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Ganglion cyst in hand as short case in surgery Give me examination and viva voice for this

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site:orthoinfo.aaos.org ganglion cyst wrist hand symptoms examination treatment

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Short case: Ganglion cyst of hand/wrist

Case presentation

“This is a [age]-year-old [sex] patient with a swelling over the dorsal/volar aspect of the wrist for [duration]. It was insidious in onset and has gradually increased in size, sometimes varying with activity. There may be dull pain or discomfort on wrist movement, but there is no history suggestive of infection, trauma, constitutional symptoms, or neurovascular deficit.
On examination, there is a solitary, well-defined, smooth, cystic swelling over the dorsum of the wrist, usually near the scapholunate region. It is fluctuant, non-pulsatile, non-compressible, non-reducible, and brilliantly transilluminant. The skin is normal and free over it. It may become less prominent on wrist flexion. Wrist movements may be mildly painful or restricted. Distal pulses, sensation, and tendon function are normal.
My clinical diagnosis is a dorsal wrist ganglion cyst.”
Ganglion cysts are the commonest hand swelling and are usually dorsal or volar at the wrist. They are classically smooth, fluctuant and brightly transilluminant. [Bailey & Love, p. 570]

Examination in a short case

1. General examination

  • Look for general health, rheumatoid arthritis or osteoarthritis if relevant.
  • Examine both hands and wrists for comparison.

2. Inspection

Expose both forearms and hands.
Look for:
  • Site: dorsal wrist is most common. Volar wrist, DIP joint, and flexor tendon sheath are other sites.
  • Number, size, shape and surface.
  • Skin: normal, stretched, scar, sinus, ulcer or colour change.
  • Visible pulsation.
  • Movement with wrist or finger movement.
  • Nail deformity if at DIP joint, suggesting a mucous cyst.

3. Palpation

Check:
  • Local temperature and tenderness.
  • Consistency: firm-cystic/fluctuant.
  • Margins: well-defined.
  • Mobility:
    • Usually mobile side-to-side.
    • May be tethered to underlying joint capsule or tendon sheath.
  • Compressibility and reducibility: usually absent.
  • Pulsatility: absent. If present, consider aneurysm.
  • Relation to tendons:
    • Ask patient to flex/extend wrist or fingers.
    • A tendon-sheath ganglion may move with tendon excursion.
  • Examine radial and ulnar pulses, capillary refill, sensation and motor function.

4. Special tests

  • Transillumination: positive, often brilliantly.
  • Fluctuation test: positive.
  • Tinel sign over the swelling if there are tingling symptoms from nerve pressure.
  • Assess wrist range of motion and pain at terminal movement.
  • Examine cervical spine and peripheral nerves if there are neurological symptoms.

5. Examine regional area

  • Adjacent wrist joint for arthritis or instability.
  • DIP joint for osteoarthritis if it is a digital mucous cyst.
  • Axillary lymph nodes are generally not necessary unless there are suspicious features.

Common viva questions with answers

1. What is a ganglion?

A ganglion is a benign cystic swelling arising from a joint capsule, ligament or tendon sheath. It contains clear, gelatinous, mucin-rich fluid and commonly communicates with the adjacent joint through a stalk.

2. What are common sites?

  1. Dorsal wrist, most commonly near the scapholunate joint
  2. Volar wrist
  3. Flexor tendon sheath at the base of finger, also called a retinacular or seed ganglion
  4. Dorsal DIP joint, called a digital mucous or myxoid cyst
[Bailey & Love, p. 570]

3. What is the commonest site?

The dorsal aspect of the wrist.

4. What are the clinical features?

  • Smooth, rounded swelling
  • Usually painless, though may cause dull aching pain
  • Fluctuant and transilluminant
  • Size can change with activity
  • May cause reduced movement, tingling or weakness if compressing a nerve
  • Usually no skin changes

5. Why does it transilluminate?

Because it contains clear gelatinous fluid.

