Case Report The Journal of Hand Surgery (Asian-Pacific Volume) 2018;23(1):116-120 • DOI: 10.

1142/S2424835518720025

Treatment of Hand Allodynia Resulting from Wrist Cutting

with Radial and Ulnar Artery Perforator Adipofascial Flaps
Hideto Irifune*,†, Nobuyuki Takahashi*, Suguru Hirayama*,
Eichi Narimatsu*, Toshihiko Yamashita†
Departments of *Emergency Medicine and †Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
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In this article, we report two cases in which recurrent adhesive hand neuropathy with allodynia were successfully treated with ra-
dial and ulnar artery adipofascial perforator flap coverage. Treatment of recurrent neuropathy, such as recurrent carpal tunnel syn-
drome and re-adhesion after neurolysis using free and pedicle flaps to cover the nerves, has been reported to show good results.
However, for severe painful nerve disorders, such as complex regional pain syndrome, the efficacy of this treatment was unclear.
We present two cases diagnosed with recurrent adhesive hand neuropathy with allodynia, resulting from wrist cutting; these cases
were treated with neurolysis and flap coverage with good results and no recurrence. This suggests that neurolysis and flap cover-
age are effective methods for treating complex regional pain syndrome.

Keywords: Allodynia, Neurolysis, Adipofascial perforator flap, Ulnar artery, Radial artery

INTRODUCTION adhesive hand neuropathy with allodynia resulting from

For the treatment of peripheral nerve disorders, such
as entrapment neuropathy and/or adhesive neuropathy,
neurolysis is an effective treatment, but may sometimes
result in recurrence. Adhesion of the surrounding tissue
to the peripheral nerve can result in recurrent adhesive
neuropathy and even complex regional pain syndrome
(CRPS). In these cases, neither conservative nor surgical
treatment is very challenging to surgeons.
For recurrent adhesive neuropathy, re-neurolysis and
flap coverage surgery have been reported to have good
results. However, the effectiveness of this method for
treating CRPS is largely unknown. A previous report
only included a small case series of causalgia.1)
Therefore, we report two cases in which recurrent
Received: Jun. 30, 2016; Revised: Sep. 1, 2016; Accepted: Sep. 3, 2016
Correspondence to: Hideto Irifune
Department of Emergency Medicine, Sapporo Medical University, S-1,
W-16, Chuo-ku, Sapporo 060-8543, Japan
Tel: +81-11-611-2111(ex 3711), Fax: +81-11-611-4963
E-mail: irifuneh@sapmed.ac.jp
wrist cutting were successfully treated with radial and
ulnar artery adipofascial perforator flap coverage.
CASE REPORT
Case 1
A 31-year-old man presented to our department with
severe right hand pain in the median nerve region; this
pain worsened with wrist extension. He had attempted
suicide more than once by cutting his wrist, although the
cuts were superficial. We diagnosed the patient with me-
dian nerve adhesive neuropathy and performed median
nerve neurolysis. Postoperatively, his pain completely
disappeared. However, about 6 months later, he experi-
enced recurrence of right hand pain that gradually deteri-
orated, leading to allodynia. Conservative treatment was
ineffective. We diagnosed the patient with re-adhesion
neuropathy and planned an additional procedure.
We performed surgical exploration 6 months after
the initial neurolysis. During surgery, the median nerve
and palmar branch widely adhered to surrounding scar
tissue (Fig. 1A). With sufficient external neurolysis and
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The Journal of Hand Surgery (Asian-Pacific Volume) • Vol. 23, No. 1, 2018 • www.jhs-ap.org
resection of the scar tissue, we restored smooth gliding
against the surrounding tissue for the median nerve and
palmar branch (Fig. 1B). Then, we elevated a 15 × 4 cm
pedicled radial artery perforator adipofascial flap (Fig.
1C). We circumferentially wrapped the median nerve
and palmar branch with this flap to avoid recurrent adhe-
sion and improve perineural blood flow (Fig. 1D). We
were able to suture the skin without tension.
The patient’s allodynia of the hand dramatically dis-
appeared by the day after surgery. Two years after sur-
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gery, no recurrence was observed, and the patient could
use his hand and wrist normally.
J Hand Surg Asian-Pac Vol 2018.23:116-120. Downloaded from www.worldscientific.com
Case 2
A 47-year-old man presented to our emergency cen-
ter with bilateral wrist cuts from a suicide attempt. We
performed primary skin suture by delicately cutting both
A B C D
A B C D
wrists. Six months after cutting his wrists, the patient
had severe bilateral hand numbness that gradually wors-
ened. This numbness also worsened when he extended
his wrist. Conservative treatment was performed, but
there was no effect, and the patient ultimately exhibited
allodynia. We performed neurolysis once for the right
median and ulnar nerves and twice for the left median
nerve; however, allodynia recurred in both.
Two years after the patient cut his wrists, we per-
formed a third surgery on the left hand. During surgery,
the median nerve widely adhered to the surrounding
scar tissue (Fig. 2A). With sufficient external neurolysis
and resection of scar tissue, we restored smooth gliding
against the surrounding tissue for the median nerve and
palmar branch (Fig. 2B). Then, we elevated a 17 × 4 cm
pedicled radial artery perforator adipofascial flap (Fig.
2C). We circumferentially wrapped the median nerve
Fig. 1. Intraoperative findings in Case 1.
(A) Adhesion of the median nerve. (B) The
median nerve after external neurolysis. (C)
The radial artery per­forator adipofascial
flaps were har­vested. (D) The flap was
turned to cover the median nerve and
was well vascularized.
Fig. 2. Intraoperative findings of the
left hand in Case 2. (A) Adhesion of the
median nerve. (B) The median nerve
after external neurolysis. (C) The radial
artery perforator adipofascial flaps were
harvested. (D) The flap was turned to
cover the median nerve and was well
vascularized.

