PERIPHERAL NERVE INJURIES

Dr. Arun More

Dr. Arun More
Orthopedics
OrthopedicsLecturer
Lecturer
MTH
MTHPokhara
Pokhara
 Peripheral nerve injuries
 Anatomy
 Mechanism
 Assessment
 Management
 Discussion
Peripheral nerve structure and function

Composed of
 Nerve fibres
 Blood vessels
 Connective tissue

 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
 Biological response to nerve injury

Nerve degeneration

 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
 Biological response to nerve injury

Nerve regeneration
 Axonal stump from proximal segment begins to grow
distally
 If endoneureal tube with its contained schwann cell is
intact the axonal sprouting occurs
 Rate of recovery 1mm/day
 Muscles nearest to the site of injury recovers first
 Followed by others as the nerve reinnervates muscles
from proximal to distal so called motor march
 If the endoneurial tube is interrupted, the sprouts may
migrate aimlessly throught the damaged area to form
a neuroma
Classification
 Neuropraxia
 the mildest form, reversible conduction
block
 loss of function, which persists for
hours
or days
 direct mechanical compression,
ischemia,
mild burn trauma or stretch
 Axontmetic
 axon continuity is disrupted
 fascicular integrity is maintained
 Wallerian degeneration occurs
 Neurotmesis
 laceration from sharp or blunt
forces
 the only important consideration is
the timing of repair
 acute repair or more bluntly
lacerated
nerves are repaired 3-4 weeks
 Etiology

 Mechanical injury
Saturday-night paralysis ,Tourniquet paralysis
 Crush and percussion injury
fractures, hematomas, compartment syndrome
 Laceration injury – 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
Clinical Signs
 Motor function
 Tinel’s sign
positive-sensory function
negative(after 4-6weeks)-total interruption
 Sweating-sympathetic fiber
 Sensory function
Chronic Injuries of Peripheral Nerves
by Entrapment

 Pain
 Paresthesia
 Loss of function
Clinical diagnosis of nerve injuries:
Highet Scale:
0 – 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
Electrophysiological Tests

 EMG
 SNAP
 SSEP
 Intraoperative NAP
EMG SNAP
SSEP
Intraoperative NAP
 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
Conservative Tx
 Indications
not long history
mild-moderate, intermittent
reversible cause
pregnancy, oral contraceptive, endocrine

abnormalities(DM…), type writer

 Method
nonsteroidal anti-inflammatory drugs
splint
Treatment
Surgical Indications
 Failed conservative tx
 Typical clinical finding
with electrodiagnostic data
 Severe
sensory loss
muscle atrophy
motor weakness
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
Techniques of Neurorrhaphy:

Epineurial
Neurorrhaphy
Perineurial
(Fascicular)
Neurorrhaphy
Interfascicular
Nerve Grafting
Injured Peripheral Nerve
Evaluation of Closed Injury
 Conclusions
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.
2. 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 가
partial function or undergoing partial regeneration
5. Careful patient selection for operation
- plexus involved
6. Nerve anastomosis failure
① inadequate resectin of scarred nerve ends
② nerve suture distration
7. A good end result requiring rehabilitation from onset
of treatment. Prevention of disuse, relief of pain,
predicting probable end results of operative
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
& small 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
 Meralgia Paresthesia

Lateral femoral
cutaneous nerve
injury (L1-2)
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 9-
procedures
Operations
 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
Operations
 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
Epineural Repair
 Nerve Graft

# leading cause of failure of nerve graft

• Inadequate resection
• Distraction of repair site
 Pathophysiology of Entrapment
 Direct compression
segmental demyelination
wallerian degeneration(distal)
 Ischemia
swelling of nerve
microcompartment SD