What are ganglion cysts. How do they form on the hand and wrist. What symptoms do ganglion cysts cause. How are ganglion cysts diagnosed and treated. When is surgery necessary for ganglion cysts.

Understanding Ganglion Cysts: Common Hand and Wrist Lumps

Ganglion cysts are the most prevalent masses or lumps found in the hand. These non-cancerous, typically harmless growths can appear in various locations, with the back of the wrist being the most common site. Characterized by their fluid-filled nature, ganglion cysts have the peculiar ability to appear suddenly, change size, and even disappear on their own.

While many ganglion cysts don’t require treatment, intervention may be necessary if the cyst causes pain, affects function, or creates cosmetic concerns. Understanding the nature of these cysts is crucial for anyone experiencing such growths or working in healthcare fields related to hand and wrist conditions.

The Anatomy and Formation of Ganglion Cysts

Ganglion cysts emerge from joint tissues, resembling balloons on stalks. They develop from tissues surrounding joints, including:

• Ligaments
• Tendon sheaths
• Joint linings

Inside these balloon-like structures is a thick, slippery fluid similar to the lubricant found in joints. This composition allows the cysts to change size and shape over time.

Common Locations for Ganglion Cysts

While the back of the wrist is the most frequent site for ganglion cysts, they can develop in several areas of the hand and wrist:

• Top and underside of the wrist
• End joint of a finger
• Base of a finger

The size of these cysts can vary, often growing larger with increased activity and shrinking with rest. This dynamic nature is one of the defining characteristics of ganglion cysts.

Causes and Risk Factors for Ganglion Cyst Development

The exact trigger for ganglion cyst formation remains unknown. However, several factors have been associated with their development:

• Age: Most common in individuals between 15 and 40 years old
• Gender: Women are more likely to be affected than men
• Activity: Frequent among gymnasts due to repeated wrist stress
• Joint condition: Mucous cysts (a type of ganglion cyst) at fingertip joints are often associated with arthritis

Are certain professions more prone to developing ganglion cysts? While specific occupations haven’t been definitively linked to increased risk, activities that involve repetitive wrist movements or place stress on the hands may contribute to cyst formation. This includes professions such as typists, musicians, and manual laborers.

Identifying Symptoms and Characteristics of Ganglion Cysts

Ganglion cysts present with various symptoms and characteristics, making their identification crucial for proper diagnosis and treatment:

• Visible lump: Most ganglions form a noticeable mass on the affected area
• Hidden cysts: Smaller ganglions may remain under the skin (occult ganglions)
• Pain and discomfort: If the cyst presses on nearby nerves
• Tingling and muscle weakness: Possible in cases of nerve compression
• Cosmetic concerns: Even painless cysts may cause anxiety due to appearance

Can ganglion cysts cause long-term damage if left untreated? In most cases, ganglion cysts do not cause permanent damage. However, if a cyst is pressing on a nerve, prolonged pressure could potentially lead to chronic pain or weakness in the affected area. It’s always best to have any persistent lump evaluated by a healthcare professional.

Diagnostic Procedures for Ganglion Cysts

Accurate diagnosis of ganglion cysts involves a combination of medical history, physical examination, and sometimes imaging tests:

Medical History and Physical Examination

During the initial appointment, your doctor will gather information about your symptoms and conduct a physical examination. Key questions may include:

• Duration of the cyst’s presence
• Changes in size over time
• Presence of pain or discomfort

The physical examination may involve applying pressure to the cyst to assess tenderness. Doctors often use a penlight to check the cyst’s translucency, which can help differentiate it from solid tumors.

Imaging Tests for Confirmation

While not always necessary, imaging tests can provide additional information:

• X-rays: Used to rule out other conditions like arthritis or bone tumors
• MRI scans: Provide detailed images of soft tissues, helpful for identifying occult ganglions
• Ultrasounds: Offer real-time imaging of the cyst and surrounding structures

How accurate are these diagnostic methods for ganglion cysts? When combined, these diagnostic approaches are highly accurate. Physical examination by an experienced healthcare provider can often diagnose ganglion cysts with confidence. Imaging tests, particularly MRI and ultrasound, can confirm the diagnosis with near certainty and provide additional information about the cyst’s exact location and relationship to surrounding structures.

