Biomedical subjects
Publications and source records attributed to Adam J Vernadakis.
The fingertip is a complex anatomic unit highly specialized in function and particularly prone to injury. Its complex design and the difficulty of secondary repairs demand great care in initial evaluation, diagnosis, and treatment for optimal long-term outcome. The goals of treatment should be to preserve length, maintain sensation, mobilize early, return function expediently, and be mindful of cosmesis.
Median nerves with neuromas-in-continuity are preferably managed by the identification and preservation of the functioning motor fascicles proximal and distal to the neuroma. The non-functioning, painful sensory fibers are divided proximally and distally and are reconstructed with nerve grafts. In cases where the proximal motor fascicle may not be safely and effectively isolated because of scarring or previous surgical intervention, the distal anterior interosseous nerve (dAIN) may be grafted to the recurrent motor branch of the median (RMB) nerve distal to the neuroma. The primarily motor fibers of the dAIN provide an expendable donor of adequate size and fascicle number to restore thenar muscle function.
After nerve injury and regeneration, significant pain may be associated with the scar and altered sensation observed within the distribution of the injured nerve. A bulbous swelling may form at the severed nerve end, constituting a traumatic neuroma. The development of a painful neuroma may be more disabling to the patient than an area of anesthesia or even loss of motor function. Effective treatment of the painful neuroma remains a difficult problem. Diminished productivity, alterations in patient lifestyle, and possible progression to chronic pain syndromes must be considered within the scope of neuroma management, and treatment must focus on alleviating the pain and restoring the functional loss caused by the nerve injury. Careful patient selection is the cornerstone of successful outcomes. Once the patient has been selected, the surgical management of the painful neuroma throughout the body is based on basic principles that vary only slightly from region to region. Using these tenets, a neuroma management algorithm has been developed based on the pathophysio-logy of the neuroma, the results of experimental studies, review of patient outcomes, and understanding the psychology of pain in the surgical patient.