Seed Ganglions

Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

 - A1 pulley ganglion
 - Pearl ganglion

Who does it affect?

Anyone

Why does it occur?

It is a fluid filled sac that occurs at the base of a finger on its front surface. They are thought to be related to changes in the lining of the joints and tendon sheaths.

Symptoms

A painless lump that comes and goes in size. The outline is quite smooth and may feel tense like a small ball or balloon (cystic).

Clinical Examination

A seed ganglion has quite typical features both in its location and appearance. With the lights turned down and a pen torch is shone through the lump, it transilluminates.

Investigations

Usually none. In unusual situations an ultrasound scan will be helpful.

Non-operative treatment

Ganglions can be aspirated under local anaesthetic. A needle is then introduced into the lump and the fluid sucked away. However they can be quite small and difficult to aspirate with a needle.

Operative treatment

If the lump has reappeared 6 weeks after aspiration or was too small to aspirate I usually recommend surgery. The surgery is a day case procedure usually under local anaesthetic and takes about 10 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

Local anaesthetic is infiltrated under the skin in line with the incision over the lump. Once numb the skin is incised and then the underlying fat is retracted. Care is taken not to injure nerves and blood vessels. At the base of the wound is the ganglion wall. The ganglion is dissected taking care not to puncture it. The base of the ganglion is identified and excised. The skin is sutured and a bulky dressing is applied.

Post-operative rehabilitation

The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. The sutures are removed at about 10 days.

Return to activities of daily living

It is my advice to keep the wound dry until the stitches are out at 10 days.

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probably advisable to delay returning to driving for at least 7 days or even when the stitches are removed.

Return to work:

Everyone has different work environments.

Returning to heavy manual labour should be prevented for approximately 4 to 6 weeks. Early return to heavy work may cause the tendons and nerve to scar into the released ligament. Please ask your surgeon for advice on this.

Complications

Overall, greater than 95% are happy with the result. However complications can occur.
There are complications specific to Ganglion surgery and also general complications associated with hand surgery.

General complications:

 - Infection (Less than 1%)
 - Neuroma (Less than 1%, a coiled painful nerve bundle) 
 - Numbness

Reflex Sympathetic Dystrophy - RSD (2% bad reaction to surgery with painful stiff hands - this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

Specific complications:

Recurrence: this is reported between 10 and 40%. We are not sure whether it is the same ganglion recurring or simply another one forming nearby.