European Journal of Plastic Surgery

https://doi.org/10.1007/s00238-021-01790-9

CASE REPORT

Medial cutaneous nerve neuroma-in-continuity within the ulnar

nerve: a report of 2 cases
Jantine PosthumaDeBoer 1 & Raf Sciot 2 & Ilse Degreef 1

Received: 25 December 2020 / Accepted: 19 January 2021

# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Cubital tunnel syndrome is the second most prevalent entrapment neuropathy in the upper extremity and, therefore, surgical
decompression of the ulnar nerve is regularly performed. During this procedure, the medial antebrachial cutaneous nerve
(MACN) branches are at risk for iatrogenic injury because of their proximity to the medial incision used. Injuries to the
MACN may lead to painful neuroma formation and, more seldomly, to formation of neuromas-in-continuity.
Neuromas-in-continuity are challenging to treat as the neuroma needs to be dissected from nervous tissue that must remain
functional. In this paper, we present two cases of MACN neuromas-in-continuity within the ulnar nerve. We provide a detailed
description of the clinical features of painful MACN neuromas-in-continuity and provide a detailed description of two different
treatment options. This work highlights the advances made in microsurgery which provides better treatment possibilities for these
highly complex sequelae of ulnar nerve decompression surgery.
Level of evidence: Level V, risk / prognostic study.

Keywords Intraneural neuroma . Neuroma-in-continuity . Ulnar nerve . Microsurgery

Introduction Although persistent or recurrent pain after surgical ulnar

Cubital tunnel syndrome is the second most prevalent entrap-
ment neuropathy in the upper extremity with surgical decom-
pression by opening the Osborne fascia as regularly per-
formed operative treatment. The medial antebrachial cutane-
ous nerve (MACN) with its anterior and posterior branches
lies in close proximity to the incision used for ulnar nerve
decompression surgery which makes it susceptible to injury.
Consequently, iatrogenic injury of the MACN is a notorious
complication after ulnar nerve decompression. It can lead to
scar pain, painful neuroma formation, hypaesthesia and
hyperalgesia both locally and in the area of the sensory distri-
bution of the MACN with a significant negative impact on the
quality of life for the patient [1–4].
nerve decompression may be due to various reasons, injury
to branches of the MACN is one of the most common causes.
Moreover, painful neuromas that arise from injured MACN
branches may mimic recurrence or persistence of the ulnar
nerve compression syndrome, and neuromas can be
misdiagnosed as such [2–4]. For the treating physician, it is
important to be aware of both the relevant MACN branches as
well as the diagnosis and treatment of painful neuromas. Here,
we report 2 particular cases with a painful MACN
neuroma-in-continuity within the ulnar nerve and the success-
ful treatment thereof.
Case reports

Case 1
* Jantine PosthumaDeBoer
Jantine.posthumadeboer@uzleuven.be In 2012, a 40-year-old otherwise healthy male patient present-
ed to our outpatient clinic after having had multiple surgical
1
Department of Orthopaedic Surgery, University Hospitals Leuven, procedures to his left elbow within a 3-year period following a
KU Leuven, Herestraat 49, 3000 Leuven, Belgium complex elbow fracture dislocation. He had a radial head im-
2
Department of Pathology, KU Leuven and University Hospitals plant with secondary capitellum erosion and concurrent
Leuven, Leuven, Belgium cubital tunnel syndrome. Therefore, a radiocapitellar joint

