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1. NERVE INJURIES
Presented by;
Arshad Abbas

2. REFERENCE BOOK
Page : 289 search
270 actual

3. NERVE INJURIES
 Nerves can be injured by ischaemia,
compression, traction, laceration or burning.
 Damage varies in severity from transient and
quickly recoverable loss of function to complete
interruption and degeneration.
 There may be a mixture of types of damage in
the various fascicles of a single nerve trunk.

4. NEURAPRAXIA
 Seddon (1942) coined the term ‘neurapraxia’ to
describe a reversible physiological nerve
conduction block(Due to compression on the nerve)
in which there is loss of some types of sensation
and muscle power followed by spontaneous
recovery after a few days or weeks.
 It is due to mechanical pressure causing
segmental demyelination and is seen typically in
‘crutch palsy’, pressure paralysis in states of
drunkenness (‘Saturday night palsy’) and the milder
types of tourniquet palsy.

6. AXONOTMESIS
 This is a more severe form of nerve injury, seen
typically after closed fractures and dislocations.
 Demylination + axonal loss.
 There is loss of conduction but the nerve is in
continuity and the neural tubes are intact.
 Wallerian degeneration occurs. It is an active
process of anterograde degeneration of the distal
end of an axon that is a result of a nerve lesion.
 Axonal regeneration starts within hours of nerve
damage.
 These axonal processes grow at a speed of 1–2
mm per day.

7. NEUROTMESIS
 In Seddon’s original classification, neurotmesis
meant division of the nerve trunk, such as may
occur in an open wound.
 It is now recognized that severe degrees of damage
may be inflicted without actually dividing the nerve.
 Rapid wallerian degeneration.
 Demylination + axonal loss and involvement of;
1. Endoneurium Fair growth
2. Perineurium Poor growth
3. Endoneurium No growth

8. CLASSIFICATION OF NERVE
INJURIES(SUNDERLAND,1978)
 1st degree ; Transient ischaemia and neurapraxia,
the effects of which are reversible.
 2nd degree ; Seddon’s axonotmesis.
 3rd degree ; Worse than axonotmesis. The
endoneurium is disrupted but the perineurial
sheaths are intact.
 4th degree ; Only the epineurium is intact, Recovery
is unlikely; the injured segment should be excised
and the nerve repaired or grafted.
 5th degree ; The nerve is divided and will have to be
repaired.

9. CLINICAL FEATURES
 If a nerve injury is present, it is crucial also to look
for an accompanying vascular injury.
 Ask the patient if there is numbness, paraesthesia
or muscle weakness in the related area.
 Then examine the injured limb systematically for
signs of abnormal posture (e.g. a wrist drop in
radial nerve palsy), weakness in specific muscle
groups and changes in sensibility.

10. ASSESSMENT OF NERVE RECOVERY
 History
 Tinel’s sign ; In a neurapraxia, Tinel’s sign is
negative. In axonotmesis, it is positive at the site of
injury because of sensitivity of the regenerating
axon sprouts.
 EMG ; If a muscle loses its nerve supply, the EMG
will show denervation potentials by the third week.

11. REGIONAL SURVEY OF NERVE
INJURIES
Kinza Sohail
Prepared from : APLEY’S SYSTEM OF
ORTHOPAEDICs AND FRACTURES

12. OBSTETRICAL BRACHIAL PLEXUS PALSY
 Obstetrical brachial plexus injury is usually caused by
excessive traction on Brachial plexus during childbirth. Eg
by pulling the baby’s head away from the shoulder
 Following patterns are seen
1) UPPER ROOT INJURY( ERB’S PALSY)
Erbs palsy is usually caused by injury Of C5 ,C6 And sometimes C7.
The abductors, external rotators of the shoulder and supinators are
paralysed . The arm is held to the side , internally rotated and pronated
. There may also be loss of finger extension.
2) LOWER ROOT INJURY (KLUMPKE’S PALSY)
It is due to injury of C8 and T1. The baby lies with the arm
supinated and the elbow flexed . There is loss of intrinsic muscle
power in the hand. There may be unilateral Horner’s syndrome.

13. MANAGEMENT
 Over the next few weeks following things may happen
1. Paralysis may recover completely
Most of the upper root lesions recover spontaneously
2. Paralysis may improve
A total lesion may partially resolve Leaving the infant with partial paralysis
3. Paralysis may remain unaltered
This is more likely with complete lesion in the presence of Horner’s
syndrome
While waiting for recovery physiotherapy is applied to keep the joints
mobile
OPERATIVE TREATMENT
If there is no bicep recovery by 3 months, operative intervention
should be considered . The shoulder is prone to fixed IR and
adduction deformity, if physiotherapy does not prevent this ,then
a subscapularis release will be needed Sometimes
supplemented by a tendon transfer.

