This document discusses the management of various nerve injuries. It begins by defining the peripheral nervous system and describing the different types of nerve injuries including transient ischemia, neuropraxia, axonotmesis, and neurotmesis. It then examines specific nerves that are commonly injured such as the brachial plexus, long thoracic nerve, radial nerve, median nerve, and ulnar nerve. For each nerve, it discusses anatomy, causes of injury, clinical features, treatment approaches, and prognosis. The document provides a comprehensive overview of managing different peripheral nerve injuries.

1. Management of Nerve Injury
Prepared By: -
Azri Salih Haji
Adnan Mohammed
Abdulaziz Muslim
Bawer Loqman
Supervised by: -
Dr. Qeydar
1
Management of Nerve Injury

2. Objectives
• Peripheral nervous System.
• Types of Nerve injury and their management.
• Prognosis.
• Brachial Plexus.
• Long thoracic Nerve.
• Nerves of the Forearm and Hand.
• Lower limb.
2
Management of Nerve Injury

3. • is made of a group of axons wrapped together and
conducting impulses.
• Each Nerve Fiber is made up of an axon surrounded by a
Schwann cell with or without Myelin layer, and they all
wrapped by a membrane called Endoneurium
• Each Bundle is made up from a group of Nerve Fibers which
are wrapped together by a membrane called Perineurium.
• Each Peripheral Nerve trunk is made up from a group of
Nerve bundles (Fascicles) which are wrapped together by a
membrane called Epineurium.
Peripheral Nervous System
3
Management of Nerve Injury

4. 4
Management of Nerve Injury

5. Peripheral Nerve Functions
Peripheral nerves transmit or
conduct electrical impulses
(action potential) between
the central nervous system
and the peripheral receptors.
1. Efferent (motor) impulses
2. Afferent (sensory)
impulses
3. Efferent Sudomotor,
vasomotor, and pilomotor
(sympathetic) impulses
5
Management of Nerve Injury

6. 1. Predominantly motor such as posterior interosseous
nerve
2. Predominantly sensory such as sural nerve
3. Mixed such as ulnar nerve
Types of Nerves
6
Management of Nerve Injury

7. I. Transient Ischemia
II. Neuropraxia
III. Axonotmesis
IV. Neurotmesis
Types of Nerve Injuries
7
Management of Nerve Injury

8. Transient Ischemia
• Causes: pressure on the nerve for few minutes – few hours
• Pathology: transient endo-neurial ischemia and anoxia
• Clinical Features:
o within 15 minute  Tingling sensation
o after 30 minutes  Loss of sensation
o after 45 minutes  Muscle weakness
o Relief of compression is followed by:
 Intense paraesthesia started within 30 seconds and last for about 5
minutes
 Complete muscle power recovery occur within 10 minutes
• Treatment : no need
• Prognosis: the nerve structure and function return to normal without any trace of
damage.
8
Management of Nerve Injury

9. Neuropraxia
• Definition: reversible physiological nerve conduction block
• Causes: mechanical pressure
• Pathology: segmental demyelination
• Cl.F: loss of sensation + loss of muscle power
• Examples: Saturday night palsy, tourniquet palsy
• Treatment: passive exercises + splint until recovery occur
• Prognosis: good; complete recovery is expected to occur
after few days or weeks.
9
Management of Nerve Injury

10. Axonotmesis
• Definition: loss of impulse conduction due to nerve fiber damage (axonal
interruption) but with a preserved nerve trunk.
• Pathology:
o At the site of injury: Axons + Schwann cells are damaged, but some neural membranes
are preserved.
o Distal to lesion and for few millimeters retrogradely and within hours the nerve fiber
under go necrosis (Wallerian degeneration)
o Within days the proximal stump of the nerve fiber grow numerous fine new axons
(axonal regeneration) which try to find their way into the distal part of the
endoneurial tube at a speed of 1-2 mm / day until they reach the end organ, then
enlarge and start functioning again.
• Examples: in closed fractures and dislocations
• Cl.F: loss of sensation and paralysis.
• Treatment: passive exercises + splint until recovery occur.
• Prognosis: good; rarely in severe form the recovery do not occur spontaneously.
10
Management of Nerve Injury

