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Flexor sheath ganglion excision

Surgeon-side topic for flexor sheath ganglion excision. Backed by 121 articles from the corpus, retrieved via combined MeSH + title-text matching.

53 citationsUpdated Oct 2026
Illustration: Flexor sheath ganglion excision

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Flexor sheath ganglia are fibrous lesions that lack specific histological features distinguishing them from other ganglia [3]. Aspiration or bursting of the cyst is considered the best primary treatment [1], with ganglion aspiration serving as a first-line intervention and surgical excision reserved for symptomatic cases [8]. Approximately 40% of lesions decrease over the first 6 years after evaluation by a hand surgeon [7]. In patients with a clinical diagnosis of wrist ganglion cyst, quality of care is not compromised by abandoning the routine submission of surgical specimens for pathological examination after excision [4].

Surgical intervention carries an approximately 10% recurrence rate, leaves scars, and presents some risk for adverse events [7]. Open surgical excision offers a significantly lower chance of recurrence compared with aspiration [10]. Advances in surgical techniques allow arthroscopic ganglion excision with recurrence rates similar to open management [5]. The recurrence and complication rates after arthroscopic resection appear comparable to open resections [15], and outcomes at 4 years of follow-up support the use of arthroscopy for dorsal wrist ganglions [32]. Arthroscopic resection is an effective long-term treatment for well-selected volar wrist ganglions arising from the radiocarpal joint [18]. Patients experience significant increases in function and decreases in pain within 6 weeks after arthroscopic resection [15].

Operation-related complications after arthroscopic volar wrist ganglionectomy are associated with anatomical location, specifically distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer [14]. Patients whose occupation or activities require forceful wrist extension should be counseled on the considerable risk of residual pain and functional limitations following open dorsal wrist ganglion excision [9]. Surgical costs from arthroscopic ganglion excision are significantly higher than open excision [39], though performing at least one aspiration before surgical excision improves cost-effectiveness [22]. There is no consensus regarding the best management of pediatric wrist ganglia, with no single treatment modality conferring a particular advantage or disadvantage [13]. A retrospective review reports a low recurrence rate of 5.3% for pediatric wrist ganglion cysts [41]. The WALANT technique can be used in pediatric patients undergoing ganglion removal with similar benefits demonstrated in the adult population, provided appropriate patient selection is made [53].

Anatomy & Pathophysiology

Histopathology and Pathogenesis

Fibrous flexor sheath ganglia lack specific histological features that distinguish them from other ganglia [3]. Intraneural ganglions are nonneoplastic, mucinous cysts located within the epineurium of peripheral nerves in the hand [23]. The pathogenesis of these lesions remains controversial, with historical support for a de novo theory proposing mucoid degeneration of fibrotic tissue following repetitive microtrauma [23]. Conversely, the articular (synovial) theory has gained worldwide acceptance as a scientifically proven explanation for the formation of intraneural ganglions [26].

Clinical Presentation and Differential Diagnosis

Trigger digit, Dupuytren's disease, and ganglion cysts are three common disorders that present as a mass at the flexor crease in the distal palm [17]. A simple clinical exam method exists to assist in distinguishing between these three conditions [17]. Trigger digit results from pathological inflammatory changes in the retinacular tendon sheath and peritendinous tissue, leading to hypertrophy that restricts flexor tendon motion [17]. Dupuytren's disease is a disorder of the palmar fascia presenting as fibromatous nodules and cords that can result in flexion contracture and decreased hand function [17]. A volar wrist ganglion can also present as trigger finger at the wrist [44].

Most patients with intraneural ganglions are aged 30 to 50 years, although occurrence in children has also been reported [26]. The ulnar nerve is the most commonly involved nerve in the upper extremity, but almost any other nerve in the vicinity of a joint can be affected [26]. Most patients present with a painless mass, while some may present with symptoms of nerve irritation or entrapment neuropathy [26].

Anatomical Structures and Relationships

The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [72]. The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx and consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [72]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [72]. The A5 pulley is a discrete structure with a histologic composition consistent with that reported for other annular pulleys [100]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [72]. Within the flexor sheath, tendon vascularity is supplied via the vincula system, specifically the vinculum longus and brevis [72].

The flexor retinaculum maintains and restrains the tendons of the extrinsic flexors of the digits within the carpal canal, keeping them close to the axis of flexion–extension of the wrist [68]. The gliding mechanism for flexor tendons in narrow crowded areas is assured by synovial sheaths surrounded by fibrous sheaths that keep the tendon close to the skeleton [73]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa, and the tenosynovial sheath to the little finger is continuous with the ulnar digital bursa [72]. In some patients, the radial and ulnar bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either digit [72].

