import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Superficial Radial Nerve Branches** Location: Dorsoradial to incision, 3-5 branches typically fan across dorsal wrist Protection: Identify in subcutaneous tissue, trace and retract with vessel loops throughout procedure **Extensor Pollicis Longus (EPL) Tendon** Location: 3rd extensor compartment at Lister's tubercle, radial side of ganglion Protection: Identify before opening retinaculum, protect during mobilization and stalk dissection **Extensor Digitorum Communis (EDC) Tendons** Location: 4th extensor compartment, ulnar side of ganglion Protection: Identify and retract ulnarly when opening retinaculum and mobilizing ganglion **Scapholunate (SL) Ligament** Location: Intercarpal ligament at ganglion stalk origin, deep to extensor tendons Protection: Excise only capsular cuff (5mm) around stalk base - preserve SL ligament integrity **ECRB and ECRL Tendons** Location: 2nd extensor compartment, may be adherent to large ganglia Protection: Careful blunt dissection during ganglion mobilization, avoid sharp dissection near tendons ## Absolute Indications **Symptomatic Ganglion Cyst with:** - Pain limiting daily activities or work - Limitation of wrist range of motion - Functional impairment (weakness, catching, instability sensation) - Significant cosmetic concern affecting quality of life - Failed conservative management (aspiration with recurrence) **Diagnostic Uncertainty:** - Atypical presentation requiring histological diagnosis - Concern for occult pathology (tumor, infection) - Solid component on imaging suggesting neoplasm ## Relative Indications - Patient preference for definitive treatment over aspiration - Recurrent ganglion after multiple aspirations - Ganglion in occupation requiring repetitive wrist use - Large ganglion (>2cm) with high aspiration failure rate ## Contraindications **Absolute:** - Active infection over surgical site - Severe medical comorbidities precluding surgery - Patient unwilling to accept surgical risks **Relative:** - Asymptomatic ganglion (observation preferred) - First presentation without trial of aspiration - Poor skin quality or previous scarring - Bleeding diathesis or anticoagulation (relative - requires optimization) - Patient with keloid tendency or connective tissue disorder **Exam Key Statement**: "The primary indication for surgical excision is a symptomatic ganglion that has failed conservative management, particularly aspiration. Aspiration has 40-60% recurrence rate, whereas surgical excision with complete stalk removal has 5-10% recurrence. I counsel patients about this difference and the surgical risks including nerve injury, stiffness, and scarring." ## Relevant Anatomy - Key Structures ### Surface Anatomy - **Lister's Tubercle**: Bony prominence on dorsal distal radius - landmark for 3rd compartment (EPL) - **Ganglion Location**: Typically dorsoradial wrist, between 3rd and 4th compartments - **Superficial Radial Nerve**: Emerges from under brachioradialis ~7-9cm proximal to radial styloid, fans into 3-5 branches over dorsal wrist ### Extensor Compartments (Dorsal Wrist) 1. **1st Compartment**: APL and EPB (radial border) 2. **2nd Compartment**: ECRL and ECRB (over radial styloid) 3. **3rd Compartment**: EPL (ulnar to Lister's tubercle) - **KEY LANDMARK** 4. **4th Compartment**: EDC and EIP (central) - **GANGLION LOCATION** 5. **5th Compartment**: EDM (ulnar side) 6. **6th Compartment**: ECU (ulnar border, in groove of ulnar head) ### Ganglion Stalk Origin - **60-70%**: Scapholunate (SL) ligament - dorsal portion - **20-30%**: Other dorsal capsular origins (lunotriquetral, radioscaphoid) - **Rare**: Extensor tendon sheath origin ### Neurovascular Structures at Risk 1. **Superficial Radial Nerve (SRN)**: 3-5 dorsal sensory branches - MOST AT RISK - Dorsal branch to thumb (over anatomic snuffbox) - Branches to index and middle finger dorsum - Typically dorsoradial to surgical field 2. **Posterior Interosseous Nerve (PIN)**: Deep to 4th compartment, innervates wrist joint - rarely at risk 3. **Radial Artery**: Volar to scapholunate joint - protected by dorsal approach **Exam Key Anatomy**: "Dorsal wrist ganglion arises from the scapholunate ligament in 60-70% of cases. The stalk passes between the 3rd compartment (EPL at Lister's tubercle) and 4th compartment (EDC). The superficial radial nerve is most at risk - it has 3-5 branches that fan across the dorsal wrist in the subcutaneous tissue. I identify and protect these branches throughout the procedure." ### Scapholunate Ligament Anatomy - **Dorsal SL ligament**: Thickest portion (3mm), primary restraint to scaphoid flexion - **Proximal (membranous)**: Thinner central portion - **Volar SL ligament**: Secondary restraint **Critical Point**: Ganglion stalk arises from DORSAL SL ligament but excision should preserve ligament integrity to prevent carpal instability. ## Incision Options ### Transverse Incision (Author's Preference) **Technique:** - 2-3cm transverse incision directly over ganglion - Follows Langer's lines and natural skin creases - Centered on ganglion palpated pre-exsanguination **Advantages:** - Superior cosmetic result (follows skin creases) - Less visible scarring - Better patient satisfaction with cosmesis **Disadvantages:** - Crosses superficial radial nerve branches (requires careful identification) - More difficult dissection in deeper layers - Harder to extend if needed **Indications:** - Standard dorsal wrist ganglion - Patient prioritizes cosmesis - Surgeon experienced with transverse approach ### Longitudinal Incision **Technique:** - 3-4cm longitudinal incision along radial border of 4th compartment - Parallels EDC tendons - Placed slightly ulnar to avoid superficial radial nerve **Advantages:** - Easier nerve protection (incision parallel to nerve course) - Better exposure of deeper structures - Easier to extend proximally or distally if needed - Better for revision surgery **Disadvantages:** - More visible scar (crosses skin creases) - Poorer cosmetic result - Higher patient dissatisfaction with scar **Indications:** - Large or complex ganglion - Revision excision - Trainee performing procedure - Concern for difficult dissection ### Positioning Principles - **Patient**: Supine with arm on hand table - **Arm Position**: Pronated (dorsal wrist accessible) - **Tourniquet**: Upper arm, 250-275 mmHg - **Exsanguination**: Esmarch or arm elevation × 2 minutes - **Magnification**: Loupes (2.5x-3.5x) recommended for nerve protection **Exam Statement on Incision Choice**: "I prefer a transverse incision over the ganglion following Langer's lines for better cosmetic outcome. However, I am careful to identify and protect superficial radial nerve branches which cross beneath this incision. A longitudinal incision is an alternative with easier nerve protection but poorer scar appearance. I discuss both options with the patient pre-operatively." ## Critical Technical Points ### Pre-operative Marking 1. **Mark ganglion WITH tourniquet deflated** - becomes less prominent after exsanguination 2. **Mark superficial radial nerve course** - dorsoradial wrist, helps guide dissection 3. **Mark Lister's tubercle** - guides identification of 3rd/4th compartments 4. **Palpate ganglion transillumination** - confirms cystic nature ### Nerve Protection Strategy 1. **Early identification** - look for nerve in subcutaneous fat immediately after skin incision 2. **Trace branches** - use blunt dissection to follow branches proximally and distally 3. **Vessel loops** - place around identified branches for protection 4. **Gentle retraction** - avoid excessive traction causing neuropraxia 5. **No cautery near nerves** - use bipolar only, away from nerve ### Stalk Identification Techniques **Most Critical Step for Low Recurrence:** 1. **Mobilize ganglion circumferentially** - free from all adherent tendons 2. **Identify thinning at base** - stalk usually thinner than ganglion body 3. **Trace toward joint** - follow stalk deep between EPL and EDC 4. **Feel for capsular attachment** - stalk inserts on dorsal capsule at SL interval 5. **Visualize SL ligament** - confirm anatomy before excision 6. **Excise capsular cuff** - take 5mm margin of capsule around stalk base **If Stalk Difficult to Identify:** - Gentle traction on ganglion shows direction of stalk - Palpate wrist joint line as guide to depth - Remove extensor tendons from field temporarily - Use loupe magnification - Small arthrotomy acceptable to visualize from inside joint ### Capsulectomy Technique - **Cuff Size**: 5mm margin around stalk base - **Preserve SL Ligament**: Do NOT excise ligament itself - **Depth**: Down to articular cartilage (joint visible) - **Shape**: Elliptical or circular based on stalk - **Do NOT Repair Capsule**: Defect will scar - repair risks stiffness ### Retinaculum Management **Option 1 - Repair (Author's Preference):** - Prevents extensor bowstringing - Maintains anatomic gliding - Use 4-0 or 5-0 absorbable suture - Ensure EPL in groove at Lister's tubercle **Option 2 - Leave Small Defect:** - May reduce adhesion formation - Risk of minor bowstringing - Acceptable alternative - Still repair majority of defect **Critical Technical Exam