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Peripheral Nerve Injuries: DR - Prateek Singh Intern Dept. of Orthopaedics Bpkihs
Peripheral Nerve Injuries: DR - Prateek Singh Intern Dept. of Orthopaedics Bpkihs
Nerve
Injuries
Dr.Prateek Singh
intern
Dept. of Orthopaedics
BPKIHS
Peripheral Nerve
Coverings
Internal topography
Fascicular arrangement constantly change throughout
the course
Etiology of peripheral nerve injuries
Secondary injury
– Results from involvement of nerve by infection, scar,
callous or vascular complications which may be
hematoma, AV fistula, Ischemia or aneurysm
Classification of nerve injuries
Seddon Classification
1.Neuropraxia:
1.Minor contusion or compression with preservation of axis –
cylinder of myelin sheath.
2.Impulse transmission physiologically interrupted.
3.Complete recovery in a few days to weeks
2.Axonotemesis :
1.More significant injury
2.Breakdown of axon and distal Wallerian degeneration but with
preservation of schwann cell & endoneurial tubes
3.Spontaneous regeneration with good functional recovery can be
expected
3. Neurotmesis
1.More severe injury
2.Complete anatomical severance, avulsion or crushing of nerve
3.Axon, Schwann cell & endoneurial tubes are completely
disrupted
4.Spontaneous recovery cannot be expected unless surgically
intervened
Sunderland Classification
Each degree of injury suggesting a greater anatomical
disruption with its correspondingly altered prognosis
Anatomically various degrees (1st – 5th) represent injury
to
Myelin
Axon
Endoneurial tube & it’s content
Perineurium
Entire nerve trunk
Sixth degree (Mackinson) or mixed injuries occur in
which a nerve trunk is partially severed and
remaining part of trunk sustains 1st to 4th degree
injury.
Mixed recovery pattern depending on degree of
injury to each portion of nerve.
Neuronal degeneration and regeneration
• Any part of neuron detached from its
nucleus, degenerates & is destroyed by
phagocytosis.
• Distal – Secondary / Wallerian Degeneration
• Proximal - Primary / Traumatic / Retrograde
Degeneration
• Time required for degeneration varies between
sensory and motor fibers and is also related to size
& myelination of fibers
• Advancing Tinel sign and presence of motor march
phenomena are signs of regeneration
Diagnosis of Peripheral nerve
injuries
• History
– Which nerve ?
– What level ?
– What is the cause ?
– What degree of injury ?
– Old or fresh injury ?
Diagnosis of Peripheral nerve
injuries
1. Motor:
– All muscles distal to the injury – paralyzed
& atonic
– Atrophy : 50 -70 % in 1st two months
– Striations & motor end plate configurations
retained for 12 – 18 months (critical limit
of delay)
2. Sensory :
• Trophic Changes
• Esp. hand and feet
• Skin – thin, glistening, breaks easily to form
ulcers that heal slowly
• Fingernails
• Ridged, distorted and brittle
• Osteoporosis (Reflex sympathetic dystrophy)
Test for peripheral nerves of upper limb
• Radial nerve injury
– very high / high / low injury
– Wrist drop / finger drop / thumb drop
– Test for triceps/ /Brachioradialis/ wrist extensors /
extensor digitorum / EPL
• Median nerve
– High / low injury
– Test for FPL / FDS / FDP (lat. half) / FCR / Abd.
Pollicis brevis ( pen test) / Oppenens pollicis
– See for pointing index / complete claw hand
• Ulnar nerve
– High / low palsy –ulnar paradox
– Test for FCU / Abd. digiti minimi / Interossei (dorsal -
Egawa’s test ; palmar – card test ) / lumbricals /Add.
Pollicis (Froment’s sign / book test )
– Ulnar claw hand
Electrodiagnostic studies
• Electromyography
• Nerve conduction velocity
• Strength duration curve
Time of Surgery
• Primary repair : First 6 – 8 hours
1. Endoneurolysis
2. Partial Neurorrhaphy
3. Neurorrhaphy
1. Epineural
2. Epi-perineural
3. Perineural
4. Nerve grafting
Method of closing gap between nerve ends
1. Mobilization ( critical nerve gap distance – value
of Grantham)
2. Positioning of extremity
– Flex knee and elbow < 90°
– Flex wrist < 40°
1. Transposition
2. Bone resection
3. Nerve stretching & bulb sutures
4. Nerve grafting
5. Nerve crossing ( pedicle grafting )
Factors that influence regeneration after
neurorrhaphy
1. Age of patient
2. Gap between nerve ends
3. Delay between time of injury and repair
4. Level of injury
5. Condition of nerve ends
6. Experience & technique of surgeon
Options
• Orthoses
• Tendon transfers
• Bony blocks
• Arthrodesis
Thank You