Chapter 4 Arthroscopic Treatment of Dorsal Wrist Ganglia

10.1055/b-0035-121114

Chapter 4 Arthroscopic Treatment of Dorsal Wrist Ganglia

A dorsal wrist ganglion or synovial cyst is a benign tumor that often disappears spontaneously. Surgery is reserved for the rare painful ganglia, or large ones of cosmetic concern. The recurrence rate and the postoperative complications of open surgery, such as stiffness in flexion and unattractive scars, are well known. Arthroscopic resection is a simple, minimally invasive technique. It has a recurrence rate similar to that following open surgery but without its complications.1

Ligament Anatomy of the Dorsal Scapholunate Region

The dorsal scapholunate (SL) region is a ligamentous complex composed of three distinct elements ( Fig. 4.1a, b ):

The dorsal segment of the SL ligament
The dorsal intercarpal (DIC) ligament
The dorsal capsuloscapholunate septum (DCSS),2 which unites the SL ligament to the DIC ligament and contributes to the stabilization of the SL bony interval ( Fig. 4.2 ).

The mucoid dysplasia associated with ganglia is intracapsular and extrasynovial and occurs at the level of this dorsal SL complex ( Fig. 4.3a–c ). Medially, the dysplasia herniates into the wrist joints, usually into the midcarpal joint ( Fig. 4.4 ). Laterally, the dysplasia extends by a pedicle between the DIC ligament or the radiolunotriquetral ligament (RLTL), either distally beneath the DIC ligament or laterally toward the radial border of the radiocarpal compartment ( Fig. 4.5 ).

**Fig. 4.1a, b** a Sagittal cut of the wrist passing through the lunate and showing the dorsal scapholunate complex. b Drawing showing the three components of the dorsal scapholunate complex: the dorsal portion of the scapholunate ligament in brown, the dorsal capsuloscapholunate septum, DCSS, in blue, and the dorsal intercarpal ligament—the integrating part of the dorsal capsule—in white.

**Fig. 4.2** Arthroscopic view of the intact dorsal capsuloscapholunate septum. The scope is placed in the 6R portal and directed toward the junction between the joint capsule and the dorsal portion of the scapholunate ligament.

**Fig. 4.3a–c** Photograph (a) and drawing (b) showing the classic position of the dorsal wrist ganglion at the dorsal portion of the scapholunate ligament in the midcarpal joint. (c) Drawing showing relationship between the ganglion, the capsule, and the wrist extensors.

Operative Technique

Patient Preparation

This procedure is performed as an outpatient surgery under regional anesthesia. The tourniquet is placed on the arm near the elbow. Countertraction is applied on the tourniquet. After exsanguinating the limb and placing an upper limb sterile drape, traction is administered using a traction tower—it is possible to use a shoulder arthroscopy tower. The required traction of 5 to 7 kg is applied using Chinese finger traps.

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