Hideto Irifune, et al. Adipofascial Perforator Flap for Allodynia
A B
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Fig. 4. Final follow-up findings in Case 2. No complications, such as skin
disorders and bulging of both hands and distal forearms, were seen.
with this flap to avoid recurrent adhesion and improve
perineural blood flow (Fig. 2D). We sutured the skin
without any problem.
In addition, we performed a second surgery on the
patient’s right hand three years after he cut his wrists.
During surgery, the median and ulnar nerves were found
to widely adhere to the surrounding scar tissue (Fig. 3A,
B). With sufficient external neurolysis and resection of
scar tissue, we restored smooth gliding against the sur-
rounding tissue for the median and ulnar nerves (Fig.
3C). Then, we elevated a 15 × 4 cm pedicled radial and
ulnar artery perforator adipofascial flaps (Fig. 3C). We
circumferentially wrapped the median and ulnar nerves
with these flaps to avoid recurrent adhesion and improve
perineural blood flow (Fig. 3D). We performed skin clo-
118
C D
Fig. 3. Intraoperative findings of the
right hand in Case 2. (A) Adhesion of
the median nerve. (B) Adhesion of the
ulnar nerve. (C) The radial and ulnar
artery perforator adipofascial flaps were
harvested. (D) The flap was turned to
cover the median and ulnar nerves and
was well vascularized.
sure without any trouble.
Allodynia in both of the patient’s hands dramatically
disappeared by the day after each surgery. Two years
after the final surgery on the left hand and one year
after the final surgery on the right hand, no recurrence
was observed, and the patient could use both hands and
wrists normally. There was no bulging of the flap transi-
tion, and his hand had a soft texture (Fig. 4).
DISCUSSION
In our experience with these cases, each patient cut
his wrists without injury to the median and ulnar nerves,
resulting in development of adhesive neuropathy with
allodynia. Although we performed neurolysis several
times in these patients, both experienced recurrence. We
considered that it was important to cover the neurolyzed
nerves with well-vascularized soft tissue to prevent re-
currence. We successfully treated these cases of recur-
rent adhesive neuropathy with allodynia using pedicled
adipofascial flaps in the forearm. Although we could
not perform perioperative electrodiagnostic studies, the
sensory and motor impairment of the median and ulnar
nerves were alleviated after transfer of the adipofascial
flaps. An electrodiagnostic study for peripheral nerve
neuropathy is highly specific and reasonably sensitive,
and it is considered the diagnostic test of choice. In these
cases, however, the patients’ pain levels were so severe
that they refused to undergo an electrodiagnostic study
and other physical examinations that may have worsened
their pain.
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The Journal of Hand Surgery (Asian-Pacific Volume) • Vol. 23, No. 1, 2018 • www.jhs-ap.org
Treatment of recurrent peripheral nerve adhesion is
challenging. Several flap covering methods to prevent
re-adhesion after peripheral neurolysis have been re-
ported. Regarding covering the nerves with flaps after
neurolysis, it is said that utilizing well-vascularized
