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Abstract
Formation of the traumatic neuroma results from abnormal nerve regeneration following a peripheral nerve injury. Numerous treatment options have been described. However, there is no one way that is completely effective in the management of these peripheral neuromas. Prevention is best. It is important to maximize nonsurgical management, including pain management and physiotherapy. At the time of surgery, definitive neuroma resection and tension-free repair or coverage will provide the least amount of subsequent nerve irritation.
REFERENCES
1. Brogan DM, Kakar S. Management of neuromas of the upper extremity. Hand Clin. 2013; 29:409–20.
2. Watson J, Gonzalez M, Romero A, Kerns J. Neuromas of the hand and upper extremity. J Hand Surg Am. 2010; 35:499–510.
3. Birch R. Nerve repair. Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, Cohen MS, editors. Green's operative hand surgery. 6th ed. New York: Elsevier Health Sciences;2010. p. 1035–74.
4. Treede RD, Jensen TS, Campbell JN, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008; 70:1630–5.
5. Wall PD, Gutnick M. Ongoing activity in peripheral nerves: the physiology and pharmacology of impulses originating from a neuroma. Exp Neurol. 1974; 43:580–93.
6. Lundborg G. A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance. J Hand Surg Am. 2000; 25:391–414.
7. Gidal BE. New and emerging treatment options for neuropathic pain. Am J Manag Care. 2006; 12:S269–78.
8. Rosenstock J, Tuchman M, LaMoreaux L, Sharma U. Pregabalin for the treatment of painful diabetic peripheral neuropathy: a double-blind, placebo-controlled trial. Pain. 2004; 110:628–38.
9. Smith JR, Gomez NH. Local injection therapy of neuromata of the hand with triamcinolone acetonide. A preliminary study of twenty-two patients. J Bone Joint Surg Am. 1970; 52:71–83.
10. Gruber H, Glodny B, Kopf H, et al. Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome. AJR Am J Roentgenol. 2008; 190:1263–9.
11. Herndon JH, Eaton RG, Littler JW. Management of painful neuromas in the hand. J Bone Joint Surg Am. 1976; 58:369–73.
12. Boldrey E. Amputation neuroma in nerves implanted in bone. Ann Surg. 1943; 118:1052–7.
13. Lim KB, Kim YS, Kim JA. Sonographically guided alcohol injection in painful stump neuroma. Ann Rehabil Med. 2012; 36:404–8.
14. Davies E, Pounder D, Mansour S, Jeffery IT. Cryosurgery for chronic injuries of the cutaneous nerve in the upper limb. Analysis of a new open technique. J Bone Joint Surg Br. 2000; 82:413–5.
15. Nath RK, Mackinnon SE. Management of neuromas in the hand. Hand Clin. 1996; 12:745–56.
16. Nunley JA, Ugino MR, Goldner RD, Regan N, Urbaniak JR. Use of the anterior branch of the medial antebrachial cutaneous nerve as a graft for the repair of defects of the digital nerve. J Bone Joint Surg Am. 1989; 71:563–7.
17. Malizos KN, Dailiana ZH, Anastasiou EA, Sarmas I, Soucacos PN. Neuromas and gaps of sensory nerves of the hand: management using vein conduits. Am J Orthop (Belle Mead NJ). 1997; 26:481–5.
18. Guse DM, Moran SL. Outcomes of the surgical treatment of peripheral neuromas of the hand and forearm: a 25-year comparative outcome study. Ann Plast Surg. 2013; 71:654–8.
19. Tupper JW, Booth DM. Treatment of painful neuromas of sensory nerves in the hand: a comparison of traditional and newer methods. J Hand Surg Am. 1976; 1:144–51.
20. Dahlin LB, Lundborg G. Use of tubes in peripheral nerve repair. Neurosurg Clin N Am. 2001; 12:341–52.
21. Sood MK, Elliot D. Treatment of painful neuromas of the hand and wrist by relocation into the pronator quadratus muscle. J Hand Surg Br. 1998; 23:214–9.
22. Hazari A, Elliot D. Treatment of end-neuromas, neuromas-in-continuity and scarred nerves of the digits by proximal relocation. J Hand Surg Br. 2004; 29:338–50.
23. Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg. 1986; 77:427–38.
24. Herbert TJ, Filan SL. Vein implantation for treatment of painful cutaneous neuromas. A preliminary report. J Hand Surg Br. 1998; 23:220–4.
