Excision of a Ganglion Cyst from Distal Middle Finger Near Nail Bed

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.