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Hand nerve repair
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Hand nerve repair



Hand nerve repair

Hand nerve repair



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  • Neuraparaxia: ischemia o demielinizationblock….remove and recovery fast. 2 e 3 grado hai recupero3 grado scarring in the endoneurium (almostrecovery)10 12 week reinnervetaion in motor unitpotential in 2 e 3 grado diagnosi second and third non operi…solo per rimuovere ostacoli alla reinnervazione come un tight carpalligament
  • Extensormuscleofforearm and fingers.itprovidesradialpalsyprovide: wristdrop, patientunableto do the hitchlikesignMuscular branches of the radial nerve: Triceps brachii (lateral and medial heads) AnconeusBrachioradialis Extensor carpiradialislongusDeep branch of the radial nerve: Extensor carpiradialisbrevisSupinatorPosterior interosseous nerveExtensor digitorumExtensordigitiminimiExtensorcarpiulnaris Abductor pollicislongus Extensor pollicisbrevis Extensor pollicislongus Extensor indicis
  • The ulnar nerve also has both extrinsic and intrinsic components. The extrinsic ulnar musculature can be tested using proximal interphalangeal flexion of the small finger and ulnar wrist flexion. An ulnar claw may follow an ulnar nerve lesion[6] which results in the partial or complete denervation of the ulnar (medial) two lumbricals of the hand. Since the lumbricals normally flex the MCP joints (aka the knuckles), their denervation causes these joints to become extended by the now unopposed action of the long finger extensors (namely the extensor digitorum and the extensor digiti minimi). The lumbricals also extend the the IP (interphalangeal) joints of the fingers by insertion into the extensor hood; their paralysis results in weakened extension. The combination of hyperextension at the MCP and flexion at the IP joints gives the hand its claw like appearance
  • Thumb abduction The thumb and index finger are arrested in adduction and hyperextension. This appearance of the hand is collectively referred as 'ape hand deformity'
  • normal values:                   - thumb: 2.5-5 mm; index: 3-5 mm; other digits: 4-6  mm and base of the palmar aspect of the digits: 5-6  mm                   - thenar and hypothenar eminences: 5-9  mm,  dorsal aspect of the digits: 6-9  mm, mid-palm region: 11  mm, dorsal aspect of the hand: 7-12 mm