11. Neurotmesis
• Definition: division of the whole nerve trunk such as in open injuries (wounds).
• Pathology:
o Wallerian degeneration and axonal regeneration occur but the new axons can’t reach
the distal stump.
o The new regenerated axons mixed with proliferating fibroblasts at the stump of
proximal part making a nodule called (Neuroma).
o If the regenerating axons did not reach the target organs (motor end plates and
sensory receptors) within 2 years, the denervated structures undergo irreversible
changes.
• Cl.F: sensory loss + paralysis.
• Treatment: surgery + passive exercises and splint until recovery occur.
• Prognosis: recovery will not occur spontaneously. Surgery repair may help but
with a fair prognosis. If recovery occurs, the function may be adequate but is
never normal.
11
Management of Nerve Injury

12. Diagnosis of Nerve injury
• History
o Type of injury
o Abnormal sensation (tingling or numbness)
o Localized weakness or inability to do some movements actively.
• Examination:
o Sensory deficit: Diminish or loss of pain or touch sensory perception in the skin
patch of sensory distribution of the specific nerve specially the Autonomous
zone.
o Motor deficit: inability to perform certain movements by muscles innervated
by the specific nerve.
o In long standing nerve injury:
 skin become smooth and dry ± pressure sores or ulcers
 Muscle become wasted
 Joint may develop postural and fixed deformities
Management of Nerve Injury 12

13. Investigations
1. NCS 2. EMG
Management of Nerve Injury 13

14. 1. Conservative treatment (passive exercises + splint) for
most types of nerve injuries until spontaneous recovery
occur.
2. Surgical repair mainly for neurotmesis and sever types
of axonotmesis.
Management of Nerve Injury 14
Principle of Treatment

15. Management of Nerve Injury 15
Factors affecting nerve recovery
Factors Good Prognosis Bad Prognosis
1. Type of injury Transient Ischemia,
Neuropraxia, mild axonotmesis
Severe axonotmesis,
neurotmesis
2. Level of injury: Low level High level
3. Type of nerve Pure nerve (sensory or motor) Mixed
4. Size of gap Narrow Wide
5. Age of patient Young Old
6. Onset of repair Early Delayed
7. Surrounding soft tissue state Healthy Unhealthy
8. Surgical technique Good Not good

16. Brachial Plexus Injuries
Anatomy:
– Nerve roots C5-T1
– Trunks
– Divisions
– Cords
– Nerves
Course:
The plexus pass between the
neck muscles beneath the clavicle
into the arm.
Management of Nerve Injury 16

17. Brachial Plexus Injuries
Types:
1. Obstetrical (birth) injuries
2. Non-obstetrical injuries
Management of Nerve Injury 17

18. Obstetrical Brachial Plexus Palsy
• Cause:
excessive traction on the
brachial plexus during
childbirth, e.g. by pulling the
baby’s head away from the
shoulder or by exerting traction
with the baby’s arm in
abduction.
Patterns (Types):
1. Upper root injury [C5, C6 ±
C7] = Erb’s palsy, typically
in overweight babies with
shoulder dystocia at
delivery;
2. Lower root injury [C8-T1] =
Klumpke’s palsy, usually
after breech delivery of
smaller babies
3. Total plexus injury.
Management of Nerve Injury 18

19. Obstetrical Brachial Plexus Palsy
Dx:
Hx:
• Hx of difficult labor
• the baby has a floppy or flail arm.
Ex:
• Erb’s palsy: The arm is held to the side (adducted), internally rotated,
elbow extended, forearm pronated, wrist flexed ± loss of finger extension.
Sensation cannot be tested in a baby.
• Klumpke’s palsy: The arm supinated, elbow flexed, loss of intrinsic muscle
power in the hand, reflexes are absent ± unilateral Horner’s syndrome.
• With a total plexus injury the baby’s arm is flail and pale; all finger muscles
are parlysed ± vasomotor impairment and unilateral Horner’s syndrome.
X-ray:
• to exclude the D.Dx (fractures of the shoulder or clavicle).
Management of Nerve Injury 19