Non-Surgical Treatment Options for Ganglion Cysts

Initial treatment for ganglion cysts is typically non-surgical, focusing on managing symptoms and potentially reducing the size of the cyst:

Observation

If the cyst causes no pain or other symptoms, your doctor may recommend a wait-and-watch approach. This is often safe as ganglions are not cancerous and may disappear on their own over time.

Immobilization

Since activity can cause the ganglion to increase in size, immobilization may help:

• Wrist brace or splint to limit movement
• Potential reduction in cyst size and pain
• Prescribed exercises for strengthening and improving range of motion as symptoms improve

Aspiration

For painful or activity-limiting cysts, fluid drainage (aspiration) may be recommended:

• Area around the cyst is numbed
• Cyst is punctured with a needle to withdraw fluid
• More effective for cysts on the top of the wrist
• Caution required for palm-side wrist cysts due to proximity to major vessels and nerves

What is the success rate of aspiration for ganglion cysts? While aspiration can provide immediate relief, it often fails to eliminate the ganglion permanently. The success rate varies, but studies suggest that up to 50% of ganglion cysts may recur after aspiration. This is because the procedure doesn’t remove the cyst’s root or its connection to the joint or tendon sheath.

Surgical Interventions for Persistent Ganglion Cysts

When non-surgical treatments fail to resolve a ganglion cyst or if the cyst returns after aspiration, surgical intervention may be considered. The primary surgical approach for ganglion cysts is excision, which involves removing the entire cyst along with its stalk.

Open Surgery

Traditional open surgery for ganglion cyst removal involves:

• Making an incision over the site of the cyst
• Carefully dissecting the cyst from surrounding tissues
• Removing the cyst along with its stalk and a portion of the joint capsule or tendon sheath
• Closing the incision with sutures

Arthroscopic Surgery

For some ganglion cysts, particularly those on the wrist, arthroscopic surgery may be an option:

• Involves smaller incisions
• Uses a tiny camera (arthroscope) and specialized instruments
• May result in faster recovery and less scarring
• Not suitable for all types of ganglion cysts

What are the success rates and potential complications of surgical removal? Surgical excision of ganglion cysts has a higher success rate compared to aspiration, with recurrence rates typically under 20%. However, like any surgery, it carries risks such as infection, scarring, and potential damage to surrounding structures. In rare cases, surgery may lead to stiffness or reduced range of motion in the affected joint.

Recovery and Rehabilitation After Ganglion Cyst Treatment

The recovery process following ganglion cyst treatment varies depending on the method used:

After Aspiration

• Minimal recovery time needed
• Patients can usually resume normal activities immediately
• A compression wrap may be recommended for a short period

Post-Surgical Recovery

Recovery after surgical excision is more involved:

• Initial healing period of 2-6 weeks
• Stitches typically removed after 1-2 weeks
• Splint or brace may be required for protection
• Gradual return to activities as advised by the surgeon

Rehabilitation

Rehabilitation may be necessary, especially after surgery:

• Exercises to restore strength and flexibility
• Hand therapy to improve function and reduce stiffness
• Gradual return to normal activities and sports

How long does it typically take to fully recover from ganglion cyst surgery? Full recovery time can vary from a few weeks to several months, depending on the location and size of the cyst, as well as the individual’s healing rate. Most patients can return to light activities within 2-4 weeks, with a gradual increase in activity levels. Complete recovery, including return to sports or strenuous activities, may take 4-6 weeks or longer.

