PMC6196439_01
Clinical appearance on initial presentation to the hand surgery service The patient had wasting of the ulnar innervated intrinsic muscles of the hand between the metacarpals. a The patient also had an ulnar claw hand deformity. When the ulnar innervated intrinsic muscles cannot fire, there is extension at the metacarpalphalangeal (MCP) joints and flexion at both the proximal and distal interphalangeal (IP) joints in the ring and small fingers (b)
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Fig1
On presentation to the office, she had classic signs of severe, chronic ulnar nerve injury: wasting of the ulnar nerve-innervated intrinsic muscles of the hand, a claw position of the ring and small fingers, and dense numbness in an ulnar sensory nerve distribution (Fig. 1).
AP (a) and lateral (b) radiograph views of the left humerus show the radio-opaque implant located at the level of the proximal to mid humeral shaft, 16.5 cm proximal to the medial epicondyle
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Fig2
X-rays showed the radio-opaque Nexplanon  at the junction of the proximal and middle thirds of the humeral shaft with the most distal end 16.5 cm proximal to the medial epicondyle (Fig. 2).
Nexplanon removal. The location of the Nexplanon was marked using intra-operative fluoroscopy before incision (a). Surgical removal of the Nexplanon was then undertaken at this location (b). The ulnar nerve was just deep to the Nexplanon and the brachial artery was in close proximity. Note the location of the Nexplanon in relation to the incision used for the attempted in-office removal
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Fig3
OR, the upper extremity surgery team used fluoroscopy to mark the location of the Nexplanon  (Fig. 3). On surgical exploration, the Nexplanon  was found deep to the brachial fascia of the arm and in direct contact with the ulnar nerve.
Identification and resection of ulnar nerve neuroma. An ulnar nerve neuroma in continuity was identified by fusiform swelling and fibrotic nerve (a). After resection of the traumatic neuroma, 3 undamaged deep ulnar nerve fascicles were left intact, but a 3 cm gap was left in the majority of the nerve (b)
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Fig4
Dissection showed that the ulnar nerve had been severely damaged at this level (Fig. 4). The appearance of her neuroma-in-continuity was classic: the neuroma was fusiform in shape and felt thickened and hard, unlike the proximal and distal, soft and pliable uninjured nerve (Fig. 4a). After the damaged, scarred nerve was removed, there was a 3 cm gap between healthy sections of the ulnar nerve (Fig. 4b).
Ulnar nerve reconstruction using cabled autologous sural nerve graft. Sural nerve autograft was harvested from the patient's leg and used to create a reversed, cabled nerve graft of matching length and diameter. It was placed into the ulnar nerve defect using a surgical microscope, 9-0 Nylon sutures, and fibrin glue
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Fig5
The healthy fascicles were dissected free and preserved (Fig. 5b). To bridge the nerve gap, the patient's sural nerve was harvested from her lower leg, cut into 3 cm long segments and bundled together to recreate the caliber and fascicles of the resected ulnar nerve (Fig. 5).