6. What are the differential diagnoses of a wrist swelling?

  • Lipoma
  • Giant-cell tumour of tendon sheath
  • Rheumatoid nodule
  • Carpal boss, which is a bony hard swelling
  • Epidermoid cyst
  • Synovial swelling
  • Abscess
  • Radial artery aneurysm or pseudoaneurysm, especially for a volar swelling
  • Soft-tissue tumour

7. What investigations will you do?

Diagnosis is usually clinical. If uncertain:
  • Ultrasound: confirms cystic nature and relation to vessels, particularly for volar ganglion.
  • X-ray wrist/hand: may identify osteoarthritis, carpal boss or bony pathology.
  • MRI: for occult ganglion, atypical swelling, or preoperative planning.

8. What is the management?

If asymptomatic:
  • Reassurance and observation.
  • Explain that it is benign and may resolve spontaneously.
If symptomatic:
  • Splintage/activity modification and analgesics.
  • Aspiration may temporarily reduce symptoms but recurrence is common.
  • Surgical excision, including removal of the stalk and a cuff of adjacent capsule, for persistent pain, recurrence after aspiration, functional impairment, nerve compression, or cosmetic concern.

9. What is the recurrence after aspiration?

It is high, often over 50%. Surgical excision has a lower recurrence rate but recurrence can still occur. [Rosen’s Emergency Medicine, p. 595]

10. Why should you be careful while aspirating a volar wrist ganglion?

The radial artery and nearby nerves may lie close to a volar ganglion. Therefore blind aspiration is avoided or performed with ultrasound guidance by an experienced clinician.

11. What are complications of surgery?

  • Recurrence
  • Scar tenderness
  • Stiffness and reduced wrist movement
  • Infection
  • Neuroma or sensory nerve injury
  • Injury to radial artery or median nerve branches in volar ganglia
  • Persistent pain

12. What is a mucous cyst?

It is a ganglion occurring over the dorsal aspect of the DIP joint, usually associated with osteoarthritis. It can cause nail-groove deformity and may rupture or become infected. [Bailey & Love, p. 570]

13. What is a seed ganglion?

A small, painful ganglion arising from the flexor tendon sheath, usually near the MCP joint or proximal phalanx. Pain is commonly provoked by gripping.

14. Is trauma the cause?

A definite traumatic cause is usually not found. Trauma may make a pre-existing lesion noticeable, but ganglia are generally related to degeneration or herniation of connective tissue around joints or tendon sheaths.

15. When would you suspect a diagnosis other than ganglion?

  • Hard or fixed swelling
  • Rapid increase in size
  • Non-transilluminant mass
  • Marked pain, fever or inflammatory skin changes
  • Pulsatile swelling
  • Significant neurological deficit
  • Atypical location or recurrence after excision

One-line conclusion for examiner

“Clinically, this is a dorsal wrist ganglion: a benign cystic swelling related to the wrist joint, confirmed by its typical site, smooth cystic consistency, and brilliant transillumination. I would assess symptoms and neurovascular status, reassure if asymptomatic, and offer specialist treatment if pain, functional limitation, nerve compression, or cosmetic concern is significant.”

For FJ

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For FJ (Final Year) surgery short case, present it in this practical format:

Case presentation

“Good morning sir/ma’am. This is a [age]-year-old [male/female] with a swelling over the dorsum of the [right/left] wrist for [duration].
The swelling was insidious in onset and gradually progressive. It may vary in size and become more prominent with activity. There may be mild pain or discomfort during wrist movements. There is no history of fever, trauma, discharge, or similar swellings elsewhere.
On examination, there is a solitary, well-defined, rounded swelling of about [size] cm over the dorsum of the wrist, near the scapholunate region. The overlying skin is normal. On palpation it is non-tender, smooth, firm-cystic/fluctuant, non-pulsatile, non-compressible, and non-reducible. It is transilluminant. It is mobile side-to-side but fixed to deeper structures. Wrist movements are [normal/mildly painful]. Distal neurovascular status is normal.
My provisional diagnosis is a dorsal wrist ganglion cyst.”

