Half of wrist ganglions resolve spontaneously
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.0-f (Published 01 April 2004) Cite this as: BMJ 2004;328:0-f
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Sir,
Your POEM filler in the introductory pages of 3rd April edition is likely
to lead to dangerous conclusions about a common hand condition amongst
casual readers. Its headline reads "Half of all ganglions resolve
spontaneously" and yet the text discusses a form of ganglion which
represents only 18-20% of all such lesions. The 'bottom line' conclusion
again fails to point this out.
This POEM draws upon the evidence of a flawed paper and then suggests
its findings apply to all ganglia. The fact is that patients do not like
these lesions and the commonest dorsal form (60-70%)most definitely causes
discomfort. This is probably through local compressive effects since in my
experience symptoms are closely related to the degree of inflation of the
lesion, waxing & waning in unison. Patients come to hand specialists
seeking removal, and the quoted article by Dias makes it quite clear that
the method of selection of those patients to be managed by masterly
neglect was most certainly not impartial or objective, stating "the
surgeon's preference dictated" whether surgery or observation was chosen
as the method of management.
The case made for non-operative management is further weakened by the
manner of arrival at figures for post-surgical recurrence, said by Dias to
have been 42%. Volar wrist ganglion surgery is challenging and yet is
stated to have been carried out by a mixed bag of "senior and junior
surgeons". Knowing the present state of the NHS, I venture to suggest that
this difficult surgery is likley to have been carried out in most cases by
unsupervised trainees! And yet in proper hands the recurrence rate after
surgery for ganglia is "very low" (Angelides).
Sadly, the bottom line of this POEM is that patients with ganglia
will be mislead by being told "Dont worry Mrs Smith, your painful lump is
likely to do just as well by leaving it alone". And cash strapped local
management will be only too happy to reinforce this unfortunate advice.
Yours sincerely,
Peter Mahaffey FRCS
Consultant Hand Surgeon
Angelides AC, Ganglions of the hand & wrist. In Green DP (Ed)
Green's Operative Hand Surgery 4th Ed New York. Churchill Livingstone 1998
Vol 2 2171-2183
Competing interests:
None declared
Competing interests: No competing interests
Wrist Ganglions
Dear Sir
We are thankful to the British Medical Journal (1) and to Mr Mahaffey (2)
for their opinions on management of wrist ganglions based on our article
(3). Our work on this subject is the biggest prospective study to date in
the English literature and reflects the current realities of clinical
practice in the management of wrist ganglions in the British National
Health Service. The implication, therefore, that the recurrence rates
after ganglion surgery would be much less if the surgery is carrield out
by a senior surgeon will remain hypothetical until the NHS is equipped
with enough resources to provide a truly consultant-based service. Isn't
it high time a meaningful,prospective, randomised study on the management
of wrist ganglions was carried out to enable the physicians and surgeons
to make appropriate decisions to treat this rather common but sometimes
symptomatic and annoying condition ? Perhaps Mr Mahaffey would like to
carry out such a study and then we would really be interested in his
findings. Our study looked specifically at palmar wrist ganglions. The
findings from our study should not be extrapolated to the management of
the dorsal wrist ganglions.
1. POEM. Half of wrist ganglions resolve spontaneously. BMJ 2004;
328. (3 April)
2. Mahaffey P. Advice on ganglion is flawed. BMJ 2004;328 (22 May)
3.Dias J, Buch K. Palmar wrist ganglion;does intervention improve outcome?
A prospective study of natural history and patient-reported treatment
outcomes. J Hand Surg (Br) 2003;2;172-6.
Competing interests:
None declared
Competing interests: No competing interests