Excision of a Ganglion Cyst from Distal Middle Finger Near Nail Bed
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Ganglion cysts (GCs) are common benign soft tissue tumors that frequently occur in the hand and wrist region.1 These mucoid cysts, when presenting near the nail bed of digits, are specifically termed digital mucous cysts (DMCs). These lesions typically originate from the distal interphalangeal (DIP) joint and can cause significant functional impairment and cosmetic concerns for affected individuals.2
The prevalence of GCs is estimated to be between 40 and 50 cases per 100,000 population, with DMCs representing approximately 10–15% of all hand-related GCs.2–5 These lesions are more commonly observed in females. When occurring near the nail bed, these cysts can lead to significant nail plate deformities due to pressure effects on the germinal matrix.
While conservative management remains the initial approach for many patients, surgical intervention becomes necessary in cases where patients experience persistent pain, recurrent drainage, nail plate deformities, functional impairment, or cosmetic concerns that impact quality of life.6,7
The surgical excision of GCs near the nail bed requires precise technique and a thorough understanding of the anatomical relationships to prevent recurrence and minimize complications. This case report describes the surgical management of a GC located on the distal phalanx of the middle finger near the nail bed. The surgical procedure was performed under local anesthesia with careful dissection to remove the cyst while preserving the surrounding nail matrix and digital nerve structures. A digital block was administered with 1% lidocaine. Approximately 3–4 ml is injected on either side of the flexor tendon sheath to block the digital nerves and another 3–4 ml on the dorsal aspect of the hand to block the dorsal sensory nerves. Complete digital anaesthesia is achieved within 5 minutes.
Following the standard sterile technique, the operative field was thoroughly prepared and draped. A finger tourniquet was carefully applied at the base of the digit to establish a bloodless surgical field. This step is essential for maintaining optimal visualization during the dissection phase and identifying critical anatomical structures.
A vertical incision was made directly over the visible cyst, following which careful subdermal dissection was performed. The dissection required particular attention to identify and separate the cyst wall, as rupture of this thin walled cyst is common during dissection. The dissection proceeded to the level of the distal joint, allowing identification of normal tissue planes before proceeding distally to fully expose the cyst wall.
Due to the cyst's location near the germinal matrix, special care was taken since it had caused nail deformity. The entire cyst was removed, including its pedicle to the distal joint. Hemostasis was obtained in this highly vascular area prior to closure.
The surgical site was closed using 6-0 absorbable sutures, with attention to anatomical reconstruction of the proximal nail fold to facilitate optimal nail plate regeneration. This choice of suture material eliminates the need for suture removal while providing adequate wound support during the healing phase. Postoperative management includes restricted finger movement for approximately 10 days to facilitate proper healing, followed by a gradual return to unrestricted hand use. Regular follow-up enables monitoring of wound healing and early identification of any potential complications.
This surgical approach is particularly relevant for hand surgeons and orthopaedic specialists performing similar procedures. This case report highlights the importance of proper surgical techniques in the management of DMCs, particularly those affecting the nail bed region. The procedure demonstrates several key principles that are essential for successful outcomes, including the necessity of complete cyst excision to prevent recurrence, the importance of careful dissection near the germinal matrix to prevent permanent nail deformity, the value of a bloodless surgical field in maintaining precise visualization, and the significance of proper wound closure technique in ensuring optimal aesthetic and functional outcomes.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Minotti P, Taras JS. Ganglion cysts of the wrist. J Am Soc Surg Hand. 2002;2(2). doi:10.1053/jssh.2002.33318.
- Gude W, Morelli V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008;1(3-4). doi:10.1007/s12178-008-9033-4.
- Lowden CM, Attiah M, Garvin G, MacDermid JC, Osman S, Faber KJ. The prevalence of wrist ganglia in an asymptomatic population: magnetic resonance evaluation. J Hand Surg. 2005;30(3). doi:10.1016/j.jhsb.2005.02.012.
- Domenicucci M, Ramieri A, Marruzzo D, et al. Lumbar ganglion cyst: nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review. World J Orthop. 2017;8(9). doi:10.5312/wjo.v8.i9.697.
- Meena S, Gupta A. Dorsal wrist ganglion: current review of literature. J Clin Orthop Trauma. 2014;5(2). doi:10.1016/j.jcot.2014.01.006.
- Shanks C, Schaeffer T, Falk DP, et al. The efficacy of nonsurgical and surgical interventions in the treatment of pediatric wrist ganglion cysts. J Hand Surg. 2022;47(4). doi:10.1016/j.jhsa.2021.12.005.
- Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN Orthop. 2013 May 28;2013:940615. doi:10.1155/2013/940615.