Prevention and Long-Term Management of Ganglion Cysts

While it’s not always possible to prevent ganglion cysts, certain measures may help reduce the risk of their formation or recurrence:

Preventive Strategies

• Avoiding repetitive wrist and hand movements
• Using proper ergonomics when working with hands
• Strengthening exercises for wrists and hands
• Wearing protective gear during high-risk activities

Long-Term Management

For individuals prone to ganglion cysts or those who have had previous cysts:

• Regular check-ups with a healthcare provider
• Prompt attention to any new lumps or pain
• Maintaining overall joint health through exercise and proper nutrition
• Avoiding activities that may have contributed to previous cyst formation

Can lifestyle changes help prevent ganglion cysts from recurring? While there’s no guaranteed way to prevent ganglion cysts, certain lifestyle modifications may help reduce the risk of recurrence. These include maintaining a healthy weight to reduce stress on joints, avoiding repetitive motions that strain the wrists and hands, and using proper form and equipment during physical activities. However, it’s important to note that even with these precautions, some individuals may still develop ganglion cysts due to factors beyond their control.

Advances in Ganglion Cyst Research and Treatment

The field of hand and wrist surgery continues to evolve, bringing new insights and treatment options for ganglion cysts:

Emerging Treatment Modalities

• Improved imaging techniques for more accurate diagnosis
• Minimally invasive surgical techniques
• Exploration of regenerative medicine approaches

Ongoing Research

Current areas of research in ganglion cyst management include:

• Understanding the molecular basis of cyst formation
• Developing targeted therapies to prevent recurrence
• Improving long-term outcomes of surgical interventions
• Investigating the role of genetics in ganglion cyst susceptibility

What future treatments might be on the horizon for ganglion cysts? While current treatments are generally effective, future advancements may include biologics or growth factors to prevent cyst formation, gene therapy to address underlying susceptibilities, or novel minimally invasive techniques that combine the benefits of aspiration and surgical excision. As research progresses, we may see more personalized treatment approaches based on individual patient factors and cyst characteristics.

Ganglion cysts, while typically benign, can cause discomfort and concern for many individuals. Understanding their nature, available treatment options, and the ongoing advancements in their management can help patients make informed decisions about their care. Whether opting for observation, aspiration, or surgical intervention, working closely with a healthcare provider is key to achieving the best possible outcome. As research continues to unravel the mysteries of these common hand and wrist lumps, we can look forward to even more effective and less invasive treatment options in the future.

Ganglion Cyst of the Wrist and Hand – OrthoInfo

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in many locations, but most often develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst hurts, if it affects function, or if you are unhappy with how it looks, there are several treatment options available.

A ganglion arises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

The most common location of a ganglion cyst is on the back of the wrist.

Ganglion cysts can develop in several of the joints in the hand and wrist, including:

• Both the top and underside of the wrist
• The end joint of a finger
• The base of a finger

They vary in size, and in many cases, grow larger with increased activity. With rest, the lump usually becomes smaller.

It is not known what triggers the formation of a ganglion.

• They are most common in younger people between the ages of 15 and 40
• Women are more likely to be affected than men.
• They are common among gymnasts, who repeatedly apply stress to the wrist.
• Ganglion cysts that develop at the end joint on the nail side of a finger — also known as mucous cysts — are typically associated with arthritis in the finger joint and are more common in women between the ages of 40 and 70.

A mucous cyst at the end of the index finger.

Most ganglions form a visible lump; however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms besides the appearance of a mass, if a cyst puts pressure on the nerves that pass across the joint, it can cause pain, tingling, and muscle weakness.

If you have a large cyst, even if it is not painful, you may feel anxious or unhappy simply because of how it looks.

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Medical History and Physical Examination

During the initial appointment, your doctor will discuss your medical history and symptoms. They may ask you:

• How long you have had the ganglion
• Whether it changes in size
• Whether it is painful

Your doctor may apply pressure to the cyst to test for tenderness or discomfort. Because a ganglion is filled with fluid, it is translucent (almost transparent). Your doctor may shine a penlight up to the cyst to see whether light shines through. This can help confirm that the mass is truly a cyst and not a solid tumor.

Imaging Tests

X-rays. X-rays create clear pictures of dense structures, like bone. Although X-rays will not show a ganglion cyst, they can be used to rule out other conditions, such as arthritis of the hand, arthritis of the wrist, or a bone tumor.

Magnetic resonance imaging (MRI) scans or ultrasounds. MRI scans and ultrasounds can better show soft tissues, like a ganglion, than X-rays. Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors. However, further imaging is often not needed prior to treatment. 