arthroplasty was performed with ulnar nerve decompression
in situ. One year after this procedure, he had a painful
ulnohumeral joint osteoarthritis and was treated with a total
elbow arthroplasty. Although initial postoperative recovery
was uneventful, the patient developed hyperaesthesia at the
medial elbow scar in the course of the following year, which
progressed to unbearable and debilitating pain. He had a pos-
itive Tinel sign over the scar without altered sensibility in the
ulnar nerve distribution or impaired motor function in the
ulnar two digits.
It was suspected that the patient suffered from ulnar
nerve or MACN adhesion to the scar, and after informed
consent, a surgical exploration with × 4 loupe magnifi-
cation was scheduled. However, during surgery, we
found that the MACN ran alongside the ulnar nerve
and formed a neuroma which seemed to enter the ulnar
nerve. The MACN calibre had increased to 4 mm over a
length of approximately 5 cm and at the location where
this nerve attached to the ulnar nerve, the ulnar nerve
had an irregular and swollen morphology for a length
of 2 cm (Fig. 1a). At this time, it was judged that exci-
sion or biopsy of the neuroma would pose too high a
risk of damaging the ulnar nerve which was clinically
fully functional, and therefore, this neuroma-
in-continuity was left intact. Instead, the nerves and
neuroma-in-continuity were wrapped in a cellulose sheet
(Divide™, DePuy Mitek, Johnson & Johnson Medical
Inc., New Brunswick, NJ, USA) and were then trans-
posed underneath the flexor pronator muscle group
(Fig. 1b, c). Postoperatively, the arm was immobilized
in a sling for 3 weeks after which full arm use was
allowed. The patient reported that the hyperaesthesia at
the medial elbow had diminished immediately postoper-
atively. One year postoperatively, the patient remained
very satisfied without symptoms, and he had normal ul-
nar nerve sensation and motor function.
a b
UN
MACN
UN
Fig. 1 a Neuroma-in-continuity (N) sprouting from the medial cutaneous antebrachial nerve (MACN) running into the ulnar nerve (UN). b Wrapping of
the neuroma-in-continuity in a cellulose sheet and (c) subsequent submuscular transposition
Eur J Plast Surg
Case 2
In June 2020, a similar case presented at our outpatient clinic.
A 46-year-old male requested a second opinion regarding
persisting ulnar-sided forearm pain. His medical history re-
vealed a cubital tunnel release with anterior transposition of
the ulnar nerve in 2013. In 2017, because of recurrent symp-
toms, a neurolysis and anterior transposition of the ulnar nerve
was performed. Although his complaints appeared to resolve
initially, the patient suffered from recurrent medial-sided arm
pain by the end of 2018, with additional reduced motor func-
tion and force of the left hand. In his file, it was mentioned that
clinical examination revealed a sensitive string-like structure
at the medial side of the elbow which was thought to be the
ulnar nerve. Electromyographic examination (EMG) of the
ulnar nerve was normal at that time. Early 2019, a third ex-
ploration and neurolysis was performed, and here, the surgeon
had found a neuroma. It was judged that dissection was im-
possible, and therefore, a partial resection of the neuroma was
performed. After this last procedure, the patient experienced a
decrease in pain severity, but local scar tenderness persisted as
well as reduced sensation in his little finger and the ulnar side
of his hand.
Upon presentation at our clinic in July of 2020, his com-
plaints had again recurred, with debilitating pain at the medial
elbow, paraesthesias in the 4th and 5th digits and a slight loss
in strength. The patient mentioned irradiating pain upon pal-
pation of the medial side of the left elbow which increased
during elbow flexion. Ultrasound investigation revealed a tra-
jectory of the ulnar nerve in the subcutaneous fat with an
increased neural diameter and surrounding oedema. A repeat
EMG of the ulnar nerve was again normal.
After informed consent, we proposed a fourth microsurgi-
cal exploration of the nerve with a sub-muscular transposition.
During surgery, we found the ulnar nerve to be severely buck-
led underneath the fascia. As we dissected further proximally
c
UN
Eur J Plast Surg
to where the ulnar nerve had a normal morphology, we also
found the MACN that ran alongside the ulnar nerve which
then, similar to the first case, formed a neuroma attached the
ulnar nerve (Fig. 2a). This time, we proceeded to excise the
neuroma by an intraneuronal neurolysis with x6 to × 20 mi-
crosurgery magnification. The MACN neuroma was released
completely from the ulnar nerve (Fig. 2b–e, Supplementary
film 1) and was then excised with the proximal stump buried
deeply subcutaneously above the elbow (Fig. 2f). The ulnar
nerve had a neuropathic appearance with a slim diameter for
several centimetres. It was further released distally up to
where its morphology and calibre appeared normal again.
Finally, the ulnar nerve was transposed to underneath the
common flexor origin (Fig. 2g).
Histopathological examination of the excised tissue re-
vealed a haphazard proliferation of Schwann cells as is typi-
cally seen in a traumatic neuroma (Fig. 2h, i).
Postoperatively, a compressive bandage was kept on
for 10 days, and the patient used a sling for 4 weeks.
The patient mobilized the limb as pain allowed. He re-
ported an immediate alleviation of his complaints after
surgery. At 3 weeks, the paraesthesias in the 4th and 5th
a UN b UN
MACN MACN
N N
d e
UN
MACN
N
g UN h i
Fig. 2 a, b Neuroma-in-continuity (N) of the MACN enveloping the
ulnar nerve (UN) and the start of the microdissection. The ulnar nerve
is released from the surrounding neuroma (c) and has a very thin calibre at
the level of the neuroma (d). e The ulnar nerve is completely released, the
neuroma is excised (f) followed by a submuscular transposition of the
digits had ceased, and sensation returned to normal. Three
months later, the patient was extremely satisfied with a
full and pain-free range-of-motion of the elbow joint and
normal sensation and motor function.
Discussion
The MACN is the second branch of the medial cord, aris-
ing from the C8 and T1 nerve roots. This purely sensory
nerve innervates the distal part of the medial upper arm,
cubital fossa, posterior olecranon and volar ulnar side of
the forearm. About 4–6 cm proximal to the medial
epicondyle, the MACN divides into an anterior and a pos-
terior branch. The anterior branch pierces the brachial
fascia anterior to the elbow and then runs subcutaneously
in the forearm. The posterior branch runs in close prox-
imity to the basilic vein with terminal branches that cross
ulnar and posterior at variable distances from the medial
epicondyle, which puts them particularly at risk for tran-
section during cubital tunnel release surgery [1–6].
Reports on the exact position and numbers of these
c
UN
N
f
UN
UN
MACN
N
ulnar nerve (g). h, i Histopathological views of the tissue after S100
staining for Schwann cells. The remnants of the MACN are indicated
with asterisks (*), and the arrows indicate irregular proliferation of nerve
branches

