|
 
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| CASE REPORT |
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| Year : 2021 | Volume
: 15
| Issue : 2 | Page : 137-146 |
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Homoeopathic management of wrist ganglion: Case series
Arunava Nath1, Deb Kumar Palit2
1 Department of Forensic Medicine and Toxicology, Pratap Chandra Memorial Homoeopathic Hospital and College, Kolkata, West Bengal, India
2 Department of Community Medicine, Pratap Chandra Memorial Homoeopathic Hospital and College, Kolkata, West Bengal, India
| Date of Submission | 15-Apr-2020 |
| Date of Acceptance | 24-May-2021 |
| Date of Web Publication | 29-Jun-2021 |
Correspondence Address:
Dr. Arunava Nath
Department of Forensic Medicine and Toxicology, Pratap Chandra Memorial Homoeopathic Hospital and College, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijrh.ijrh_29_20
Introduction: Ganglion cysts are soft tissue swellings occurring most commonly in the hand or wrist. Studies have reported 8%–50% of them resolve spontaneously in adults within 2 years approximately. Cases Summary: We present three cases of wrist ganglion treated successfully with individualized homoeopathic medicines; the results were evident within few weeks. Individual curative response of a homoeopathic medicine in each case was assessed through Modified Naranjo Criteria for Homoeopathy-Causal Attribution Inventory, which further elucidated role of constitutional treatment in homoeopathy.
Keywords: Individualized homoeopathy, modified Naranjo criteria, Paget's test, transillumination test, wrist ganglion
How to cite this article:
Nath A, Palit DK. Homoeopathic management of wrist ganglion: Case series. Indian J Res Homoeopathy 2021;15:137-46 |
| Introduction | |  |
Ganglion cysts of the wrist and back of the hand have been described by Hippocrates[1] more than two millennia ago. They are benign fluid-filled masses that can arise from joint capsules, tendon sheaths, and bursae.[2] They occur on the dorsal side (70%), or volar side (20%) of wrist and tendon sheath of fingers, toes (6.6%).[3],[4] Some lesser common sites of ganglion cysts include intraneural origin located within the perineurium or epineurium,[5],[6],[7] intraosseous or intratendinous[8] over hip, usually associated with hip disorders.[9] They are three times more prevalent in females than in males and occur mostly between the second and fourth decades of life.[10] A history of trauma is elicited in at least 10% of cases and is considered a causative factor although the pathogenesis remains unclear.[11] Most of the ganglion cysts are asymptomatic besides swelling. The indications for treatment include pain, stiffness, weakness, and cosmetic concern.[12] Surgical excision remains the gold standard for the treatment of ganglion cysts[13] with complication rate range of 0%–56%.[2] The clinical presentation is usually adequate for diagnosis, and X-ray evaluation is rarely indicated (except in the case of “occult wrist ganglion” where magnetic resonance imaging is needed to make a diagnosis).[14] In 2015, a systematic review by Head et al. reported a 76% and 58% reduction in the recurrence of ganglion cyst compared to aspiration in randomized controlled trials and cohort studies, respectively.[15] A search on PubMed database revealed electroacupuncture stimulation of ganglion cyst as a favorable alternative to conservative or surgical treatment though the mechanism was obscure.[16] Patients want treatment modality that would be safe, minimally invasive, less time consuming, having low recurrence, and cost effective.[17]
In §186 of Organon of Medicine, Dr. Samuel Hahnemann has advised the use of active dynamic aid for local maladies resulting from injuries.[18] Banerjea SK has stated that sycosis produces incoordination everywhere, resulting in over-production, growth, and infiltration of tissues.[19] According to Ghatak N, all kinds of tumors and tumors' growths are sycotic.[20] Roberts HA has opinionated stiffness, soreness, lameness and slowness of recovery as the characteristics of sycotic manifestations. He has advocated sycotic patient to take meat sparingly, and it is better for him to use nuts, beans, or cheese more freely.[21] Homoeopathic medicines such as Benzoicum acidum 3x ointment as an external adjunct along with the internal administration of the drug in high dilution are reported to be indicative in cases of ganglion.[22],[23] Calcarea fluor and Ruta 3x are indicated in ganglia or encysted tumors of the wrist. Clarke JH has recommended Sulphur for ganglion of the wrist given on general indications.[23] Ray T described four cases of wrist ganglion treated with Bacillinum in different potencies with favorable results. Susceptibility, past history and family history of the cases were given importance for selection of the remedy. He further stated that ganglion was a symptom of tubercular diathesis from the blending of two miasms, namely psora and sycosis.[24] Central Council for Research in Homoeopathy has initiated an efficacy trial (protocol published in 2019) of individualized homoeopathy (IH) in cases of wrist ganglion which is going on and outcomes yet to be published.[25]
Here, we have presented three cases suffering from wrist ganglion treated with individualized homoeopathy IH and the results were evident within few weeks.
