Coverage of neuroma in continuity

Abstract

Neurogenic pain can develop after microsurgical repair of a median nerve injury or when the lesion is underestimated and therefore not treated at all. Nerve injury with neuromatous pain may be associated with tumefaction at the wrist, increased pain and tingling when tapped [1]. The aim of the treatment is to both minimize pain and preserve residual function of the median nerve. Surgical procedures such as neurolysis do not always relieve the patients’ pain. Reconstruction with grafts is reserved only for cases with very poor sensory and motor recovery. Neurolysis should be performed carefully to avoid devascularization of the nerve and formation of a new scar around the nerve [2]. Particular attention has been given to the coverage and wrapping of a neuroma with different pedicle flaps as the pronator quadratus muscle flap [3], the Becker flap [4], the reverse island radial fascial flap with or without inclusion of the radial artery [2,5-7] and the local synovial flap [8]. With regards to free flaps, Wintsch [9] believes that a thin flap of gliding fascia is the ideal flap to cover a nerve, whereas Jones [10] advocates the use of a small hemi-latissimus dorsi muscle flap. The lateral arm flap [2,11,12] and the scapular flap [2,11] represent other options but the thickness of the subcutaneous tissue and the overlying skin often produce very prominent flaps [10]. Goitz and Steichen [13] reported the coverage of a scarred median nerve with a free omental flap. The purpose of this study is to review the treatment of painful neuroma of the median nerve at the wrist treated with external neurolysis and coverage using the ulnar artery perforator adipofascial flap (UAPAF) or the radial artery perforator adipofascial flap (RAPAF).