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Nerve injury and its treatment
This document discusses the structure and function of peripheral nerves, as well as types and management of peripheral nerve injuries. Some key points: - Peripheral nerves are composed of axons, connective tissue and blood vessels. They transmit sensory and motor signals between different body parts. - Common sites of peripheral nerve injury include the radial, ulnar and median nerves. Injuries can cause sensory loss, muscle weakness or wasting. - Management depends on the severity and location of injury. Conservative treatment focuses on prevention of contractures while surgical intervention may be needed for open wounds or lack of recovery. Primary repair within hours or delayed repair within 2 weeks of injury can reattach severed nerve fibers.
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Nerve injury and its treatment
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- 2. Nerve is definedas a bundle of fibre that use electrical and chemical signal to transmit sensory and motor information from one body part to another. Peripheral nerves are made up of 1. Axon 2. Connective tissue- endoneurium perineurium epineurium STRUCTURE OF PERIPHERAL NERVE
- 3. Structure of aNerve • Endoneurium surrounds each fiber • Groups of fibers are bound into fascicles by the perineurium • Fascicles are bound together by epineurium
- 5. Entire nerveis supplied through the mesoneurium Blood supply is :- Intrinsic ( longitudnal) Extrinsic ( segmental)
- 6. Primary/ Traumatic/ Retrograde degeneration:- - Reaction proximal to the point of detachment. Secondary/ Wallerian/ Orthograde degeneration:- - Occurs distal to the point of injury.
- 7. If endoneuraltube with its contained schwann cells is intact, then sprout may readily pass along their former course & after regeneration the schwann cell innervates their previous end again. Growth rate: 1 mm/day or 1 inch/month Motor March: Muscle nearest to the site of injury recovers first, followed by others as the nerve reinnervates muscles from proximal to distal.
- 9. If endoneurialtube is interrupted, then aimless migration of axonal sprouts occurs throughout the damaged area into the epineural , perineural or adjacent tissue End neuroma- wide separation of proximal & distal stump Side neuroma- partial nerve cut Neuroma in continuity
- 10. TRACTION CONTUSION COMPRESSION LACERATION DETERMINES TYPE, MANAGEMENT & PROGNOSIS OF NERVE INJURY
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- 13. MOTOR -PALPATE MUSCLE BELLY SENSORY - AUTONOMOUS ZONE SUDOMOTOR - LOSS OF SWEATING POSTURE / REFLEX FUNCTIONAL TINEL’S SIGN
- 14. All musclessupplied by branches of nerve distal to that level are paralyzed and become atonic. EMG changes are not seen - 8-14 days Spontaneous fibrillation – 3 weeks (onset of atrophic changes within muscle fiber) Striations and end plate configurations are retained for up to 12 months . Complete disruption and replacement of muscle fibre - 3 years.
- 15. Sensory lossfollows – definite anatomical pattern Overlapping from adjacent nerves – confusing Autonomous zone- isolated zone of supply of particular nerve Intermediate zone- larger area corresponds more closely to the anatomical distribution of nerve Maximal zone – when a nerve is intact & adjacent nerves are blocked, area of sensibility exceeds the anatomical distribution of nerve
- 16. Perception ofpin prick – first recovers Pain fibers - small diameters- faster regeneration Touch fibers – larger diameter - slow regeneration
- 17. RECOGNITION OFNERVE INJURY DETECTION OF RECOVERY & MONITORING ITS PROGRESS
- 18. ELECTRICAL STIMULATION Faradic& Galvanic stimulation STRENGTH DURATION CURVES E.M.G. NERVE CONDUCTION VELOCITY
- 19. ELECTROMYOGRAPHY Electromyography is thetechnique of recording the electrical activity within the striated muscle belly via inserting a needle in it. The electrical signal generated by a muscle tissue detected via electrode which is further amplified and monitored by oscilloscope or a speaker or recorded in system Alteration in signal is seen as various neuromuscular diseases There are 2 common ways to perform EMG via using 3 small monopolar needle electrode or by coaxial or concentric electrode
- 22. A graphplotting the intensity of electrical stimulus to the length of time it must flow to produce response The curve is defined by rheobase and chronaxie Rheobase-is minimal amount of stimulus strength that will produce a response.it is used to measure membrane excitability Chronaxie-it is the stimulus duration that yields the response and stimulus is exactly 2x of rheobase.
