how to read a radiograph in orthopaedics

1. Post graduate CME 2015
NRI Medical college, Guntur
Dr.V.S.Ravindranath

2. Etiology of nerve injuries
Trauma
Thermal
Chemical
Mechanical
Infection: leprosy
Ischaemia
Metabolic or collagen disease
Malignancy
Endo or exo-toxins
Radiation

3. Seddon Classification
Neuropraxia :
preservation of axis – cylinder of myelin sheath
physiologically interrupted
Complete recovery in a few days to weeks
Axonotemesis :
Breakdown of axon and distal Wallerian degeneration
preservation of schwann cell & endoneurial tubes
Spontaneous regeneration- good functional recovery
Neurotmesis :
Complete anatomical severance, avulsion or crushing of nerve
Axon, Schwann cell & endoneurial tubes are completely disrupted
Spontaneous recovery cannot be expected unless surgically intervened
Classification of nerve injuries

4. Each degree of injury --a greater anatomical disruption
altered prognosis
Anatomically various degrees (1to 5) represent injury to
Myelin
Axon
Endoneurial tube & it’s content
Perineurium
Entire nerve trunk
Sixth degree (Mackinson) or mixed injuries
Mixed recovery pattern
Sunderland classification

5. Diagnosis of Peripheral nerve injuries
History
Fresh or old injury ?
What is the cause ?
Which is the nerve ?
What is the level ?
What is the degree of injury ?

6. Diagnosis of Peripheral nerve injuries
Motor system:
paralyzed & atonic
Atrophy : 50 -70 % in 1st two months
Striations & motor end plate configurations retained for
12 – 18 months (critical limit of delay)

7. Sensory :
Sensory loss usually follows a definite anatomical pattern,
although factor of overlap from adjacent nerves may be
present
Autonomous zone
median , ulnar, radial
L4,L5,S1
Weber 2 point discrimination test
Tinel’s sign.

8. Trophic Changes
Esp. hand and feet
Skin – thin,
glistening,
breaks easily ,
ulcers that heal slowly
Fingernails
Ridged, distorted and brittle
Osteoporosis (Reflex sympathetic dystrophy RSD)

9. Reflex
Abolishes all reflexes transmitted by that nerve, either
afferent or efferent arc.
Complete & incomplete lesion. So , not a reliable guide to
injury severity.
Autonomic :
Loss of sweating
Loss of pilomotor response
Vasomotor paralysis in autonomous zone

10. Neuronal degeneration and regeneration
Any part of neuron detached from its nucleus, degenerates & is destroyed by
phagocytosis.
Distal – Secondary ( Wallerian Degeneration)
Proximal - Primary / Traumatic / Retrograde
Degeneration
Time required for degeneration varies
sensory fibres
motor fibers
size
myelination of fibers
Advancing Tinel sign
presence of motor march phenomena

11. Test for peripheral nerves of upper limb
Radial nerve injury
High or low injury
Wrist drop
Finger drop
Thumb drop
Test for triceps,Brachioradialis,
Wrist extensors
Extensor digitorum and EPL

13. Definition
Classification
Clinical features
Investigations
Management
What is the principle of the management?
What are the procedures of tendon transfers?
Definition
Hyperextension at MCP and flexion at
the IP joints
Classification
Total or partial
Median or ulnar claw hand
Clinical features
Wasting of the compartments
Ape hand deformity
Pen test
Froment’s sign
Card test
Egawa test
Claw hand

14. Median nerve
High or low injury
Test for FPL, FDS ,FDP (lat. half) , FCR
Abd. Pollicis brevis ( pen test) ,Oppenens pollicis
Pointing index
Claw hand

16. Ulnar paradox
Higher the lesion ,lesser the deformity
The presence of normally acting long flexors of the fingers
Intrinsic minus deformity

17. Foot drop
Common peronial nerve
Ankle drop
Toe drop

18. Electrodiagnostic studies
Electromyography
Nerve conduction velocity
Strength duration curve
Ultrasounic assesment(4D)

19. Time of Surgery
When do you want to interfere?
Primary repair
First 6 – 8 hours
Delayed primary repair
First 7 – 18 days
Secondary repair
more than 3 weeks

20. Types of Nerve Repair :
Endoneurolysis
Partial Neurorrhaphy
Neurorrhaphy
Epineural
Epi-perineural
Perineural
Nerve grafting

21. Gap between nerve ends
Mobilization ( critical nerve gap distance – value of
Grantham)
Positioning of extremity(to be avoided)
Flex knee and elbow
Flex wrist
Transposition
Nerve grafting
Nerve crossing ( pedicle grafting )
Bone resection

22. Prognostic factors for nerve regeneration.
Age of patient
Gap between nerve ends
Delay between time of injury and repair
Level of injury
Condition of nerve ends
Experience & technique of surgeon

23. Other Options
Orthoses
Tendon transfers
Bony blocks( Campbell’s bone block)
Arthrodesis

24. Thank you

25. Claw hand
Definition
Classification
Clinical features
Investigations
Management
What is the principle of the management?
What are the common tendon transfers?

26. Ulnar nerve
High
low palsy
ulnar paradox-- mechanism
Test for FCU
Abd. digiti minimi
Interossei (dorsal - Egawa’s test ; palmar – card test )
/ lumbricals /Add. Pollicis (Froment’s sign book
test )
Ulnar claw hand

27. Median nerve
High or low injury
Test for FPL, FDS ,FDP (lat. half) , FCR
Abd. Pollicis brevis ( pen test) ,Oppenens pollicis
Pointing index
Claw hand