DR.K.S.N.

CHENNA KESAVA RAO (

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INCIDENCERadial nerve- 45% Ulnar nerve -30% Median nerve-15% Peroneal nerve and lumbosacral plexus -3% MECHANISM Nerve may be damaged by fracture fragments Entrapement between fracture fragments during reduction Direct injury by sharp objects In late stages nerve may be trapped in callus or fibrous tissue

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Acute nerve injuries are easily misssed,especially if associated with fractures or dislocations Clinical features includes Numbness Paraesthesia or Muscle weakness in the related areas Signs of abnormal postures Weakness in specific muscle groups Areas of altered sensations

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Chronic nerve injuries Anesthetic skin may be smooth and shiny, with evidence of diminished sensations Muscle groups will be wasted Postural deformities may become fixed METEV SIGN-chronic nerve entrapment in healed callus can give the appearance of a hole in the bone

CLINICALLY ` Loss of pain perception in the tip of little finger indicates ulnar nerve injury ` Loss of pain perception at the tip of index fingermedian nerve injury `hitchhikers sign-inability to extend the thumb -indicates radial nerve injury `in lower limb loss of pain perception at in the sole of the foot - indicates sciatic or tibial nerve `Inability to extend great toe or foot indicates -peroneal or sciatic nerve injury
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Medical Research Council (MRC) Scale for Muscle Strength

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Nerve conduction velocity Electromyography Tinel sign Sweat Test Skin Resistance Test Electrical Stimulation

Stimulation of a peripheral nerve by an electrode placed on the skin overlying the nerve readily evokes a response from the muscle innervated by that nerve. This response can be seen, palpated, and measured

The nerve is stimulated proximal to, distal to, and across the level of injury with subsequent distal evoked potential recording achieved using a needle or surface pick-up electrode . Immediately after injury, stimulation proximal and distal to the insult elicits a normal response, although stimulation across the injured segment may vary, depending on the presence of axonal or myelin injury.

Muscle activity observed with a needle pick-up electrode (e.g., monopolar, concentric, single fiber) placed in myotomes innervated by an injured nerve provides crucial information. The basic monopolar needle electrode samples approximately eight muscle fibers, and by assessing different sites, fair representation of muscle groups is possible. The muscle initially is observed at rest (insertional activity, approximately 200 ms) and subsequently during volitional muscle recruitment

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At approximately 10 to 14 days after neural injury, abnormal spontaneous rest potentials (positive sharp waves) appear in innervated myotomes where axonal injury has occurred At 14 to 18 days, fibrillations appear Denervation potentials (fibrillations or positive sharp waves or both) last indefinitely until the muscle has become reinnervated or fibrotic.

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The Tinel sign is elicited by gentle percussion by a finger or percussion hammer along the course of an injured nerve. A transient tingling sensation should be felt by the patient in the distribution of the injured nerve rather than at the area percussed, and the sensation should persist for several seconds after stimulation. It should be tested for in a distal-to-proximal direction. A positive Tinel sign is presumptive evidence that regenerating axonal sprouts that have not obtained complete myelinization are progressing along the endoneurial tube

A Sunderland type 1 injury or neurapraxia should not show an advancing Tinel sign because wallerian degeneration and axonal regeneration do not occur A distally advancing Tinel sign should occur in Sunderland types 2 and 3 nerve injuries. A Sunderland type 4 or type 5 injury would not show an advancing Tinel sign unless repaired.

SWEAT TEST- Sympathetic fibers within a peripheral nerve are resistant to mechanical trauma. The presence of sweating within the autonomous zone of an injured peripheral nerve reassures the examiner to a degree, suggesting that complete interruption of the nerve has not occurred SKIN RESISTANCE TEST- In it a Richter dermometer is used. The autonomous zone with absence of sweating shows an increased resistance to the passage of electrical current. ELECTRICAL STIMULATION- Galvanic stimulation is useful in determining chronaxy and the strength-duration curve

Treatment depends upon the type of fracture whether closed or open Nerve injury associated with closed fracture ,the type of damage generally is neuropraxia or axonotmesis and nerve recovery is good with conservative treatment When the nerve injury associated with an open fracture, the type of nerve damage is often neurotmesis in such cases nerve should be explored.

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The classification of nerve injuries proposed by Seddon in 1943 Neurapraxia:-Transmission of impulses is physiologically

interrupted for a time, but recovery is complete in a few days or weeks.

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Axonotmesis:-breakdown of the axon and distal wallerian

degeneration but with preservation of the Schwann cell and endoneurial tubes. Spontaneous regeneration with good functional recovery can be expected.
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Neurotmesis:-more severe injury with complete anatomical

severance of the nerve or extensive avulsing or crushing injury. The axon and the Schwann cell and endoneurial tubes are completely disrupted. The perineurium and epineurium also are disrupted to varying degrees.

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splints Aer C S F l e li t Nerve injury Br i l lexus i jur

k up spli t ulder bducti t dr p spli t spli t

R di l erve i jur Axill r C mm i jur erve i jur per eal erve

Passive

movements of joints to prevent contractures Physiotherapy-exercises and nerve stimulation

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If fractures needs open reduction, nerve should be explored Generally open fractures with neurotmesis need surgery 1.primary repair-done within 6-8 hours after injury if wound is clean 2.delayed primary repair between 7-18days after injury if wound contaminated 3.seconadary reapair-18 days after injury, if injury seen late, failure of conservative treatment ,cases with signs of nerve irritation

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ENDONEUROLYSIS-freeing of trapped nerve PARTIAL NEURORRHAPHY-done if one half of large nerve disrupted NEURORRHAPHY AND GRAFTING-if gap present (commonly graft taken from sural nerve) TENDON TRANSFER-done after 18 months of injury if indicated when nerve has not regenerated or patients present late ARTHRODESIS(FAIL JOINTS)-if no tendons available for transfer and there is no hope for recovery