| Case Reports | | |
Case 1
A 10-year-old girl visited the Out Patient Department (OPD) of Pratap Chandra Memorial Homoeopathic Hospital and College (PCMHH&C) on August 27, 2019, complaining of swelling on the dorsal aspect of left wrist for the past 2 months which was gradually increasing in size. The swelling was slightly painful which was aggravated on any motion of the hand. There was no history of trauma. She visited a surgeon who recommended surgical treatment. Her mother also informed that she was suffering from diminished appetite for the past 6 months.
Past history
In the past, she had suffered from malarial fever at the age of 6 years, took allopathic treatment and recovered. She also suffered from typhoid fever at the age of 7 years, took homoeopathic treatment and recovered.
Family history
Her father was hypertensive; mother suffered from hypothyroidism.
Mind symptoms
Patient desired for company and was averse to bathing.
Physical generals
Patient's appetite was poor, and thirst was moderate. The tongue was moist and thinly white coated. There were craving for sweets and desire for meat. There was strong aversion to milk and no significant intolerance of any food item. Stool was constipated, hard, passed at 2–3-days interval, with much difficulty. Urine was clear and occasionally offensive. Sweating was moderate but offensive, particularly in palms and soles. Sleep duration was 6–7 h daily, with dreams which she didn't remember. Thermally, she was very sensitive to cold temperature.
General survey
The patient was conscious, alert, and cooperative. Clinically, mild pallor was observed; cyanosis, edema, jaundice, or clubbing not detected. She was thin built and her weight was 27 kg.
On examination
Soft cystic swelling was felt underneath the skin of dorsum of left wrist which was painful on pressure, not adhered to the skin. The dimension of the swelling was 9 mm (craniocaudal) ×8 mm (mediolateral). Paget's test and transillumination tests were positive.
Diagnosis
The diagnosis was made by history and physical examination [Figure 1]a, pretreatment].
The symptoms considered for the analysis and evaluation of the case were as follows:
- Patient desired for company
- Had aversion to bathing
- Appetite was poor
- Desire for sweets
- Aversion to milk
- Constipated, passage of hard stool at 2–3-day interval
- Sweating was offensive
- Thermally, she was very chilly
- Swelling on the dorsal aspect of left wrist
Repertorization and remedial analysis
Repertorium Homeopathicum Syntheticum (Edition 9.1) was consulted as the case presented with characteristic mind and physical symptoms. Sulphur (19/9), Rhus toxicodendron (16/9) Phosphorus (21/8), Silicea terra (17/8) and Carbo vegetabilis (15/8) were the medicines in the top gradation. Sulphur covered all the symptoms with highest gradation [Figure 2].
Remedy selection and administration
Sulphur 30c one medicated globule number 20 was dispensed in 10 ml of distilled water, the whole quantity to be taken once in early morning in empty stomach. This single dose was followed by Liquid placebo (LPL) once daily, early morning in empty stomach for 14 subsequent days.
Investigations advised
Complete blood count (CBC); stool for ova, parasites, and cyst to rule out any chronic inflammatory process and worm infestations.
She was also advised to maintain proper hygiene, have balanced and fiber-rich diet, and avoid excessive movements of the hand.
