Surgical Management of Neuromas of the Hand and Wrist

Review Article Surgical Management of Neuromas of the Hand and Wrist

Abstract Steven Regal, MD Neuromas of the hand and wrist are common causes of peripheral Peter Tang, MD, MPH nerve pain. Neuromas are formed after the nerve sustains an injury, and they can be debilitating and painful. The diagnosis is made by a thorough history and physical examination. The treatment options are quite varied, but conservative measures tailored to the patient should be initiated first. No surgical treatment has been proven superior to others or to nonsurgical treatment.

euromas of the hand and wrist Etiology Ncan be a mentally and physically disabling condition for patients. A Sunderland classified nerve injuries neuroma is the abnormal growth of based on the histologic structure of nerve tissue that consists of a disorga- nerves and expanded Seddon’s neu- nized architecture of axons, Schwann rotmesis category with two additional cells, macrophages, and fibroblasts as a degrees of injury. In Sunderland’s5 result of the biologic response to nerve third- and fourth-degree injuries, the trauma or an unsuccessful nerve repair endoneurium is disrupted and the (Figure1). Neuroma formation may epineurium remains intact, leading result secondary to a peripheral nerve to disorganized axon growth and injury, such as a laceration, crush in- fusiform swelling at this site (Figure From the Division of Hand, Upper jury, chronic irritation or stretch, or 2). Yuksel et al6 hypothesized that Extremity, and Microvascular Surgery, the result of a nerve repair. Patients the perineurium is a barrier to re- Department of Orthopaedic Surgery, who experience a digit amputation generating axon so when the peri- Allegheny General Hospital, have a reported 2.7% to 30% inci- Pittsburgh, PA. neurium is damaged, fascicular escape dence of developing a symptomatic can occur. With escape, the re- Dr. Tang or any immediate family neuroma.1,2 In a nerve injury where member is a member of a speakers’ generating axons grow into the epi- bureau or has made paid the axon is disrupted, the distal portion neural tissue in a disorganized fashion presentations on behalf of AxoGen of the axon will undergo Wallerian along with Schwann cells, fibroblasts, and Synthes; serves as a paid degeneration. The proximal portion of and blood vessels. The regenerating consultant to Globus Medical; and has received research or institutional the neuron sprouts toward the empty axons form the patterns of whorls, support from AxoGen. Neither neural tube and will grow 1 to 2 mm spirals, and convolutions, which are Dr. Regal nor any immediate family per day to restore the nerve’s function. characteristics of neuroma histology. member has received anything of A neuroma will form if the proximal value from or has stock or stock neuron fails to effectively reach the options held in a commercial company Clinical Evaluation or institution related directly or distal nerve end.3,4 With more than indirectly to the subject of this article. 150 different treatment options for (Diagnosis) J Am Acad Orthop Surg 2019;27: symptomatic neuromas, the optimal 356-363 management remains unknown and History and Physical Examination DOI: 10.5435/JAAOS-D-17-00398 hence, the challenge. This article re- views the nonsurgical and surgical A thorough history and physical Copyright 2018 by the American Academy of Orthopaedic Surgeons. management of symptomatic neuro- examination is critical in establishing mas of the hand and wrist. the correct diagnosis. Often, a surgical

