Successful treatment of a painful neuroma using fascicular shifting in the ulnar nerve: Case report

The authors report the case of a forty-year old man with an inveterate ulnar nerve neuroma following a laceration injury of his left wrist twenty-three years ago. He presented with a typical ulnar claw-hand deformity and debilitating neuropathic pain in his hand (VAS 8.4). Pre-operative imaging revealed a neuroma of the ulnar nerve at the Guyon’s canal. Moreover, a complete atrophy of all intrinsic hand muscles innervated by the ulnar nerve was present. A Zancolli lasso procedure was performed to reduce the clawing effect. The neuroma was resected producing a nerve defect of five centimeters. Since the injury dated back more than two decades and any motor recovery was deemed impossible at that point, the motor fascicle of the ulnar nerve, i.e. the deep branch, was harvested and used as an autologous nerve graft to bridge the defect. The deep branch fascicle was dissected proximally, harvested and shifted into the defect to be coapted with the superficial branch fascicle in an end-to-end fashion. The presented procedure resulted in satisfying and sustained pain reduction (VAS 2.5) at two-year follow-up. Hence, the authors recommend considering fascicular shift procedure in peripheral sensory nerve reconstruction as a cost-effective alternative.