Cite this article
Sudhir Rao. Excision of a ganglion cyst from distal middle finger near nail bed. J Med Insight. 2025;2025(495). https://doi.org/10.24296/jomi/495Procedure Outline
Table of Contents
Transcription
CHAPTER 1
Hi, my name is Sudhir Rao. I'm an orthopaedic surgeon. I'm going to talk about a case that was just recorded. This is a patient with a mucus cyst or a ganglion cyst in the middle finger. This is a fairly common condition. Most people do not need surgery, but some request that the cyst be excised. This patient had pain and recurrent drainage from the cyst. In addition, he also had a deformity of the nail plate. So, I will describe the procedure as recorded in the video. This patient was operated under local anesthesia. I anesthetized the digit with 1% lidocaine, and after we prepped and drape the patient, we applied a tourniquet to the base of the digit. This is important because you don't want bleeding during the surgery. Once the tourniquet is applied, I made a vertical incision directly overlying the visible cyst. And it was really important to dissect at the subdermal level because the cyst is right underneath the skin and the wall of the cyst is adherent to the skin. And more often than not, you'll up rupturing the cyst when you raise your skin flaps. Nevertheless, if you see, I dissected proximal to the cyst, to the level of the distal joint. This way I was able to identify normal tissue and then dissect distally to expose the wall of the cyst. Many of these cysts arise from the distal joint and they have a small pedicle, and it's important to identify this pedicle, and excise the entire mass. In this instance, the cyst was very close to the germinal matrix of the nail, and this caused pressure on the germinal matrix and a resulting deformity of the nail plate. As you see, the entire cyst was excised and this being a very vascular area, it is really important to achieve hemostasis before you close the skin. The skin was repaired with 6-0 absorbable Monocryl sutures. It is necessary to reconstitute the proximal nail fold so it heals adequately, and the nail regenerates in a perfect manner. After surgery, I usually restrict excessive finger movement for about 10 days to allow healing, and after that they have unrestricted use of the hand.
CHAPTER 2
All right, so I'm just going to anesthetize the finger with a lidocaine block. This is 1% lidocaine. You're gonna feel a little poke on your hand, okay? Okay. Okay. One little poke. We doing good? Mm-hm. All right. We'll flip your hand over. This one hurts just a little bit more, okay? Okay. One poke in your palm. So usually I will put about 5 cc on either side of the finger. You have a finger tourniquet, right? Yeah. Okay. Another little poke. That finger should start getting numb in the next five minutes. What we are gonna do is get your hand cleaned up and ready to go. Okay.
CHAPTER 3
So lay your hand down. Just relax and think about something nice.
CHAPTER 4
All right, so this is a ganglion cyst or a mucous cyst near the nail fold. It usually arises from the distal joint of the finger. We're gonna put a tourniquet on the base of the finger. Are you feeling anything. Good. So just relax and enjoy the ride, okay? Just have a med cup. Don't tense your hand, just relax. Thank you. Show me a marking pen.
CHAPTER 5
You put a roll under his hand there. What's that? You wanna put a roll under there so we can...? Yeah, you can. Yeah. So hand me a 15. I need both my pickups. And let's have the double hooks. So this ganglion is very superficial, and as soon as I make the incision, you can see some of that gelatinous stuff coming out. That's the material from the ganglion cyst. We want to try and isolate the cyst itself so the dissection becomes extremely superficial. 15 back.
CHAPTER 6
Steady the finger. Let me have you hold this. So I'm dissecting right beneath the dermis. And right there is the ganglion.
CHAPTER 7
Where it probably has a tail that goes further towards the joint. So that's where I'm dissecting. So unless we remove the whole thing, it can come back. Steve? Yes, sir. Can you have them get some 6-0 Monocryl. We actually may have some here. We got it for the last case.
CHAPTER 8
I do. Yeah. So I'm just gonna remove this whole thing. Now because that ganglion sits right on the nail bed, it often leads to a deformity of the nail. And I don't know if you guys can see that, but there's a hollow depression out there, and that's from that ganglion causing pressure on that nail bed. And the root of the ganglion went right all the way up to the distal joint of the finger. I think we've removed everything.
CHAPTER 9
Now this is a very vascular area so I'm gonna cauterize as much as we can. Let's open that Monocryl. Can you gimme the Monocryl? 6-0? Yep.
CHAPTER 10
You sending this? No. Now the other thing I'm gonna do is the wall of the cyst was extremely thin, so I'm gonna remove a little piece of the skin right there. So when we suture this up, we have healthy tissue, and we will also reconstitute that nail fold the way it's supposed to be. I'll take the 6-0. And we are gonna use very fine absorbable sutures. Go ahead and cut that. 6-0 Monocryl. Go ahead and steady that finger. Do you have a wet sponge? Let's leave a small tail. I usually use 4-0 or 5-0 nylon for closure. But sometimes it helps to use absorbable sutures near the nail so you don't have to remove them at a later time. Steve, do you wanna count? Absolutely. We'll use some two-inch Coban for dressings. Two-inch Coban. Ray-Tecs - one, two, three. Four, five, six, seven, eight, nine, ten. One suture up, two and three. Three sutures correct. Blades one, two. Two blades, count is correct. Looking hard to see with that clear cup. Yeah.
CHAPTER 11
Let me just have the Mayo scissors. Most important part of the operation is to make sure the tourniquet is off the finger.
CHAPTER 12
I usually hold pressure for a couple minutes to make sure it's not bleeding. We are all done. You can relax. That's the ganglion with its pedicle. All right, let's get some Vaseline. Yeah, you have more? We have... Big sticker coming off. Okay. Open that up. Okay. So I'm gonna wrap two fingers together. Okay. Just because it's easier to wrap two than one. Sounds good. But you can unwrap that after 48 hours, and just put a... 48 hours? Okay. Yeah. Okay, cut that off. So after 48 hours you can remove this. Just cover it with a couple Band-Aids. That's all you need. Okay. Go easy on that finger. Don't move it too much. Okay.