Hand nerve repair Presentation Transcript

  • 1. HANDNERVEINJURY REPAIR Diagnosis& Treatment Stefano Avvedimento, MD
  • 3. SUNDERLAND CLASSIFICATION Peripheralnerveinjury Degree Severity Description Fibrilla tions Motor unit Recovery Pattern Rate of Recovery Surgery First Neurapraxia Demyelinationwithrestoration in weeks - Normal Complete Fast (daysto 12 weeks) None Second Axonotmesis Disruptionofaxonwithregeneratio n and full recovery + + Complete Slow (3cm/month) None Third Axonotmesis Disruptionofaxon and endoneuriumcausingdisorganize dregeneration + + Varies Slow (3cm/month) and Partial Varies Fourth Neuroma in Continuity Disruptionofaxon, endoneurium and perineuriumwithintactepineurium and no regeneration + - None None Yes Fifth Neurotmesis Transectionof the nerve + - None None Yes *Sixth MixedInjury Mixtureofone or more of the aboveconditions Variesbyfascicledepending on injuries * MackinnonS, Dellon AL. Surgeryof the peripheralNerve. New york: ThiemeMedical 1988
  • 4. Epidemiology 10% ofnerveinjurie s involve peripheralner ves Etiology  Mostcommonly the digitalnerves  Penetratinginjuries  Trauma Injury  Avulsion or traction  Ischemia and others non mechanicalfactors (Thermal, electric,radiation)
  • 5. Pathophysiology: Normalresponsetoaninjury •Injury •Walleriandegeneration •ProliferationofSchwanncells and releaseofneurotrophic and neurotropic factors •Axonelongation
  • 6. Problemsofregeneration Largegaps ( > 15-30 mm) Nervetooclose Neuroma formation Fasciculardisorganization
  • 7. Historyof the patient (Age, pastmedicalhistory, medications, handdominance and the eventsof the injury) Nerveinjurypresentation Physicalexamination •Motor evaluation •Sensoryevaluation Nerveinvolved Levelofnerveinjury Complete or partial lesion
  • 8. Motor evaluation: RadialNerveInjury Wristdrop Unabilitytoextend the thumb Extensionof the elbow, wrist and fingers
  • 9. Motor evaluation: UlnarnerveInjury Extrinsicmusculatur e Adductorpollicis (Fromentsign) Intrinsicmusculature Mediallumbricalsof the hand (Clawhand)
  • 10. Motor evaluation: MediannerveInjury Thumbabductor (ape handdeformity) FDP Thumb, index and middle fingers (Pope’sBlessingsign)
  • 11. Sensoryevaluation Radial, Ulnar and MedianNervessensorydistributionof the hand
  • 12. Twopointdiscrimination test Ability to discern that two nearby objects touching the skin are truly two distinct point *Threshold distances •Thumb 2.5-5 mm •Index 3-5 mm •Otherdigits 4-6 mm •Thenar and hypothenar eminences: 5-9mm •Dorsalaspectof the digits 6-9 mm •Midpalmarregion 11 mm •Dorsalaspectof the hand 7-12 mm *
  • 13. Surgicalnerverepair 1. End to end closure 2. Nervegraft 3. Nerveconduit 4. Nerve transfer Twodecision s Timeof surgery Typeofsurgery 1. Primaryrepair ( <2daysfrominjury) 2. Delayedrepair ( in the first week) 3. Secondaryrepair ( >7days)
  • 14. Timing ofnerverepair Primaryrepair superiorto secondaryrepair Contraindications •Woundcontaminated •Vascularizedbednotpresent •Concomitantinjuries (In complex woundsnerverepairafterrepair ofvascular and skeletalstructures) •Patientunstable •Repair no tension free
  • 15. Direct Suture Only small nerve gaps, in which minimal tension is required to contrast the elastic properties of the nerve, can be directly repaired
  • 16. TypesofNeurorraphy EPINEURAL FASCICULAR Although Fascicular repair purportedly ensures correct orientation of regenerating axons, there is little evidence that it is superio to the less exact but simpler epineurial repair
  • 17. NerveGrafts Fornervegapsthatcannotbe repairedprimarlywithouttension >2 cm upper arm > 1cm digitalnerves 4 cm nerve gap at the elbowrepairedwith a suralnervegraft 4 Cm
  • 18. Source ofnervegrafts: SuralNerve The sural nerve in the adult can provide 30 to 40 cm of nerve Graft.
  • 19. •Donor site morbidity •Needtochangepatient position during the harvesting Problems Classicalharvest Endoscopicharvest
  • 20. Medial and lateralantebrachialcutaneousnerves  MABCN  LABCN •Medial part of the arm •Anterior and posteriorbranch in the forearm •Lateral part of the forearmmedial tocephalicvein
  • 21. Othersourcesofnervegrafts Distal Posterior Interosseous Nerve Graft Gracilis Branch of Obturator Nerve Graft
  • 22. Nerveconduits •Biocompatibletubesth at guide nerveregrowth •Releaseofneurotrophi c and neurotropicfactors •PresenceofSchwann cells in experimentalstudies •Differentmaterials
  • 23. Nerveconduit: Business or Goodoption ? •Notusefulforgaps> 3cm •Efficacynotprovenforr epairof big diameternerves
  • 24. Arterial and VeinConduits •Onlyfewstudiespublis hed in literature •Forsmallgaps< 3cm •Readilyaccessible • Minimal donor site morbidity 2,8 cm
  • 25. Nerve Transfer Nerve transfers involve taking nerves with less important roles — or branches of a nerve that perform redundant functions to other nerves — and “transferring” them to restore function in a more crucial nerve that has been severely damaged Indications •Needtodirect motor axonsquicklyto a denervatedmuscle
  • 26. Ulnarnerveinjuryrepairedwithinterosseousner ve transfer Interosseous N.Ulnar N. Preop Postop