Case Reports

Posttraumatic Saphenous Neuroma After Open Tibial Fracture

Am J Orthop. 2015 November;44(11):E461-E464

References

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Making the diagnosis of neuroma-related neuralgia can be challenging and nebulous. A characteristic history and positive Tinel sign over the affected area are helpful clinical indicators. However, the clinical finding most predictive of favorable surgical outcome is symptomatic relief after local injection of 1% lidocaine to the affected area. This is an important diagnostic test, especially when attempting to differentiate painful neuroma from other causes of posttraumatic lower extremity pain (eg, CRPS). Such an injection should be performed in the diagnosis and treatment of symptomatic neuroma, and some authors would suggest that insufficient relief of symptoms with diagnostic nerve block is a contraindication to surgical treatment.¹⁹

Several treatments for painful neuromas have been described, with variable results.^19,20 The most widely accepted treatment of a complete nerve transection with associated neuroma is neurectomy with reimplantation of the proximal end into adjacent bone, muscle, or vein.^14,15 Balcin and colleagues²¹ suggest that vein transposition produces the most favorable outcomes. Simple neurolysis of in-continuity neuromas has also been described with favorable results.

Conclusion

Neuralgia-producing neuromas of the saphenous nerve are relatively uncommon but can lead to persistent pain and frustrating symptoms for the patient. As noted, the diagnosis may elude clinicians, especially in patients with less obvious clinical presentations. We suggest the following algorithm to help distinguish between painful neuroma and other causes of posttraumatic leg pain: (1) physical examination (including testing for instability, joint line tenderness, patellofemoral pain, Tinel sign, and Semmes-Weinstein testing) should be performed, and plain radiographs taken of the involved bones and joints; (2) if all of the above reveal no abnormality, and there is a positive Tinel sign directly over the course of a nerve, an injection of lidocaine over the region of the potential neuroma can be diagnostic; (3) should several abnormalities be present, further investigation using magnetic resonance imaging, bone scan, and/or electromyography may provide additional information that leads to a diagnosis.