Broad frame work of management in peripheral nerve
BROAD FRAME WORK OF
PERIPHERAL NERVE LESIONS
, TERMINAL COMPLICATIONS
OF UNTREATED PERIPHERAL
Dr. J.V Subba raju
Final year PG
As in any other injury, initial management of a
patient with peripheral nerve damage should
begin with careful assessment of the vital
When indicated, appropriate actions to prevent
cardiopulmonary failure and shock should be
taken, and systemic antibiotics and tetanus
prophylaxis should be provided.
In complete penetration injuries of laceration
type , early exploration is appropriate.
In grossly contaminated injuries or nerve is
transected with ragged ends, nerve ends are
tagged and delayed repair ( 2-6 weeks) can be
For complete or incomplete injuries in which
surgery is contemplated serial EMG should be
If clinical evidence of regeneration or recovery
ensues and progresses during time frame (
usually 12 weeks ) surgery is most likely not
If at 12 weeks no EMG or clinical evidence of
regeneration or return of function exists ,
operative treatment is indicated.
Factors influencing prognosis of
Age – best results are seen in children
following repair as adaptations of central cortex
both for sensory and motor function is excellent
Level of injury – more proximal the injury the
more incomplete is the overall return of motor
function especially in more distal structures.
Delay between time of injury or repair –
delay of repair affects motor recovery more
profoundly than sensory recovery.
Satisfactory reinnervation of muscles can occur
after denervation upto 12 months. (Sunderland )
Irreversible changes develop in muscle after 24
With respect to sensory recovery nerve can be
repaired even after 2 years for satisfactory
recovery. However early repair has the best
Gap between nerve ends.- gaps between
nerve ends can be over come by
c)Position of extremity.
Condition of nerve ends - a clear cut sharp
nerve injury has got better prognosis following
primary repair than crushed or avulsion injuries
which needs secondary repair.
Types of nerves - pure motor and pure
sensory recovery is fast when compared to
Is indicated in neuropraxia or axonotmesis .
In closed injuries, compression injuries.,
Main objective is to preserve mobility of whole
Regardless of level or cause of injuries ,
affected muscles are kept in a state of
relaxation by supportive splints.
Tone of muscles is maintained by galvanic
stimulation and light massage until nerve
Splinting – purpose of splinting is
To immobilize all part of hand in
position that will promote healing
and prevent deformity.
To correct an existing deformity
and promoting function in that
To compensate weakness
Two types of splints.
Static splints – which prevents
When a sharp injury has obviously divided a
nerve, early exploration is indicated for
diagnostic, therapeutic, and prognostic
When abrading, avulsing, or blasting wounds
have rendered the condition of the nerve
unknown, exploration is required for
identification of the nerve injury and for marking
the ends of the nerve with sutures for later
When a nerve deficit follows blunt or closed
trauma, and no clinical or electrical evidence of
regeneration has occurred after an appropriate
time, exploration of the nerve is indicated.
When a nerve deficit follows a penetrating
wound, such as that caused by a low-velocity
gunshot, the part is observed for evidence of
nerve regeneration for an appropriate time. If
there is no evidence of regeneration, exploration
Time of surgery
Primary repair- indicated in clean sharp nerve
injuries done in the first 6 to 8 hours or
Delayed primary repair done in the first 7 to 18
days is appropriate the wound is clean, and
there are no other major complicating injuries.
Secondary repair- done in crushed , avulsed
injuries with life of patient is endangerd . It is
done at delay of 3 – 6 weeks
Coaptation – the key to functional recovery is
coaptation of motor to motor and sensory to
sensory funiculi. These can be brought about
by anatomical , electrophysiological and
Maintenance of coaptation can be brought by
suture materials like 8.0 to 10.0 nylon.
Suture less maintenance can be brought by
fibrin clot , micropore tape , collagen
tubulization and adhesives.
It is an endoneurial exploration for assesing the
injury of fasciculi .
If most of the fasciculi are intact and can be
separated and traced through the neuroma,
nothing further should be done.
