PERIPHERAL NERVE INJURIES

Anatomy:
Macroscopic
Mixed spinal nerve sensory and motor root; sympathetic rami; posterior
and anterior rami.
Microscopic:
Axon, Schwann cells, Myelin endoneurium; Group of axons fasicle
perineureum, nerve sheath or epineureum
Classification:
Seddon:
a. Neuropraxia: Physiological interruption of nerve impulsedegeneration of myelin only, complete motor but some sensory loss
a. Axonotmesis:
Incomplete division only axon divided,
endoneural tube intact closed fractures, dislocations, pressure etc.
b. Neurotmesis: Complete division open fractures, GSW, traction etc.
Sunderland: I-V : Myelin, axon, endoneurium, peri neural, entire nerve
Pathology
Nerve injury clot Wallerian degeneration, Axonal sprouts, regeneration at the
rate of 1 mm per day end or side neuroma / recovery.
Other structures muscles, end plates, joints, brain
Etiology of nerve injury
Fractures, dislocations, pressure, wounds, GSW etc.
Symptoms
Motor Loss of motor power depending on the level and closest muscle group
Sensory According to the zone of supply
Sympathetic Anhydrosis
Causalgia (Incomplete injury) Hyperhidrosis, warmth, redness
Signs
Inspection:
Attitude e.g. claw hand Ulnar N.
Scar of injury
Anesthetic skin looks smooth & shiny, fingers thin and tapering, nail
fissured
Trophic changes
Muscle wasting
Palpation:
Skin feels cool, smooth and dry
Anesthetic skin
Neuroma
Tinnel sign
Movement:
Lack of active movements
X-rays:
Osteoporosis
Investigations
Is there a nerve lesion? Level? Type? Recovery?
1.
Tinnel sign
2.
EMG
3.
NCS
2.
Sweat test, Skin pressure test
Treatment
Conservative
Neuropraxia & some axontomesis
Care of paralysed part: a. Protection of skin
b. Movement of joints & muscles
c. Splints
d. Electric stimulation

Operative
Neurontemesis & some axontomesis
Timing: Clean wound primary repair
Contaminated wound tagging & late repair
Very early repair difficult; late repair impossible; Must be done before 18
months of injury
Nerve surgery
Nerve repair Neurorrahaphy
Method of bridging the gap: Mobilization of nerve. Position of the limb,
transposition of nerve, nerve grafting, cable grafting, shortening of bone.
Secondary surgery
Tendon transfers
Arthrodesis
Amputation
Prognosis
Type of lesion
Level of lesion
Type of nerve
Size of gap
Age, Time and associated lesions
MEDIAN NERVE INJURIES
High lesion - At or above the elbow
Low lesion In the forearm or wrist
Etiology:
GSW, fracture dislocation at the elbow, wrist cut, dislocation of lunate, colles
fracture, CTS
Clinical features
Low lesion wasted thenar muscle, Opponens pollicis, Loss of sensation
High lesion wasted forearm muscle, Benediction attitude, thumb, index and
middle finger and wrist flexors, pronators , Ochsners clasping test (FDP index),
Pen touch test (APB);Trophic changes, Ape like thumb
Treatment:
Primary or secondary repair
Opponens plasty
Wrist arthrodesis