20. Management of Nerve Injury 20

21. Obstetrical Brachial Plexus Palsy
Prognosis:
– Paralysis may recover completely (most of the upper root lesions)
– Paralysis may improve (some upper roots and most total lesion)
– Paralysis may remain unaltered (some complete lesions, especially in the
presence of a Horner’s syndrome).
Rx:
– Physiotherapy is applied to keep the joints mobile until the spontaneous
recover occur.
– Surgery (If there is no biceps recovery) by
• nerve grafts or nerve transfer
• subscapularis release, tendon transfer
• rotation osteotomy of the humerus.
Management of Nerve Injury 21

22. Long Thoracic Nerve
Anatomy:
– Originate from C5, 6, 7 roots
and supply serratus anterior
muscle.
Cause of injury:
1. carrying loads on the
shoulder, and even viral
illnesses or toxoid injections
2. damaged in shoulder or neck
injuries (usually an
axonotmesis)
3. during operations such as first
rib resection, trans-axillary
sympathectomy or radical
mastectomy
Management of Nerve Injury 22

23. Long Thoracic Nerve
Clinical features
– Paralysis of serratus anterior is
the commonest cause of
winging of the scapula.
– The patient may complain of
aching and weakness on lifting
the arm.
– Examination shows little
abnormality until the arm is
elevated in flexion or
abduction. The classic test for
winging is to have the patient
pushing forwards against the
wall or thrusting the shoulder
forwards against resistance.
Management of Nerve Injury 23

24. Long Thoracic Nerve palsy
Treatment
1.Usually spontaneous recovery ( it may take a year or
longer).
2.If occur after direct injury or division  surgical repair.
3.Persistent winging of the scapula occasionally requires
operative stabilization by transferring pectoralis minor or
major to the lower part of the scapula.
Management of Nerve Injury 24

25. Axillary Nerve
Anatomy:
– It originates from (C5, 6) nerve
roots and then arises from the
posterior cord of the brachial
plexus and runs around the
surgical neck of the humerus,
deep to the deltoid and supplies
the deltoid and a patch of skin
over the muscle.
Causes of Injury:
– During shoulder dislocation or
fractures of the humeral neck.
– Iatrogenic injuries occur in trans-
axillary operations on the shoulder
D.Dx:
– Rupture of the rotator cuff.
Management of Nerve Injury 25

26. Axillary Nerve
Clinical features
– Motor: Weakness of shoulder
abduction (continuation phase).
– Sensory: small area of numbness
over the deltoid (the ‘sergeant’s
patch’).
– On long standing conditions there
will be wasting of the deltoid
muscle.
Treatment
– Nerve recovery is expected within
3 months (in 80% of cases).
– If no recovery  surgery
Management of Nerve Injury 26

27. Radial – Median – Ulnar Nerves
Management of Nerve Injury 27

28. Management of Nerve Injury 28
Radial – Median – Ulnar Nerves

29. Radial Nerve Palsy
Anatomy:
– Originates from C5-8 & T1, then arises from posterior
cord  post compartment of arm  spiral groove of
humerus  ant. compartment of arm  divides into two
branches (Superficial branch pass into the lateral
compartment of forearm to the dorsum of hand & post
interosseous N. pass into the post compartment of
forearm).
Level of Injury:
– The radial nerve may be injured at
the elbow (low level), in the arm
(high level) or in the axilla (very high
level).
Management of Nerve Injury 29

30. Radial Nerve Palsy
Management of Nerve Injury 30
Clinical Features Low level injury High level injury Very high level injury
Mechanism of Injury • Fracture s and
dislocations
around elbow.
• Local wound
around elbow.
• Iatrogenic after
operation for
head of radius
• Fracture shaft of
humerus
• Tourniquet palsy
• Trauma or
operation around
shoulder and
axilla
• Example: Saturday
Night palsy,
Crutches palsy
Symptoms Clumsiness of hand Hand paralysis Hand paralysis
Signs • Fingers drop
• Wrist extension is
preserved
• No sensory loss
• Fingers drop
• Wrist drop
• Sensory loss of
dorsal surface of
first web space
• Finger drops
• Wrist drops
• Sensory loss of
dorsum of 1st web
space
• Weak elbow
extension

