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Orthopedics 5th year, 8th/part two & 9th lectures (Dr. Bakhtyar)

Orthopedics 5th year, 8th/part two & 9th lectures (Dr. Bakhtyar)



The lecture has been given on Feb. & Mar. 26th, 2011 by Dr. Bakhtyar.

The lecture has been given on Feb. & Mar. 26th, 2011 by Dr. Bakhtyar.



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    Orthopedics 5th year, 8th/part two & 9th lectures (Dr. Bakhtyar) Orthopedics 5th year, 8th/part two & 9th lectures (Dr. Bakhtyar) Presentation Transcript

    • Peripheral nerve injuries
    • Structure of the nerve Axon myeline sheath Schwann cell layer Endoneurium Perineurium Epineurium
    • Pathology The nerve is injured by: Ischaemia Compression Traction Laceration burning
      • Types of injury
      • Transient ischaemia
      • Neurapraxia
      • Axonotmesis
      • Neurotmesis
      • Axonotmesis
      • Segmental interruption of the axons
      • Loss of conduction
      • But the neural tubes are intact
      • Seen in closed fractures and dislocations
      • Distal to the lesion -> Wallerian degeneration
      • Axonal regeneration occurs by formation of the new axonal processes
      • which grow at a speed of 1-2 mm per t
    • Neurotmesis Division of the nerve trunk Occurs in open wounds Neural tubes are destroyed A Neuroma is formed( regenerating fibers + Schwann cells + fibroblasts) Function may be adequate but is never normal even after surgical repair.
    • Diagnosis Symptoms : (1) Numbness (2) Tingling (3) Weakness Signs: (1) Abnormal posture ( wrist drop) (2) Atrophy of the muscles (3) Change in sensibility Tinels sign : shows progression in nerve recovery Electrodiagnostic tests (1) level of injury (2) Severity (3) progress of nerve recovery
      • Principles of treatment
      • Closed injuries : If no muscle power restoration at the expected time, exploration
      • Open injuries : Primary repair OR graft
      • Missed cases : Delayed repair except when:
      • The patient has adapted to the functional loss.
      • High lesions when reinnervation is unlikely within the critical 2-year period.
      • Pure motor loss, which can be treated by tendon transfer.
      • Excessive scarring
      • Intractable joint stiffness.
    • In the HAND always try to repair to regain at least protective sensation
      • Care of paralyzed part
      • Skin must be protected from friction damage and burn.
      • The joints are moved in full range of motion twice daily.
      • Dynamic splint
      • Obstetric brachial plexus injuries
      • Caused by excessive traction on the brachial plexus during childbirth
      • .
      • C5+C6+C7+C8+T1
      • Clinical features :
      • Difficult delivery
      • Flail arm.
      • Further examination reveals one of the following:
      • (A) Erb’s palsy
      • (B) klumpke’s palsy
    • Erb’s palsy: Injury of C5+ C6 The arm is held to the side, internally rotated, and pronated. (i.e paralysis of the abductors and external rotators of the shoulder + the supinators)
    • Klumpke’s palsy: Less common The arm is flail and pale All muscles of the fingers are paralyzed ± Ipsilateral Horner’s syndrome
    • Treatment: If there is no biceps recovery by 3 months, surgery is performed: If the roots are not avulsed: Nerve graft If the roots are avulsed : Nerve transfer If severe internal rotation : Subscapularis release ± tendon transfer OR Rotation osteotomy of the humerus Physiotherapy in all cases Prognosis in Klumpke’s palsy is poor.
    • Axillary nerve injury (C5) Supplies (1) Deltoid (2) Skin over the lower ½ of the deltoid. Injured in (1) Shoulder dislocation (2) # of humeral neck Clinically (1) Loss of abduction (2) Numbness over the deltoid.
    • Treatment: Spontaneous recovery during 8 weeks. If not: Exploration + repair OR graft. If failed: Tendon transfer OR Shoulder arthrodesis. .