The superficial palmar fascia covers a triangular area of the central palm, with four central bands extending distally toward each of the fingers, but no central band for the thumb [75]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers, with fibers dorsal to the bundle called Cleland ligament and those palmar to the bundle called Grayson ligament [75].

Imaging and Diagnostic Considerations

Recent advances in MRI technology, specifically the 3-dimensional FSE extended echo train sequence called cube, have revolutionized the visualization of intraneural ganglions and their articular branches [26]. High-resolution MRI techniques have the potential to improve patient outcomes by allowing better preoperative planning and more accurate surgical intervention for intraneural ganglions [26]. Wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis [102].

Classification

Histological Subtypes: Cystic soft tissue tumours of the dorsal aspect of the wrist demonstrate two distinct histological subtypes [31]. Both histological tissue types coexist at recurrence, with equal recurrence rates observed in both initial synovial and ganglion groups [31].

Other Considerations: A simple physical exam maneuver can assist in distinguishing between trigger digit, Dupuytren's disease, and flexor sheath ganglion cysts [17]. Trigger digit, Dupuytren's disease, and ganglion cysts can all present as a mass at the flexor crease in the distal palm [17]. Ultrasonography and electromyographic studies are helpful in confirming the diagnosis of ganglions [20]. Ultrasound is useful in distinguishing giant cell tumor of tendon sheath from ganglion cysts [49]. Recent advances in MRI technology, specifically the 3-dimensional FSE extended echo train sequence, provide better visualization of intraneural ganglions and their articular connections [26]. Nerve tumors are rare and often overlooked in the differential diagnosis of upper extremity masses [28]. Inappropriate surgery for nerve tumors can result in irreversible loss of function, necessitating strict tumor surgery techniques and careful preoperative planning [28].

Clinical Presentation

Ganglion cysts represent the most common lumps encountered in the hand and wrist region [17]. A simple clinical examination method assists in distinguishing flexor sheath ganglion cysts from trigger digit and Dupuytren's disease [17]. Trigger digit manifests with locking and clicking symptoms, most commonly at the A1 pulley of the ring finger [17]. Lack of full motion due to painful triggering or locking can lead to secondary contracture of the proximal interphalangeal (PIP) joint [17]. Dupuytren's disease involves the palmar fascia, presenting as fibromatous nodules and cords that may result in flexion contracture and decreased hand function [17].

Fibrous flexor sheath ganglia lack specific histological features to distinguish them from other ganglia [3]. Consequently, in patients with a clinical diagnosis of wrist ganglion cyst, quality of care is not compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision [4]. Most patients with intraneural ganglions present with a painless mass [26], while some present with symptoms of nerve irritation or entrapment neuropathy [26]. In many cases, definitive diagnosis is made only at the time of surgery [26]. The ulnar nerve is the most commonly involved nerve in the upper extremity for intraneural ganglions [26].

Uncommon etiologies should be considered in patients with atypical symptoms of carpal tunnel syndrome, which can be caused by an interosseous ganglion of the lunate [90]. Bilateral plexiform neurofibromas of the posterior interosseous nerve can mimic dorsal wrist ganglions [82]. Neurofibromas presenting as dorsal wrist masses may be firm and immobile, with pain elicited by direct pressure and worsened by wrist movement [82]. A Tinel sign over a mass mimicking a ganglion cyst may elicit severe pain but no radiating paresthesias [82]. Inappropriate surgery for nerve tumors can result in irreversible loss of function [28].

Investigations

Clinical Examination

A careful physical examination is essential to direct care and future testing if indicated [45].

Imaging

Ultrasonography: Ultrasonography is helpful in confirming the diagnosis of ganglion cysts [20].

Electromyography: Electromyographic studies are helpful in confirming the diagnosis of ganglion cysts [20].

MRI: Recent advances in MRI technology have provided better visualization of intraneural ganglions and articular connections to the cyst [26]. The 3-dimensional FSE extended echo train MRI sequence, called cube, has revolutionized the visualization of intraneural ganglions and the articular branches that connect them to the joint [26]. High-resolution MRI techniques have the potential to improve patient outcomes by allowing better preoperative planning and more accurate surgical intervention [26]. The anatomical location of a volar wrist ganglion on preoperative MRI is a risk factor for operation-related complications after arthroscopic ganglionectomy [14]. Operation-related complications after arthroscopic volar wrist ganglionectomy are associated with the cyst being distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer [14].