31. Radial Nerve Palsy
Treatment
• Open injuries needs surgical exploration.
• Closed injuries
 If associated with fractures and dislocations  are usually neuropraxia
and recover spontaneously within 12 weeks
 If no recovery occurs after 12 weeks, or if the palsy occurs after
manipulation or surgery (iatrogenic)  needs exploration and surgery
While recovery is awaited, the treatment is splint & physiotherapy for
the hand joints to prevent contractures until recovery occur.
Management of Nerve Injury 31

32. Ulnar Nerve Palsy
Management of Nerve Injury 32

33. Ulnar Nerve Palsy
Management of Nerve Injury 33
Low Level High Level
Site Near wrist Near elbow
Causes • cuts on shattered glass
• ganglion or ulnar artery aneurysm
• Prolonged pressure on the volar aspect
of the wrist
• with elbow fractures or dislocations
• With any where wounds
• severe valgus deformity of the elbow
• prolonged pressure on the elbows in
anaesthetized or bed-ridden patients
Symptoms • numbness of the ulnar one and a half
fingers
• claw hand deformity
• Grip strength is diminished
• numbness of the ulnar one and a half
fingers
• The hand is not markedly deformed ‘high
ulnar paradox’
• Grip strength is diminished
Signs • Hypothenar and interosseous wasting
• Finger abduction is weak
• loss of thumb adduction, makes pinch
difficult.
• Froment’s sign
• Hypothenar and interosseous wasting
• Finger abduction is weak
• loss of thumb adduction, makes pinch
difficult.
• Froment’s sign

34. Management of Nerve Injury 34
Froment’s sign

35. Ulnar Nerve Palsy
Treatment
• Surgical exploration + repair +/- anterior transposition of the ulnar
nerve at the elbow
• Hand physiotherapy while recovery is awaited.
• Prognosis is not good (because the is mixed type). The resultant
deformity may improved by tendon transfer.
Management of Nerve Injury 35

36. Median Nerve Palsy
Management of Nerve Injury 36

37. Median Nerve Palsy
Management of Nerve Injury 37
Low Level High Level
Site Near wrist Near elbow
Causes • Cuts in front of wrist
• Carpal Tunnel Syndrome
• Fractures & dislocations around elbow
• Cuts or gunshot wounds
Symptoms sensation is lost over the thenar
eminence & radial three and a half
digits
sensation is lost over the thenar eminence
& radial three and a half digits
Signs • Loss of thumb opposition
• Inability to make or to maintain a
tightly made “OK sign”
• In long standing lesion there will
be wasting of thenar eminence
• Loss of thumb opposition
• Inability to make or to maintain a tightly
made “OK sign”
• In long standing lesion there will be
wasting of thenar eminence
• Finger pointing sign

38. Management of Nerve Injury 38
Median Nerve
Palsy

39. Median Nerve Palsy
• Treatment
– If the nerve is divided  surgical repair.
• Prognosis
– If there has been no recovery, the disability is severe
because of sensory loss and deficient opposition.
Management of Nerve Injury 39

40.  NERVES OF LOWER LIMB
• Arise from lumbar and sacral plexus
• Main nerves of lumbar plexus are:
1. Femoral nerve
2. Obturator nerve
3. Lateral cutaneous nerve of thigh
• Main nerves of sacral plexus are
1. Superior gluteal nerve
2. Inferior gluteal nerve
3. Pudendal nerve
4. Sciatic nerve which terminates by
dividing into:
a. Tibial nerve
b. Common peroneal nerve
Management of Nerve Injury 40
Lower extremity nerves injury

41. Femoral Nerve Palsy
Causes of Injuries:
– gunshot wound
– pressure or traction during an operation
– bleeding into the thigh.
Clinical features
– The patient is unable to extend the knee actively.
– There is numbness of the anterior thigh and
medial aspect of the leg.
Treatment
– A thigh haematoma may need to be evacuated.
– Nerve cut is treated by suturing
Management of Nerve Injury 41
Femoral Nerve

42. • Common causes
– Hip or Femur fracture
– Total hip arthroplasty
– Gun shot wounds
– Tumor (neurofibroma,
schwannoma,
neurofibrosarcoma,
lipoma, lymphoma…etc) Management of Nerve Injury 42
Sciatic Nerve Palsy
Sciatic Nerve