Follow-up and outcome
Follow-ups were done at 2-week intervals. Marked changes in symptomatology were elicited at the end of treatment [Figure 1]b. Although the cystic swelling became impalpable after 5 weeks, the treatment was continued for 3 months to address any recurrence of old complaints or any new complaints [Table 1]. The causal attribution was ascertained through modified Naranjo criteria. [Table 2]. | Table 2: Case 1, assessment of the case according to Modified Naranjo criteria for homeopathy inventory
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Case 2
Another case of 21-year-old girl visited the OPD of PCMHH&C on May 07, 2019, and complained of swelling on the dorsal aspect of right wrist for the past 3 months which was gradually increasing in size. The swelling was asymptomatic in the beginning but later became painful on deep pressing. She did not report of any other ailment. She had taken homoeopathic medicines earlier for treatment of the swelling but could not provide the prescription.
Past history
She suffered from typhoid fever at the age of 17 years, took allopathic treatment and recovered. She also suffered from dengue fever at the age of 19 years, took homoeopathic treatment and recovered.
Family history
Her father was hypertensive; mother suffered from hypothyroidism.
Mind symptoms
Irritable, fear of dogs.
Physical generals
Her appetite was good and thirst was profuse. The tongue was moist and clean. There were desire for eggs and craving for sweets. No specific food intolerance or aversion was there. Stool was constipated, hard, passed at 2–3-day interval with much difficulty. Sweating was moderate and offensive, particularly in the head and neck. Sleep was good, with dreams of falling from heights occasionally. Her menstrual cycle was regular, flow lasting for 4 days with no associated complaints. Thermally, she was very sensitive to cold temperature.
General survey
The patient was conscious, alert, and cooperative. Clinically, no pallor, cyanosis, edema, jaundice, or clubbing detected. Her weight was 54 kg. Blood pressure was 120/80 mmHg.
On examination
A soft cystic swelling underneath the skin of dorsum of right wrist was observed which was painful on deep pressure, not adhered to the skin. The dimension of the swelling was 14 mm (craniocaudal) ×9 mm (mediolateral). Paget's test and transillumination tests were positive.
Diagnosis
The diagnosis was made by history and physical examination [Figure 3]a, pretreatment].
The symptoms considered for the analysis and evaluation of the case were as follows:
- Patient was irritable
- She was fearful of dogs
- Appetite was good
- Thirst profuse
- Desire for eggs and sweets
- Constipated: hard stool at 2–3-day interval which passed with much difficulty
- Sweating was offensive
- Dreams of falling from heights
- Thermally, she was very chilly
- Swelling on the dorsal aspect of right wrist.
Repertorization and remedial analysis
Repertorium Homeopathicum Syntheticum (Edition 9.1) was consulted as the case presented with characteristic mind and physical symptoms. Sulphur (25/11), Phosphorus (23/11) Calcarea carbonica (21/10), Silicea terra (19/10) and Belladonna (17/10) were the medicines in the top gradation. Sulphur covered all the symptoms with highest gradation [Figure 4].
Remedial selection and administration
Sulphur 30c one medicated globule number 20 was dispensed in 10 ml distilled water, the whole quantity to be taken once in early morning in empty stomach, followed by LPL once daily, early morning in empty stomach for 14 subsequent days.
Advice
She was also advised to maintain proper hygiene, have balanced and fiber-rich diet, and avoid excessive movements of the hand.
Follow-up and outcome
Follow-ups were done at 2-week intervals. Marked changes in symptomatology were elicited at the end of treatment [Figure 3]b. Although the cystic swelling became impalpable after 3 months, the treatment was continued for nearly 4½ months to address any recurrence of old complaints or any new complaints [Table 3]. The causal attribution was ascertained through modified Naranjo criteria. [Table 4]. | Table 4: Case 2, assessment of the case according to Modified Naranjo criteria for homeopathy inventory
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Case 3
A 16-year-old boy visited the OPD of PCMHH&C on March 26, 2019, complaining of swelling on the ventral aspect of left wrist for the past 1 month which was gradually increasing in size. The swelling was slightly painful, aggravated with any motion of the hand. He had not sought for any treatment before the present consultation.