356 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Steven Regal, MD and Peter Tang, MD, MPH or traumatic scar can localize the Figure 1 clinician’s examination to the site of the neuroma. Hallmark features of neuroma pain include spontaneous pain; hyperalgesia or allodynia to touch, pressure, or movement; and the sensation of a burning or elec- trical pain.4,7 A positive Tinel sign is often found at the site of the neuroma, and the area distal to this will have altered sensation (hypoesthesia, hyperalgesia, or anesthesia).4,8,9 A modified Hendler back pain rating scale is a useful tool to evaluate neuroma pain with prognostic im- Electron microscopic image of peripheral nerve (A). Electron microscopic image of neuroma showing hypertrophic nerves with perineural fibrosis (B). plications. The test is composed of three components: a body diagram pain drawing, a numerical scale who have all three of the compo- the surgical versus nonsurgical suc- quantifying pain, and a list of pain nents experience an exaggerated re- cess rates exist.9-11 descriptors (Figure 3). Patients who sponse to pain and are not surgical have significant hand dysfunction candidates. Patients who only have Management that negatively impacts their daily one of the above components will lives will have a pain drawing on the likely have a good outcome, whereas Nonsurgical Management body diagram that does not corre- those who have two of the three are It is important for the surgeon to have spond to the anatomic course of likely to have suboptimal results. knowledge of nonsurgical manage- a peripheral nerve, have a score of The modified Hendler back pain ment of neuromas of the hand and 20 or more points on the numerical rating scale helps the practitioner wrist. Conservative options should be scale, and use three or more ad- differentiate organic from functional exhausted before any surgical inter- jectives to describe the pain. Patients pain, although no studies examining vention, and it may be the treatment of

Figure 2

Diagram representing Seddon and Sunderland degrees of nerve injury.

May 15, 2019, Vol 27, No 10 357

17 Figure 3 guided steroid injection. Rasmus- surgical techniques available to treat sen et al18 reported on 51 interdigital neuromas suggests that there is not neuromas of the foot treated with a a benchmark procedure to effectively single steroid injection with 4-year treat all neuromas. The surgical follow-up; 80% had pain relief management of painful neuromas within the first 3 months. However, should follow three basic principles only 11% had lasting improvement that have been previously described in pain at 4 years, and 47% eventu- by Nath and Mackinnon: (1) If there ally underwent surgical excision. are appropriate distal nerve and Although the injection of local anes- sensory receptors available, a nerve thetic and/or corticosteroid may not graft can be used to guide the re- provide a definite treatment, it may generating nerve stump distally into be useful for diagnostic purposes. the native nerve and distal targets; Pharmacologic management of neu- (2) if a distal nerve or sensory re- ropathic pain consists of numerous ceptors are not available and res- classes of medications, each with their toration of function is critical, own advantages, disadvantages, ad- innervated free tissue can be trans- verse effects, and different efficacy rates ferred to accept the regenerating among patients. The first medications nerve fibers from the injured nerve; Body diagram to be used by patients that proved efficacious for neuropathic and (3) if function of the injured to draw location and direction of pain. pain in placebo-controlled trials were nerve is not critical, the local tissue is the tricyclic antidepressants. A recent not amenable for a nerve graft, or if choice for those who cannot tolerate a Cochrane review of 61 randomized the patient has had numerous pre- surgery or choose not to have surgery. controlled trials examining the anal- vious unsuccessful surgical proce- Physical therapy modalities, such as gesic effect of antidepressants on neu- dures for pain control, the neuroma percussion, massage, and ultrasonog- ropathic pain concluded that tricyclic can be resected and the proximal raphy, have been reported to decrease antidepressants are effective in treating stump can be implanted into muscle, neuroma pain either through desensi- neuropathic pain; one out of every bone, or vein.9,11 Historically, man- tization or reducing inflammation and three patients treatedwillgetatleast agement of neuromas has focused on local scarring around the nerve.12-14 moderate pain relief.19 Otherclassesof transposition of the resected neu- Desensitization protocols often prog- medications include selective norepi- roma into nonneural tissue. The ress from soft, nonirritating materi- nephrine and serotonin reuptake in- availability of decellular nerve allo- als, such as paraffin wax, to more hibitors (venlafaxine, duloxetine), graft makes reconstruction a more noxious stimuli like constant touch or gabapentinoids (gabapentin, pre- viable treatment as long as distal pressure that assists in the physiologic gabalin), opioids (oxycodone, nerve ends are present (Figure 4). and psychologic return to normalcy tramadol), antiepileptics (carbamaze- over time. The use of vibration can pine), and topical agents, such as Neuroma Resection stimulate A-b fibers and “block out” lidocaine and capsaicin. These medi- painful C fiber activity.11,15 Analgesic cations have been used to effectively Excision of a neuroma is one of the and neuropathic agents are alterna- treat and alleviate neuropathic pain. oldest described surgical techniques. tive nonsurgical options that can be These medications should be started at Tupper and Booth21 found that of prescribed early following any trau- low doses and gradually increased to 232 neuromas, 68% had excellent or matic nerve injury to optimize prog- avoid unwanted adverse effects.16,20 An satisfactory results from neurectomy nosis and reduce chronic pain in the in-depth review of the pharmacologic alone. However, Guse and Moran22 upper limb.16 treatment of neuropathic pain is retrospectively reviewed 56 patients Steroid injections have been used beyond the scope of this article. with a peripheral neuroma distal to to treat neuromas with varying de- the elbow and compared outcomes grees of success, but most studies are of neuromas that underwent nerve focused on the lower extremity. A Surgical Management transposition into bone or muscle, 2014 study found that 7 of 14 patients Surgical management is best used simple excision, or nerve repair. The with lower extremity amputation in patients who have failed at least revision surgery rates and mean neuroma pain had .50% reduction 6 months of conservative measures.8,9 Disabilities of the Arm, Shoulder, in pain after an ultrasonography- The existence of a large variety of and Hand (DASH) score were