Statement**: "The most important technical point is complete excision of the stalk at its origin from the scapholunate ligament with a cuff of dorsal capsule. I trace the stalk carefully to the SL interval and excise a 5mm margin of capsule. This is the key difference between surgical excision (5-10% recurrence) and aspiration (40-60% recurrence). I protect the integrity of the SL ligament itself to prevent carpal instability." ## Intra-operative Complications ### Ganglion Rupture During Mobilization **Recognition:** - Sudden decompression of tense mass - Gelatinous material visible - Loss of clear tissue planes **Management:** - Continue with dissection - rupture acceptable - More important to identify stalk - Irrigate to clear mucin - Ensure all cyst wall removed - Still excise stalk with capsular cuff **Prevention:** - Gentle handling of ganglion - Sharp dissection around periphery - Avoid grasping ganglion directly with instruments ### Superficial Radial Nerve Injury **Recognition:** - Nerve transection visible - Altered sensation in distribution - Tinel's sign at injury site **Immediate Management:** - Small branch (<1mm): May observe - Larger branch (>1mm): Primary repair with 8-0 or 9-0 nylon under magnification - Document injury and repair in operative note - Counsel patient post-operatively **Prevention:** - Early identification of all branches - Vessel loop retraction - No blind dissection in subcutaneous tissue - No cautery near nerves ### EPL Tendon Laceration **Recognition:** - Visible tendon transection - Loss of thumb IP extension when tested **Immediate Management:** - Primary repair if clean laceration: 4-0 braided non-absorbable with modified Kessler core + 6-0 epitendinous - Partial laceration (<50%): Repair epitenon only - Delayed reconstruction if tendon quality poor - Splint thumb IP in extension 6 weeks - Refer to hand surgeon if unsure **Prevention:** - Identify EPL before opening retinaculum - Maintain awareness of EPL position throughout - Blunt dissection around ganglion-tendon interface - Use loupe magnification ### Scapholunate Ligament Injury **Recognition:** - Visible tear in SL ligament - Excessive gapping between scaphoid and lunate - Widening >3mm compared to contralateral **Immediate Management:** - Small capsular injury: Acceptable, no repair needed - Significant SL ligament tear: Primary repair with suture anchor or transosseous sutures - Consider K-wire stabilization of SL joint if unstable - Immobilize 6-8 weeks if repaired - Consider hand surgeon consultation **Prevention:** - Excise only capsular cuff (5mm) - Visualize SL ligament before excision - Preserve ligament substance - Sharp dissection at capsule-ligament interface **Exam Statement on Complications**: "The most common complication is superficial radial nerve injury in 5-10%, causing numbness or painful neuroma. I prevent this by early identification and protection of all nerve branches. Recurrence occurs in 5-10% with complete excision - I reduce this by ensuring complete stalk excision with capsular cuff. EPL injury is rare but devastating - I protect it by identifying the tendon at Lister's tubercle before opening the retinaculum." ### Step 1: Patient Positioning and Marking Patient supine with arm on hand table. **CRITICAL**: Palpate and mark ganglion BEFORE exsanguination - becomes less prominent when tourniquet inflated. Mark superficial radial nerve course dorsoradially. Mark Lister's tubercle (EPL landmark). Check transillumination confirms cystic nature. Apply tourniquet to upper arm. **Exam Key Statement**: "I position the patient supine with the arm on a hand table. Before exsanguination, I mark the ganglion as it becomes less prominent with the tourniquet. I also mark the expected course of the superficial radial nerve dorsoradially and Lister's tubercle to identify the 3rd compartment." - Ganglion not marked before exsanguination = difficult to locate - Superficial radial nerve course not planned = higher injury risk - Wrong wrist prepared (time-out protocol critical) - Tourniquet complications (pressure too high, time too long) ### Step 2: Exsanguination and Tourniquet Elevate arm for 2 minutes or use Esmarch bandage for exsanguination. Inflate tourniquet to 250-275 mmHg. Apply surgical drape. Use loupe magnification (2.5x-3.5x) for better visualization of nerves and stalk. **Technical Tip**: "I exsanguinate the arm with elevation or Esmarch and inflate the tourniquet to 250 mmHg. I use loupe magnification (2.5-3.5x) throughout the procedure for better nerve visualization and stalk identification." - Inadequate exsanguination = poor visualization - Tourniquet too tight or too long = nerve injury, skin necrosis - No magnification = higher risk of nerve injury and incomplete stalk excision ### Step 3: Skin Incision Transverse incision 2-3cm over ganglion following Langer's lines (author's preference), OR longitudinal 3-4cm along radial border of 4th compartment. Incise skin sharply with #15 blade. Use fine-toothed forceps for skin handling to minimize trauma. **Exam Key Statement**: "I use a transverse incision over the ganglion following Langer's lines for superior cosmetic result. This is my preferred approach. An alternative is a longitudinal incision along the 4th compartment which may be easier for nerve protection but gives a more visible scar. I discuss both options with the patient." - Incision not centered over ganglion = inadequate exposure - Transverse incision crosses superficial radial nerve branches = requires careful dissection - Excessive incision length = poor cosmesis ### Step 4: Superficial Radial Nerve Identification **CRITICAL STEP**: Immediately identify branches of superficial radial nerve in subcutaneous tissue, dorsoradial to incision. Typically 3-5 branches fan across dorsal wrist. Use blunt dissection with fine scissors to expose nerves. Place vessel loops around identified branches for protection throughout procedure. **Exam Key Statement**: "The most important early step is identification of the superficial radial nerve branches. These are in the subcutaneous fat dorsoradially and are most at risk - injury occurs in 5-10%. I use blunt dissection to identify all visible branches and place vessel loops for protection throughout the procedure." - Superficial radial nerve injury = painful neuroma, numbness, worst complication (5-10%) - Blind sharp dissection in subcutaneous tissue = nerve transection - Cautery near nerve = thermal injury - Excessive traction on nerve = neuropraxia ### Step 5: Extensor Retinaculum Exposure Develop subcutaneous plane to expose extensor retinaculum overlying ganglion. Identify Lister's tubercle (bony prominence on dorsal radius). Identify EPL tendon running ulnar to Lister's in 3rd compartment. Identify EDC tendons in 4th compartment ulnar to EPL. Ganglion lies between 3rd and 4th compartments. **Technical Tip**: "I expose the extensor retinaculum and identify key landmarks: Lister's tubercle marks the 3rd compartment containing EPL. The 4th compartment with EDC is ulnar to this. The dorsal wrist ganglion arises between these two compartments, from the scapholunate ligament deep to the retinaculum." - Loss of anatomic orientation = tendon injury risk - EPL not identified early = laceration risk during retinaculum opening - Inadequate exposure = incomplete excision ### Step 6: Retinaculum Opening Open extensor retinaculum LONGITUDINALLY between 3rd (EPL) and 4th (EDC) compartments. This is where ganglion stalk emerges from deep to superficial. Protect EPL radially and EDC ulnarly during opening. Ganglion stalk often becomes visible passing through this interval. **Exam Key Statement**: "I open the extensor retinaculum longitudinally between the 3rd and 4th compartments. The ganglion stalk passes through this interval from the scapholunate ligament deep in the wrist to the superficial ganglion. I protect EPL radially and EDC ulnarly during this step." - EPL laceration = devastating, no thumb IP extension, requires tendon transfer - EDC injury = finger extension weakness - Inadequate retinaculum opening = stalk not visualized, incomplete excision ### Step 7: Ganglion Mobilization Mobilize ganglion circumferentially using sharp and blunt dissection. Ganglion has thick fibrous wall but NO true capsule. Dissect ganglion off adherent tendons (EPL, EDC, ECRB, ECRL) using blunt technique. Avoid grasping ganglion with instruments (may rupture). Ligate or cauterize small feeding vessels. **Technical Tip**: "I mobilize the ganglion circumferentially, carefully dissecting it off all surrounding tendons using predominantly blunt dissection. The ganglion is often adherent to EPL and extensor tendons. I avoid grasping the ganglion directly as rupture makes stalk identification harder, though rupture is acceptable if it occurs." - Tendon laceration during dissection (EPL most critical) - Premature ganglion rupture = more difficult stalk identification - Incomplete mobilization = stalk not accessible - Nerve injury if branch not previously identified ### Step 8: Stalk Identification (Most Critical Step) **MOST IMPORTANT STEP**: Trace ganglion to its stalk. Stalk is narrowed portion at base of ganglion. Follow stalk deep