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Hand nerve repair

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Hand nerve repair

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Hand nerve repair

  1. 1. HANDNERVEINJURY REPAIR Diagnosis& Treatment Stefano Avvedimento, MD
  2. 2. NERVEANATOMY
  3. 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
  4. 4. Epidemiology 10% ofnerveinjurie s involve peripheralner ves Etiology  Mostcommonly the digitalnerves  Penetratinginjuries  Trauma Injury  Avulsion or traction  Ischemia and others non mechanicalfactors (Thermal, electric,radiation)
  5. 5. Pathophysiology: Normalresponsetoaninjury •Injury •Walleriandegeneration •ProliferationofSchwanncells and releaseofneurotrophic and neurotropic factors •Axonelongation
  6. 6. Problemsofregeneration Largegaps ( > 15-30 mm) Nervetooclose Neuroma formation Fasciculardisorganization
  7. 7. Historyof the patient (Age, pastmedicalhistory, medications, handdominance and the eventsof the injury) Nerveinjurypresentation Physicalexamination •Motor evaluation •Sensoryevaluation Nerveinvolved Levelofnerveinjury Complete or partial lesion
  8. 8. Motor evaluation: RadialNerveInjury Wristdrop Unabilitytoextend the thumb Extensionof the elbow, wrist and fingers
  9. 9. Motor evaluation: UlnarnerveInjury Extrinsicmusculatur e Adductorpollicis (Fromentsign) Intrinsicmusculature Mediallumbricalsof the hand (Clawhand)
  10. 10. Motor evaluation: MediannerveInjury Thumbabductor (ape handdeformity) FDP Thumb, index and middle fingers (Pope’sBlessingsign)
  11. 11. Sensoryevaluation Radial, Ulnar and MedianNervessensorydistributionof the hand
  12. 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. 13. 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)
  14. 14. Timing ofnerverepair Primaryrepair superiorto secondaryrepair Contraindications •Woundcontaminated •Vascularizedbednotpresent •Concomitantinjuries (In complex woundsnerverepairafterrepair ofvascular and skeletalstructures) •Patientunstable •Repair no tension free
  15. 15. Direct Suture Only small nerve gaps, in which minimal tension is required to contrast the elastic properties of the nerve, can be directly repaired
  16. 16. TypesofNeurorraphy EPINEURAL FASCICULAR Although Fascicular repair purportedly ensures correct orientation of regenerating axons, there is little evidence that it is superio to the less exact but simpler epineurial repair
  17. 17. NerveGrafts Fornervegapsthatcannotbe repairedprimarlywithouttension >2 cm upper arm > 1cm digitalnerves 4 cm nerve gap at the elbowrepairedwith a suralnervegraft 4 Cm
  18. 18. Source ofnervegrafts: SuralNerve The sural nerve in the adult can provide 30 to 40 cm of nerve Graft.
  19. 19. •Donor site morbidity •Needtochangepatient position during the harvesting Problems Classicalharvest Endoscopicharvest
  20. 20. Medial and lateralantebrachialcutaneousnerves  MABCN  LABCN •Medial part of the arm •Anterior and posteriorbranch in the forearm •Lateral part of the forearmmedial tocephalicvein
  21. 21. Othersourcesofnervegrafts Distal Posterior Interosseous Nerve Graft Gracilis Branch of Obturator Nerve Graft
  22. 22. Nerveconduits •Biocompatibletubesth at guide nerveregrowth •Releaseofneurotrophi c and neurotropicfactors •PresenceofSchwann cells in experimentalstudies •Differentmaterials
  23. 23. Nerveconduit: Business or Goodoption ? •Notusefulforgaps> 3cm •Efficacynotprovenforr epairof big diameternerves
  24. 24. Arterial and VeinConduits •Onlyfewstudiespublis hed in literature •Forsmallgaps< 3cm •Readilyaccessible • Minimal donor site morbidity 2,8 cm
  25. 25. 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
  26. 26. Ulnarnerveinjuryrepairedwithinterosseousner ve transfer Interosseous N.Ulnar N. Preop Postop

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