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


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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)

  1. 1. Peripheral nerve injuries
  2. 2. Structure of the nerve Axon myeline sheath Schwann cell layer Endoneurium Perineurium Epineurium
  3. 3. Pathology The nerve is injured by: Ischaemia Compression Traction Laceration burning
  4. 4. <ul><li>Types of injury </li></ul><ul><li>Transient ischaemia </li></ul><ul><li>Neurapraxia </li></ul><ul><li>Axonotmesis </li></ul><ul><li>Neurotmesis </li></ul>
  5. 5. <ul><li>Axonotmesis </li></ul><ul><li>Segmental interruption of the axons </li></ul><ul><li>Loss of conduction </li></ul><ul><li>But the neural tubes are intact </li></ul><ul><li>Seen in closed fractures and dislocations </li></ul><ul><li>Distal to the lesion -> Wallerian degeneration </li></ul><ul><li>Axonal regeneration occurs by formation of the new axonal processes </li></ul><ul><li>which grow at a speed of 1-2 mm per t </li></ul>
  6. 6. 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.
  7. 7. 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
  8. 8. <ul><li>Principles of treatment </li></ul><ul><li>Closed injuries : If no muscle power restoration at the expected time, exploration </li></ul><ul><li>Open injuries : Primary repair OR graft </li></ul><ul><li>Missed cases : Delayed repair except when: </li></ul><ul><li>The patient has adapted to the functional loss. </li></ul><ul><li>High lesions when reinnervation is unlikely within the critical 2-year period. </li></ul><ul><li>Pure motor loss, which can be treated by tendon transfer. </li></ul><ul><li>Excessive scarring </li></ul><ul><li>Intractable joint stiffness. </li></ul>
  9. 9. In the HAND always try to repair to regain at least protective sensation
  10. 10. <ul><li>Care of paralyzed part </li></ul><ul><li>Skin must be protected from friction damage and burn. </li></ul><ul><li>The joints are moved in full range of motion twice daily. </li></ul><ul><li>Dynamic splint </li></ul>
  11. 11. <ul><li>Obstetric brachial plexus injuries </li></ul><ul><li>Caused by excessive traction on the brachial plexus during childbirth </li></ul><ul><li>. </li></ul><ul><li>C5+C6+C7+C8+T1 </li></ul><ul><li>Clinical features : </li></ul><ul><li>Difficult delivery </li></ul><ul><li>Flail arm. </li></ul><ul><li>Further examination reveals one of the following: </li></ul><ul><li>(A) Erb’s palsy </li></ul><ul><li>(B) klumpke’s palsy </li></ul>
  12. 13. 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)
  13. 16. Klumpke’s palsy: Less common The arm is flail and pale All muscles of the fingers are paralyzed ± Ipsilateral Horner’s syndrome
  14. 17. 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.
  15. 19. 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.
  16. 22. Treatment: Spontaneous recovery during 8 weeks. If not: Exploration + repair OR graft. If failed: Tendon transfer OR Shoulder arthrodesis. .