Nonsurgical Treatment

Initial treatment of a ganglion cyst is nonsurgical.

Observation. If you have no pain or other symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur. This is typically safe because ganglions are not cancerous and may disappear on their own in time.

Immobilization. Activity often causes the ganglion to increase in size, which may increase pressure on surrounding nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.

Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.  This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Unfortunately, aspiration often fails to eliminate the ganglion because the root or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not addressed. Thus, in many cases, the ganglion cyst returns after an aspiration procedure.

Aspirations are most often used for ganglions located on the top of the wrist. Ganglions on the palm side of the wrist can be tricky to aspirate because they are near major vessels and nerves.

During an aspiration procedure, the fluid is drained from the ganglion cyst.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 Surgical Treatment

Your doctor may recommend surgery if your symptoms are not relieved by nonsurgical methods, or if the ganglion returns after aspiration. The procedure to remove a ganglion cyst is called an excision.

Surgery involves removing the cyst as well as addressing the stalk from which the cyst arises. This may mean removing part of the involved joint capsule or tendon sheath to ensure removal of the root of the cyst. Even after excision, there is a small chance the ganglion will return.

Excision is usually an outpatient procedure, meaning patients go home the day of surgery after a period of observation in the recovery area. There may be some tenderness, discomfort, and swelling after surgery. You are usually able to resume normal activities 2 to 6 weeks after the procedure.

A ganglion cyst at the wrist is removed during a surgical procedure called excision.

Ganglion cysts rarely, if ever, cause permanent disability. Cysts that do not go away on their own and cause symptoms almost always respond to surgery. In the rare case that a ganglion comes back after surgery, a revision surgery can be performed to remove the cyst again. After removal, most patients experience relief of symptoms. 

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Ganglion cyst | NHS inform

Ganglion cysts are soft, gel-like masses that often change size.

They tend to be smooth and round, and are:

• the most common type of swelling in the hand, wrist and foot
• harmless and can safely be left alone

If you have a ganglion, try to stay positive. There’s a lot you can do to help yourself.

What causes ganglion cysts?

A ganglion cyst starts when the fluid leaks out of a joint or tendon tunnel and forms a swelling beneath the skin.

The cause of the leak is generally unknown, but may be due to trauma or underlying arthritis.

How common are they?

Ganglion cysts are 3 times more common in women than men between 20 and 40 years of age.

Types of ganglion cysts

Ganglions can form:

• at the back of the wrist – these typically occur in young adults and often disappears without treatment
• at the front of the wrist – these may occur in young adults, but also seen in older people with arthritis
• at the base of the finger (flexor tendon sheath) – these usually occur in young adults
• on the finger (mucoid cyst) – these usually occur in middle-aged or older people

Approximately 80% of ganglions are found in the wrist.

Ganglion cyst symptoms

If you have a ganglion cyst the swelling can become noticeable, but often there are no symptoms at all.

Sometimes a ganglion can cause pain and limit movement in your joint. Some people are also concerned about the cysts appearance.

Most symptoms settle with time.

How they’re diagnosed

To diagnose a ganglion cyst, a healthcare professional will ask you about it and examine your wrist and hand.

Giving a diagnosis is usually straightforward. However, scans may be helpful if the diagnosis is uncertain.

Treating a ganglion cyst

About 50% of ganglions disappear on their own without treatment. In the early stages you should wait to see if this happens.

You won’t need treatment unless the cyst is painful.

Medication

Many people take medication to cope with their pain and symptoms, and help them remain active.

You may be prescribed pain medication to ease the pain. Make sure you take any medication as prescribed, and get advice from a GP, pharmacist or suitably trained healthcare professional.

Surgery

If the ganglion hasn’t reduced in size after 6 months or is causing significant functional difficulty and/or pain, you may be referred for further help and possible surgery.

Surgery is considered if it causes significant pain or restricts movement in your joint. However, there’s a chance it will come back even after surgery.

Ganglion cyst at the back of the wrist

Draining this ganglion can reduce the swelling but it often returns.