25. Gorkisch K, Boese-Landgraf J, Vaubel E. Treatment and prevention of amputation neuromas in hand surgery. Plast Reconstr Surg. 1984; 73:293–9.
26. Belcher HJ, Pandya AN. Centro-central union for the prevention of neuroma formation after finger amputation. J Hand Surg Br. 2000; 25:154–9.
27. Wood VE, Mudge MK. Treatment of neuromas about a major amputation stump. J Hand Surg Am. 1987; 12:302–6.
28. Barbera J, Albert-Pamplo R. Centrocentral anastomosis of the proximal nerve stump in the treatment of painful amputation neuromas of major nerves. J Neurosurg. 1993; 79:331–4.
29. Krishnan KG, Pinzer T, Schackert G. Coverage of painful peripheral nerve neuromas with vascularized soft tissue: method and results. Neurosurgery. 2005; 56:369–78.
30. Yuksel F, Kislaoglu E, Durak N, Ucar C, Karacaoglu E. Prevention of painful neuromas by epineural ligatures, flaps and grafts. Br J Plast Surg. 1997; 50:182–5.
31. Adani R, Tarallo L, Battiston B, Marcoccio I. Management of neuromas in continuity of the median nerve with the pronator quadratus muscle flap. Ann Plast Surg. 2002; 48:35–40.
Fig. 1.
Three types of neuroma. (A) A neuroma (asterisk) originated from completely severed median nerve. (B) Neuromas-in-continuity of the median (black arrow) and ulnar nerve (white arrow). (C) Neuromas of the digital nerve in amputation stump.
Fig. 2.
(A) A neuroma (asterisk) originated from completely severed median nerve. Because distal part of severed nerve was available (black arrows), (B, C) the gap was repaired with a sural nerve cable graft.
Fig. 3.
(A) Amputation stump neuroma formation to the ulnar digital nerve of the thumb. Restoration of function was so critical, but a distal nerve was not available. (B) Modified neurovascular island flap from the middle finger was performed.
Fig. 4.
(A) Hypertrophic neuroma-in-continuity of the digital nerve (black arrow) was observed. (B) After excision of the neuroma, 5 mm sized nerve defect was noted. (C) Autologus vein was harvested and (D) digital nerve repair using the vein conduit was performed.
Fig. 5.
(A, B) After traumatic forearm amputation, hypertrophic neuromas of the median (asterisk) and ulnar nerve (double asterisk) were developed. (C, D) Excision of the neuromas were performed and the nerve were placed in unscarred muscle. Unfortunately, new neuromas of the both nerves were developed after the operation. N, nerve.
Fig. 7.
(A, B) Neuromas of the ulnar and radial digital nerve (empty arrows) were observed. (C) After excision of the neuromas, relocation of the nerve ends into the mid and proximal phalanx (black arrow) was performed, respectively. (D) Excised digital nerves including the neuromas.
Fig. 8.
Translocation of the neuroma into the muscle. (A) A neuroma arising from palmar cutaneous branch of the median nerve. After resection of the neuroma proximally, the nerve was implanted into the pronator quadratus muscle. The pronator quadratus muscle was one of the most commonly used muscles for transposition. (B) A neuroma arising from the superficial radial nerve. The neuroma was resected and then the nerve was implanted within the brachioradialis muscle.
Fig. 9.
Centra-centralization. (A) Centra-central nerve repair involved the coaptation of 2 nerve cords of central origin. (B) This technique could also be applied for 1 nerve if it was split into 2 fascicles of equal size. The 2 nerves or fascicles had simple end-to-end repair.
Fig. 10.
(A) After traumatic forearm amputation, hypertrophic neuromas of the median and ulnar nerve were redeveloped. (B) After resecting the neuromas, normal nerve fascicles were observed. (C) Microscopic end to end neurorrhaphy of the median and ulnar nerve was performed. (D) Repaired nerve was underneath the deep forearm muscles. N, nerve.
Fig. 11.
Coverage with flap. (A) A neuroma-in-continuity of the ulnar nerve was developed after sural nerve graft. (B, C) The abductor digiti minimi (empty arrow) was mobilized to cover the neuroma-in-continuity. (D) The flap coverage with vascularized muscle mass (black star) might provide a vascularized and nourished milieu and protect the nerve from the mechanical irritability.
Table 1.
Treatment options of the neuromas based on location
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