Past history
The patient had suffered from malarial fever at the age of 10 years, took allopathic treatment and recovered. He also suffered from dengue fever at the age of 7 years, took homoeopathic treatment and recovered.
Family history
His father was diabetic. Mother suffered from some cardiac ailments.
Mind symptoms
Patient desired for company. He was fearful of dogs. There was dread of thunderstorm.
Physical generals
Appetite was average. The tongue was moist and clean. Thirst was moderate. There was craving for salt and desire for meat and fish. There was strong aversion to sweets and intolerance to sour. The patient complained of occasional mucoid stool. Urine was clear. Sweating was profuse and offensive, stained white. Sleep was good, with dreams which were not remembered. Thermally, he was very sensitive to cold temperature.
General survey
The patient was conscious, alert, and cooperative. He was thinly built. Clinically no anemia, cyanosis, edema, jaundice, or clubbing detected. His weight was 39 kg.
On examination
Soft cystic swelling was felt underneath the skin of ventral aspect of left wrist, which was painful on pressure, not adhered to the skin. The dimension of the swelling was 13 mm (craniocaudal) ×8 mm (mediolateral). Paget's test and transillumination tests were positive.
Diagnosis
The diagnosis was made by history and physical examination [Figure 5]a, pretreatment].
The symptoms considered for the analysis and evaluation of the case were as follows:
- Patient desired for company
- He was fearful of dogs
- There was dread of thunderstorm
- Desire for salt
- Aversion to sweets
- Intolerance to sour
- Occasional mucoid stool
- Sweating was profuse and offensive
- Thermally, he was very chilly
- Swelling on the ventral aspect of left wrist.
Repertorization and remedial analysis
Repertorium Homeopathicum Syntheticum (Edition 9.1) was consulted as the case presented with characteristic mind and physical symptoms. Phosphorus (28/11), Sulphur (19/11) Calcarea carbonica (17/10), Causticum (17/10) and Silicea terra (17/10) were the medicines in the top gradation. Phosphorus covered all the symptoms with highest gradation [Figure 6].
Remedial selection and administration
Phosphorus 30c one medicated globule number 20 was dispensed in 10 ml distilled water, the whole quantity to be taken in early morning in empty stomach for 1 day. LPL once daily, early morning in empty stomach for 14 subsequent days, was also given.
Advice
CBC, stool for routine and microscopical examination were advised to rule out any intestinal infections. Also advised to maintain proper hygiene, have balanced diet, and avoid excessive movement of the hand.
Follow-up and outcome
Follow-ups were done at 2-week intervals. Marked changes in symptomatology were elicited at the end of treatment [Figure 5]b. Although the cystic swelling became impalpable after 2 months, the treatment was continued for more than 4 months to address any recurrence of old complaints or any new complaints [Table 5]. The causal attribution was ascertained through modified Naranjo criteria [Table 6]. | Table 6: Case 3, assessment of the case according to Modified Naranjo criteria for homeopathy inventory
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Reporting of adverse events
The patients were advised to report any adverse or untoward medical events after the administration of IH during their treatment period. Chances of medicinal aggravation were averted by prescribing minimum doses in the three cases. Had there been still any unfavorable event(s), antidoting or change of plan of treatment could have been adopted as per suitability of the case(s). However, no of such adverse events were reported.
| Discussion | | |
We have presented three case reports of ganglion over dorsal aspects of left and right wrist and over volar aspect of left wrist with encouraging outcomes. The cases were diagnosed based on history and physical examination. While prescribing we consulted homoeopathic materia medica and keeping in view the dominating miasm in each case, the medicines were prescribed. As the post-treatment findings revealed reduction of the sizes of the swelling were reduced in all the three cases [Figure 1]b, [Figure 3]b and [Figure 5]b, posttreatment findings]. The individual curative response of a homoeopathic medicine was assessed through Modified Naranjo Criteria for Homoeopathy (MONARCH) Inventory.[26] The total scores were 10 for all the 3 cases thus suggesting a “definite” association between the medicine and the outcome (definite ≥9; probable 5–8; possible 1–4; and doubtful ≤0) [Table 2], [Table 4] and [Table 6]. Reporting of the cases adhered to the HOM-CASE-CARE guidelines.[27]
Although history of trauma is considered to be one of the causative factors behind wrist ganglion, none of these three cases had such a history. Symptomatic cases are managed with either painful or surgical maneuvers in standard therapy, but we treated with IH with a positive clinical outcome in the most rapid and gentle manner.