posterior MACN branches vary. Race and Saldana [6]
performed a cadaver study on 20 arms and found 1 to 3
divisions of the anterior branch and 3 to 7 divisions of the
posterior branch that cross between 6 cm proximal and
6 cm distal to the medial epicondyle. The authors there-
fore warn that when using the standard incision for ulnar
nerve surgery it is highly likely that terminal branches are
injured unless they are carefully dissected.
Benedikt et al. [1] found 23% of crossing branches proxi-
mal and 77% distal to the medial epicondyle in 40 cadavers.
On average, there were 2.95 crossing branches distal to the
medial epicondyle with an average distance of 2 cm to the
epicondyle. Likewise, Manoukov et al. [4] found 1 to 3 pos-
terior branches of which 18% emerged proximally and 72%
distally to the medial epicondyle in a study of 13 cadavers.
The average distance from the medial epicondyle was
2.53 cm, which is around 1 cm distal to where the ulnar nerve
penetrates the heads of the flexor carpi ulnaris muscle (FCU).
Also, they reported that the distance to the distal crossing
increased in elbow flexion, a potentially protecting manoeuvre
to the posterior branches from damage during surgery.
The fact that vigilance for the MACN is warranted in ulnar
nerve surgery is further underlined by Lowe et al. [2] who
studied its position in 97 patients undergoing ulnar nerve re-
lease. They found that the posterior branch crossed at an av-
erage distance of 1.8 cm proximal to the medial epicondyle in
61% of patients and that all patients had at least 1 branch
crossing distally at an average 3.1 cm distance. Indeed, we
may derive from these studies that most, if not all, patients
undergoing cubital tunnel release surgery have at least one
posterior MACN branch crossing the operative field and that
caution is required not to damage them.
Persistent pain after ulnar nerve decompression surgery is
not uncommon. It is reported to occur in about 10% of patients
who suffered a moderate compression; however, in patients
treated for severe ulnar nerve compression, it can be as high as
20–35% [7]. The pain may be attributed to pressure on the
ulnar nerve by scar formation, kinking, and compression of a
transposed nerve by fascial flaps or tendinous bands, but also
to the formation of MACN neuromas due to iatrogenic injury.
Reoperation is often considered in case of persistent or recur-
rent pain. Neuroma formation is estimated to occur between
40 and 73% of patients with persistent pain after ulnar nerve
decompression surgery. Mackinnon et al. [3] reported a very
high incidence of MACN neuromas of 73% in patients need-
ing secondary procedures due to persistent pain after surgery
to the ulnar nerve in a chart study of 100 patients.
Iatrogenic injury to a branch of the MACN may cause a
variety of symptoms. Most benign is a simple loss or reduced
Eur J Plast Surg
sensation, mostly in the olecranon or posteromedial forearm
region, which is noticed only upon touch and is generally well
tolerated [2–4, 6]. However, when the transected branch ad-
heres to the scar, it may induce scar pain. This is usually sharp
and local but sometimes radiates distally to the sensory ulnar
nerve distribution. Scar tethering is reported to lead to a longer
length of nerve damage and neuroma formation. Once patients
develop such elongated types of neuroma, they often have
neuropathic pain which is notoriously difficult to treat. Also,
neuromas can become so severely painful that upper limb
function is heavily impaired and patients are debilitated
[2–4, 8]. Furthermore, these painful neuromas often cause
symptoms highly similar to cubital tunnel syndrome and
may be misdiagnosed as recurrent ulnar nerve compression
[4]. Again, vigilance is important to set the correct diagnosis
in persisting pain after longitudinal incisions at the ulnar as-
pect of the elbow.
Neuromas develop after nerve injury as a result of fail-
ure of a regenerating nerve to reach its peripheral targets,
and as a consequence, degeneration and fibrosis of the
nerve fibres occur. Neuromas-in-continuity are usually
the consequence of partial nerve injury. They may devel-
op within one nerve after internal damage to the nerve
fascicles, and usually, the distal part of this nerve no lon-
ger functions properly [9]. Alternatively, after transection,
the axonal sprouts of the proximal portion of the damaged
nerve fascicles may grow out of their own neurotubular
sheaths and show aberrant in-growth into a nervous struc-
ture that lies within close proximity to the damaged end,
which is not its own distal end. As such, here we report 2
cases with a neuroma-in-continuity of the MACN within
the ulnar nerve. Sprouting and invasion of axons of dam-
