This document discusses the management of peripheral nerve injuries. It covers diagnostic tests such as imaging, electrodiagnostic studies, and clinical tests. General treatment considerations are presented for both open and closed injuries. Surgical techniques for nerve repair include primary repair, nerve grafting, and tendon transfers. Factors that influence nerve regeneration are also outlined. Specific techniques are described for managing brachial plexus injuries and median nerve injuries.

1. Management in
Peripheral Nerve Injuries
Dr. Jose Austine
Resident, Dept. of Orthopaedic surgery,
Kasturba Medical College, Mangalore
Moderators
Dr. Deepak Pinto
Dr. Sunil Murthy

2. Ø Diagnostic tests
Ø General treatment considerations in
Nerve injury
Ø Nerve Repair
Ø Tendon transfer
Ø Management in specific peripheral
nerve injury

3. Diagnostic Tests

4. Diagnostic Tests
Imaging
Electro
diagnostic
studies
Tinel’s sign Sweat test
Skin
resistance
test
Electrical
stimulation

5. Electro-diagnostic studies
• Best and most accessible correlative electro-physiologic
confirmations of a peripheral neural injury.
• Presence, location, severity and possibly the prognosis of the
neural insult can be determined.
• Recovery pattern can be obtained when the study is done
sequentially over time.
• EDX is done at 3-6 weeks to allow Wallerian degeneration and
regeneration to occur to be able to detect features of the same.
• Absence of regeneration features at 3 months is an indication to
explore the nerve.

6. Nerve conduction study
• Orthodromic motor
study
• Antidromic-
orthodromic sensory
study
• Retrograde study(F
wave study)

7. Nerve conduction
velocity
Amplitude Latency
DurationF wave amplitude H reflex

8. Electromyography
• Technique of recording the electrical activity within a striated
muscle belly by inserting needle in it.
• Electrical signal generated by the muscle tissue is detected by
an electrode which is further amplified and monitored by
oscilloscope or a speaker or recorded in system.
Uses of EMG:
üPresence of nerve injury
üComplete/ incomplete nerve injury
üLevel of injury
üWhether any regeneration occurring

10. • Initial post injury phase- Normal unless prior injury
• At 10-14 days- Positive sharp waves
• At 14-18 days- Fibrillations; Voluntary motor unit
potentials have attenuated amplitudes
• At 3 months- Motor unit potential amplitude
progressively increases; Polyphasic waves (Nerve
regeneration process)
• Between 2-6 months- Larger than normal appearing
potentials till nerve regeneration is complete

11. • Positive sharp waves and Fibrillations = Wallerian degeneration occurring
• Polyphasic waves = Nerve regeneration process
• EMG recording looked for in specific muscles-
ØBrachioradialis - Radial Nerve
ØAbductor Pollicis Brevis- Median Nerve
ØAbductor digiti minimi- Ulnar Nerve

12. Tinel’s sign
• Gentle percussion along the course of an injured nerve.
• Distal to proximal
• Transient tingling sensation felt in the distribution of the injured nerve rather
than at the area percussed, and the sensation should persist for several
seconds after stimulation.
• Positive Tinel sign is presumptive evidence that regenerating axonal sprouts
that have not obtained complete myelinization are progressing along the
endoneurial tube.

13. • Neurapraxia – Absent
• Axontmesis- Present and progressive
• Neurotmesis- Present and non-progressive
• Strong response at site- Poor prognosis
• Fading response at site- Good prognosis
• Persistent response at site- Unequivocal
Tinel’s sign

14. • Sympathetic fibers within a peripheral nerve are resistant to mechanical trauma.
• Presence of sweating within the autonomous zone of an injured peripheral nerve
suggests that complete interruption of the nerve has not occurred.
• Dusting the extremity with quinizarin powder which assumes a deep purple color
throughout the area of normal sweating.
• Remains dry and light gray throughout the denervated area.
Sweat test

15. • Assesses autonomic disruption
• Richter dermometer is used.
• Autonomous zone with absence of sweating shows an
increased resistance to the passage of electrical current.
• Adjacent innervated areas have a normal resistance
Skin resistance test

16. Electrical stimulation

17. General treatment
considerations in
Nerve injuries

18. General treatment
considerations in Nerve injuries
Initial management of a patient with peripheral
nerve damage should begin with careful assessment
of the vital functions.
ATLS
Protocol
Open injury Closed injury

19. Open Injury
• An open wound with peripheral nerve injury should
be cleansed and debrided thoroughly.
• Immediate primary repair
ü Clean and sharply incised
ü Patient condition satisfactory
ü Adequate personnel and equipment
• Delayed Primary Repair (after 3-7 days)

20. • Secondary repair
ØContamination is severe
ØCrushing, abrading or blast injuries
ü Wound cleaned, debrided and sterile dressing applied
ü Ends of nerve marked with prolene or stainless steel
ü Loose end to end apposition to prevent retraction
ü In the presence of a segmental gap in the nerve, suturing the
ends to the soft tissues prevents their retraction.
Open Injury

21. Closed Injury
• Assessment of residual function and documentation of
discrete deficit.
• Early active motion of all joints.
• Gentle passive exercises.
• All joints of the extremity must be kept supple, and soft-
tissue contractures must be avoided.
• Dynamic and static splinting to support joints and to prevent
contractures.

