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Question for Physiotherapists

QUESTION | My hairdresser has a ganglion on the anterior aspect of his wrist just below the thumb. His hairdressing activities aggravates it such to increase the size rather than causing pain. Are there any solutions or should he just leave it alone? I gather surgery is tricky with the closeness of nerves and vessels in the area.  



ANSWER |
 A ganglion is a fluid collection due to an underlying or nearby abnormality of some sort. For example, this may be a tear in a tendon sheath or degeneration of a joint capsule. The body's response to injury or degeneration is often to bring fluid into the area, which can then collect as a ganglion within a membrane sheath. As this ganglion increases in size, it can sometimes be visible at the skin surface as it bulges upwards towards the region of least resistance.  

As you have noted, certain activities may increase the local inflammation and therefore increase the fluid accumulation, leading to an apparent increase in the size of the ganglion. Sometimes, the patient may experience pain in the region. It is important clinically to determine whether this pain is coming from the underlying condition itself or from the pressure of the ganglion on the surrounding tissues.  

If a ganglion is not bothering a patient too much, there is no harm in leaving it alone. It is difficult to predict whether it will increase or decrease in size with time.  

If a ganglion is bothersome, either in terms of pain or appearance, then the initial treatment is usually an aspiration of the fluid and an injection of steroid into the region to try to quell the underlying cause and to stop the ganglion from reforming. This is a very simple procedure, but has a recurrence rate of over 50%. The location that you have described does indeed contain important neurovascular structures, such as the radial artery and the median nerve. For this reason, I do not personally aspirate a ganglion here, but prefer to send to a radiologist to perform under ultrasound guidance, where the structures can be seen and avoided.  

If the aspiration and injection fail to relieve the ganglion and symptoms, or if the patient prefers a single procedure instead, then surgical excision may be performed. The ganglion and its membrane sheath are excised and followed to the source, where the underlying structure is debrided or repaired as required. Post-operatively, the patient needs to keep this area dry until the wound has healed and the sutures have been removed. Generally, time back to activities ranges from a few days for light office work up to 3 months for heavy construction work. The recurrence rate after surgery is about 15%.  

As you correctly point out, it is important that the nerves and vessels in the area are avoided during surgery, but surgery is often done in close proximity to nerves and vessels, and it is therefore important that this is performed by a surgeon who understands the anatomy of the region, uses appropriate optical magnification and is gentle with the soft tissues.
Dr Kwan Yeoh

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