Problems after surgery include:

• persistent pain
• loss of wrist movement
• painful trapping of nerve branches in the scar

There’s a 10% chance of it coming back again after surgery.

Ganglion cyst at the front of the wrist

Draining this ganglion may be useful, but it can be dangerous as the cyst is often close to the artery at the wrist (where you can feel the pulse).

Problems after surgery include:

• persistent pain
• loss of wrist movement
• trapping of nerve branches in the scar

For these reasons, many surgeons advise against operating on these cysts.

There’s a 30 to 40% chance of it coming back again after surgery.

Ganglion cyst at the base of the finger

These ganglions feel like a dried pea at the base of the finger, and can cause pain when gripping.

Problems after surgery include:

• persistent pain
• loss of finger movement
• painful trapping of nerve branches in the scar

There’s a small chance of it coming back again after surgery.

Finger ganglion cyst

These ganglions are associated with wearing out of the end joint of a finger. Pressure from the cyst may cause a furrow in the fingernail. Occasionally the cyst fluid leaks through the thin overlying skin.

Problems after surgery include:

• infection
• stiffness and pain from the worn out joint

There’s a 10% chance of it coming back again after surgery.

Work

If you have a ganglion cyst try to stay at or get back to work as soon as possible. You don’t need to be fully pain and symptom free to return to work.

Research shows the longer you’re off work the less likely you are to return.

Ganglia. Full description: causes, symptoms, diagnosis, treatment

Tendon ganglion (hygroma) is a benign, neoplastic, cystic neoplasm that occurs in the area of ​​tendon sheaths or joints.

Most often, the tendon ganglion is formed on the back of the hand, but there are also quite frequent cases of hygroma of the knee joint, less often on the back of the foot. Not a single case of degeneration of the ganglion into a malignant tumor has been recorded.

Symptoms:

The tendon ganglion is not considered dangerous, but it can cause pain during the work of the tendon and often becomes quite noticeable visually, and in advanced stages, squeezing of the vessels begins, which leads to stagnation of blood in the veins and pain. On palpation, the ganglion is defined as a tumor-like, round and inactive formation with clear boundaries. Occurs in the region of the joint and is distinguished by a hard-elastic consistency.

When the tendon ganglion is still small, the patient usually does not experience any discomfort.

Reasons for :

In most cases, the causes of the emergence and development of the tendon ganglion is the constant impact (for example, friction or pressure) on a certain area, which is why this disease is often called an occupational disease.

In essence, the hygroma is a degenerative synovial cyst. So, tendon ganglion symptoms, treatment and everything you need to know about this disease.

When to go to the doctor:

As soon as you have a neoplasm, contact a specialist immediately

Forms of the disease:

The ganglion has a connective tissue capsule, often multi-layered. Inside the capsule consists of cavities, which may be several or only one. These cavities contain thickened synovial fluid.

There are several types of hygroma:

• Valve – a valve is formed at the junction of the hygroma capsule and the maternal membrane. When the pressure in the parental cavity is increased by stress or trauma, the synovial fluid begins to flow into the ganglion cavity, but does not move back, as it is blocked by a valve.
• Fistula – tendinous ganglion cavities have an anastomosis together with connections to the tendon sheath or joint. In such cases, the liquid from the hygroma, from time to time, pours out and fills the maternal cavity.
• Isolated – in this case, the ganglion cavity is completely isolated and separated from the maternal membrane. But it still has a place of adhesion with it.

Diagnosis:

The diagnosis is usually made on the basis of the history and characteristic clinical manifestations. X-rays may be ordered to rule out osteoarticular pathology. In doubtful cases, ultrasound, magnetic resonance imaging or ganglion puncture are performed.

Treatment:

Tendon ganglion, conservative and surgical treatment:

Conservative treatment: When the ganglion is still small, the method of mechanical crushing can be used. This is a very painful procedure, which is also generous with relapses. The fact is that when crushed, the liquid in the ganglion cavities can pour out into the surrounding tissues. Sometimes inflammatory reactions or even suppuration may begin. And the damaged shell, after a certain period of time, can recover and then most likely a new ganglion will appear. In official medicine, this method has hardly been used since the 80s of the last century because of its cruelty, pain and inefficiency.

