Original Article

ASPIRATION COMBINED WITH SETON INSERTION

FOR TREATMENT OF WRIST GANGLIONS

FARZANA MEMON, REHAN ABBAS, MAHMOOD A. KHAN, M. SAEED QURAISHY

Department of Surgery (Unit V), Dow University of Health Sciences & Civil Hospital, Karachi

ABSTRACT
Objective: To evaluate the results of Aspiration combined with Seton insertion in the treatment of wrist Ganglions.
Design & Duration: Prospective, quasi experimental study from Jan. 2004 to Dec. 2006.
Setting: Surgical Unit V, Civil Hospital, Karachi.
Patients: Fifty five patients who presented with wrist Ganglia.
Methodology: All patients were assessed in detail clinically, and treated by aspiration with 14 gauge IV cannula
and 10cc syringe followed by Seton (Silk No.1 on straight needle) insertion through the cavity. Seton was removed
on the 12th day. The average follow-up time was one year.
Results: Out of 55 patients, 51(92.7%) had a Dorsal Carpal Ganglion and 4(7.3%) a Volar Ganglion. Twenty nine
(52.7%) cases were males and 26(47.3%) females, with an age range from 17-35 years. All patients complained of
a localized swelling, while 12(21%) had pain during activity. Fifty two (95%) cases had a smooth recovery, while
two had residual swellings requiring re-aspiration and one developed signs of inflammation which subsided on
conservative management. No recurrence of the ganglion occured in any case.
Conclusion: Aspiration combined with seton insertion for treating Ganglions of wrist is a simple, economic, cosmetic,
uncomplicated procedure which can be done in the out-patient department. It is a reliable and safe alternative to
open resection for successful eradication of the wrist Ganglion.

KEY WORDS: Wrist, Ganglion, Aspiration, Seton

INTRODUCTION The exact aetiology is unclear but mucoid degeneration

A ganglion is a common benign lesion arising as a di-
verticular swelling from synovial tissue in relation to
joints and tendons containing synovial fluid1,2. The
most common location for hand and wrist ganglion is
the dorsum of the wrist - the dorsal wrist ganglion (60
to 70%)3,4. It arises from the scapho-lunate joint con-
nected with dorsal scapho-lunate interosseous ligament
near the area of capsular attachment. Occasionally they
arise on the volar aspect near the radial artery but may
also be intra-tendinous or intra-osseus.
of the connective tissue seems to be a probable cause,
with breakdown product of collagen collecting in pools,
which coalesce to form a large cyst5. Most patients pre-
sent with a swelling, some with pain due to pressure
on the posterior interosseus nerve6 and some for cosmetic
reasons. The diagnosis of carpal ganglions is made after
assessing the location, size, consistency, history and
examination7.
Aspiration and ultrasonography may help to confirm
the diagnosis8. Ganglion should not be treated, unless
symptomatic. Treatment options include massage, as-
piration, corticosteroid injections, suture fixation, surgical
and arthroscopic resection9.

PATIENTS & METHODS

Correspondence:
Dr. Farzana Memon, Assistant Professor Surgery,
Surgical Unit V, Civil Hospital, Karahci.
Res: 568 - Chaman Street, Garden East, Karachi.
Phones: 0333-2122139.
E-mail: dr_fimemon@hotmail.com
From January 2004 to December 2006, 55 patients pre-
sented with wrist ganglion in the Out-patient department
of Surgical Unit V, Civil Hospital, Karachi. All were
assessed clinically and treated by aspiration and seton
insertion. Parameters studied included age, sex, site,

205 Volume 23, Issue 3, 2007

 Treatment of Wrist Ganglion
size, symptoms and complications.
Technique
After aseptic measures 14 guage IV cannula was inserted
into the ganglion and the metallic needle removed. A
10 ml syringe was then fitted to the cannula and aspi-
ration of the jelly like transparent material was perfor-
med by applying pressure on the ganglion with the
thumb. After complete evacuation the syringe was dis-
connected from the cannula and silk No.1 on a straight
needle was passed through the cannula into the ganglion
and brought out through the other side of the ganglion.
The cannula was removed and the seton fixed over the
skin. An aseptic dressing and crepe bandage were then
applied over the wrist.
First dressing was removed on the 4th day and a small
second dressing applied. Seton was removed on the
12th day. No anaesthesia was used during the proce-
dure. All patients were followed up every month for
initial 3 months and at 6 months interval for one year.
RESULTS
Amongst the 55 patients with wrist ganglion, 29 (52.7%)
were males and 26 (47.3%) females, with an age range
of 17-35 years. Fifty one (92.7%) patients had a dorsal
carpal ganglion while four (7.3%) patients presented
with a volar ganglion. Five (9%) recurrent cases were
referred from elsewhere, two underwent surgical exci-
sion initially and three aspiration.
All patients complained of a swelling, while 12 (21.8%)
had associated pain causing interference with daily acti-
vities. Fifty two (95%) patients had a smooth recovery,
while three (5%) developed complications. Two patients
developed a residual swelling on the 4th day and were
re-aspirated with seton in place. One case developed
the signs of inflammation which was treated conserva-
tively. The seton was removed on the 12th day in all
these patients. There was no recurrence of the ganglion
in any case in this series.
DISCUSSION
A ganglion is the herniation of synovial tissue in relation
to the joints or tendons containing synovial fluid. Com-
monest site is dorsal carpal ganglion; however occasional
volar ganglions are also reported.
Recurrence rate after puncture or aspiration alone is
greater than 50%10, while aspiration followed by corti-
costeroid injection of ganglion also has higher rate of
recurrence11. Seton insertion alone for ganglion has a
recurrence rate of 13.8%12. Open surgical resection for
206
F. Memon, R. Abbas, M. A. Khan, M. S. Qureshi
the dorsal ganglion has a recurrence rate of 5.10 %13-14.
Ganglion surgery is more than a minor procedure and
requires a formal operative environment and careful te-
chnique in order to minimize injury to adjacent structures
and complications like residual pain due to injury to
dorsal branch of interosseus nerve and scapho-lunate
instability. Besides the patients also complain of a scar
on the wrist.
The latest technique of arthroscopic aspiration also has
a reported recurrence rate of 5%, though Tienshih et al9
claimed no recurrence after arthroscopic resection in
their series.
Our study conducted on 55 patients by aspiration with
wide bore intravenous cannula followed by seton inser-
tion is very simple and can be done in 5-7 minutes as
an out-patient procedure. Aspiration completely evacua-
tes the ganglion cavity while seton acts as a foreign
body and evokes fibrosis. This technique is cost effective
with virtually no complication or residual scar. No post
procedure limitation of hand movements required and
no recurrence reported yet. Therefore it is an alternative
to open or arthroscopic resection.
CONCLUSION
Aspiration of ganglion with wide bore intravenous can-
nula followed by seton insertion through the ganglion
and fixation of suture over the skin is simple, economical
and an effective alternative to arthroscopic or surgical
resection.
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