43. Clinical features
– In a complete lesion
The hamstrings & all muscles below the knee
Sensation is lost below the knee, except saphenous nerve distribution area
Foot drop and a high-stepping gait.
In late cases the limb is wasted, with fixed deformities of the foot and trophic
ulcers on the sole.
– In partial lesions:
Features of Common peroneal Nerve injuries
Features of tibial nerve injuries
Management of Nerve Injury 43
Sciatic Nerve Palsy

44. Treatment
• If the nerve is divided  suture.
• While recovery is awaited, a below-knee drop-foot
splint is fitted.
• Great care is taken to avoid damaging the
insensitive skin and to prevent trophic ulcers.
• The chances of recovery are generally poor and, at
best, will be long delayed and incomplete.
Management of Nerve Injury 44
Sciatic Nerve Palsy

45. MCQ
• Which nerve is affected by sciatic neuropathy?
1.Peroneal nerve
2.Tibial nerve
3.Both
• 3. However…
• Initially, peroneal nerves are preferentially affected in
sciatic nerve lesion
Management of Nerve Injury 45

46. Management of Nerve Injury 46
Common Peroneal Nerve Palsy

47. Common Peroneal Nerve Palsy
Management of Nerve Injury 47
Common Peroneal Nerve Deep Peroneal Nerve Superficial Peroneal
Nerve
Site of injury Around knee In leg In leg
Causes of injury Wounds or fractures
around fibular neck
Correction of Knee valgus
deformity
Pressure of splint or in
bed ridden
Mass as ganglion
anterior compartment
syndrome
during operations on
the ankle
stretched by a severe
inversion injury of the
ankle
Sensory loss front and outer half of
the leg and the dorsum
of the foot
in a small area of skin
between the first and
second toes
In lateral aspect of leg &
dorsum of foot
Motor loss Foot drop with loss of
foot dorsiflexion &
eversion
weakness of foot
dorsiflexion
weakness of eversion

48. Common Peroneal Nerve Palsy
Treatment
– Direct injuries  exploration and repair or grafted
– While recovery is awaited a splint may be worn to
control ankle weakness.
– If there is no recovery, the disability can be minimized by
tibialis posterior tendon transfer or by hind-foot
stabilization; the alternative is a permanent splint.
Management of Nerve Injury 48

49. Management of Nerve Injury 49
Tibial Nerve

50. • The tibial nerve is rarely injured except in open wounds.
• The distal part (posterior tibial nerve) is sometimes involved in
injuries around the ankle.
• Mnemonic; TIP= Tibial Inverts and Plantarflexes, if injured, cannot stand on TIP toes
Management of Nerve Injury 50
Tibial Nerve palsy

51. • Clinical features
– The tibial nerve
– unable to plantarflex the ankle or flex the toes
• sensation is absent over the sole.
• Because both the long flexors and the intrinsic muscles are involved,
there is not much clawing.
• With time the calf and foot become atrophic and pressure ulcers may
appear on the sole.
– The posterior tibial nerve
• Fractures and dislocations around the ankle
• sensory loss and clawing of the toes
Treatment
• Cut nerve  sutured
• Splint  till recovery occur
Management of Nerve Injury 51
Tibial Nerve palsy

52. Let’s create a case…
• A 52 yo woman was referred for evaluation of 6 months
history of left foot drop. She initially felt numbness over
( where? ). This was shortly followed by left foot
dropping. Most recently, she noted a sensation of
tightness and pain from ( where? ) to ( where? ).
1. the top of the foot and the lateral calf,
2. from her hip down to her knee and into her calf
Management of Nerve Injury 52
• This is a sciatic neuropathy case.

53. • On exam, left ankle dorsiflexion was 1/5 on MRC scale, (weak or strong?
) on ankle eversion. Ankle inversion was (weak or strong?). Toe
extension was (weak or strong?). Hip abduction was (weak or strong?).
Knee flexion was (weak or strong?). Reflexes were normal except for (
which? ). There was sensory disturbance to light touch on ( where? ).
• Of note, there was a well healed surgical scar over the left lateral thigh.
1. Weak
2. Weak
3. Weak
4. Strong
5. Weak
6. left ankle
7. The top of the foot, lateral foot and calf,
8. lateral knee, and posterior calf on the left side
Management of Nerve Injury 53

54. Management of Nerve Injury 54
Thank You

55. Management of Nerve Injury 55
Any
Questions ?