Examination sequence

Inspection

  • Site: dorsal wrist is commonest
  • Number, size, shape, surface
  • Skin over swelling
  • Scar, sinus, ulceration, venous prominence
  • Pulsation
  • Compare with opposite wrist
  • Ask patient to flex and extend wrist, look for change in prominence

Palpation

  • Temperature
  • Tenderness
  • Consistency: firm-cystic / fluctuant
  • Margins: well-defined
  • Surface: smooth
  • Mobility: side-to-side mobility may be present; tethered deep
  • Compressibility: absent
  • Reducibility: absent
  • Pulsatility: absent
  • Fluctuation: positive
  • Transillumination: positive

Function and neurovascular status

  • Active and passive wrist movements
  • Pain on terminal dorsiflexion
  • Finger movements and grip
  • Radial and ulnar pulses
  • Capillary refill
  • Median, ulnar and radial nerve sensory-motor examination

Completion

  • Examine the opposite hand and wrist.
  • Examine other joints if inflammatory arthritis or osteoarthritis is suspected.

Viva questions for FJ

What is your diagnosis?
Dorsal wrist ganglion cyst.
Define ganglion.
A ganglion is a benign cystic swelling arising from a joint capsule, ligament or tendon sheath, containing thick gelatinous mucinous fluid.
What is the commonest site?
Dorsum of wrist, usually arising from the scapholunate region.
Other sites?
  • Volar aspect of wrist
  • Flexor tendon sheath at base of finger: seed or retinacular ganglion
  • Dorsal DIP joint: mucous or myxoid cyst
Why is it called a cyst? Does it have an epithelial lining?
It is a pseudocyst. It has no true epithelial or synovial lining.
What are the clinical features?
Painless or mildly painful smooth swelling, variable size, fluctuant, transilluminant, and sometimes discomfort during wrist movements. Nerve compression may rarely cause tingling or weakness.
What are the differential diagnoses?
  • Giant-cell tumour of tendon sheath
  • Lipoma
  • Rheumatoid nodule
  • Carpal boss
  • Epidermoid cyst
  • Abscess
  • Synovial swelling
  • Radial artery aneurysm/pseudoaneurysm, especially for volar wrist swelling
  • Soft-tissue tumour
How will you differentiate from giant-cell tumour of tendon sheath?
Giant-cell tumour is usually solid, firm, non-transilluminant, and commonly occurs on the volar aspect of fingers near tendon sheaths. A ganglion is cystic and transilluminant.
Investigations?
Usually clinical diagnosis.
  • Ultrasound if diagnosis is doubtful or before aspiration of a volar lesion
  • X-ray to exclude bony lesion or osteoarthritis
  • MRI for occult ganglion or an atypical swelling
Management of asymptomatic ganglion?
Reassurance and observation, as it is benign and may resolve spontaneously.
Management of symptomatic ganglion?
  • Activity modification, splintage, analgesia
  • Aspiration in selected dorsal wrist ganglia
  • Surgical excision for persistent pain, functional limitation, recurrence, nerve compression, or cosmetic concern
Why is aspiration not preferred in volar wrist ganglion?
Because of close relation to the radial artery and nerves. There is risk of injury, and recurrence is common.
What is done during excision?
The cyst is dissected carefully, its stalk is traced to the joint capsule or tendon sheath, and the cyst with stalk and a small cuff of capsule is excised to reduce recurrence.
Complications of surgery?
  • Recurrence
  • Stiffness
  • Scar tenderness
  • Infection
  • Neuroma/sensory nerve injury
  • Injury to radial artery in volar ganglion
  • Persistent pain
What is a mucous cyst?
A ganglion over the dorsal DIP joint, often associated with osteoarthritis. It can cause nail deformity and may rupture, leading to infection.
Important closing statement:
“Ganglion is a benign lesion, but I would rule out an atypical or malignant swelling if it is hard, fixed, rapidly enlarging, non-transilluminant, recurrent, or associated with constitutional symptoms.”