between EPL and EDC toward wrist joint. Stalk passes through retinaculum and inserts on dorsal wrist capsule at scapholunate (SL) interval. Gentle traction on ganglion demonstrates stalk direction. Use loupe magnification. **Exam Key Statement**: "This is the most critical step. I trace the ganglion to its stalk and follow the stalk to its origin at the scapholunate ligament. Complete stalk excision is the key difference between surgical excision with low recurrence (5-10%) and aspiration with high recurrence (40-60%). I use gentle traction on the ganglion to identify the stalk direction." - Stalk not identified = 40-60% recurrence rate (as high as aspiration) - Scapholunate ligament injury = carpal instability, DISI deformity - Radial artery injury (rare, volar to SL joint) - Stalk transected before origin reached = incomplete excision ### Step 9: Capsulectomy and Stalk Excision Excise stalk at its origin from dorsal wrist capsule with 5mm cuff of capsule around base. Capsulectomy should extend down to visualize scapholunate ligament and articular cartilage. **PRESERVE scapholunate ligament integrity** - excise only capsule, not ligament. Specimen includes: ganglion + stalk + capsular cuff. **Exam Key Statement**: "I excise the stalk at its origin with a 5mm cuff of dorsal wrist capsule to ensure complete removal. This capsulectomy extends to the scapholunate ligament level. I am careful to preserve the SL ligament integrity - injury would cause carpal instability. The capsular defect does not need repair and will scar." - Scapholunate ligament injury = DISI pattern carpal instability - Inadequate capsulectomy (<5mm margin) = recurrence - Damage to articular cartilage = arthritis risk - Radiocarpal joint violation = acceptable but increases stiffness risk ### Step 10: Specimen Removal and Inspection Remove specimen en bloc (ganglion + stalk + capsule). Send ALL tissue for histopathology. Inspect defect: visualize scapholunate ligament (should be intact), confirm complete stalk excision, no retained cyst fragments. Capsular defect 1-2cm is acceptable and expected. **Technical Tip**: "I send all excised tissue for histopathology to confirm the diagnosis of ganglion cyst and exclude other pathology. Histology shows thick fibrous wall with NO epithelial lining and mucinous contents. I inspect the base and confirm the scapholunate ligament is intact with no retained cyst fragments." - Specimen not sent for histology = missed diagnosis - Retained cyst fragments = recurrence - SL ligament injury not recognized = delayed instability ### Step 11: Hemostasis Deflate tourniquet. Achieve meticulous hemostasis with bipolar cautery for small vessels and ties for larger vessels. Avoid cautery near nerve branches (use ties or clips). Irrigate wound with saline. Ensure complete hemostasis before closure - hematoma increases infection and stiffness risk. **Exam Key Statement**: "I deflate the tourniquet and achieve careful hemostasis. I use bipolar cautery for small vessels but avoid cautery near the superficial radial nerve branches where I use ties or clips instead. Meticulous hemostasis prevents hematoma formation which increases infection and stiffness risk." - Inadequate hemostasis = hematoma formation - Cautery near nerve = thermal injury, delayed neuroma - Unrecognized tendon injury = delayed rupture ### Step 12: Retinaculum Repair Repair extensor retinaculum with interrupted 4-0 or 5-0 absorbable sutures (Vicryl or Monocryl). Ensure EPL tendon lies in anatomic position at Lister's tubercle. Retinaculum repair prevents extensor bowstringing. Some surgeons leave small defect to prevent adhesions - both approaches acceptable. **Technical Tip**: "I repair the extensor retinaculum with absorbable sutures to restore anatomy and prevent extensor bowstringing. I ensure EPL sits in its groove at Lister's tubercle. Leaving a small defect is an alternative to reduce adhesion formation, but I prefer anatomic repair for better gliding mechanics." - Retinaculum too tight = extensor adhesions, stiffness - EPL malposition = altered thumb mechanics - Suture through tendon = tendon injury - No repair = bowstringing (usually minor) ### Step 13: Wound Closure Close subcutaneous tissue with 5-0 absorbable suture (Monocryl) if needed - minimize dead space. Close skin with 5-0 nylon interrupted sutures or subcuticular 5-0 Monocryl. Apply Steri-Strips. Dress with soft gauze and crepe bandage - wrist in neutral position. No rigid splint needed unless patient prefers for pain control. **Exam Key Statement**: "I close the skin meticulously with fine sutures for best cosmetic