358 Journal of the American Academy of Orthopaedic Surgeons

Figure 4

Intraoperative photograph demonstrating an end-neuroma of the posterior cutaneous nerve of the arm caused iatrogenically during a posterior plating of a humeral shaft fracture performed 9 months ago (A) managed by neuroma resection and reconstruction with decellular nerve allograft (B) with placement of nerve wraps at the coaptation sites (C). recorded. Transposition into bone or possible. An end to side repair was results in nerve conduction studies muscle had a revision surgery rate of described by Al-Qattan24 to be used and Rosen hand function scores at 36%, whereas the DASH score was for neuroma prevention and treat- 2-year follow-up. Decellular nerve 22.4. Simple excision had a 47% ment. Eight patients were treated allografts have been shown to be an revision surgery rate and a DASH with this technique (three had effective treatment for nerve gaps score of 31.9, whereas nerve repair painful neuromas of the superficial up to 3 cm, but larger randomized had an 11% revision surgery rate radial nerve [SRN]) and were pain studies are needed to determine and a DASH score of 11.4. As a free with more than 16 months of the efficacy compared with nerve result of the high revision surgery follow-up. Thomsen et al25 retro- autograft.27 rates and poor DASH scores, the spectively reviewed 10 digital nerve authors’ recommended against sim- neuromas treatedwithresection ple excision as a treatment option. and bridging collagen conduits. The Neuroma Resection and As an alternative to resection alone, average quick-DASH score was Transposition Into Muscle Tay et al23 reported decreased neu- 19.3; 50% had static 2-point dis- Nerve transposition into muscle was roma formation in a rat model when crimination less than 10 mm, and first described in 1918 by Moszkoqicz the transected nerve was treated with none had recurrence of Tinel sign at who had “success” in 2 cases.11 short (4 seconds) or long (10 sec- the final follow-up. A randomized, Mackinnon et al28 showed that a onds) mono- or bipolar diathermy prospective study of 136 digital sensory nerve implanted proximally versus no treatment. The control nerve transections treated with end- into muscle had less scar formation groups had an 83% to 100% in- to-end repair with or without nerve in a primate model, and the nerve cidence of neuroma formation while autograft versus polyglycolic acid fibers were of smaller diameter both the short and long monopolar conduit showed no significant dif- and decreased density as compared diathermy groups had a significant ferences between the groups with with those left exposed in a wound. reduction in neuroma formation greater than 70% excellent or good Dellon and Mackinnon8 showed (30%). Only the long-duration outcomes; a subanalysis of nerve histologic and electron microscopic bipolar diathermy had a signifi- gaps greater than 8 mm showed that evidence that previous sensory neu- cant reduction in neuroma forma- the conduit group had significantly romas transposed into muscles did tion (25%). No other published improved sensory recovery and mov- not form a “classic neuroma,” did articles in the English language exist ing two-point discrimination com- not invade the muscle, and had less regarding the prevention/treatment of pared with the repairs done with scar tissue than neuromas not con- neuromas with diathermy. sural nerve autograft, which left all fined by muscle. The goals of neu- those patient’s with a persistent roma transposition into muscle numbness on the lateral foot.26 A include complete resection of the Neuroma Resection With recent randomized trial of 32 distal neuroma and transposition of the Nerve Repair median and/or ulnar nerve lacer- transected nerve end well away After resection of a neuroma, a tension- ations treated with direct repair or from an area that is subject to free primary suture repair is often not collagen conduit showed equivocal repeated trauma, movement, and

