Management of Neuroma of the Medial Dorsal Cutaneous Nerve with Proximal Phalanx Intra-articular Fracture
The optimal management approach for a neuroma of the medial dorsal cutaneous nerve with a proximal phalanx intra-articular fracture requires surgical intervention for both conditions, with surgical excision and transposition of the neuroma followed by appropriate fixation of the intra-articular fracture to optimize functional outcomes and minimize pain.
Neuroma Management
Diagnosis and Assessment
- Painful neuromas present with characteristic symptoms including spontaneous electric, shooting or burning pain, allodynia, hyperalgesia, and cold intolerance 1
- Diagnosis is confirmed through medical history, physical examination, Tinel's test (tapping over the suspected neuroma site elicits pain), and diagnostic nerve blockade 1
Surgical Treatment Options
- Surgical treatment is the most effective approach for painful neuromas that are refractory to conservative management 2
- Surgical options include:
- Surgical intervention has been shown to significantly improve patient-reported pain, depression, and quality of life scores 2
Timing Considerations
- Early referral to a plastic surgeon or multidisciplinary consultation is important as symptoms become increasingly difficult to treat over time 1
- Neuroma treatment should be performed before or simultaneously with fracture management to prevent exacerbation of neuroma symptoms during fracture healing 1
Proximal Phalanx Intra-articular Fracture Management
Assessment and Classification
- Radiographic evaluation with at least three projections is essential to properly characterize the fracture 4
- Intra-articular fractures require careful assessment of joint congruity and displacement 5
Surgical Management
- Intra-articular fractures with displacement require surgical fixation to restore joint congruity 5
- Surgical fixation options include:
- Post-reduction radiographic parameters should aim for less than 3 mm of radial shortening and less than 10° of dorsal tilt 5
Post-surgical Care
- Early active motion is critical to prevent stiffness and should be initiated as soon as fracture stability allows 4
- Buddy taping with adjacent digits provides stability while allowing early active motion 4
- Dorsal night splinting in 10° flexion helps maintain proper alignment during healing 4
Integrated Management Approach
Surgical Planning
- A single-stage procedure addressing both the neuroma and fracture is preferred when possible 2
- For the neuroma component:
- Excision of the neuroma with relocation of the nerve stump into bone, muscle tissue, or a vein 1
- For the fracture component:
- Anatomic reduction and stable fixation of the intra-articular fracture 5
Rehabilitation Protocol
- Regular radiographic evaluation for the first 3 weeks and at cessation of immobilization 4
- Early active range-of-motion exercises including all joints of the affected digit 4
- Above chest level activities should be restricted until fracture healing is evident 5
- Overly aggressive physical therapy should be avoided as it may increase the risk of fixation failure 5
Potential Complications
- Joint stiffness is the most common complication, minimized by early active motion 4
- Persistent neuroma pain may require additional surgical intervention 2
- Intra-articular fractures have risk of post-traumatic arthritis if anatomic reduction is not achieved 5