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
7. Historyof the patient
(Age, pastmedicalhistory, medications, handdominance and the
eventsof the injury)
Nerveinjurypresentation
Physicalexamination •Motor evaluation
•Sensoryevaluation
Nerveinvolved
Levelofnerveinjury
Complete or partial
lesion
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.
14. 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)
16. Direct Suture
Only small nerve gaps, in which minimal tension is required to contrast the
elastic properties of the nerve, can be directly repaired
28. 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
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