14. LONG THORACIC NERVE
 Long thoracic nerve ( C5 ,6 ,7) May be damaged in the
shoulder or neck injuries( usually in axonotmesis).
However serratus anterior plasy is also seen after
carrying heavy Loads on the shoulder or even after viral
illness.
 CLINICAL FEATURES
 Paralysis of serratus anterior is the common cause of winging
of scapula. The patient may complain of aching and
weakness on lifting the arm. The classic test for winging is
have the patient Pushing forward against the wall
 TREATMENT
The nerve usually recover spontaneously. Persistent winging
Of scapula require operative stabilisation by Transferring
pectoralis minor or major to the lower part of scapula.

15. SPINAL ACCESSORY NERVE
 The spinal accessory nerve (C2-C6) supply the
sternocleidomastoid muscle and the upper half of
trapezius. Because of its superficial course the
nerve is easily injured during operations performed
In the posterior triangle of the neck( lymph node
biopsy) . The nerve is occasionally injured during
whiplash injury .
 TREATMENT
 Surgical injuries should be explored immediately .If
the exact cause of Injury is uncertain then wait for 8
weeks for recovery, if this does not occur the nerve
should be explored To confirm diagnosis amd to
repair lesion by grafting

16. SUPRASCAPULAR NERVE
 The nerve arises from the upper trunk of the brachial
plexus (C5 ,C6) and supply the supraspinatus and
infraspinatus muscle. It may be injured in fractures Of
scapula , dislocations of shoulder, By direct blow or by
carrying heavy load over shoulder
 CLINICAL FEATURES
Patient present with pain in suprascapular region And
weakness of shoulder abduction. There is usually wasting of
supraspinatus and infraspinatus with diminished power of
abduction and external rotation
TREATMENT
This is usually axonotmesis which Clear up spontaneously after
3 months. If no recovery is seen at this stage the nerve should
be explored. The operative approach is through posterior
incision

17. AXILLARY NERVE
 The axillary nerve (C5, C6) arises from the posterior cord
of the brachial plexus. It supply the teres minor and the
posterior part of deltoid. The nerve is sometimes ruptured
in the brachial plexus injury . More often it is injured
during shoulder dislocation Or fracture of the humeral
neck
 CLINICAL FEATURES
The patient complain of shoulder weakness and the deltiod is
wasted. Although abduction can be initiated (by supraspinatus) It
cannot be maintained
 TREATMENT
Nerve injury Associatied with fractures or dislocations recover
spontaneously in about 80 percent of cases if the deltoid shows no
sign of recovery By 8 weeks EMG should be performed If the test
show denervation then the nerve should be explored through
posterior approach

18. RADIAL NERVE
 The radial nerve can be injured at The elbow , in the
upper arm or in the axilla.
 Treatment
Open injuries should be explored and the nerve
repaired Or grafted as soon as possible
 Closed injuries are usually first or second degree
lesions And the function eventually return. While
recovery is awaited the small joints of the Hand
must be put through full range of passive movement
 If recovery does not occur The disability can be
largely overcome by Tendon transfers.

19. ULNAR NERVE
 Injuries of the ulnar nerve are usually Either near the
wrist or Near the elbow
 CLINICAL FEATURES
 Low lesions are often caused by cuts On shattered glass.
There is numbness of ulnar one and Half finger. The hand
assumes a typical Posture in response – the claw hand
deformity with hyperextension of the metacarpophalangeal
joints of the ring and little finger Due to weakness of intrinsic
muscles
 Entrapment of the ulnar nerve In the guyons Canal Is often
seen in long distance cyclists who lean with pisiform pressing
on the handlebars .
 Ulnar neuritis is caused by Entrapment of nerve In the medial
epicondylar ( cubital ) tunnel Especially where there is severe
valgus deformity Of elbow or prolonged pressure On the
elbow in bedridden patients

20. TREATMENT
 Exploration And suture of a divided nerve are well
and anterior transposition at the elbow permits
closure of gaps upto 5cm. Hand physiotherapy
keep the hand supple and useful

21. MEDIAN NERVE
 The median nerve provides the motor supply to the
flexor muscles in the forearm except flexor carpi
ulnaris And the ulnar head of the flexor digitorum
profundus( which is supplied by the ulnar nerve) It
also supply the thenar muscles .
 Treatment
If the nerve is injured suture or nerve grafting Should
always be attempted . Postoperatively the wrist is
splinted in flexion To avoid tension. When movements
are commneced wrist extension should be prevented

22. PERIPHERAL NERVE INJURY
By : Afsha inam
Reference book : APLEY’S SYSTEM OF
ORTHOPAEDICs AND FRACTURES PAGE 285

23. FEMORAL NERVE
 The femoral nerve may be injured by
a gunshot wound, by pressure or
traction during an operation or by
bleeding into the thigh.
 Quadriceps action is lacking and the
patient is unable to extend the knee
actively.
 There is numbness of the anterior
thigh and medial aspect of the leg.
 The knee reflex is depressed.
 Severe neurogenic pain is common.
Management
 A clean cut of the nerve may be
treated successfully by suturing or
grafting but results are disappointing.
 The alternative would be a caliper to
stabilize the knee.

