Medical Therapy

Initial therapy involves protection of the joints, including the surrounding ligaments and tendons, from further stress. Splints, slings, or both may be used in these cases. For example, a radial nerve injury results in a loss of wrist and finger extension, a wristdrop. wrist!resting splint may be used to support the hand in a neutral wrist position and place the hand in a more functional position. In patients with brachial plexus nerve injuries, particularly when "#!$ is affected, continued downward stress at the glenohumeral joint may cause the glenohumeral joint to subluxate without the muscle support of the rotator cuff muscles. sling is helpful to unload this joint, prevent complete shoulder dislocation, and decrease pain. The hormone erythropoietin has been used with some success to accelerate function use after an injury.%&&, &'( )hysical therapy is started in the early stages following nerve injury to maintain passive range of motion in the affected joints and to maintain muscle strength in the unaffected muscles. *o definitive studies have been done to support the use of electrical muscle stimulation to prevent muscle degeneration. In cases of muscle denervation, galvanic direct current stimulation is necessary to elicit a muscle contraction. The ris+s of galvanic stimulation include a thermal burn beneath the electrodes. ,ecause no studies have shown that external stimulation will stop total degeneration of the muscle fibers and-or neuromuscular junction, the authors do not believe that direct current stimulation is worth the ris+ of a thermal burn. If the nerve does not regenerate in time to reinnervate the muscle, there is no need to stimulate the muscle. .ith reinnervated muscle, it is theoretically possible to use alternating current stimulation. /owever, it is necessary to have a large number of reinnervated muscle fibers to stimulate the muscle with alternating current. The authors recommend exercise and biofeedbac+ strategies to increase the strength of a reinnervated muscle.

Surgical Therapy
0acerations
In patients with neurologic deficits following a laceration, an operative procedure to explore the nerve should be performed as soon after injury as possible. .ith clean, sharp injuries to the nerve, a direct repair is performed. .ith more crushing or avulsion injuries, the nerve ends are reapproximated so that motor and sensory topography can be aligned. The definitive reconstruction is done at 1 wee+s or when the wound permits.%&1, &2, &#(

3unshot wounds
Typically, gunshot wounds associated with neurologic deficit have good potential for neurologic recovery. Thus, unless an associated vascular or bony problem is present, the patient with a neurologic deficit following a gunshot wound is managed conservatively and monitored with fre4uent clinical examinations. ,y 1 months following injury, if no evidence of clinical recovery or electrical recovery is noted on electrodiagnostic testing, surgical exploration is recommended.

"losed injuries
In patients with closed traction injuries, surgical intervention is recommended 1 months following nerve injury. These patients are reexamined both clinically and with electrodiagnostic studies. .ith no evidence of reinnervation clinically or electrically, surgical intervention is necessary.

)ostoperative 5etails
The patient is immobili6ed in a bul+y dressing for several days following surgery. The postoperative dressing 7including the drain and pain pump8 is removed '!1 days following surgery. The area of nerve coaptation then is immobili6ed for a longer time postoperatively 7nerve graft for &9!&2 d, nerve repair for 1 w+8, although the patient is instructed in range!of!motion exercises for the joints proximal and distal to the immobili6ed region. For example, a median nerve repair at the wrist would be immobili6ed with a wrist! resting splint, and the patient would continue with range of motion for the fingers, elbow, and shoulder. Following surgery, the patient is sent to the hand therapist, initially for the splint and then for exercises. Initially, the goals of therapy are to regain passive range of motion of the joints and soft tissues that have

been immobili6ed. The patient should be instructed in exercises to maintain strength in the unaffected muscles. In the later stages, sensory and motor reeducation is recommended to maximi6e the outcome.

Follow!up
Initially, the patient is monitored for postoperative wound healing. fter immobili6ation and once the patient regains full passive range of motion, the patient is monitored every few months to evaluate for evidence of reinnervation. .ith nerve regeneration, a Tinel sign progresses distally along the nerve. .ith muscle reinnervation, a muscle contraction is visible: and with sensory reinnervation, the patient responds to light touch. 5epending on the level of injury, the patient may continue to progress for varying periods: distal injuries respond more 4uic+ly than proximal brachial plexus injuries, which respond for '!1 years following surgery.

;utcome and )rognosis

.ith restoration of nerve continuity, axons may regenerate and, thus, reinnervate the motor end plates and sensory receptors.%'<( .hen the nerve injury is very proximal 7ie, brachial plexus injury, sciatic nerve injury8, nerve regeneration may not occur in sufficient time for muscle reinnervation. For example, in a lower trun+ brachial plexus injury, reinnervation of the ulnar nerve intrinsic hand muscles is not possible due to the long period of muscle denervation because of the long distance necessary for nerve regeneration. /owever, if surgery is performed within 1!$ months following nerve injury, the patient is expected to recover use of most muscles, excluding muscles in the hand or foot in injuries at the trun+ level or higher. 5istal nerve transfers are used to recover distal extremity motor function. cross!sectional study evaluated the biomedical and psychosocial factors associated with disability following upper!extremity nerve injury after a follow up of between $ months and &# years. The authors state that substantial disability, cold sensitivity, and pain are reported by patients with peripheral nerve injury. 5isability, as assessed using 5 S/ 75isabilities of the rm, Shoulder, and /and8 =uestionnaire scores, was predicted by pain catastrophi6ing, sensitivity to cold, time elapsed since injury, employment status, intensity of pain, older age, and the presence of brachial plexus injury. %'>(

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