Feeding jejunostomy short case with model viva answer

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Feeding jejunostomy (FJ) short case: Model presentation

“Good morning sir/ma’am. This patient has a feeding jejunostomy tube in situ.
On inspection of the abdomen, there is a tube entering through the left upper/left lower quadrant, usually lateral to the rectus muscle. The tube is secured to the skin, and the surrounding skin is inspected for erythema, edema, discharge, leakage, excoriation, bleeding, granulation tissue, and infection.
The tube site is clean and dry, with no evidence of peritubal leak or cellulitis. The tube is patent and properly fixed. There is no abdominal distension, tenderness, guarding, or rigidity. The patient has no features of dehydration or electrolyte imbalance.
A feeding jejunostomy is an enteral access in which a tube is placed into the proximal jejunum for administration of feeds, water, and selected medications, when oral or gastric feeding is not possible or is undesirable.
I would review the indication for FJ, duration of feeding, type and rate of feed, daily fluid balance, nutritional status, tube patency, bowel function, and any complications.”

Examination of feeding jejunostomy

1. General examination

Look for:
  • General condition and conscious level
  • Hydration
  • Nutritional status: weight loss, muscle wasting, edema
  • Pallor
  • Signs of sepsis: fever, tachycardia
  • Evidence of electrolyte disturbance, especially in a malnourished patient started on feeds

2. Inspection of abdomen and tube

  • Note any abdominal scar from prior surgery, for example oesophagectomy, gastrectomy, pancreatic surgery.
  • Identify the FJ tube and its site.
  • Check:
    • Tube fixation and external length
    • Kinking, cracking, blockage, or dislodgement
    • Leak of feed or intestinal contents
    • Skin erythema, warmth, tenderness, induration
    • Purulent discharge or foul smell
    • Granulation tissue
    • Excoriation of surrounding skin
    • Abdominal distension

3. Palpation

  • Local temperature and tenderness around the tube
  • Induration or collection around the site
  • General abdominal tenderness, guarding, rigidity
  • Look for signs of peritonitis if there is a leak or recent displacement

4. Ask or check from records

  • Indication and date of insertion
  • Type of procedure: open, laparoscopic, Witzel jejunostomy, needle-catheter jejunostomy
  • Type of feed, volume, rate, and tolerance
  • Episodes of diarrhea, vomiting, pain, distension, tube blockage, or leakage
  • Input-output chart, weight trend, blood glucose, and electrolytes

Model viva questions and answers

What is a feeding jejunostomy?

A feeding jejunostomy is a surgically, laparoscopically, radiologically, or endoscopically placed tube entering the jejunum to provide enteral nutrition when oral or gastric feeding is not feasible.

What is the difference between a feeding jejunostomy and a jejunostomy stoma?

A feeding jejunostomy is a tube placed in the jejunum for nutrition. A jejunostomy stoma is a surgically exteriorized bowel opening, usually for fecal diversion after bowel surgery.

What are the indications for feeding jejunostomy?

  • Major upper gastrointestinal surgery, especially oesophageal or gastric resection, where oral intake will be inadequate postoperatively
  • Obstruction of oesophagus, stomach, or duodenum with a functioning distal small bowel
  • Severe dysphagia when prolonged enteral nutrition is needed
  • Gastric outlet obstruction
  • Gastric dysmotility or severe gastroparesis
  • When gastric feeding is unsuitable and prolonged small-bowel feeding is anticipated
  • Selected major abdominal or trauma surgery patients expected to have prolonged inadequate oral intake
Surgical jejunostomy is commonly made during major oesophagogastric surgery when early postoperative oral intake is likely to be insufficient. [Bailey & Love, p. 359]

Where is the tube inserted?

Usually into proximal jejunum, approximately 20-40 cm distal to the duodenojejunal flexure or ligament of Treitz. [Mulholland and Greenfield’s Surgery, p. 152]

Name the techniques of feeding jejunostomy.

  • Witzel tunnel jejunostomy
  • Needle-catheter jejunostomy
  • Open surgical jejunostomy
  • Laparoscopic jejunostomy
  • Radiologically inserted jejunostomy
  • Percutaneous endoscopic jejunostomy in selected cases

What is a Witzel jejunostomy?