May 15, 2019, Vol 27, No 10 359

Figure 5 of 26.5 months. Excellent or good results were found in 87% of patients with 12 patients having complete and permanent pain relief. With a mean follow-up of 15 months, Herbert and Filan35 successfully treated 14 of 14 patients with neuromas with stump excision and transposition into a vein. Two patients who had persistent pain were reexplored and found that the nerve had pulled out of the vein; they were treated with the same technique and had “excellent results” at the final follow-up. A disadvantage of transposing a neuroma into a vein is that a painful neuroma can develop if the vein collapses or if nerve pulls away from the vein.22

Surgical Management of Neuromas Based on Zones Sood and Elliot7 divided painful end- neuromas of the hand and wrist into three zones (Figure 5). Zone 1 neuromas are located distal to the metacarpal phalangeal joint and include digital nerves and terminal branches of Zones of the hand to be used to guide relocation of end-neuromas in the hand nerves that provide sensation to the and wrist. dorsum of the hand. Zone 2 neuromas include pain from the common digital nerves, the palmar cutaneous branches mechanical stimulation. The im- be loss of distal sensation/function of of the median and ulnar nerves, and planted nerve end should be tension the involved nerve. dorsal branch of the ulnar nerve. freeandbeplacedinanareathat Zone 3 neuromas comprise the radial will prevent regeneration into the Neuroma Resection and border of the wrist and forearm, and skin and minimize the formation they include pain from the SRN, lat- 9 Transposition Into Vein of scar tissue. Transposition into a eral antebrachial cutaneous (LABC) muscle with large excursion (abduc- Histologically, Koch et al34 examined nerve, medial antebrachial cutaneous tor pollicis longus) or intrinsic hand femoral nerve neuromas in a rat (MABC) nerve, and posterior cutane- muscles has been shown to be less modelthatwereresectedandim- ous nerve of the forearm (PCNF). effective than transposition into the planted into the femoral vein. Neu- Several authors have suggested using pronator quadratus (PQ).9,22 Other romas that underwent this treatment the zones of the hand to help guide successful sites of neuroma resection were smaller in size, had higher neu- surgical relocation procedures for the and transposition in muscle include ral tissue to connective tissue ratios, the PQ, brachioradialis, brachialis, and had a greater amount of orga- neuromas. The first choice for reloca- biceps brachii, and triceps.7-9,22,29-31 nized fascicles compared with the tion for zone 1 neuromas is the proxi- Good to excellent results are reported controlgroup,whichunderwentre- mal phalanx or metacarpal; for zone with neuroma resection and trans- section alone. With a clinical study, 2, first choice of relocation is the PQ, position into muscle and will be dis- Koch et al33 then followed 24 neu- and for zone 3 neuromas, it is recom- cussed further based on the zone of romas in 23 patients treated with mended to relocate the neuroma to injury.1,7,8,30-33 In all cases of neuroma neuroma excision and transposition muscles of the arm and forearm, espe- resection and transposition, there will into a vein with an average follow-up cially the brachioradialis.7,22,29-31,36

