Excision and Inter-Positional Sural Nerve Graft for Post-Traumatic Non-Conducting Ulnar Nerve Neuroma

Document Type : Original Article

Authors

1 The Department of Plastic Surgery, Faculty of Medicine, Mansoura University

2 The Department of Radiodiagnosis, Faculty of Medicine, Mansoura University

Abstract

Introduction: Ulnar nerve injuries around the wrist result
in paralysis of intrinsic muscles and sensory loss of little
finger and ulnar half of ring finger. Formation of traumatic
neuroma of the ulnar nerve adds pain at the site of nerve
repairs.
Patients and Methods: 10 patients were included in this
study. Clinical, radiological and electrophysiological assessment
indicate surgery in these patients where neuroma was
excised, identification of sensory and motor fascicles of the
ulnar nerve was done and cable nerve grafts were used to
bridge the nerve defects. Assessment of the outcome was done
in patients who finished follow-up for at least one year.
Results: Pain at the site of neuroma disappeared after
surgery. All patients were followed-up and 6 patients needed
tendon transfer after one year. Sensory recovery was achieved
after one year. Trophic changes and cold intolerance was
improved.
Discussion: Primary repair of ulnar nerve injuries is the
gold standard treatment for such injuries. Claw hand, weakness
of the hand grip and abduction deformities are the main motor
defects which can be corrected by tendon transfers. However,
sensory defects and cold intolerance affected the outcome of
surgery. When the diagnosis of non-conducting neuroma is
made, neuroma resection and reconstruction improve the
clinical outcome.
Conclusion: The unfavorable outcomes of ulnar nerve
injuries can be improved by resection of neuroma in continuity
and nerve grafting. Multidisciplinary team is needed to achieve
the best clinical outcomes.

