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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Musculoskeletal Procedures > 72 – Aspiration and Injection of Wrist Ganglia 72 Aspiration and Injection of Wrist Ganglia Ganglion cysts are common tumors that arise from joint capsules or synovial sheaths of tendons. When ganglia maintain their connection to the synovial sheath, they can be mobile and vary in size. Ganglia occur at all ages, but most commonly appear in women between the ages of 20 and 40 years. The dorsal or volar aspects of the wrist are the most common sites. Ganglia may be obvious or occult. Obvious ganglia may slowly enlarge or develop suddenly after trauma. Obvious ganglia often appear as firm, nontender, pea- to marble-sized lesions beneath the skin. Occult ganglia may compress superficial nerves and cause dull aching. Ganglia also frequently produce weakness and altered range of motion in the wrist and fingers. Imaging methods such as ultrasonography or magnetic resonance imaging may help to identify a suspected ganglia. Hitting a dorsal wrist ganglia with a large Bible has been a treatment used for centuries. If the cyst ruptures, the body absorbs the fluid, and the lesion can be cured in 30% of individuals. In addition to the high recurrence rate, this techniques carries a significant risk of fracture and other injury to surrounding tissues. Aspiration and steroid injection has become the most commonly performed nonsurgical intervention for ganglia. A large-bore needle can be placed within a ganglia to remove the thick, viscous fluid. Simple aspiration is associated with high rates of recurrence (>50%). Injection of corticosteroid after aspiration can help to shrink or resolve the lesions and reduces recurrences to between 13% and 50%. Hyaluronidase is a naturally occurring enzyme that liquefies the contents of the ganglion and permits complete removal of ganglion contents and penetration of the steroid to the cyst wall. Ganglia recurrence can be reduced by injecting 1500 units (10 mL reconstituted) of hyaluronidase for 20 minutes before the injection of the steroid. The volume, cost, and additional complexity of this step has discouraged many practitioners from hyaluronidase injection. The only U.S. manufacturer of hyaluronidase discontinued production in 2002. Surgical intervention may be needed for recurrent or symptomatic lesions, but even surgical excision has recurrence rates higher than 5% to 10%. Most ganglia in children resolve without intervention. The rate of spontaneous resolution P.580
in adults appears to be less but is still significant enough to counsel patients about the option of observation. INDICATIONS

  • Symptomatic ganglia over the wrist (or other non-weight-bearing joints)
  • Ganglia for which patients select nonsurgical intervention

RELATIVE CONTRAINDICATIONS

  • Uncooperative patients
  • Ganglia overlying artificial joints
  • Coagulopathy or bleeding diathesis
  • Presence of septic arthritis or bacteremia

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PROCEDURE A large ganglion is depicted on the dorsum of the wrist.

(1) A large ganglion on the dorsum of a wrist.

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Enter the ganglion from the side (horizontally) using a 16- or 18-gauge, 1-inch needle (Figure 2A). The needle is cross-clamped near its base with a straight hemostat (Figure 2B). After the aspirating syringe fills with the thick gel-like contents, the hemostat is used to stabilize the needle. The aspirating syringe is removed, and the injecting syringe that contains corticosteroid is attached to the needle (Figure 2C). The steroid-lidocaine solution (e.g., 0.4 mL of Celestone and 1.6 mL of 1% lidocaine) is injected into the ganglion, and the cyst enlarges with the fluid.

(2) Aspiration and injection of a ganglion using a 16- to 18-gauge, 1-inch needle.

PITFALL: Insertion of a large-bore needle can be uncomfortable. Stretch the skin before needle insertion. Consider intradermal injection of 1% lidocaine at the needle insertion site before the procedure. PITFALL: Movement of the large needle when replacing syringes can make the procedure very uncomfortable and dislodge the needle tip from inside the cyst. Keep the tip immobile by maintaining firm grasp of the hemostat and bracing (anchoring) this hand on the patient’s wrist or forearm. P.583
Splinting or compression is advocated by many physicians after aspiration and injection. An ace wrap can be used over the site.

(3) Splint or compress the site after aspiration and injection.

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CODING INFORMATION

CPT® Code Description 2002 Average 50th Percentile Fee
20612 Aspiration and injection of ganglion cyst, any site †
† Because this is a new code for 2003, there is no 2002 fee available.
CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING Consult the ordering information that appears in Chapter 65. Ganglion cysts are best aspirated with 16- or 18-gauge, 1-inch needles. A hemostat may be used to exchange the injection syringe for the aspiration syringe. Needles, syringes, and ace wraps may be ordered from local surgical supply houses. Hemostats may be ordered from instrument dealers. The only U.S. manufacturer of hyaluronidase has been Wyeth, but Wyeth discontinued production of hyaluronidase in 2002. A suggested tray for performing soft tissue aspirations and injections is listed in Appendix D. Skin preparation recommendations appear in Appendix H. BIBLIOGRAPHY Beetham WP, Polley HF, Slocumb CH, et al. Physical examination of the joints. Philadelphia: WB Saunders, 1965:56–57. Buttaravoli P, Stair T. Minor emergencies: splinters to fractures. St. Louis: Mosby, 2000:290–291. Ho PC, Griffiths J, Lo WN, et al. Current treatment of ganglion of the wrist. Hand Surg 2001;6:49–58. Jones JG. Selected disorders of the musculoskeletal system. In: Taylor RB, ed. Family medicine principles and practice,5th ed. New York: Springer, 1998:1005–1015. Klippel JH, Weyand CM, Wortmann RL. Primer on the rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation, 1997:141. Leversee JH. Aspiration of joints and soft tissue injections. Prim Care 1986;13:579–599. Mercier LR, Pettid FJ, Tamisiea DF, et al. Practical orthopedics, 4th ed. St. Louis: Mosby, 1991:104–105. Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7–12. Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheumatol Pract 1986;Mar-May:52–63. Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg Br 1997;22:219–221. Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am 2001;26:599–602. Wilson FC, Lin PP. General orthopedics. New York: McGraw-Hill, 1997:424–425.

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