PERIPHERAL NERVE INJURIES

Dr. Arun More Orthopedics Lecturer MTH Pokhara

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Anatomy Mechanism Assessment Management Discussion

Composed of Š Nerve fibres Š Blood vessels Š Connective tissue
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Outer most Epineural sheath encloses fascicles with surrounding alveolar tissue called Epineurium Fascicles are nerve bundles covered with connective tissue called Perineurim Vary in diameter of 2-25 micrometer

Nerve degeneration
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Part of neuron distal to the point of injury undergoes secondary or wallerian degeneration Proximal part undergoes primary or retrograde degeneration for a single node

Nerve regeneration Š Axonal stump from proximal segment begins to grow distally Š If endoneureal tube with its contained schwann cell is intact the axonal sprouting occurs Š Rate of recovery 1mm/day Š Muscles nearest to the site of injury recovers first Š Followed by others as the nerve reinnervates muscles from proximal to distal so called motor march Š If the endoneurial tube is interrupted, the sprouts may migrate aimlessly throught the damaged area to form a neuroma

Classification

the mildest form, reversible conduction block Š loss of function, which persists for hours or days Š direct mechanical compression, ischemia, mild burn trauma or stretch
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axon continuity is disrupted fascicular integrity is maintained Wallerian degeneration occurs

laceration from sharp or blunt forces Š the only important consideration is the timing of repair Š acute repair or more bluntly lacerated nerves are repaired 3-4 weeks
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Mechanical injury
Saturday-night paralysis ,Tourniquet paralysis

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Crush and percussion injury
fractures, hematomas, compartment syndrome

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Laceration injury ² blunt, penetrating injury Stretch injury - brachial plexus High-velocity trauma - RTA , gunshot wounds Iatrogenic injury

Acute Denervation

Fibrillation potentials and positive sharp waves

Regeneration

Long duration, small amplitude polyphasic motor unit potentials

Diagnosis
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Motor function Tinel¶s sign positivepositive-sensory function negative(after 4-6weeks)-total interruption 4-6weeks)-

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SweatingSweating-sympathetic fiber Sensory function

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Pain Paresthesia Loss of function

Clinical diagnosis of nerve injuries:

Highet Scale: 0 ² total paralysis. 1- muscle flicker. 2-muscle contraction. 3- muscle contraction against gravity. 4- muscle contraction against gravity and resistance. 5-normal muscle contraction .

Tinel sign : A positive Tinel sign is presumptive evidence that regenerating axonal sprouts that have not obtained complete myelinization are progressing along the endoneurial tube. @- neuropraxia(sunderland1) -------negative Tinel sign. @- axonotmesis (sunderland2,3) -------positive Tinel sign. (sunderland4-------- negative Tinel sign ) @- neurotmesis (sunderland 5) ------- negative Tinel sign. Other diagnostic test: Sweat test.,skin resistance test, electrical stimulation

Diagnosis

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EMG SNAP SSEP Intraoperative NAP

EMG

SNAP

SSEP

Intraoperative NAP

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Diagram of EMG tracing depicting normal insertion activity, which also may be present immediately after denervation.

A, Diagram of EMG tracing demonstrating positive sharp wave consistent with denervation 10 to 14 days after injury. Rhythm is regular, amplitude is 100 to 400 uV, duration is 5 to 150 msec, and rate is 2 to 40 Hz. B, Diagram of EMG tracing demonstrating spontaneous denervation fibrillation potentials present within 14 to 18 days after injury. Rhythm is regular, amplitude is 50 to 1000 uV, duration is 0.5 to 2 msec, and rate is 2 to 30 Hz .