22. • Early surgical exploration is avoided unless open reduction planned.
• Awaiting re-innervation seems reasonable.
• Early ultrasound imaging of the involved nerve can determine the extent of
injury.
• Periodic EMG, nerve conduction velocity studies, and frequent clinical
evaluation.
• If no evidence of regeneration then nerve exploration.
If the nerve deficit follows manipulation or casting of a closed fracture in the
absence of a prior nerve deficit, early exploration of the nerve is indicated.
Closed Injury with Fracture

23. Nerve repair

24. Methods of nerve repair
1. Primary – within hours
2. Delayed primary – within 3-7 days
3. Secondary – more than 7 days
Nerve repair (Neurorrhaphy)

25. • Epineural
Techniques

27. • Perineural or
fascicular
Techniques

28. • Group fascicular
Techniques
Epineural repair Group fascicular repair

29. • Mixed neurorraphy
Ø Utilizes elements of all of the above.
ØFirst, epineural stitches as splint and then fascicular or group
fascicular repair.
ØAlso uses fibrin nerve glue.
Techniques

30. Repair augmentation

31. Repair augmentation
• Tantalum
• Plasma clots
• Gold films
• Surgicel
• Collagen
• Fibrin clot
• Surgical tape
• Liquid plasticizers

32. Principles of Nerve Repair
üIncision is important, should extend well proximal and distal and when
possible should follow the course of the nerve.
üPreparation of nerve stump and approximation without tension to
preserve blood supply.
üConsider normal excursion of the nerve with limb movements.
üExtremity should be moved through ROM during repair itself.
üLacerated fascicles must be dissected proximally and distally until
adequate exposure is obtained for repair.
üEpineural vessels must be preserved because they serve as an important
guide for fascicular orientation during repair.

33. Management of nerve defects
• Mobilization
• Transposition
• Limb positioning
• Resection osteotomy
• Neuromatous neurotization
• Nerve grafting

34. Nerve grafting
Sources
ü Lateral cutaneous nerve of thigh
ü Medial brachial and ante brachial cutaneous nerve
ü Radial sensory nerve
ü Sural nerve (up to 40 cm)
ü Lateral cutaneous nerve of forearm
ü Terminal branches of PIN (for digital nerves)

35. Nerve grafting techniques
• Trunk grafting
ØUsing full thickness segment of major nerve trunk
• Inter-fascicular nerve graft
ØCable graft using multiple strands of cut nerve
• Pedicle graft
ØFor high combined ulnar and median nerve palsy where ulnar
nerve is used a pedicle graft to repair median nerve

36. Nerve grafting techniques
• Free vascularized nerve graft
• Biological conduits ± stem cells
• Artificial conduits
ØCollagen
ØPolyglycolic acid
ØPoly L Lactic acid

37. Factors influencing regeneration
after neurorrhaphy
1. Age
• More successful in children than in adults
• May relate to central adaptation to peripheral nerve injury
2. Gap between nerve ends
• Recovery better if gap is small
• Nature of injury is most important factor in determining extent of defect
• Sharp cut injury- proximal and distal end damage limited- Minimal resection and gap
• High velocity injury- proximal and distal damage extensive- Wide resection and gap
• Nerve grafting is advised if, after nerve is mobilized, the gap cannot be closed by flexing
the main joint of the limb 90 degree

38. Factors influencing regeneration
after neurorrhaphy
3. Level of injury
• More proximal the injury, the more complete the overall return of
motor and sensory function.
4. Delay between time of injury and nerve repair
• Delay of neurorrhaphy affects motor recovery more than sensory
recovery
• Significant loss of motor end plates and increased muscle fibrosis by
18 months after denervation(basis of critical limit of delay)
5. Condition of nerve ends

39. Tendon transfers

40. Principles of Tendon transfer
1. Prevention and correction of contracture
ØThere must be free range of movements in the joint to be activated by
transplanted muscle.
ØJoint must be supple.
ØAny bony deformity or malalignment should be corrected by
osteotomy. Any necessary
bone grafting must be accomplished before transfer.
ØNecessary operations to restore any loss of sensibility should also
precede tendon transfer.
ØJoint proximal to parts to be moved should be stabilised either by
tendon action or by arthrodesis.

41. Principles of Tendon transfer
2. Tissue equilibrium
ØNerve and blood supply of the transferred muscle must not be
impaired.
ØThe transferred tendon should pass through the gliding bed(either
through subcutaneous fat or through a tendon sheath)
ØTransfer should not pass through the raw bone
ØTransfer should not be done until any scarred tissue has been
satisfactorily replaced.

42. Principles of Tendon transfer
3. Adequate strength
ØThe muscle to be transferred should be healthy(appear dark pink or
red).
ØThe strength of the muscle to be transferred should be grade 4 or 5
since muscle usually loses strength by 1 grade when transferred.
Ø Muscles
that do not contract with a stimulus (pinch or electrocautery)
are probably nonfunctional and should not be chosen as
active donor muscles.
4. Amplitude of motion
ØAmplitude of motion should be sufficient.