outcome - cosmesis is important to patients for dorsal wrist scars. I apply a soft dressing with the wrist in neutral position. I do not routinely splint as early mobilization reduces stiffness, but I offer a removable splint if the patient prefers for initial comfort." - Skin closure too tight = wound breakdown, necrosis - Excessive dead space = seroma formation - Dressing too tight = compartment syndrome (extremely rare) - Unnecessary rigid splinting = wrist stiffness ## Immediate Post-operative Care (0-2 weeks) **Day 0-2:** - Elevate hand above heart level to reduce swelling - Finger ROM exercises immediately - full fisting and extension - Ice for pain and swelling control - Analgesia: paracetamol ± NSAIDs, avoid opiates if possible **Day 2-14:** - Dressing change at 48 hours - assess wound - Remove bulky dressing, apply light dressing - Wrist ROM encouraged from day 2-7 (surgeon preference) - Gentle wrist flexion/extension, radial/ulnar deviation - Avoid heavy loading **Week 2:** - Suture removal at 10-14 days - Assess wound healing - Assess ROM and nerve function - Begin scar massage ## Intermediate Recovery (2-6 weeks) **Week 2-4:** - Progressive wrist ROM exercises - Gentle strengthening (light grip exercises) - Scar massage with moisturizer bid - Return to light activities of daily living - Driving when comfortable (usually 2-3 weeks) **Week 4-6:** - Unrestricted wrist ROM - Progressive strengthening - Return to light work/sport - Scar maturation ongoing ## Late Recovery (6 weeks+) **Week 6-12:** - Return to full activities including heavy work and sport - Continue scar management for 3-6 months - Monitor for recurrence (rare, usually occurs 6-12 months if present) ## Follow-up Schedule - **2 weeks**: Wound check and suture removal - **6 weeks**: ROM assessment, return to activity clearance - **PRN**: If concerns about recurrence, stiffness, or nerve symptoms ## Rehabilitation Protocol - **No formal hand therapy needed** for routine cases - Hand therapy referral if: - Significant stiffness at 6 weeks - Nerve injury symptoms - Complex regional pain syndrome concerns - Patient occupation requires maximal function **Exam Statement on Post-op Care**: "I encourage early mobilization to prevent stiffness. Patients begin finger ROM immediately and wrist ROM within the first week. Sutures are removed at 10-14 days. Most patients return to full activities by 4-6 weeks. Recurrence after complete stalk excision is 5-10%, much lower than the 40-60% recurrence after aspiration." ## References 1. **Gude W, Morelli V.** Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. *Curr Rev Musculoskelet Med* 2008;1(3-4):205-11. PMID: 19468908. [Comprehensive review of ganglion pathophysiology and management options] 2. **Dias J, Buch K.** Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. *J Hand Surg Br* 2003;28(2):172-6. PMID: 12631492. [Natural history and treatment outcomes] 3. **Thornburg LE.** Ganglions of the hand and wrist. *J Am Acad Orthop Surg* 1999;7(4):231-8. PMID: 10434077. [Classic review of hand and wrist ganglions] 4. **Zubowicz VN, Ishii CH.** Management of ganglion cysts of the hand by simple aspiration. *J Hand Surg Am* 1987;12(4):618-20. PMID: 3611666. [Aspiration technique and recurrence rates] 5. **Angelides AC, Wallace PF.** The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. *J Hand Surg Am* 1976;1(3):228-35. PMID: 1018089. [Landmark paper on ganglion pathogenesis and anatomy] 6. **Clay NR, Clement DA.** The treatment of dorsal wrist ganglia by radical excision. *J Hand Surg Br* 1988;13(2):187-91. PMID: 3385299. [Surgical technique and outcomes] 7. **Westbrook AP, Stephen AB, Oni J, et al.** Ganglia: the patient's perception. *J Hand Surg Br* 2000;25(6):566-7. PMID: 11106520. [Patient perspectives on ganglion treatment] 8. **Varley GW, Needoff M, Davis TR, et al.** Conservative management of wrist ganglia. Aspiration versus steroid infiltration. *J Hand Surg Br* 1997;22(5):636-7. PMID: 9752922. [Comparison of aspiration techniques] 9. **Gundes H, Kilicoglu O, Turker M, et al.** Ganglion cyst surgery under local anesthesia: a prospective study of complications and recurrence. *J Plast Surg Hand Surg* 2016;50(3):162-5. PMID: 26924234. [Complications and recurrence after surgery] 10. **Head L, Gencarelli JR, Allen M, et al.** Wrist ganglion treatment: systematic review and meta-analysis. *J Hand Surg Am* 2015;40(3):546-53.e8. PMID: 25617955. [Systematic review comparing all treatment modalities including aspiration, surgery, and observation]

Ganglion Cyst Excision - Dorsal Wrist

Ganglion Cyst Excision - Dorsal Wrist