GENERAL CONSIDERATIONS OF TREATMENT. FACTORS THAT INFLUENCE REGENERATION AFTER NEURORRHAPHY :

1-Age 2-Gap Between Nerve Ends 3-Delay Between Time of Injury and Repair 4-Level of Injury 5-Condition of Nerve Ends

Treatment
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Indications not long history mildmild-moderate, intermittent reversible cause pregnancy, oral contraceptive, endocrine abnormalities(DM«), type writer Method nonsteroidal anti-inflammatory drugs antisplint

Treatment
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Failed conservative tx Typical clinical finding with electrodiagnostic data Severe sensory loss muscle atrophy motor weakness

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TECHNIQUE OF NERVE REPAIR: Endoneurolysis (Internal Neurolysis Partial Neurorrhaphy Neurorrhaphy and Nerve Grafting

Methods of Closing Gaps Between Nerve Ends: Mobilization Positioning of Extremity Transposition Bone Resection Nerve Stretching and Bulb Suture Nerve Grafting

Epineurial Neurorrhaphy

Perineurial (Fascicular) Neurorrhaphy

Interfascicular Nerve Grafting

Injured Peripheral Nerve

Evaluation of Closed Injury

1. Immediate primary repair in sharp injuries with suspected transsection of nerve Immediate repair is especially important for brachial plexus and sciatic nerve transsections because delay leads not only to retraction but also to severe scaring Bluntly transsected nerve best repaired after a delay of several weeks. weeks.
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A focally injured nerve should be explored if no functional return within 8-10 weeks

3. Decision - making as to whether neurolysis or resection & repair in a lesion in gross continuity based on intraoperative electrophysiological evaluation

Conclusions
4. Split repair with usually graft - lesion in continuity partial function or undergoing partial regeneration 5. Careful patient selection for operation - plexus involved 6. Nerve anastomosis failure inadequate resectin of scarred nerve ends nerve suture distration 7. A good end result requiring rehabilitation from onset of treatment. Prevention of disuse, relief of pain, treatment. predicting probable end results of operative procedures. procedures.

Entrapment of Thoracic Outlet
‡ Etio
- Cervial rib or anomalous transverse process of C7 - Fibromuscular bands or scalene muscle abnomality

‡ Inv.
- X-ray - NCV & EMG - Angiography ± vascular anomaly

‡ Tx : Supraclavicular approach

scalene anterior and medius M.

Carpal Tunnel Syndrome

thenal atrophy

Entrapment of Radial Nerve

Entrapment of Ulnar Nerve
- Cubital tunnel - Guyon¶s canal

Motor Deficit of Ulnar Nerve
‡ Bediction posture : clawing of ring & finger ‡ Froment¶s sign : weakness of adductor pollicis, there will
be flexion of the interphalangeal joint of the thumb because of substitution of the median innervated flexior pollicus longus for a weak adductor pollicis

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Meralgia Paresthesia
Lateral femoral
cutaneous nerve injury (L1-2) (L1

Tarsal Tunnel Syndrome

Etiology of peripheral nerve injuries: - Metabolic or collagen diseases - Malignancies -Endogenous or exogenous toxins -Thermal -Chemical -Mechanical trauma

Diagnostic tests: Electrodiagnostic studies provide the clinician with a base of knowledge as follows: : 1-Documentation of injury Location of insult 2 3-Severity of injury 4-Recovery pattern 5-Prognosis 6-Objective data for impairment documentation 7-Pathology 8-Selection of optimal muscles for tendon transfer 9procedures

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Neurolysis : internal/external Nerve repair end-toend-to-end repair : epineural/fascicular autologous graft : sural N. Neurotization intercostal N./accessory N./cervical plexus within 1 year Muscle and tendon transfer

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Neurolysis : internal/external Nerve repair end-toend-to-end repair : epineural/fascicular autologous graft : sural N. Neurotization intercostal N./accessory N./cervical plexus within 1 year Muscle and tendon transfer

Epineural Repair

Nerve Graft

# leading cause of failure of nerve graft ‡ Inadequate resection ‡ Distraction of repair site

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Direct compression segmental demyelination wallerian degeneration(distal) Ischemia swelling of nerve microcompartment SD

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