Histopathology

Cystic soft tissue tumours of the dorsal aspect of the wrist have two distinct histological subtypes [31]. The coexistence of both histological tissue types was observed at recurrence in cystic soft tissue tumours of the dorsal wrist [31]. Recurrence rates were equal in both initial synovial and ganglion groups of dorsal wrist cystic soft tissue tumours [31].

Treatment

Non-Operative

Ganglion aspiration is considered a first-line intervention for wrist ganglions [8]. Approximately 40% of wrist ganglion lesions decrease in size over the first 6 years following evaluation by a hand surgeon [7]. Performing at least one aspiration prior to surgical excision improves the cost-effectiveness of treating dorsal wrist ganglions, particularly because patient preferences may preclude the routine performance of two aspirations [22]. Operative treatment does not result in less pain intensity or disability, or higher satisfaction compared with non-operative treatment [107].

Operative

Indications: Surgical intervention for wrist ganglions carries an approximately 10% recurrence rate, leaves scars, and presents some risk for adverse events [7]. Surgeons should maintain a high index of suspicion for ganglion cysts in presentations of atraumatic, progressive, and painful elbow contracture [21]. Nerve tumors are rare and often overlooked in the differential diagnosis of upper extremity masses; inappropriate surgery can result in irreversible loss of function, necessitating strict tumor surgery techniques and careful preoperative planning [28]. Be wary of offering surgery to young, less educated patients with dorsal volar or wrist ganglia, as the surgery is often unrewarding for both the surgeon and the patient [54].

Surgical Approach / Technique: Arthroscopy allows for the simultaneous treatment of ganglions and other pathologies [2]. The recurrence and complication rates of arthroscopic ganglion cyst resection appear to be comparable to open resections [15]; however, open excision of dorsal wrist ganglia leads to a lower recurrence rate than arthroscopic excision [24]. Ultrasound-guided excision of dorsal wrist ganglions using a 2 mm portal under local anesthesia is reliable and efficient, with a classic rate of recurrence for this pathology [38]. Hand surgeons are divided regarding the need to immobilize the wrist after dorsal wrist ganglion excision [43]. In cases of a ganglion within the ulnar nerve communicating with the distal radioulnar joint, excision of the articular nerve branch is advised to avoid recurrences [16]. For periglenoidal ganglion cysts, the described technique combines the advantages of open and arthroscopic surgery, allowing the surgeon to address underlying intra-articular pathology, completely evacuate the ganglion cyst, and protect the suprascapular nerve [27]. Subsequent excision of the ganglion and external neurolysis resulted in complete return of nerve function, muscle bulk, and strength in a case of suprascapular nerve denervation secondary to attenuation by a ganglionic cyst [6]. Treatment of the intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion [108]. Methylene blue staining can be used to visualize the wrist ganglion capsule as an aid for complete resection in children [37].

Complications: A synovial fistula is a rare complication of recurrent dorsal wrist ganglion excision, potentially caused by extensive capsular excision and steroid injection [34].

Complications

Recurrence

Surgical intervention for wrist ganglions carries an approximate recurrence rate of 10% [7], with reported rates for surgical excision ranging from 1% to 50% [79]. Open surgical excision offers a significantly lower chance of recurrence compared with aspiration [10] and results in a lower recurrence rate than arthroscopic excision for dorsal wrist ganglia [24]. Arthroscopic resection recurrence rates range from 8.5% to 30% [79]. Dominant side, female sex, and age of 24 years or less are the most influential risk factors for recurrence after arthroscopic excision of dorsal wrist ganglia [29]. In children aged >10 years, open excision surgery has a recurrence rate of 2.8% to 35% [19]. Cystic soft tissue tumours of the dorsal aspect of the wrist exhibit equal recurrence rates in both initial synovial and ganglion histological groups [31]. Excision of the articular nerve branch is advised to avoid recurrences in cases of ganglions within the ulnar nerve communicating with the distal radioulnar joint [16].

Operative Complications

The pooled complication rate for open excision of dorsal wrist ganglions is 5.6% (median 2.8%) [84], while the pooled complication rate for arthroscopic excision is 4% (median 3.6%) [84]. Surgical intervention leaves scars and carries some risk for adverse events [7]. The most common complications reported across open and arthroscopic excision populations include joint stiffness, wound infection, neuropraxia, neuroma formation, hematoma requiring surgical drainage, hypertrophic scar, paresthesia, radial artery damage, and extensor tenosynovitis [84]. Operation-related complications after arthroscopic volar wrist ganglionectomy are associated with the anatomical location of the ganglion being distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer [14]. Dye-assist arthroscopic inside-out ganglionectomy is safe and uncomplicated [117].