- 23. Right shift ofcurve showing poorer excitability Upward kink in strength duration curve indicate partial denervation
- 27. LESIONS OF RADIAL NERVE 1.Very high lesion (in the axilla) 2. High lesion (humeral shaft level) 3. Low lesion(around the elbow ) 4. CHEIRALGIA PARESTHETICA (at the wrist)
- 28. Supinator muscle examination Test of brachioradialis Examinationof extensors of wrist and fingers Wrist drop
- 29. VERY HIGH LESION(IN THE AXILLA) 1.Weakness of wrist, fingers and thumb extension – wrist,fingers and thumb drop 2.Weakness of elbow extension – due to paralysis of the triceps 3. Absent of triceps reflex 4. Sensory loss in the distribution of the more proximal cutaneous branches
- 30. 1. Wrist drop/ weakness of wrist extension – due to paralysis of the Extensor Carpi Radialis Longus and Brevis 2. Finger drop / weakness of fingers extension at the MCPJ – due to paralysis of the Extensor Digitorum 3. Thumb drop / weakness of the whole thumb extension – due to paralysis of the Extensor Pollicis longus and brevis HIGH LESION (HUMERAL SHAFT) CLINICAL FEATURES
- 31. LOW LESION (AROUNDTHE ELBOW) CAUSES The posterior interosseous branch of the radial nerve is injured in : Dislocation of the head of radius Accidently injured during surgical excision of the head of the radius LOW LESION (AROUND THE ELBOW) CLINICAL FEATURES The wrist extension is preserved No wrist drop because branch to ECRL arise proximal to the elbow. Weakness of the fingers and thumb extension at the MCPJ No sensory loss
- 34. 1. INJUY ABOVEELBOW (HIGH ULNAR LESION) MOTOR AFFECTION 1. Paralysis of all muscles supplied (1 muscle in forearm , 15 muscles in hand) 2. Weak flexion of the wrist, with radial deviation of the hand (FCU) 3. Inability to flex the DIP of the medial 2 fingers (medial ½ FDP) 4. Inability to put the hand in the writing position (interossei & medial 2 lumbricals) 5. Loss of adduction of the thumb (adductor pollicis) Partial Claw Hand DEFORMITY Flat hypothenar eminence SENSORY LOSS palmar & dorsal surfaces of medial 1½ fingers.
- 35. 2. INJURY ATOR ABOVE THE WRIST (LOW ULNAR LESION) Motor: Limited to hand muscles only. Sensory Loss: Loss of sensation from the palmar surfaces of the medial 1 fingers only – because the palmar & dorsal cutaneous branches are intact.
- 36. Ulnar paradox • Handis not markedly deformed because the ulnar half of flexor digitorum profundus is paralysed and the fingers are therefore less clawed
- 37. SENSORY DISTRIBU TION C-Distal tothe elbow B/w 2 heads of FCU D-At the level of medial epicondyle E-In the brachial plexus A-ulnar tunnel syndrome,where the nerve passes between pisiform & hook of hamete B-At wrist specially from laceration, occupaional trauma & ganglion
- 38. A-Involuntary abduction of littlefinger B-Hypothenar muscle wasting C-ulceration of skin Wasting of interosseus muscles
- 39. Card test for interosseous Abductordigiti minimi Froment book test-adductor policis Palpation of ulnar nerve lateral to FCU tendon Egawa test-Testing the dorsal interosseous muscle
- 40. Paralysis ofulnar nerve and claw-finger deformity
- 43. HIGH MEDIAN NERVELESION 1. Wasting of muscles of forearm 2. Wasting of thenar eminence 3. Weakness of thumb abduction and opposition (APB + FPB) 4. Pointing Index (FDP, FDS, FPL) 5. Lost sensation at radial 3 1/2 digits 6. Weak Ok sign 7. Ape hand deformity
- 44. LOW MEDIAN NERVELESION I. Wasting of thenar muscle II. forearm muscle spared III. Paralyzed muscle of the hand IV. Weakness of thumb abduction and opposition V. Loss of abductor pollicis brevis + flexor pollicis brevis VI. Lost sensation at radial three and half digits
- 45. Benediction attitude Ape thumbdeformity FcrlPL CARPAL TUNNEL SYNDROME
- 46. Pronator teres Abductor pollicis brevis Loss of power indicates a lesion above the wrist. AIN-FPL
- 47. Muscle examined Flexor pollicislongus- this muscle is tested by holding thumb at its base and patient asked to bend terminal phalanx Flexor digitorum superficialis and profundus –Oschner’s clasping test is when the patient is asked to clasp the hand the index finger of the affected side fails to flex remains to pointing index
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- 50. •Loss of sensationover the ‘regimental badge’ area •Flattening of the shoulder •Deltoid muscle contraction
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- 54. Decreased sensation andnumbness on the outer half of the leg or dorsum of the foot. Weakness of the ankle or foot Foot drop Toe drag while walking High stepping gait SIGNS AND SYMPTOMS
- 57. Sensation changes inthe bottom of the foot and toes, including burning sensation, numbness, tingling, or other abnormal sensation, or pain. Weakness of foot muscles. Weakness of the toes or ankle. Ankle that rolls outwards. Muscle atrophy SIGNS AND SYMPTOMS
- 58. TREATMENT OF NERVEINJURY CONSERVATIVE -In closed injury -Aim-preservation of maximal range of motion and prevention of contractures -NSAIDS to relief pain -Resting from any activities that cause the symptoms to get worse. -Applying ice to the sore area (due to sensory loss) -A stretched muscle will become fibrotic so to keep the paralyzed muscle in relax position and to prevent joint contractures different splints are used.