aged nerve endings into intact nerves has been studied in
the context of nerve bypass grafting and is referred to as
neurotisation. It is stated that regenerating axons can form
from both ‘recipient’ and ‘donor’ nerves [10]. In the cases
we described here, however, it appears that the MACN
sprouts failed to achieve a functional neurotisation to the
ulnar nerve and painful neuromas-in-continuity
developed.
The treatment of painful neuromas is considered challeng-
ing and is not always successful. In general, the neuroma is
dissected from its surrounding tissues followed by capping the
distal nerve with bipolar cautery and transposition deep into
the subcutis or a local muscle belly. Wrapping the affected
nerve end with autologous tissue or artificial materials has also
been described [2–4, 8].
Management of a neuroma-in-continuity is considered to
be even more challenging than the treatment of a neuroma,
Eur J Plast Surg
since it needs to be dissected from nervous tissue that must
remain unharmed. Treatment options include neurolysis, neu-
roma resection with interposition nerve grafting, wrapping in
local flaps, submuscular transfer with wrapping with cellulose
membrane, or resection of the neuroma using microsurgical
techniques [3, 4, 8]. Technical advancements in the field of
microsurgery have allowed for meticulous dissection with
high magnification; however, risk always remains in terms
of microvascular damage to the nerve, damage to remaining
viable axons and the formation of intraneuronal scars.
With the aim to avoid surgery in such highly complex
sequelae in the future, basic scientific work is undertaken
to investigate the application of molecular treatments
against neuroma formation. Pre-clinical research on the
use of targeted antibodies is performed to selectively stop
neuroma-in-continuity formation by selective destruction
of aberrant neurons [9]. This designated ‘molecular neu-
rosurgery’ seems highly appealing; however, results are
still very preliminary and the feasibility of such innova-
tive and even promising future strategies is yet unclear.
Therefore, at present, (microsurgical) treatment of painful
neuromas-in-continuity is still recommended. Elliot et al.
[8] reported on 14 neuromas-in-continuity, 2 of which in
the ulnar nerve. Treatment included external neurolysis of
the neuroma and circumferential wrapping with local fas-
cial flaps. In 8 patients, the symptoms resolved complete-
ly. Furthermore, they obtained a significant pain reduction
in all patients in various categories of pain, except in
hypersensitivity pain. Notably, the neuromas-in-
continuity studied in this work lie more distal than the
cases that we described here, so these results may not be
exactly comparable. Nonetheless, these results indicate
that patients may be successfully treated, although a con-
siderable number of patients will continue to experience
residual complaints of some sort. It is important to inform
the patients correctly prior to consenting to surgery in
order to manage expectations.
Conclusions
We reported 2 cases of a neuroma-in-continuity of the
MACN within the ulnar nerve after prior cubital tunnel
release surgery. First, knowledge of the nervous anatomy
at the medial side of the elbow and foremost the position of
the MACN and its branches is highly important to prevent
iatrogenic injury to these structures in medial elbow inci-
sions and ulnar nerve surgery. If a painful
neuroma-in-continuity arises after damage to the MACN,
this may mimic recurrent cubital tunnel syndrome.
Treating physicians should however keep in mind this al-
ternative differential diagnosis. We reported 2 surgical
treatment options for painful neuroma-in-continuity with
a time interval of 8 years which highlights the technical
advancements in the field of microsurgery over the past
years. Whereas in earlier days, we opted for wrapping
and submuscular transposition of the neuroma-in-
continuity; we were now able to microsurgically dissect
and excise the neuroma followed by submuscular transpo-
sition of the ulnar nerve, yielding good clinical outcome in
our patients.
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s00238-021-01790-9.
Declarations
Conflict of interest Jantine PosthumaDeBoer, Raf Sciot and Ilse
Degreef declare no conflict of interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
No ethical approval was necessary for this case report.
Patient consent Written informed consent was obtained from the pa-
tient regarding publishing his data and photographs.
Informed consent The authors confirm that human research participants
provided informed consent for publication of their data and images.
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