360 Journal of the American Academy of Orthopaedic Surgeons

Surgical Management of Zone 1 damage and resultant fascicular into the PQ. An intravenous cannula Neuromas escape.9,38 In contrast to other zone was placed proximal to the buried Zone 1 neuromas include all neuro- 1 neuromas, bowler neuromas have nerve, and 0.125% bupivacaine solu- mas volar and dorsal to the meta- been treated successfully with neu- tion was infused continuously for carpal phalangeal joint. Amputation rolysis and/or neurectomy and graft- 7 days. Pain to palpation of the neu- of the finger is the most common ing. A recent case report successfully roma was present in all cases before cause for digital neuromas, and it has treated a bowler neuroma with surgery and completely relieved post- been reported to occur in 2.7% to transection of the adductor pollicis operatively. Seventy percent of patients 30% of cases.1 Van der Avoort et al1 insertion followed by dorsal trans- experienced some pain with palpation retrospectively reviewed 583 pa- position of the ulnar digital nerve at the site of relocation, but all patients tients with a peripheral nerve injury and subsequent reattachment of ad- reported the new location was less and found that those with a digital ductor pollicis volar to the transposed frequently traumatized with routine amputation (177 patients) were nerve. The patient returned to bowling use of the hand. Evans and Dellon32 more likely to develop a neuroma at 5 months and had no recurrence of enrolled 13 consecutive patients with than those with a nerve injury symptoms at 3-year follow-up.38 painful palmar cutaneous branch of the without an amputation treated with median nerve neuromas that were primary nerve repair (7.3% versus Surgical Management of Zone 2 treated with resection of the neuroma 1%). Most procedures to treat zone Neuromas and implantation into the PQ. At a 1 neuromas involve relocation of the Neuromas of the common digital mean follow-up of 19 months, 6 pa- nerve to a proximal site in bone or nerves, the palmar cutaneous branches tients were graded as excellent and had muscle. Hazari and Elliot36 reported of the median and ulnar nerves, and no residual pain, had increased on 108 neuromas in zone 1 treated dorsal branch of the ulnar nerve com- pinch/grip strength, and returned to with proximal relocation; 98% of pose zone 2. The PQ is one of the most previous work status. The remaining the relocated nerves had complete commonly used muscles for implanta- seven patients had minimal residual pain relief at the primary site, al- tion of a resected neuroma. This tech- pain but worked at a new job ca- though 17% of the relocated nerves nique involves dissection and resection pacity or had some degree of limita- had pain at the site of relocation and of the neuroma and the nerve proxi- tion of wrist movement and were 23% required more than one sur- mally, with implantation into the PQ graded as good. gery. Their most common treatment muscle at a depth of 0.5 cm.7 Care was relocation of two bony segments mustbetakentohavesufficientlength Surgical Management of Zone 3 proximal into the radial surface of of the nerve, so that there is no tension Neuromas the bone. If the neuroma was in the with wrist or forearm range of motion. Zone 3 neuromas encompass neuro- middle or proximal phalanx, the Evans and Dellon32 had good to ex- mas of the radial wrist and forearm and neuroma was taken through the in- cellent results in 13 of 13 patients with arise from the SRN, MABC, LABC, terosseous muscle in the palm and end-neuromas of the palmar cutane- and PCNF.31 Atherton et al31 recom- relocated into a drill hole on the ous branch of the median nerve that mended transferring neuromas of the dorsoradial surface of the meta- were implanted into the PQ at a mean SRN to the brachioradialis muscle, carpal. The authors recommended follow-up of 19 months. Atherton neuromas of the LABC to the bra- relocating two bony segments prox- et al30 relocated 46 painful end- chialis muscle above the elbow, neu- imal to minimize trauma and to avoid neuromas into the PQ; 31 of 46 re- romas of MABC to the biceps muscle any possible palmar-dorsal sensory located nerves had no pressure pain at above the elbow, and neuromas of the nerve interconnections, which has the PQ, 12 nerves had mild pain with PCNF to the brachioradialis below the been previously described and occurs pressure, and 3 nerves had moderate elbow or if proximal, into the triceps most commonly at the middle of the pressure pain. With extremes of supi- muscle. In their study of 33 patients, proximal phalanx.37 nation, pronation, and wrist exten- they reported on 51 painful end- Neuritis of the ulnar digital nerve of sion, 10 nerves had mild pain and 7 neuromas in zone 3 arising from the the thumb, also known as bowler nerves had moderate movement pain. SRN (29), LABC (16), MABC (2), and thumb, is caused by abundant fibrous Sood and Elliot7 reportedon13 PCNF (4). All neuromas were excised tissue formation around the nerve as a painful neuromas in zone 2 that were and relocated proximally: 40 im- result of persistent compression or treated with intraneural dissection of planted into the brachioradialis, 3 im- trauma, which infrequently forms a the neuroma and excision from its planted into the radius bone, and 1 into neuroma possibly from perineurium parent nerve followed by implantation the flexor carpi radialis. Forty-seven of