Another method of conservative treatment is ganglion puncture, this method is used not only for therapeutic purposes (when for some reason it is not possible to perform an operation), but also for diagnosis (the contents of the ganglion are taken for research).

For treatment, fluid is pumped out of the ganglion, then the cavity is filled with specialized preparations that contribute to the sclerosis of the ganglion capsule. After that, a bandage and plaster are applied to the place where the ganglion is located to immobilize the limb for a week. Immobilization is important to reduce the production of synovial fluid.

Surgical treatment: when conservative methods are ineffective, and the ganglion causes pain, grows or is too prominent, then only surgical intervention remains – bursectomy.

During this operation, the synovial bag is completely cut, then the tendon ganglion and all its membranes are removed. The operation can be performed under local anesthesia, on an outpatient basis. An anesthetic is injected around the site of ganglion formation and the entire operation takes no more than half an hour.

However, unfortunately, it is impossible to carry out a complete and adequate removal of the ganglion during an outpatient operation, since pain sensitivity remains inside the tissues. Best of all, if the operation is performed under general anesthesia, then there will be a complete shutdown of tissue sensitivity. After the operation, the site where the ganglion was is stitched together and in most cases heals in just 10 or 12 days.

It is very important that after the operation to remove the tendon ganglion, the operated area of ​​the limb is firmly fixed using a plaster splint, which is removed after 2-3 weeks. While the scar is forming, you should not allow movements of the limb in the area where the ganglion was, otherwise there will be a risk of relapse.

Expert advice can be obtained by phone: +7(495) 961-27-67

Treatment of tendon ganglion of the hand in the clinic of St.

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What is tendon ganglion? How is the removal going? Recovery after surgery

The tendon ganglion is a small subcutaneous mass located at the base of the finger. The disease develops gradually, for no apparent reason, more often in women. Attention is drawn to when there are pains with pressure in the area of ​​\u200b\u200bdensification. This is especially noticeable to housewives who carry packages loaded with groceries home from the store. The package handles twisted into a tourniquet put pressure on the bases of the fingers, causing pain when they hit the seal.

What is a tendon ganglion?

In orthopedics, ganglion refers to a cavity of tendon sheaths that is filled with a gel-like fluid.

On examination, it is very difficult to notice a slight swelling at the base of the finger on the hand (Fig. 1).

On palpation (palpation) of the hand, the doctor determines a dense formation that looks like a small “pea”. The skin over the formation is freely displaced. When you move your finger, the “pea” retains its location.

Fig.1

Nikitin Alexander Vladimirovich

Traumatologist-orthopedist “SM-Clinic”

“Hygroma does not pose a danger to health and life. If it does not look like an obvious cosmetic defect and does not hurt, then it can not be removed. However, if the hygroma limits the mobility of the joint , hurts and interferes, it is better to perform an operation and get rid of the neoplasm.

Tendon ganglion treatment

The only way to treat this disease is an operation, during which it is necessary to remove the membranes and contents of the ganglion. The operation can be performed on an outpatient basis under local anesthesia. After anesthetizing the necessary area of ​​the hand, a skin incision is made. When diluting the edges of the wound, the tendon ganglion is isolated.

After making sure that the digital neurovascular bundles are set aside and cannot be damaged, the ganglion is excised.

Soft tissues excised during the operation must be sent for histological examination.

Fig.2. Tissues excised during the operation: sheaths of the tendon ganglion (a), contents of the cavity (b).

Fig.2.

Recovery

In the postoperative period, dressings are performed, the sutures are removed 10 days after the operation. A plaster cast is not required. In order to develop a hand faster, physiotherapy treatment, therapeutic exercises, massage of the hand and forearm are prescribed.

There are no means of preventing tendon ganglion development.

There are contraindications. Specialist consultation is required.

Author of the article:
Nikitin Alexander Vladimirovich
operating traumatologist at the SM-Clinic

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