If stimulation fails to elicit a response, and few if
any intact fasciculi can be found, resecting the
neuroma and neurorrhaphy are probably
Techniques of neurorraphy includes
a) Partial neurorraphy –done in
partial severance of larger nerves
such as sciatic and cords of brachial
plexus. At cut ends END TO END
neurrorraphy is done.
b) Epineural neurorraphy .involves
c) Perneural neurorrhaphy –
involves matching of fasciculi and
d) Epiperineural neurorrhaphy –
involves both epineurium and
e) Inter fascicular nerve grafting –fascicular gap can
be overcome by nerve grafting technique.
A gap between cut ends of nerve of more than 2.5
– 4 cms is un acceptable for neurorrhaphy and
nerve grafting may be required.
Source of graft
sural nerve (most commonly used) ,
medial and lateral cutaneous nerve of forearm,
posterior interroseus nerve at wrist (for digital
superficial radial nerve( for radial nerve injuries),
dorsal branch of ulnar nerve.
Types of graft
Pedicle nerve graft
Interfascicular nerve graft
vascularised nerve graft (helps to increse
number of schwann cells that survive during
grafting procedure., increases rate of axonal
regeneration , decreases amount of intra
Useful in restoring lost functions due to
peripheral nerve injuries.
Transfer of tendons is the final step in
It should not be done until scar tissue has
A satisfactory range of passive movements is
needed before transfer.
Malalignment of bone must be corrected by
osteotomy before transfer.
Irrepairable nerve damage.
Loss of function of
muculotendinous unit due to
trauma or diseases.
In non progressive or slowly
disorders like multiple sclerosis
and cerebral palsy.
When a peripheral nerve is severed at a given
level, all motor function of the nerve distal to
that level is abolished
All muscles supplied by branches of the nerve
distal to that level are paralyzed and become
Atrophy of muscle bulk progresses rapidly to
50% to 70% at the end of about 2 months
Atrophy continues at a much slower rate, and
the connective tissue component of the muscles
Striations and motor end plate configurations
are retained for longer than 12 months, whereas
the empty endoneurial tubes shrink to about one
third their normal diameter .
Complete disruption and replacement of muscle
fibers may not become complete until after 3
Sensory loss usually follows a definite
After severance of a peripheral nerve, only a
small area of complete sensory loss is found.
This area is supplied exclusively by the severed
nerve and is called the autonomous zone
A larger area of tactile and thermal anesthesia is
readily delineated and corresponds more closely
to the gross anatomical distribution of the nerve
Complete severance of a peripheral nerve
abolishes all reflex activity transmitted by that
nerve. This is true in severance of the afferent or
the efferent arc.
Interruption of a peripheral nerve is followed
by loss of sweating and of pilomotor response
and by vasomotor paralysis in the autonomous
The area of anhidrosis usually corresponds to,
but may be slightly larger than, the sensory
affected area becomes colder than the adjacent
normal areas, and the skin may be pale,
cyanotic, or mottled in an area often extending
beyond the maximal zone of the injured nerve.
Trophic changes occur commonly and are most
evident in the hands and feet.
The skin becomes thin and glistening and, when
subjected to trauma that ordinarily does little
harm, breaks down to form ulcers that heal
fingernails become distorted, often ridged or
Osteoporosis often follows peripheral nerve
It is more likely to be pronounced in incomplete
lesions associated with pain.
Incomplete lesions of the median nerve seem to
be associated more often with osteoporosis,
with changes occurring in the distal phalanges
of the thumb and index and long fingers.
Partial ankylosis from fibrosis of the periarticular
structures also may develop.
Reflex Sympathetic Dystrophy
a clinical entity characterized by pain, swelling,
stiffness, discoloration, hyperhidrosis, and
osteoporosis in an extremity resulting from an
abnormal and prolonged response of the
sympathetic nervous system.
It occurs as a complication in about 3% of major
The clinical picture varies as the patient passes
through the early, intermediate, and late stages of
The late stage may last several months or many
years and is characterized by a stiff, cool, and
atrophic extremity. The degree of pain
experienced during this stage varies. The skin
may be devoid of hair or, in contrast, may have
an abnormal growth of hair .
Osteoporosis as classically described by Sudek
in 1900 typically is found during this stage.