.

346

GREENDYKE, S. D., WILSON, M. R. and SHEERER, T. R. (1989). Volar wrist ganglia arising from the scaphotrapezial joint: anatomy, clinical presentation and treatment. Paper read to the 44th Annual meeting of the American Society for Surgery of the Hand in Seattle, September 1989. HOBBS, R. A., MAGNUSSEN, P. A. and TONKIN, M. A. (1990). Palmar cutaneous branch of the median nerve. Journal of Hand Surgery, ISA:1 :3843. LISTER, G. D. and SMITH, R. R. (1978). Protection of the radial artery in the resection of adherent ganglions of the wrist. Plastic and Reconstructive Surgery, 61: 1: 127-129. ROSSON, J. W. and WALKER, G. (1989). The natural history of ganglia in children. Journal of Bone and Joint Surgery, 71B: 4: 707-708. ZACHARIAE, L. and VIBE-HANSEN, H. (1973). Ganglia. Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chirurgica Scandinavica, 139: 625-628.

Accepted:23 January 1990 L. G. H. Jacobs, Department of Ortbopaedic Surgery, Centre, Nottingham NG7 ZUH. 0 1990The

University Hospital, Queen’sMedical

British Society for Surgery of the Hand

02~7681/90/0015~342/S10.00

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