May 15, 2019, Vol 27, No 10 361

51 nerves had total resolution of pain and relocating proximally using the tions. Careful history and physical and hypersensitivity at the original delineated techniques for a primary examination are essential for correct neuroma site, 48 of 51 relocated nerves neuroma based on its location. diagnosis and management. Conser- had no spontaneous pain at the relo- However, when preservation of the vative options should be exhausted cation site, and 43 of 51 nerves had no nerve is necessary for function (eg, before any surgical intervention. Neu- pain on pressure at the relocation site. median nerve at the carpal tunnel), romas that fail this should then follow The authors warn that failure of relo- resection and translocation of a the three basic principles that were cation surgery in this zone may be neuroma-in-continuity would lead to previously described for surgical man- secondary to incomplete “clearing” of poor results. Adani et al39 treated nine agement. Unfortunately, the literature the nerves involved; in a cadaver study, median nerve neuroma-in-continuity does not clearly support one technique. 75% of SRN and LABC had partial or at the level of the carpal tunnel with For optimal outcomes, patients who complete overlap of cutaneous inner- neurolysis and PQ muscle flap. At a undergo surgery should have signs and vation. Secondary to the overlapping mean follow-up of 23 months, eight symptoms consistent with neuroma of sensory zones and possible inter- of nine patients experienced pain re- andpaininananatomicdistribution. connections between nerves, the au- lief, six patients had regression of the thors recommended having a high Tinel sign, and no patients were dis- suspicion for more than one involved satisfied with their final results. Other References nerve and dual neuroma excision and authors use intraoperative neuro- Evidence-based Medicine: Levels of transposition when appropriate. Pre- physiologic testing to decide if neu- evidence are described in the table of operative local anesthestic injections rolysis alone or resection with contents. In this article, references 26 may help exclude a secondary nerve grafting would lead to better out- and 27 are level II studies. References causing neuroma pain. comes. The question is whether the 3, 9, 13, 17, 19, and 23 are level III neuroma has the potential for further studies. References 1, 2, 4, 6-8, 11, recovery before irreversible muscle Management of Neuromas 12, 14-16, 18, 20-22, 24, 25, 28-37, damage sets in if the nerve in question Incontinuity and 39 are level IV studies. Refer- is motor. If nerve stimulation proxi- ences 5, 10, 38, and 40 are level V A neuroma-in-continuity is the result mal to the neuroma-in-continuity fails studies. of an intact nerve being injured, which to evoke muscle contraction or a nerve leads to dysfunction of the distal por- action potential cannot be detected References printed in bold type are tion of the nerve as a result of internal through the site in question, then re- those published within the past 5 years. damage of the fascicles. The support- section of the neuroma to healthy ing structure of the nerve remains 1. van der Avoort DJ, Hovius SE, Selles RW, fascicles and then reconstruction with van Neck JW, Coert JH: The incidence of intact; but, the damaged nerve fibers nerve grafting is advocated.40 symptomatic neuroma in amputation and undergo degeneration, and a disorga- neurorrhaphy patients. J Plast Reconstr Digital nerve neuroma-in-continuity Aesthet Surg 2013;66:1330-1334. nized collection of nerve cells and have had poor results with neuroma connective tissue result at the injury 21,22 25 2. Martins RS, Siqueira MG, Heise CO, excision alone. Thomsen et al Yeng LT, de Andrade DC, Teixeira MJ: site. Although altered, along with pain retrospectively reviewed 10 neuroma- Interdigital direct neurorrhaphy for and hypersensibility, neuroma-in- in-continuity of the hand that un- treatment of painful neuroma due to finger continuity may have some preserved amputation. Acta Neurochir (Wien) 2015; derwent resection and repair with 157:667-671. 3,36 sensory and motor function. collagen tubes; all gaps were less Hazari and Elliot36 reported on 14 3. Mavrogenis AF, Pavlakis K, Stamatoukou than 20 mm. With a mean follow- A, et al: Current treatment concepts for neuroma-in-continuity (9 following up of 11.8 months, no patient had a neuromas-in-continuity. Injury 2008; digital nerve microsurgical epineural reoccurrence of pain at the neuroma 39(suppl 3):S43-S48. repair and 5 following crush injuries site. However, five patients contin- 4. Stokvis A, van der Avoort DJ, van Neck JW, to 3 digital nerves, 1 SRN, 1 dorsal Hovius SE, Coert JH: Surgical management ued to have cold intolerance, and of neuroma pain: A prospective follow-up branch of ulnar nerve) that were only 50% had two-point discrimi- study. Pain 2010;151:862-869. treated with resection and proximal nation less than 6 mm. 5. Sunderland S: The anatomy and physiology relocation. When grouped with 83 of nerve injury. Muscle Nerve 1990;13: other neuromas treated with proxi- 771-784. mal relocation, 77% were pain free Summary 6. Yuksel F, Kislaoglu E, Durak N, Ucar C, at the final follow-up. For noncriti- Karacaoglu E: Prevention of painful neuromas by epineural ligatures, flaps cal nerves, the authors recommend Treating hand and wrist neuromas is a and grafts. Br J Plast Surg 1997;50: transecting the neuroma-in-continuity challenge with many treatment op- 182-185.