Nerve and Vascular Injury

Suprascapular nerve denervation secondary to attenuation by a ganglionic cyst can result in complete return of nerve function, muscle bulk, and strength following subsequent excision of the ganglion and external neurolysis [6]. Intraneural ganglions of the hand are rare and remain poorly understood, with the pathogenesis remaining controversial [23]. An adventitial cyst of the radial artery with a wrist joint connection can present with progressive weakness and thenar atrophy due to median nerve compression [35].

Histopathology and Diagnostic Considerations

In patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision [4].

Recovery

Other Considerations: Subsequent excision of the ganglion and external neurolysis resulted in complete return of nerve function, muscle bulk, and strength [6].

Key Evidence

  • [L4] Bursting or aspiration of flexor sheath ganglia appears to be the best primary treatment. [1] (10.1142/s0218810417500289)
  • [L4] Arthroscopy allows for the simultaneous treatment of ganglions and other pathologies. [2] (10.1016/j.jhsa.2012.04.042)
  • [L4] Fibrous flexor sheath ganglia did not have any specific histological features to distinguish them from other ganglia. [3] (10.1016/0266-7681(94)90181-3)
  • [L3] This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. [4] (10.1016/j.jhsa.2010.03.021)
  • [L4] Advances in surgical techniques have allowed surgeons to conduct arthroscopic ganglion excision with recurrence rates similar to those of open management. [5] (10.5435/jaaos-d-22-00105)
  • [L4] Subsequent excision of the ganglion and external neurolysis resulted in complete return of nerve function, muscle bulk, and strength. [6] (10.2106/00004623-198668040-00025)
  • [L5] Current best evidence suggests that about 40% of lesions decrease over the first 6 years after evaluation by a hand surgeon, that most ganglions recur after aspiration, and that surgical intervention has about a 10% recurrence rate, leaves scars, and has some risk for adverse events. [7] (10.1016/j.jhsa.2010.11.048)
  • [L4] Ganglion aspiration should be considered as a first-line intervention, with surgical excision remaining an effective option for symptomatic cases. [8] (10.1177/1753193411434376)
  • [L4] Patients whose occupation or activities require forceful wrist extension should be counseled on the considerable risk of residual pain and functional limitations that may occur after open dorsal wrist ganglion excision. [9] (10.1016/j.jhsa.2015.05.030)
  • [L1] Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions. [10] (10.1016/j.jhsa.2014.12.014)
  • [L4] There is no consensus within the literature regarding the best management of pediatric wrist ganglia, and no single treatment modality confers a particular advantage or disadvantage over another. [13] (10.1177/1558944720966716)
  • [L3] The operation-related complications after arthroscopic volar wrist ganglionectomy are associated with its anatomical location: distal to the bifurcation of the radial artery and concurrently penetrated up to the superficial fascia layer. [14] (10.1186/s12891-025-08766-x)
  • [L4] Patients experienced significant increases in function and decreases in pain within 6 weeks after arthroscopic ganglion cyst resection, and the recurrence and complication rates appear to be comparable to open resections. [15] (10.1016/j.jhsa.2008.11.025)
  • [Case_report] Excision of the articular nerve branch is advised to avoid recurrences. [16] (10.1016/j.jhsa.2011.08.008)
  • [L4] [17] (10.1177/15589447221109644)
  • [L4] Arthroscopic resection was an effective treatment method for well-selected volar wrist ganglion arising from the radiocarpal joint in long run. [18] (10.1016/j.main.2006.07.028)
  • [L4] Ganglions in children aged >10 years resemble adult ganglions, occurring mainly on the dorsal aspect and are amenable to open excision surgery, which has a recurrence rate of 2.8% to 35%. [19] (10.1016/j.jhsa.2021.12.015)
  • [L4] Surgeons should maintain a high index of suspicion for ganglion cysts in such presentations. [21] (10.1016/j.jhsa.2020.06.005)
  • [L2] As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. [22] (10.1016/j.jhsa.2022.09.002)
  • [Case_report] [23] (10.1016/j.jhsa.2010.08.033)
  • [L3] This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision. [24] (10.1177/15589447211003184)
  • [L4] [26] (10.1016/j.jhsa.2015.05.025)
  • [L4] The described technique combines the advantages of open and arthroscopic surgery, allowing one to address the underlying intra-articular pathology, completely evacuate the ganglion cyst, and protect the suprascapular nerve. [27] (10.1016/j.arthro.2005.10.022)
  • [L5] Nerve tumors are rare and often overlooked in the differential diagnosis of upper extremity masses; inappropriate surgery can result in irreversible loss of function, necessitating strict tumor surgery techniques and careful preoperative planning. [28] (10.1016/j.hcl.2004.03.003)
