Algorithm for Surgical Management of Symptomatic Hand and Digital Neuromas

Symptomatic neuromas of the hand and digits are a common cause of persistent pain and functional limitation after peripheral nerve injury. Surgical options have broadened from traditional "passive" strategies toward reconstructive and "active" techniques. Although current literature describes both active and passive techniques, it lacks a clear, practical overview of when to use which surgical approach for the treatment of neuromas in the hand.

We performed a scoping review of surgical treatments for symptomatic neuromas distal to the wrist and integrated these findings with established principles of peripheral nerve surgery. On this basis, we developed a pragmatic, anatomy-driven treatment algorithm intended to guide operative decision-making.

The literature is predominantly retrospective, with substantial variability in included neuroma types, operative techniques, and outcome reporting. Across studies, many patients report meaningful pain improvement following surgery, whereas direct comparisons between techniques remain limited by heterogeneity. The proposed algorithm prioritizes reconstruction when a distal target is available, using primary repair when feasible and interposition reconstruction with autograft or allograft when a gap precludes direct coaptation. When reconstruction is not appropriate or no distal target exists, the algorithm outlines location- and context-specific options for nerve end management and biologic targeting, tailored to anatomic constraints and local tissue conditions.

A structured approach to symptomatic neuromas of the hand can streamline evaluation and treatment selection. The proposed algorithm, supported by a practical considerations framework, provides a reproducible pathway for contemporary surgical management of hand and digital neuromas.