24. SCIATIC NERVE
 Division of the main sciatic nerve is rare except in
gunshot wounds.
 Traction lesions may occur with traumatic hip
dislocations and with pelvic fractures.
 In a complete lesion the hamstrings and all muscles
below the knee are paralysed; the ankle jerk is absent.
 The patient walks with a drop foot and a high-stepping
gait to avoid dragging the insensitive foot on the ground.
Management
 Suture or nerve grafting should be attempted even
though it may take more than a year for leg muscles to
be re-innervated.

25. PERONEAL NERVES
 The common peroneal nerve is often damaged at
the level of the fibular neck by severe traction when
the knee is forced into varus
 Or by pressure from a splint or a plaster cast, from
lying with the leg externally rotated, by skin traction
or by wounds.
 Management
Direct injuries of the common peroneal nerve and its
branches should be explored and repaired or grafted
wherever possible.

26. TIBIAL NERVE
 The tibial (medial popliteal) nerve is rarely injured
except in open wounds.
 The distal part (posterior tibial nerve) is sometimes
involved in injuries around the ankle
Management
 A complete nerve division should be sutured as
soon as possible.
 While recovery is awaited, a suitable orthosis is
worn (to prevent excessive dorsiflexion) and the
sole is protected against pressure ulceration.

27. CARPAL TUNNEL SYNDROME
 The syndrome is common at the menopause,
in rheumatoid arthritis, pregnancy and
myxoedema.
Management
 Light splints that prevent wrist flexion can help
those with night pain or with pregnancy-related
symptoms.
 Steroid injection into the carpal canal, likewise,
provides temporary relief.
 Open surgical division of the transverse carpal
ligament usually provides a quick and simple
cure.
 The incision should be kept to the ulnar side of
the thenar crease so as to avoid accidental
injury to the palmar cutaneous (sensory) and
thenar motor branches of the median nerve.
 Endoscopic carpal tunnel release offers an
alternative with slightly quicker postoperative
rehabilitation; however, the complication rate is
higher.

28. PROXIMAL MEDIAN NERVE COMPRESSION
 Compression at this elbow site is rare
Management
 Surgical decompression involves division of the bicipital
aponeurosis and any other restraining structure (pronator teres,
arch of flexor digitorum superficialis); great care is needed in the
dissection.
Anterior interosseous nerve syndrome
 The anterior interosseous nerve can be selectively compressed
at the same sites as the proximal median nerve.
Management
 The condition usually settles spontaneously within a few months.
 If it does not, surgical exploration and release or tendon transfer
may be considered

29. ULNAR NERVE COMPRESSION
 Cubital tunnel syndrome is caused by bone
abnormalities, hypertrophy and overuse.
 operative decompression is indicated.
 Options include simple release of the roof of the
cubital tunnel, anterior transposition of the nerve
into a subcutaneous or submuscular plane, or
medial epicondylectomy.
 Simple release is preferable as it avoids the
potential denervation associated with transposition
or the persisting epicondylar pain associated with
epicondylectomy.

30. RADIAL NERVE COMPRESSION
 It may also be caused by a space-occupying lesion
pushing on the nerve – a ganglion, a lipoma or
severe radio-capitellar synovitis.
Management
 Surgical exploration is warranted if the condition
does not resolve spontaneously within three
months or earlier
 If muscle weakness is disabling, tendon transfer is
needed.

31. TARSAL TUNNEL SYNDROME
 Pain and sensory disturbance over the plantar
surface of the foot may be due to compression of
the posterior tibial nerve behind and below the
medial malleolus.
Management
 The nerve is exposed behind the medial malleolus
and followed into the sole; sometimes it is trapped
by the belly of abductor hallucis arising more
proximally than usual.
 Unfortunately symptoms are not consistently
relieved by this procedure.

32. TRIPLE PARALYSIS
 Combined loss of ulnar, median and radial nerve
function causes very severe disability.
 The patient has a ‘flexor driven’ hand as only the
long flexors of the fingers and the wrist flexors are
active.
 Multiple tendon transfers to stabilize the wrist,
fingers and thumb in extension are needed.

33. TYPES OF NERVE OPERATIONS AND
SURGICAL TECHNIQUES
By : Jehangir
Reference book : Operative Techniques in Orthopaedic
Surgery" by Sam W. Wiesel

34.  Nerve Repair Surgery ; Nerve repair surgery aims
to restore function to a damaged nerve by
reconnecting the nerve ends. The surgeon will
carefully sew the ends of the damaged nerve
together with fine stitches.
 Recovery ; Recovery from nerve repair surgery can
take several months. It typically involves physical
therapy and pain management.
 Neurolysis ; The surgical dissection and exploration
of a damaged nerve with the goal of freeing the
nerve from local tissue restrictions or adhesions.
External neurolysis is releasing scar tissue from the
nerve.Internal neurolysis is releasing the
compressed tissue.

35.  Neurectomy ; A neurectomy involves the removal of
a portion of a nerve or the entire nerve that is
causing pain.
 Nerve Grafting ; Nerve grafting involves taking a
healthy nerve from another part of the body and
using it to repair a damaged nerve.
 Types of Nerve Grafting ;
1. Autografts
2. Allografts
3. Nerve Transfer
 Neuromodulation ; It involves the use of electrical
impulses to stimulate the nerves and
reduce chronic pain.