tissue prevents external pressure and re-adhesion of
the surrounding tissue, improves nerve nutrition, and
maintains nerve gliding.2,3) As a result, the neurolysis ef-
fect is maintained. Several studies have reported good
results of flap coverage after neurolysis in the forearm.
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Strickland et al. achieved good results in preventing
carpal tunnel syndrome by wrapping with a hypothenar
fat pad flap.4) However, there is a disadvantage with this
J Hand Surg Asian-Pac Vol 2018.23:116-120. Downloaded from www.worldscientific.com
method; since it utilizes a flap with less volume, only the
carpal tunnel region may be covered. Tham et al. utilized
a reverse radial artery fascial flap for recurrent carpal
tunnel syndrome. This method provides a large cover-
age area, but sacrifices the radial artery.5) Adani et al.
treated a painful median nerve neuroma with radial and
ulnar artery perforator adipofascial flaps.6) This method
utilizes a larger flap without sacrificing the radial or ul-
nar arteries. Sekiguchi et al. reported the use of brachial
artery perforator-based propeller flap coverage after
ulnar nerve neurolysis.7) Yamamoto et al. reported that
recurrent carpal tunnel syndrome causing neuroma was
treated with nerve graft and a free anterolateral thigh
flap.8) Moreover, Yamamoto reported the use of a free
temporoparietal fascial flap for recurrent superficial ra-
dial nerve adhesion.9) Thus, coating with a flap for adhe-
sion neuropathy, including the method used in our cases,
is considered a very effective method.
On the other hand, few studies have reported on the
flap coverage method for treatment of CRPS. Jupiter et
al. reported that treatment of causalgia using neurolysis
with local flap coverage of the peripheral nerves ob-
tained good results.1) Dahlin et al. reported that median
nerve neurolysis with coverage of free and pedicled flaps
for the treatment of recurrent severe carpal tunnel syn-
drome obtained good results in 10/14 cases.2) In both our
cases, hand allodynia, caused by nerve adhesion result-
ing from cuts to the wrist, dramatically disappeared after
flap coverage. Thus, flap coverage after peripheral nerve
neurolysis might be effective for treating cases of CRPS.
Distally-based perforator adipofascial flaps of the
radial and ulnar arteries are widely used as a method
for covering hands that have soft tissue defects.10,11) In
particular, this method is performed without sacrificing
the major artery and can cover a wide area. Moreover,
local adipofascial flaps can be done in the same opera-
tive field and involve a shorter operative time, with no
microsurgical anastomosis and low risks related to donor
site morbidities.6)
In conclusion, surgical treatment of intractable neuro-
logical disorders is challenging. In our experience, radial
and ulnar artery perforator adipofascial flaps were effec-
tive for median and ulnar nerve coverage after neurolysis
for adhesive neuropathy with allodynia. This method to
treat CRPS is likely to be useful as therapy for intrac-
table neurological disorders in the wrist.
CONFLICTS OF INTEREST
The authors declare that there is no conflict of inter-
est regarding the publication of this paper.
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