43. Principles of Tendon transfer
5. Straight line of pull
Ø The origin and the newly transferred insertion should be in a straight line.
Ø Whenever acute angle is used, a pulley should be used.
Ø Transferred tendon should retain its own sheath or should be inserted into
sheath of another tendon.
Ø Tendon should be attached under moderate tension.
Ø When tendon is split to provide insertion to various points, tension should be
equal to all points.
Ø Freed end of the transferred tendon should be attached as close to the
insertion of paralysed tendon.
Ø Muscle detached from its insertion some time before transfer will have
developed a contracture; its tendon should be anchored under more tension
than usual because it will stretch and regain some of its excursion.

44. Principles of Tendon transfer
6. Synergism
ØIt is desirable to use a synergistic muscle as it is easier to
rehabilitate the muscle after surgery.
ØAgonists are preferred to antagonists.
7. One tendon- One function
8. Expendable donor

45. Management in
specific peripheral
nerve injuries

46. Brachial plexus injuries
Surgical goals
1. Restoration of elbow flexion
2. Restoration of shoulder abduction
3. Restoration of sensation to the medial border of
the forearm and hand

47. Brachial plexus injuries
Various surgical techniques employed
1. Primary neurorrhaphy
2. Neurolysis
3. Nerve grafting
4. Neurotization
5. Tendon transfers
6. Shoulder arthrodesis

48. Brachial plexus injury- Nerve transfers

49. Brachial plexus injury- Nerve transfers

50. Brachial plexus injury- Nerve transfers

51. Critical limit of delay of suture
Motor
• High lesions – 9 months
• Low lesions – 15 months
Sensory
• Lesions above pronator teres – 12 months
• Lesions below FPL – 9 months
Median nerve injury

52. Tendon transfer in MN Palsy
Aim of Surgery
Restore ,
1. Thumb opposition
2. Flexor pollicis longus function
3. Index finger profundus function

53. OPPONENSPLASTY
Principles
• Pull from the direction of the Pisiform
• Parallel to fibers of APB
• Should pass through supple subcutaneous bed

54. • Pulley distal to Pisiform – more metacarpal
flexion and less abduction
• Pulley proximal to Pisiform – more metacarpal
abduction and less flexion
OPPONENSPLASTY
Technical considerations

55. Tendon transfer for Opposition
ØBurkhalter technique- Transfer of EIP
ØRiordan/ Brand technique- Transfer of FDS of ring finger
ØCamitz technique- Transfer of palmaris longus
ØGroves and Goldner- FCU combined with FDS transfer
ØLittler and Cooley- Transfer of abductor digiti quinti

57. Transfer for FPL Palsy
•Thumb IP joint fusion is more reliable
•Brachioradialis to FPL

58. Transfer for FPL Palsy
• Brachioradialis to FPL

59. Transfer for FDP Palsy
• Expose all FDP’s in distal forearm
Suture side to side to active ones
• ECRB to FDP

60. Critical limit of delay of suture
9 – 15 months
Radial nerve injury

61. RN injury- Tendon transfer

62. Critical limit of delay of suture
High lesions – 9 months
Low lesions – 15 months
Ulnar nerve injury

63. UN injury- Tendon transfer
Restoration of Thumb adduction
Ø Boyes technique- Transfer of brachioradialis or
radial wrist extensor
Ø Smith technique- Transfer of ECRB
Ø Modified Royle Thompson technique- Transfer for
FDS for both thumb adduction and opposition

64. RESTORATION OF INTRINSIC FUNCTION OF FINGERS
Static Dynamic
Prevent hyperextension of MP joints by
either shortening their palmar capsules
or creating “checkrein” ligaments or
tenodeses
Must be positive for Bouvier manoeuvre
• Zancolli’s volar capsulorrhaphy and
flexor pulley advancement(Bunnel-
Palande)
• Riordan static tenodesis
• Dermadesis and flexor pulley
advancement
• Srinivasan’s extensor diversion
grafting
• Michael’s bone block procedure
• Parkes static tenodesis
• Fowler’s wrist tenodesis technique
Involve transferring functional muscle
tendon units to restore another by
transferring the working unit to a new
location.
• Stiles-Bunnell- Brand’s 4 tailed
FDS transfer
• Zancolli’s Lasso procedure
• EIP and EDM transfers(Fowler’s)
• Brand’s ECRL and ECRB transfer
• Wrist motor transfers
• Riordan’s FCR transfer
• Palmaris longus transfer

65. Critical limit of delay of suture
12 months
Peroneal nerve injury

66. CPN injury- Tendon transfers
1. Barr’s transfer
Anterior transfer of tibialis
posterior through the anterior
interosseous membrane.

67. CPN injury- Tendon transfers
2. Ober’s transfer
Anterior transfer of tibialis posterior circumventing the tibia.

68. CPN injury- Tendon transfers
3. Kaufer’s procedure
Split transfer of the
tibialis posterior tendon.

69. CPN injury- Tendon transfers
4. Srinivasan’s procedure
Split transfer of the tibialis
posterior tendon.