362 Journal of the American Academy of Orthopaedic Surgeons

7. Sood MK, Elliot D: Treatment of painful 20. Carroll I: Pharmacologic management of 30. Atherton DD, Leong JC, Anand P, Elliot D: neuromas of the hand and wrist by upper extremity chronic nerve pain. Hand Relocation of painful end neuromas and relocation into the pronator quadratus Clin 2016;32:51-61. scarred nerves from the zone II territory of muscle. J Hand Surg Br 1998;23:214-219. the hand. JHandSurgEurVol2007;32: 21. Tupper JW, Booth DM: Treatment of 38-44. 8. Dellon AL, Mackinnon SE: Treatment of painful neuromas of sensory nerves in the the painful neuroma by neuroma resection hand: A comparison of traditional and 31. Atherton DD, Fabre J, Anand P, Elliot D: and muscle implantation. Plast Reconstr newer methods. J Hand Surg Am 1976;1: Relocation of painful neuromas in zone III Surg 1986;77:427-438. 144-151. of the hand and forearm. J Hand Surg Eur Vol 2008;33:155-162. 9. Watson J, Gonzalez M, Romero A, Kerns J: 22. Guse DM, Moran SL: Outcomes of the Neuromas of the hand and upper extremity. surgical treatment of peripheral neuromas 32. Evans GR, Dellon AL: Implantation of J Hand Surg Am 2010;35:499-510. of the hand and forearm: A 25-year the palmar cutaneous branch of the comparative outcome study. Ann Plast Surg median nerve into the pronator 10. Novak CB, Mackinnon SE, Patterson GA: 2013;71:654-658. quadratus for treatment of painful Evaluation of patients with thoracic outlet neuroma. JHandSurgAm1994;19: syndrome. JHandSurgAm1993;18:292-299. 23. Tay SC, Teoh LC, Yong FC, Tan SH: The 203-206. prevention of Neuroma formation by 11. Nath RK, Mackinnon SE: Management of diathermy: An experimental study in the rat 33. Koch H, Haas F, Hubmer M, Rappl T, neuromas in the hand. Hand Clin 1996;12: common peroneal nerve. Ann Acad Med Scharnagl E: Treatment of painful neuroma 745-756. Singapore 2005;34:362-368. by resection and nerve stump transplantation into a vein. Ann Plast Surg 12. Fisher GT, Boswick JA Jr: Neuroma 24. Al-Qattan MM: Prevention and treatment 2003;51:45-50. formation following digital amputations. J of painful neuromas of the superficial Trauma 1983;23:136-142. radial nerve by the end-to-side nerve repair 34. Koch H, Herbert TJ, Kleinert R, Hubmer M, 13. Wu J, ChiuPainful DT: neuromas: A review concept: An experimental study and Scharnagl E, Pierer G: Influence of nerve of treatment modalities. Ann Plast Surg preliminary clinical experience. stump transplantation into a vein on 1999;43:661-667. Microsurgery 2000;20:99-104. neuroma formation. Ann Plast Surg 2003; 50:354-360. 