After inserting the tube into the jejunum, the tube is buried in a serosal tunnel by suturing the jejunal wall over it. This reduces leakage. The jejunum is then fixed to the anterior abdominal wall. [Mulholland and Greenfield’s Surgery, p. 152]

Why do we prefer enteral feeding over parenteral nutrition when the gut is functioning?

Enteral feeding:
  • Maintains intestinal mucosal integrity
  • Is more physiological
  • Has lower cost
  • Has fewer catheter-related infectious complications
  • Helps preserve gut-associated immune function

What feeds are given through FJ?

Usually sterile, liquid, polymeric or semi-elemental enteral feeds. Feeds are started slowly, often continuously through a pump, then increased according to tolerance and nutritional requirements.

Can bolus feeds be given through an FJ?

Continuous controlled feeding is generally preferred because the jejunum has limited reservoir capacity. Rapid bolus feeding may cause cramps, abdominal distension, diarrhea, and dumping-type symptoms.

How do you confirm that the tube is functioning?

  • Check that the tube is externally intact and has not migrated.
  • Flush gently with sterile or clean water as per local protocol.
  • Assess ease of flushing and absence of leak or pain.
  • If displacement is suspected, do not use the tube until its position is confirmed, typically by contrast imaging as advised by the surgical team.

What are the complications of FJ?

Early complications

  • Bleeding
  • Tube blockage, kinking, displacement, or accidental removal
  • Peritubal leakage
  • Bowel injury
  • Peritonitis due to leakage or dislodgement
  • Wound infection

Late complications

  • Skin excoriation, cellulitis, local abscess
  • Granulation tissue
  • Persistent leak
  • Tube occlusion or migration
  • Small-bowel obstruction, volvulus, intussusception, or rarely bowel ischemia
  • Enterocutaneous fistula after removal
Perioperative complications include bleeding, tube displacement, and leakage causing peritonitis. Later, granulation tissue and local site infection can occur. [Bailey & Love, p. 359]

What are feed-related complications?

  • Diarrhea
  • Abdominal cramps and distension
  • Nausea or vomiting
  • Dehydration
  • Hyperglycemia
  • Electrolyte imbalance
  • Refeeding syndrome in severely malnourished patients
Enteral feeding can cause bloating, vomiting, and diarrhea; rapid introduction of nutrition in chronically malnourished patients can precipitate electrolyte abnormalities and refeeding syndrome. [Bailey & Love, p. 359]

How will you manage a blocked FJ tube?

  • Stop the feed.
  • Check for kinks or external compression.
  • Attempt a gentle water flush using an appropriate syringe, following local protocol.
  • Do not use excessive force, sharp instruments, or unsuitable agents.
  • If blockage persists, inform the surgical/nutrition team for tube replacement or further management.

What will you do if the tube comes out?

  • Stop feeds immediately.
  • Cover the site with a sterile dressing.
  • Assess the patient for pain, leakage, peritonitis, or sepsis.
  • Inform the surgical team urgently.
  • Do not blindly reinsert the tube, especially in a recently created tract, because this can cause intraperitoneal placement and peritonitis.

What are contraindications to jejunal feeding?

  • Mechanical intestinal obstruction distal to the tube
  • Paralytic ileus
  • Bowel ischemia
  • Perforation or generalized peritonitis
  • Severe uncontrolled shock or hemodynamic instability
  • Inadequate functioning small bowel, for example severe short bowel syndrome
Enteral feeding is inappropriate when nutrient absorption is not expected, including in mechanical intestinal obstruction, paralytic ileus, or insufficient functioning bowel. [Bailey & Love, p. 359]

One-line conclusion

“This patient has a feeding jejunostomy for enteral nutritional support. I would ensure that the tube is correctly secured and patent, assess feed tolerance and nutritional status, and actively look for local, mechanical, gastrointestinal, metabolic, and septic complications.”
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