Keywords

Main Subjects

References

1- Sunderland S.: The anatomy and physiology of nerve
injury. Muscle Nerve, 13: 771-784, 1990.
2- Mackinnon S.E. and Dellon A.L.: Results of treatment of
recurrent dorsoradial wrist neuromas. Ann. Plast. Surg.,
19 (1): 54-61, 1987.
3- Mackinnon S.E., Dellon A.L., Hudson A.R. and Hunter
D.A.: Alteration of neuroma formation by manipulation
of its microenvironment. Plast. Reconstr. Surg., 76: 345-
352, 1985.
4- Yüksel F., Kis¸laogˇlu E., Durak N., Uçar C. and Karacaog
ˇlu E.: Prevention of painful neuromas by epineural
ligatures, flaps and grafts. Br. J. Plast. Surg., 50: 182-
185, 1997.
5- Sapienza A. and Green S.: Correction of the Claw Hand.
Hand Clin., 28: 53-66, 2012.
6- Kouyoumdjian J.A.: Peripheral nerve injuries: A retrospective
survey of 456 cases. Muscle Nerve, 34: 785,
2006.
7- Vordemvenne T., Langer M., Ochman S., et al.: Longterm
results after primary microsurgical repair of ulnar
and median nerve injuries: A comparison of common
score systems. Clin. Neurol. Neurosurg., 109: 263, 2007.
8- Allan C.H. and Vanderhooft E.: Functional outcomes after
nerve grafting. Atlas Hand Clin., 10: 93, 2005.
9- Kim D.H., Han K., Tiel R.L., Murovic J.A. and Kline
D.G.: Surgical outcomes of 654 ulnar nerve lesions. J.
Neurosurg., 98: 993, 2003.
10- Andreisek G., Crook D.W., Burg D., Marincek B. and
Weishaupt D.: Peripheral neuropathies of the median,
radial and ulnar nerves: MR imaging features. Radiographics,
26: 1267-1287, 2006.
11- Cobb T.K., Carmichael S.W. and Cooney W.P.: Guyon’s
canal revisited: An anatomic study of the carpal ulnar
neurovascular space. J. Hand Surg., 9: 861-869, 1996.
12- Sunderland S., Marshall R.D. and Swaney W.E.: The
intraneural topography of the circumflex, musculocutaneous
and obturator nerves. Brain, 32: 116-29, 1959.
13- Sunderland S.: The intraneural topography of the radial,
median and ulnar nerves. Brain, 68: 243-98, 1945.
14- Williams H.B. and Jabaley M.E.: The importance of
internal anatomy of the peripheral nerves to nerve repair
in the forearm and hand. Hand Clin., 2: 689-707, 1986.
406 Vol. 44, No. 3 / Excision & Inter-Positional Sural Nerve Graft
15- Chow J.A., Van Beek A.L., Meyer D.L. and Johnson M.C.:
Surgical significance of the motor fascicular group of the
ulnar nerve in the forearm. J. Hand Surg. Am., 10: 867-
72, 1985.
16- Brandt K.E. and Mackinnon S.E.: Microsurgical repair
of peripheral nerves and nerve grafts. In: Aston S.J.,
Beasley R.W., Throne C.H.M., editors. Grabb and Smith’s
Plastic Surgery, 5th edition. Philadelphia: Lippincott
Williams & Wilkins, 1997.
17- Wang Y., Sunitha M., Kevin C. and Chung K.C.: How to
Measure Outcomes of Peripheral Nerve Surgery. Hand
Clin., 29 (3): 349-361.
18- Bergmeister K.D., Große-Hartlage L., Daeschler S.C.,
Rhodius P., Böcker A., Beyersdorff M., Kern A.O., Kneser
U. and Harhaus L.: Acute and long-term costs of 268
peripheral nerve injuries in the upper extremity. PLoS
One, 6; 15 (4): e0229530, 2020.
19- Sunderland S.: Ulnar nerve lesions. In Nerves and Nerve
Injuries. Edinburgh: Churchill Livingstone, 750-779,
1978.
20- Dellon A.L., Curtis R.M. and Edgerton M.T.: Reeducation
of sensation in the hand after injury and repair. Plast.
Reconstr. Surg., 53: 297, 1974.
21- Vikström P., Björkman A., Carlsson I.K., Olsson A.K.
and Rosén B.: Atypical sensory processing pattern following
median or ulnar nerve injury - a case-control study.
BMC Neurol., Sep. 19; 18 (1): 146, 2018.
22- Watson J., Gonzalez M., Romero A. and Kerns J.: Neuromas
of the Hand and Upper Extremity. J. Hand Surg.,
35A: 499-510, 2010.
23- Carlsson I., Cederlund R., Hoglund P., Lundborg G. and
Rosen B.: Hand injuries and cold sensitivity: Reliability
and validity of cold sensitivity uestionnaires. Disability
and rehabilitation, 30: 1920-8, 2008.
24- Elliot D., Lloyd M., Hazari A., et al.: Relief of the pain
of neuromas-in-continuity and scarred median and ulnar
nerves in the distal forearm and wrist by neurolysis,
wrapping in vascularized forearm fascial flaps and adjunctive
procedures. J. Hand Surg. Eur., 35: 575-82,
2010.
25- Jones N.F., Shaw W.W., Katz R.G., et al.: Circumferential
wrapping of a flap around a scarred peripheral nerve
for salvage of end-stage traction neuritis. J. Hand Surg.
Am., 22: 527-35, 1997.
26- Ghoraba S.M., Mahmoud W.H., Elsergany M.A. and Ayad
H.M.: Ulnar Nerve Injuries (Sunderland Grade V): A
Simplified Classification System and Treatment Algorithm.
Plast. Reconstr. Surg. Glob Open, 21; 7 (11): e2474, 2019.
27- Barrios C., Amillo S., Pablos J. and Canadell J.: Secondary
repair of ulnar nerve injury: 44 cases followed for 2 years.
Acta. Orthop. Scand, 61: 46, 1990.
28- Terzis J.K. and Kokkalis Z.T.: Outcomes of Secondary
Reconstruction of Ulnar Nerve Lesions: Our Experience.
Plast. Reconstr. Surg., 122: 1100, 2008.
29- Ding W., Li X., Pan J., Zhang P., Yin S., Zhou X., Li J.,
Wang L., Wang X. and Dong J.: Repair Method for Complete
High Ulnar Nerve Injury Based on Nerve Magnified
Regeneration. Ther. Clin. Risk Manag., Mar. 3 (16): 155-
168, 2020.

Files

Share

How to cite

Statistics