Hand Surgery Source

NEUROMA

Introduction

Neuromas are benign, non-neoplastic peripheral nerve tumors caused by abnormal nerve regeneration after irritation or injury. Neuromas of the upper extremity are common and may cause disabling pain or loss of motor function. There are numerous operative and non-operative treatments that have shown varying degrees of clinical efficacy.1,2

Pathophysiology

  • Neuromas tend to be small and firm in texture.
  • Neuromas occur after a partial or complete nerve injury triggers an intrinsic reparative response involving the proliferation of disorganized axons, myofibroblasts, endothelial cells and Schwann cells.
  • Nerve injuries that may lead to neuroma formation:
    • A transected nerve if the nerve ends are not reunited (terminal neuroma)
    • Crush or stretch injuries with preserved continuity of the nerve (neuroma in continuity)
    • Scars induced by inflammation around a nerve even in absence of direct nerve injury

Incidence and Related Conditions

  • Neuromas of the upper extremity include: Pacinian Corpuscle Neuromas, Bowler’s Thumb, Neuroma-in-Continuity of the median, ulnar and radial nerves, radial sensory nerve neuromas, dorsal ulnar sensory nerve neuromas, digital nerve neuromas, medial antebrachial cutaneous nerve neuromas and lateral antebrachial cutaneous nerve neuromas with symptoms in the area of the flexor carpi radialis.
  • As a group, neuromas are uncommon, comprising <5% of all tumors of the hand.
  • The incidence of neuroma pain in upper limb amputees ranges from 4–25%.

Differential Diagnosis

  • Tender papule
  • Osteoarthritis
  • Osteoid osteoma
  • Pacinian corpuscle hypertrophy and hyperplasia3
  • Synovioma
  • Schwannoma
  • Traumatic aneurysm
ICD-10 Codes

NEUROMA

Diagnostic Guide Name

NEUROMA

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
NEUROMA, UPPER LIMB D36.12      

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Neuroma
  • Dorsal radial sensory neuroma from untreated laceration at level of the radial styloid prior to resection and transposition.
    Dorsal radial sensory neuroma from untreated laceration at level of the radial styloid prior to resection and transposition.
  • Median Nerve Neuroma-in-Continuity
    Median Nerve Neuroma-in-Continuity
Pathoanatomy Photos and Related Diagrams
Radial Nerve Anatomy
  • Radial sensory nerve: 1- Incision for release of the first extensor compartment; 2 - Dorsal radial sensory nerve located in superficial subcutaneous tissue.
    Radial sensory nerve: 1- Incision for release of the first extensor compartment; 2 - Dorsal radial sensory nerve located in superficial subcutaneous tissue.
Symptoms
Neuropathic pain may be caused by mechanical or chemical irritation, local scar tissue and dyesthetic sensory symptoms.
Paresthesias
Typical History

Neuromas typically arise from iatrogenic injury, trauma or chronic irritation.
Neuromas of the hand can be debilitating and painful, often preventing patients from continuing with their normal daily activities.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Anticonvulsants
Operative
  • Resection of neuroma with or without a suture tied around the distal end of the nerve after neuroma resection.
  • Resection with subsequent nerve grafting or primary repair.  Nerve grafts should be 10-20% longer than nerve gap to reduce tension and account for graft shrinkage.
  • Containment of the neuroma.
  • Nerve translocation into muscle.
Treatment Photos and Diagrams
Surgical Treatment of Neuroma
  • Radial sensory neuroma (1); Level of reaction and ligation; (3) Muscle which will receive the transposed proximal nerve end.
    Radial sensory neuroma (1); Level of reaction and ligation; (3) Muscle which will receive the transposed proximal nerve end.
Complications
  • Loss of sensory and/or motor function following excision
  • Continued pain post-resection
Outcomes
  • If a neuroma cannot be resected and repaired, for example a badly scarred neuroma of the radial sensory nerve over the radial styloid, then resection of the neuroma, tying a suture around the proximal stump and using this suture to anchor the transposed proximal nerve end in an adjacent muscle usually provides symptom relief.
  • Pacinian corpuscle hyperplastic is usually diagnosed and treated by excision of the mass.
  • Multiple operative techniques have been described with varied success.
  • If a neuroma can be resected and repaired with or without a graft and if the repair will lie in a healthy soft tissue bed, then this is an excellent surgical treatment for symptomatic neuromas.
Key Educational Points
  • Novel techniques that diminish the healing response, such as diathermy and cryosurgery, are being explored.
  • Not all neuromas develop painful symptoms.
References
  1. Guse D, Moran S. Outcomes of the surgical treatment of peripheral neuromas of the hand and forearm: a 25-year comparative outcome study. Ann Plast Surg 2013;71(6):654-8.  PMID: 22868319
  2. Depaoli R, Coscia DR, Alessandrino F. In-continuity neuroma of the median nerve after surgical release for carpal tunnel syndrome: case report. J Ultrasound 2014;18(1):83-5. PMID: 25767645
  3. Jones NF, Eadie P.  Pacinian corpuscle hyperplasia in the hand.  J. Hand Surg Am 1991;16(5):865-869.

Reviews

  1. Watson J, Gonzalez M, Romero A, et al. Neuromas of the hand and upper extremity. J Hand Surg Am 2010;35(11):1901-10. PMID: 20193866
  2. Brogan D, Kakar S. Management of neuromas of the upper extremity. Hand Clin 2013;29(3):409-20. PMID: 23895721

Classics

  1. Odier L. Manuel de Medecine Pratique, ed 2. Paris: J. Paschoud, 1811.
  2. Grant G. Methods of treatment of neuromata of the hand. J Bone Joint Surg Am 1951;33-A(4):841-8. PMID: 14880538
  3. Strickland J, Steichen J. Nerve tumors of the hand and forearm. J Hand Surg Am 1977;2(4):285-91. PMID: 197148