PERIPHERAL NERVE INJURIES

PATHOLOGY
Nerves can be injured by ischaemia ,compression, traction, laceration or burning. Aetiology:-Direct trauma -Systemic causes-DM,leprosy,lead poisoning - Entrapment neuropathies e.g.,carpal tunnel,cubital tunnel,supinator syndromes

Nerve injuries typesSeddons

Neurapraxia Axonotmesis Neurotmesis

Neurapraxia
A reversible physiological nerve conduction block followed by spontaneous recovery after a few weeks. It is due to mechanical pressure causing segmental demyelination and is seen typically in crutch palsy, Saturday night palsy,tourniquet palsy.

Axonotmesis
There is loss of conduction but the nerve is in continuity and the neural tubes are intact. The denervated target organs (motor end-plates and sensory receptors) gradually atrophy, and if they are not re- in nervated within 2 years they will never recover.

Neurotmesis
In Seddon's original classification, neurotmesis meant division of the nerve trunk

BRACHIAL PLEXUS

MEDIAN NERVE INJURY

Plexus Nerve Muscle Finding Root APB Thumb Abd

C8T1 Lower trunk Median Medial cord C8T1 Lower trunk Median OP Thumb opp Medial cord ----Median Sensory loss Median claw hand-loss of lat 2 lumbricals Oschners clasp test(pointing index) Ape thumb deformity Pen test

Median Nerve

RADIAL NERVE INJURY

Root C5,6,7,8
C7, C8 C5,C6 C7,8 ---

Plexus* POST C
POST C POST C Post C ---

PN Radial
Radial Radial Radial Radial

Muscle ECR, ECU

Finding Wr drop

EDC,EI Fing drop BR EPL, EPB ---Elb flx Th Ext Sens

Triceps, med hd

Triceps, long head Triceps, lateral head

Superficial Radial

Post

Brachioradialis ECRL ECRB Supinator sens Ext Digit Abd Pol Longus Interosseous Ext Pol Longus

ULNAR NERVE INJURY

Root Plexus PN Muscle Finding c8,T1 MC Ulnar Palm Int Fing Add C8T1 MC Ulnar Dors Int Fing Abd Ulnar claw hand-due to loss of intrinsic function Card test-Finger adduction Froments book test-Adductor pollicis

Ulnar nerve
Elbow Flexor carpi ulnaris

Flex Dig Prof III/IV Dorsal uln cut Wrist Abductor

Adductor Pollicus

Opponens

Digiti Minimi
Flexor

Flex Pollicus Br
Dorsal/palmar Interosseous

3rd/4th lumbricals

THE DEGREE OF INJURY

Tinel's sign -peripheral tingling or dysaesthesia' provoked by percussing the nerve . In a neurapraxia, Tinel's sign is negative. In axonotmesis, it is positive at the site of injury because of sensitivity of the regenerating axon sprouts.After a delay of a few days or weeks, the Tinel sign will then advance at a rate of about 1mm each day.

THE DEGREE OF INJURY

Electromyogram (EMG)&Nerve conduction study(NCS) Studies can be helpful (Campion, 1996). If a muscle loses its nerve supply, the EMG will show denervation potentials at the third week. This excludes neurapraxia but it does not distinguish between axonotmesis and neurotmesis;

PRINCIPLES OF TREATMENT
Treating underlying cause Oral corticosteroids-to reduce inflammation & edema Active and passive physiotherapy to muscles Galvanic stimulation Dynamic splints To prevent contracture of the affected muscle

PRINCIPLES OF TREATMENT
Nerve exploration . Exploration is indicated: (1) if the nerve was seen divided and needs to be repaired; (2) type of injury (e.g. a knife wound or a high energy injury) suggests that the nerve has been divided or severely damaged; (3) if recovery is inappropriately delayed and the diagnosis is in doubt.

Epineurial neurorrhaphy

Perineurial (fascicular) neurorrhaphy

Nerve grafting
Free autogenous nerve grafts can be used to bridge gaps too large for direct suture. The sural nerve is most commonly used Neurotization

Care of paralysed parts

While

recovery is awaited the skin must be protected from friction damage and bums. The joints should be moved through their full range twice daily to prevent stiffness and minimize the work required of muscles when they recover. 'Dynamic' splints may be helpful.

Tendon transfers

Motor recovery may not occur if the axons, regenerating at about 1mm per day, do not reach the muscle within 1824 months of injury. The principles can be summarized as follows:

Tendon transfers

The donor muscle should be expendable Have adequate power Be an agonist or synergist The recipient site should be stable Have mobile joints and supple tissues The transferred tendon shouldbe routed subcutaneously Have a straight line of pull Be capable of firm fixation

Radial nerve tendon transfer

Robert jones transfer Boyds transfer

CLAW HANDULNAR&MEDIAN
Boyds transfer Riordan transfer Fowlers technique

Common peroneal nerve

palsy
Trauma at fibular neck DM,leprosy,injectionpalsy,compression neuropathy(lithotomy) -causes foot drop & toe drop & sensaory impairment over dorsum of foot -Foot drop preventive splint -transtibial & transosseous transfer