- 59. Splints for nervepalsy -Cock up splint -Knuckle bender splint -Opposition splint and thumb index finger web space splint -Aeroplane splint -Foot drop splint
- 61. SURGICAL INTERVENTION -In openwound(except penetrating wounds) in which nerve has been ijured , direct inspection at the time of irrigation and debridement is indicated. -When a sharp injury has obviously divided a nerve. -When abrading, avulsing or blasting wounds has rendered condition of a nerve unknown. -Blunt or closed trauma with no clinical or electrical evidence of regeneration after an appropriate time(3-4month). -Nerve is intact before closed reduction but significant deficit is found immediately after.
- 62. NERVE REPAIR Primary repair(withinhours)-An acute primary repair may be undertaken if the wound is clean, the mechanism of injury is a sharp laceration, the patient's condition is stable, and the surgical team and its facilities are available Delayed primary repair(within 8-15days)-If constellation of primary repair circumstances is not encountered, perform a delayed primary repair within 8 to 15 days. If repair is to be delayed, the nerve ends can be tagged with wire suture to facilitate later identification at the time of acute exploration of the wound . if nerve end can be easily approximated they loosely sutured to prevent retraction during interval of delayed repair Secondary repair( after 2 weeks)-is indicated in heavily contaminated wounds, if soft-tissue coverage is poor and requires flaps, if the amount of nerve damage cannot be assessed early , or if the diagnosis is initially missed.
- 63. TYPES OF NEURORRHAPHY Epineurialrepair- Is indicated for small nerves, for nerves with only one or two fascicles, and for primary repair of a clean laceration in a larger nerve. Fascicular repair-especially in nerves with two to five large fascicles or if epineurium constitutes a large part of the cross- sectional area of the nerve. Group fascicular repair-is similar in principle to fascicular repair except that recognizable groups of fascicles are joined instead of individual fascicles. This technique employed in nerve grafting.
- 64. Epineurial Repair With interrupted7-0 or 8-0 nylon sutures
- 65. Fascicular Repair With interrupted9-0 or 10-0 nylon suture
- 66. Mobilization ofthe nerve on both ends of the lesion Positioning the joints in a favorable position Transposition Bone resection Nerve graft Nerve transplant/ Neurotization Non neural tubes (Vein/ Silicon)
- 67. TYPE OFNERVE LEVEL OF INJURY WOUND CONDITION AGE OF PATIENT
- 68. • Poor prognosisin:- - High lesion - Mixed nerve - Gap between nerve ends - Adult - Delayed repair - Associated damage- vessel & tendon - Surgery skill/experience/facility lack
- 69. TENDON TRANSFER FORVARIOUS PEREPHERAL NERVE INJURY PREREQUISITES WHEN Radial nerve when nerve repair performed and suitable recovery is anticipated then tendon transfer should be delayed for 6month Indication for early transfer 1.To act as a substitute during regrowth of nerve(as internal splints) 2.To act as helper as reinnervation proceeds 3.To intervene when the result of nerve repair is poor or irreparable Median nerve and Ulner nerve High nerve palsy 4 month Low nerve palsy 3month
- 70. Tendon transfer Wrist Extension Thumb Extension Finger Extension Brand PT toECRB PL to EPL FCR to EDC Jones PT to ECRB PL to EPL(rerouted) FCR to EDC Boyes PT to ECRB FDS of Ring finger to EPL&EIP FDS of Long finger to EDC Tendon Transfer for Radial nerve Palsy FCR to APL &EPB FCR is PREFFERED Over FCU Difference between Brand and jones
- 72. FOR INTRINSICS PALSY thelong finger extensors are capable of extending the interphalangeal joint if the metacarpophalangeal joints are stabilized and cannot hyperextend STATIC PROCEDURE DYNAMIC PROCEDURE -Zancolli capsulodesis -Fowler tenodesis - Bouvier’s test:-If extensor can extend the pip with mcp joint flexed -< 40 degree fowler transfer EIP tendon of index and EDQP Radial side of extersor aponeurosis of each finger Riordan transfer PL and EDQP Radial side of extersor aponeurosis of each finger Brand transfer ECRL or ECRB with graft Radial side of extersor aponeurosis of each finger Bunnel transfer FDS of the ring finger Radial side of extersor aponeurosis of each
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- 74. TENDON TRANSFER FORMEDIAN AND ULNAR NERVE PALSY For thumb adduction ROYLE THOMPSON TRANSFER FDS of RING finger divided into 2 slips To EPL and Adductor pollicis BRANDS FDS of RING finger To adductor pollicis Boyes Brachioradialis To adductor pollicis SMITH ECRB To Adductor pollicis
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- 76. For thumb opposition RIORDIANRING FINGER SUBLIMIS with pulley over FCU Epl ,Extensor Apponeusosis, APB BRAND Ring finger sublimis(2slips) Proximal slip to ulner side of mcp joint distal slip to APB and EPL BURKHALTER ET AL EIP APB , MCP joint capsule , EPL CAMITZ PL APB
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- 78. For lower limbnerve palsy OBER Anterior transfer of posterior tibial tendon Other method for same procedure BARR
- 79. Split transfer ofanterior tibial tendon
- 80.