We treated the three cases on the basis of totality of symptoms and susceptibility.[28] Out of three cases, two cases were treated with Sulphur whose reference we find in homeopathic literature.[23] The third case was treated with Phosphorus whose characteristic modalities in the treatment of wrist ganglion we were unable to find. Both the remedies are mainly antipsoric, but have antisycotic properties as evident from homoeopathic literature.[29],[30],[31] The presented cases had different sites of cystic manifestations and were treated based on homoeopathic principles. They were evidence based from pre and post-treatment physical findings. We waited for few more weeks and asked patients to report if there was recurrence of any old or new complaints. The patients in the cases presented were from the second and third decade of life as corroborated from age-wise distribution.[32] The other comorbid conditions involving both the mental and physical planes such as irritability, appetite, thirst, and consistency of the stool were addressed with the same individualized medicines. At the end of the treatment, the patients reported to be better.
A case series reporting only of three cases is, however, though inadequate to infer definite efficacy of homoeopathy in wrist ganglion, for which further controlled trials are warranted. The diagnosis and prognosis of the cases were done based on the clinical findings; and advanced imaging techniques were not used due to limited resources. In future, controlled trials can be implemented with methodological rigors and sound imaging techniques with adequate sample size, which will further validate our results. Further, studies may also include cases of ganglia located at different sites of the body, treated with individualized medicines. Even changes of the ganglion cystic swelling during treatment can be assessed from histopathological point of view.
| Conclusion | | |
The outcome of the treatment based on IH was favorable. We considered the physical nature of the swelling along with pain as prognostic indicators. The size of the swelling and the pain manifestations reduced significantly with treatment. MONARCH inventory scores were 10 for all the 3 cases which suggested a “definite” causal attribution between the medicine and the outcome.
Declaration of patient consent
The authors certify that they have obtained appropriate patient consent form. Two of the patients were minor so assents were given by them and consents were given by their respective guardians. In the form, the patients have expressed their willingness and agreed that their images and other clinical information to be reported in the journal. The patients have understood that their names and initials are not included in the manuscript and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgment
The authors deeply acknowledge the institutional head of PCMHH&C for allowing us to collect data for the case reports. We gratefully acknowledge the active cooperation and participation made by the patients and the supporting staffs.
Financial support and sponsorship
Nil.
Conflicts of interest
None declared.
| References | | |
| 1. | Domenicucci M, Ramieri A, Marruzzo D, Missori P, Miscusi M, Tarantino R, 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;8:697-704.  |
| 2. | Angelides AC, Wallace PF. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am 1976;1:228-35. |
| 3. | Westbrook AP, Stephen AB, Oni J, Davis TR. Ganglia: The patient's perception. J Hand Surg Br 2000;25:566-7. |
| 4. | Weishaupt D, Schweitzer ME, Morrison WB, Haims AH, Wapner K, Kahn M. MRI of the foot and ankle: Prevalence and distribution of occult and palpable ganglia. J Magn Reson Imaging 2001;14:464-71. |
| 5. | Spinner RJ, Carmichael SW, Atkinson JL. Intraneural ganglion cyst. J Neurosurg 2006;104:990-2. |