14. Ducic I, Mesbahi AN, Attinger CE, Graw K: 25. Thomsen L, Bellemere P, Loubersac T, The role of peripheral nerve surgery in the Gaisne E, Poirier P, Chaise F: Treatment by 35. Herbert TJ, Filan SL: Vein implantation for treatment of chronic pain associated with collagen conduit of painful post-traumatic treatment of painful cutaneous neuromas: amputation stumps. Plast Reconstr Surg neuromas of the sensitive digital nerve: A A preliminary report. J Hand Surg Br 1998; 2008;121:908-914. retrospective study of 10 cases. Chir Main 23:220-224. 2010;29:255-262. 15. Chu MM, Chan RK, Leung YC, Fung YK: 36. Hazari A, Elliot D: Treatment of end- Desensitization of finger tip injury. Tech 26. Weber RA, Breidenbach WC, Brown RE, neuromas, neuromas-in-continuity and Hand Up Extrem Surg 2001;5:63-70. Jabaley ME, Mass DP: A randomized scarred nerves of the digits by proximal prospective study of polyglycolic acid relocation. J Hand Surg Br 2004;29: 16. Laing T, Siddiqui A, Sood M: The conduits for digital nerve reconstruction in 338-350. management of neuropathic pain from humans. Plast Reconstr Surg 2000;106: neuromas in the upper limb: Surgical 1036-1045. 37. Bas H, Kleinert JM: Anatomic variations in techniques and future directions. Plast sensory innervation of the hand and digits. J Aesthet Res 2015;2:165. 27. Boeckstyns ME, Sorensen AI, Vineta JF, Hand Surg Am 1999;24:1171-1184. et al: Collagen conduit versus microsurgical 17. Kesikburun S, Yasar E, Dede I, Goktepe S, neurorrhaphy: 2-year follow-up of a 38. Swanson S, Macias LH, Smith AA: Tan AK: Ultrasound-guided steroid prospective, blinded clinical and Treatment of bowler’s neuroma with digital injection in the treatment of stump electrophysiological multicenter nerve translocation. Hand (N Y) 2009;4: neuroma: Pilot study. J Back Musculoskelet randomized, controlled trial. J Hand Surg 323-326. Rehabil 2014;27:275-279. Am 2013;38:2405-2411. 39. Adani R, Tarallo L, Battiston B, Marcoccio 18. Rasmussen MR, Kitaoka HB, Patzer GL: 28. Mackinnon SE, Dellon AL, Hudson AR, I: Management of neuromas in continuity Nonoperative treatment of plantar Hunter DA: Alteration of neuroma of the median nerve with the pronator interdigital neuroma with a single formation by manipulation of its quadratus muscle flap. Ann Plast Surg corticosteroid injection. Clin Orthop Relat microenvironment. Plast Reconstr Surg 2002;48:35-40. Res 1996;188-193. 1985;76:345-353. 40. Kline DG, Nulsen FE: The neuroma in 19. Saarto T, Wiffen PJ: Antidepressants for 29. Elliot D: Surgical management of painful continuity: Its preoperative and operative neuropathic pain. Cochrane Database Syst peripheral nerves. Clin Plast Surg 2014;41: management. Surg Clin North Am 1972; Rev 2007:CD005454. 589-613. 52:1189-1209.

May 15, 2019, Vol 27, No 10 363