The wristManagement of painful cutaneous neuromas around the wrist
Introduction
Painful neuromas around the wrist can be debilitating to the patient and frustrating for the surgeon. Many potentially sound and satisfactory surgical reconstructions around the wrist are ruined only by the development of a painful neuroma.
A neuroma is a large number of nerve minifascicles arranged in a chaotic fashion, formed by a large proportion of small, unmyelinated fibres with unrestrained growth of perineurial cells.1 A neuroma is a sequela of abnormal regeneration after a nerve injury. The pathophysiology of pain from a neuroma is not fully understood. However, it is believed to be associated with the unmyelinated fibres, molecular changes and mechanical activities.
Three cutaneous nerves are particularly vulnerable to injury during wrist procedures. First, the superficial radial nerve (SRN) is at risk during any thumb base procedure such as trapeziectomy, and procedures involving the distal radius such as percutaneous pinning of the distal radius and de Quervain's release.2 Second, the palmar cutaneous branch (PCB) of the median nerve is at risk during any volar sided procedures to the radial half of the wrist, including plating of distal radius, volar ganglion excision, scaphoid reconstruction and carpal tunnel release.3 Third, the dorsal cutaneous branch (DCB) of the ulnar nerve is at risk during any surgical procedures involving the distal ulna, triangular fibrocartilage complex, carpus and ulnar metacarpals.
The wrist is a high-risk site for the development of painful neuromas, perhaps due to the superficial location of the cutaneous nerves and the lack of substantial subcutaneous envelope.4 When a nerve has been cut, the best method of preventing neuroma formation is acute repair or grafting.5 Once a neuroma has formed, the management becomes more complex, with less predictable results. Prevention is thus paramount.
In this article, we will review the relevant anatomy of the cutaneous nerves followed by a discussion on the diagnosis and management options when they become painful neuromas.
Section snippets
Anatomy
The radial nerve divides into superficial and deep branches as it passes in front of the lateral epicondyle. At the distal third of the forearm, SRN travels beneath the tendon of brachioradialis and pierces the deep fascia approximately 8 cm proximal to the radial styloid process, to run along the dorsoradial aspect of the distal forearm.6 It divides into medial and lateral branches as it crosses the wrist. The lateral branch supplies the radial half of the base of the thumb. Often, the lateral
Diagnosis
The diagnosis of a painful neuroma around the wrist is usually fairly straightforward.14, 15 There is often a history of injury or an incision over the known course of the nerves together with clinical signs of a tender neuroma, sensory deficit in a predictable anatomical area and dysaesthesia would allow the diagnosis to be made.2 The neuroma is not necessarily palpable and can be small in size yet very tender. It is however reliably associated with a positive Tinel's sign. A more subtle, yet
Nonoperative treatment
Before embarking on surgical management, a trial of non-operative measures, involving a multidisciplinary approach, should always be attempted first. A pain specialist should be involved to optimize the medical treatment of these patients. Analgesic agents can be administered topically or systemically. Topical treatments such as a lidocaine patch or capsaicin may be applied over areas of hypersensitivity. Capsaicin cream, which exists in low strengths of 0.025% or 0.075%, can be prescribed by a
Conclusions
Peripheral cutaneous nerves at the wrist are vulnerable to injury during surgery. The best tactic for painful neuroma is to avoid injuring these nerves in the first place. The best way to achieve this is by having a sound anatomic knowledge and meticulous surgical technique. Once an injury has occurred, early recognition and primary repair may decrease the incidence of neuroma formation. Once a painful neuroma has formed, it is important to commence non-surgical measures involving a
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