  • [L4] Dominant side, female sex, and age of 24 years or less are considered to be the most influential risk factors for recurrence after arthroscopic excision of dorsal wrist ganglia. [29] (10.1016/j.arthro.2013.04.002)
  • [L4] The study demonstrated two histologically distinct tissue types at primary surgery and the coexistence of both tissue types at recurrence, with equal recurrence rates in both initial synovial and ganglion groups. [31] (10.1177/17531934241251721)
  • [L4] The outcomes, recurrence, and complications rates after 4 years of follow-up presented in this study support the use of arthroscopy as a treatment for dorsal wrist ganglion. [32] (10.1177/1558944717743601)
  • [Case_report] A synovial fistula is a rare complication of recurrent dorsal wrist ganglion excision, potentially caused by extensive capsular excision and steroid injection. [34] (10.1016/j.jhsa.2012.02.015)
  • [L4] [35] (10.1016/j.jhsa.2006.10.001)
  • [L2] [37] (10.1016/j.jhsa.2015.01.015)
  • [L4] The ultrasound-guided excision of dorsal wrist ganglion, using a 2 mm portal, under local anesthesia was reliable and efficient, with a classic rate of recurrence for this pathology. [38] (10.1016/j.hansur.2019.10.007)
  • [L4] Surgical costs from arthroscopic ganglion excision are significantly more than open excision. [39] (10.1016/j.jhsa.2017.05.012)
  • [L4] This retrospective review reports a low recurrence rate of 5.3% for pediatric wrist ganglion cysts, indicating potential merit in the surgeon's operative and postoperative techniques. [41] (10.1177/1558944717751195)
  • [L2] The systematic review and survey of Canadian hand surgeons reveal that hand surgeons are divided regarding the need to immobilize the wrist after dorsal wrist ganglion excision. [43] (10.1177/15589447211014631)
  • [L4] This is the first reported case of triggering pathology at the wrist to be treated with interventional radiological measures rather than open surgery and demonstrates the efficacy of the technique. [44] (10.1177/1753193412453699)
  • [L5] [49] (10.1016/j.jhsa.2010.08.015)
  • [L4] The WALANT technique can be used in pediatric patients undergoing ganglion removal with similar benefits previously demonstrated in the adult population, provided appropriate patient selection is made. [53] (10.1016/j.jhsa.2025.05.010)
  • [Commentary] Be wary of offering surgery to young, less educated patients with dorsal volar or wrist ganglia as the surgery is often unrewarding for both the surgeon and the patient. [54] (10.1177/1753193412466985)
  • [L3] [79] (10.1177/1558944720921477)
  • [L4] [82] (10.1016/j.jhsa.2019.10.016)
  • [L2] [84] (10.1177/1753193417734428)
  • [L4] This case highlights the importance of considering uncommon aetiologies in patients with atypical symptoms of carpal tunnel syndrome. [90] (10.1177/17531934241227809)
  • [L5] The A5 pulley is a discrete structure, with measurements as noted as well as a histologic composition consistent with that reported for the other annular pulleys. [100] (10.1016/s0363-5023(98)80051-8)
  • [L4] Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis. [102] (10.1177/1558944717695752)
  • [L3] Operative treatment did not result in less pain intensity or disability, or higher satisfaction compared with non-operative treatment. [107] (10.1177/1753193412442468)
  • [Case_report] Treatment of the intratendinous ganglion should include preserving the tendon, which may be weakened by the ganglion. [108] (10.1177/1753193412453428)
  • [L4] Dye-assist arthroscopic inside-out ganglionectomy is safe and uncomplicated, worth of clinical promotion. [117] (10.1186/s12891-024-07797-0)

See Also

References

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[5] Ganglions in the Hand and Wrist: Advances in 2 Decades. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00105

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[9] Outcomes of Open Dorsal Wrist Ganglion Excision in Active-Duty Military Personnel. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.05.030

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[35] Adventitial Cyst of the Radial Artery With a Wrist Joint Connection. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.10.001

[37] Visualization of the Wrist Ganglion Capsule by Methylene Blue Staining as an Aid for Complete Resection in Children. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.015

[38] Dorsal wrist ganglions: A new procedure to perform excision under ultrasound guidance. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2019.10.007

[39] Cost Minimization Analysis of Ganglion Cyst Excision. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.05.012

[41] Pediatric Ganglion Cysts: A Retrospective Review. HAND. 2018. DOI: 10.1177/1558944717751195

[43] Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice. HAND. 2021. DOI: 10.1177/15589447211014631

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