-Presented

by Ankita tiwari

Nerve Repairs (timing)

Primary nerve repair: Indicated for clean, sharply cut nerves. Performed immediately after an injury or within 1 to 2 weeks Secondary nerve repair: Usually indicated in the presence of a severely crushed , avulsed nerve or multilevel lesions. Early secondary repairs r performed within 6 weeks nd late secondary repairs after 3 months.

Injured Peripheral Nerve

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

1 NEUROLYSIS: It is the process of:

1. release of a nerve sheath by cutting it longitudinally.(internal neurolysis) 2. operative breaking up of perineural adhesions.(external neurolysis) 3. relief of tension upon a nerve obtained by stretching. 4. destruction or dissolution of nerve tissue.

Epineural Repair

Completely transected nerve. Cut nerve end debrided and serially sectioned until the axoplasmic outflow mushrooms under positive intrafascicular pressure nd fasicular pattern is identified and relatively free of scar. Magnification increased to 25 power and 10-0 nylon sutures used. 8-10 sutures for large nerve nd 2 for small one. Leading cause of failure is gapping ,overriding,buckling,straddling of fascicle ends.

Fascicular Repair

Perineurial repair. Nerve ends prepared nd epineurium is dissectd away. Fascicles r seperated nd coaptation is perfrmd btwn matching fascicles wid sutures placd into d inner epineurium.nd not to enter in endoneurium. Advantage is accurate coaptation of similar size fascicles. Disadvantage is stimulation of grtr amnts of intraneural scar by increased dissection nd foreign material.

Nerve Graft

Inadequate resection Distraction of repair site

Nerve-lengthening techniques(tissue expansion or nerve distraction) Or bridged by tubes of biological or nonbiologic material Eg. Polyglycolic acid,autogenous vein and amnion.

Tendon transfers Application of motor power of one muscle to another weaker or paralysed muscle by transfer of its tendinous junction. Donor mst b strengthened postoperatively.

Detailed history.
Nature of injury Level of injury Date of injury/repair Patients problems.

Evaluation of sympathetic function. MMT

Aware of d limitation in PROM due to muscle shortening or contractures. Trick motions rebound,supplementary action,antagonist,common tendons.

ROM Sensibility examination.

An initial latent period of 3-4 weeks ,axonal regeneration progresses at a rate of approx. 1mm/day. Sensibility recovery occur in following sequence
Deep pressure and pinprick,moving touch,static light touch At first, a stimulus will be poorly localized and may radiate proximally or distally. Accurate localization is among d last sensibility functions to recover. Typical tests tinels sign-sharp/dull discrimination, Semmes weinstein light touch deep-pressure testing

Pain asssmnt.
Burning pain in distribution of injured nerve (causalgia) Extreme pain when touched(neuroma)

Analysis of d impact of injury on d patients functional status

maintain range motion.

maintain nerve integrity. increase muscle strength.

increase sensation.
manage neuropathic pain.

To prevent stretch of the sutured nerve end, a plaster slab is applied after the operation and worn for 2-3weeks,with adjacent joint positioned to reduce tension. No passive stretch of nerve is allowed for 8weeks. The limb is supported initially in elevation to prevent oedema, and exercise are given to maintain the range of any free joint during this period of immobilization.

Lumbrical bar splint Ulnar Nerve

Dynamic splint for ulnar nerve injury

Short opponens for Median Nerve

C-bar for correction of a thumb adduction contracture

Long arm splint for more proximal Radial nerve injury

Splinting for Radial Nerve Volar wrist splint Begin with wrist extension at 60 and Serial splint towards neutral

Dynamic splint, no active wrist extension

Dynamic Splint, Active wrist extension

The limb must be supported comfortably in elevation. Active movements of the unaffected joint of the limb are encouraged. Pulsed electromagnetic energy (PEME) should be given daily through the dressing to the affected part

Free active movement are encouraged in order to retain range. Passive physiological movement must be given in the absence of normal voluntary movement. Electrical stimulation for proprioceptive feedback of recovering muscle. Position-hold exercises. Avoid putting tension on the nerve ends at this stage.

Deeper massage is given to help free adhesion scar and soften indurated areas It safe in this stage to introduce graduated resistance to all movement which will help to free adherence and mobilise any residual stiffness of joints. Pain is usually decreased by the use of TENS. Splint can be used in night only.

More vigorous resisted exercises are now introduced.(pre) Passive stretching is required if full mobility of the soft tissues has no being gained. Serial stretch plaster are necessary in stubborn cases. Special care must be taken to assess the patient suitability to wear splint. Desensitization.

Localization of stimulus. Identification of sand paper on dowels. Identification of textures. Identification of velcro letters on wood. ADL with vision occluded