SCIENTIFIC ARTICLE Treatment of Painful Median Nerve Neuromas With Radial and Ulnar Artery Perforator Adipofascial Flaps Roberto Adani, MD, Pierluigi Tos, MD, Luigi Tarallo, MD, Massimo Corain, MD Purpose To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps. Methods Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel’s sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18e84 mo). Preoperative and postoperative pain was measured with a visual analog scale. Results Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site. Conclusions Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve. (J Hand Surg Am. 2014;39(4): 721e727. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Median nerve, neuroma, pain, perforator flaps, fascial flaps. P AINFUL MEDIAN NERVE NEUROMAS at the wrist represent a complex clinical problem. 1 Neuro- genic pain can develop after microsurgical re- pair of a median nerve injury or when the lesion is underestimated and therefore not treated at all. An injury leading to neuromatous pain may be associated with swelling at the wrist and increased pain and tingling when tapped. The aim of the treatment is to both mini- mize pain and preserve residual function of the median nerve. Neurolysis is often the first attempt, but it does not always relieve the pain. Reconstruction with grafts is reserved for cases with poor sensory and motor re- covery. Neurolysis should be performed carefully to avoid devascularization of the nerve and formation of a new perineural scar, which may be more aggressive than before. 2 Particular attention has been given to the coverage and wrapping of a neuroma with pedicle flaps such as the pronator quadratus muscle flap, 3 the Becker flap, 4 the reverse island radial fascial flap with From the Department of Hand Surgery and Microsurgery, University Hospital of Verona, Verona; the Department of Microsurgery, CTO Torino, Torino; and the Department of Orthopaedic Surgery, University of Modena and Reggio Emilia, Modena, Italy. Received for publication June 24, 2013; accepted in revised form January 14, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Roberto Adani, MD, Department of Hand Surgery and Micro- surgery, University Hospital Verona, Ospedale GB Rossi, Piazzale LA Scuro 10, Verona, Italy; e-mail: roberto.adani@ospedaleuniverona.it. 0363-5023/14/3904-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.01.007 Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 721