| 6. | Swartz KR, Wilson D, Boland M, Fee DB. Proximal sciatic nerve intraneural ganglion cyst. Case Rep Med 2009;2009:810973. |
| 7. | Colbert SH, Le MH. Case report: Intraneural ganglion cyst of the ulnar nerve at the wrist. Hand (N Y) 2011;6:317-20. |
| 8. | Greendyke SD, Wilson M, Shepler TR. Anterior wrist ganglia from the scaphotrapezial joint. J Hand Surg Am 1992;17:487-90. |
| 9. | Burnett RA, Westermann R, Bedard N, Liu S, Callaghan JJ. Ganglion cyst as a rare complication of hip arthroscopy resolved with THA: A case report. Iowa Orthop J 2018;38:87-91. |
| 10. | Thornburg LE. Ganglions of the hand and wrist. J Am Acad Orthop Surg 1999;7:231-8. |
| 11. | 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 Br 2005;30:302-6. |
| 12. | Head L, Allen M, Boyd KU. Long-term outcomes and patient satisfaction following wrist ganglion aspiration. Plast Surg (Oakv) 2015;23:51-3. |
| 13. | Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7-12. |
| 14. | Gude W, Morelli V. Ganglion cysts of the wrist: Pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med 2008;1:205-11. |
| 15. | Head L, Gencarelli JR, Allen M, Boyd KU. Wrist ganglion treatment: Systematic review and meta-analysis. J Hand Surg 2015;40:546-53. |
| 16. | Tekeoğlu I, Doğan A. Electroacupuncture in the treatment of a ganglion of the wrist-A case report. Acupunct Med 2006;24:29-32. |
| 17. | Mohan SM, Mohan BK, Lal KH, Mohan SS. Management of wrist ganglia by transfixation technique: Our experience in a rural teaching institution. J Evol Med Dent Sci 2014;3:6781-9. |
| 18. | Singh M, Singh S. First Corrected, Re-Translated and Redacted Edition of Organon of Medicine with Word Meanings below Each Aphorisms 6 th and 5 th Editions by Samuel Hahnemann. 2 nd ed. Kolkata: Homoeopathic Publications; 2015. |
| 19. | Banerjea SK. Miasmatic Prescribing. New Delhi: B. Jain Publishers (P) Ltd.; 2010. |
| 20. | Ghatak N. Chronic Disease-Its Cause and Cure. Sasaram: World Homoeopathic Links;1931. |
| 21. | Roberts HA. The Principles of Art and Cure by Homoeopathy-A Modern Textbook. 3 rd ed. New Delhi: B Jain Publishers (P) Ltd.;2007. |
| 22. | Hughes R. The Principles and Practice of Homoeopathy. Reprint ed. New Delhi: B Jain Publishers (P) Ltd.; 2004. |
| 23. | Murphy R. Lotus Materia Medica. 3 rd ed. New Delhi: B. Jain Publishers (P) Ltd.; 2010. |
| 24. | Ray T. A clinical symptom of Bacillinum. The Hahnemannian Gleanings 1985;52:321-2. |
| 25. | Central Council for Research in Homoeopathy. Protocol for efficacy of individualised homoeopathic medicine in cases of wrist ganglion: A prospective, parallel arm, randomised, double-blind, placebo-controlled trial. Indian J Res Homoeopathy 2019;13:118-24. [Full text] |
| 26. | Lamba CD, Gupta VK, Haselen RV, Rutten L, Mahajan N, Molla AM, et al. Evaluation of the modified naranjo criteria for assessing causal attribution of clinical outcome to homeopathic intervention as presented in case reports. Homeopathy 2020;109:191-7. |
| 27. | van Haselen RA. Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline. Complement Ther Med 2016;25:78-85. |
| 28. | Close S. The Genius of Homoeopathy. Reprint ed. New Delhi: Indian Books and Periodicals Publishers; 2001. |
| 29. | Dubey SK. Textbook of Materia Medica. Millennium ed. Calcutta: Books and Allied (P) Ltd.; 2000. |
| 30. | Kent JT. Repertory of the Homoeopathic Materia Medica. 4 th ed. Calcutta: Economic Homoeo Pharmacy; 1982. |
| 31. | Schroyens F. SYNTHESIS Repertorium Homoeopathicum Syntheticum the Source Repertory. 9.1 ed. New Delhi: B. Jain Publishers (P) Ltd.; 2011. |
| 32. | Arora B. A loop suture technique in treatment of wrist and ankle ganglion. Indian J Appl Res 2016;6:441-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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