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Peripheral nerve injuries
This document discusses peripheral nerve injuries, including: - Classification systems for nerve injuries including Seddon and Sunderland classifications. - Causes of nerve injuries including trauma, radiation, and ischemia. - Evaluation of patients including history, physical exam, and electrodiagnostic tests. - Surgical principles for nerve repair including primary repair, nerve grafts, and nerve transfers. - Post-operative management including splinting and physical therapy. - Potential complications include failure of repair, neuromas, and infections.
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Peripheral nerve injuries
- 1. By Dr Salihi Abdulmalik NationalOrthopaedic Hospital Dala-Kano 14th March, 2021
- 2. INTRODUCTION RELEVANTSURGICAL ANATOMY CLASSIFICATION EVALUATION OF PATIENT WITH NERVE INJURY PRINCIPLE OF REPAIR OUTCOME CURRENT/FUTURE TRENDS CONCLUSSION REFERENCES
- 3. A nerveis an enclosed cable-like bundle of axons Can be categorized as either afferent, efferent or mixed nerve
- 4. Myelinated andunmyelinated Nerve injuries are fairly common Affects 5% of patients following trauma
- 7. Trauma ◦ Mechanical Laceration Compression Crush injury ◦ Chemical ◦ Thermal ◦ Traction Radiation Infection; leprosy malignancy Ischemia
- 8.
- 9. Neurapraxia ◦ Minorcontussion or compression ◦ Impulse transmission physiologically interrupted ◦ No anatomical damage ◦ Complete recovery within few days to weeks
- 10. Axonotemesis ◦ Breakdownof axon ◦ Neural tube is intact ◦ Wallerian degeneration occur ◦ Spontaneous recovery can be expected
- 11. Neurotmesis ◦ Nervetrunk division ◦ Wallerian degeneration ◦ Scarring prevents regeneration ◦ Spontaneous recovery not possible
- 13. Presentation ◦ Emergency;multiply injured, #s/dislocations, vascular injuries ◦ Elective
- 14. Multidisciplinary History ◦Nerve involve ◦ Level ◦ Cause ◦ Degree of injury
- 15. Numbness Paresthesia Muscles weakness PMH; DM and double crush phenomenon Smoking Deformities Muscles wasting Skin dryness Atrophic nail changes Sensory impairment Power
- 16. Low/high lesion Claw hand Hypothenar and interosseous wasting Sensory loss ring and little finger PAD/DAB Froment’s sign Ulnar paradox
- 17. At wrist/forearm Thenar eminence wasting Pointing sign Pinch defect
- 18. Low lesion- #s/dislocation around the elbow High – humeral #/tourniquet Very high – shoulder trauma/surgery, crutch palsy, Saturday night palsy
- 19. Low lesion ◦Can not extend MCPJ ◦ wrist extension is preserved; ECRL supplied proximal to elbow
- 20. Axillary nerve ◦Can not maintain abduction ◦ Regimental badge sign Sciatic nerve ◦ Foot drop ◦ Trophic ulcer
- 21. X ray EMG Nerve conduction velocity MRI CT
- 22. Nerve seento be divided Injury suggests nerve is divided or severely damaged Recovery inappropriately delayed and the diagnosis is in doubt
- 23. Repair ◦ Primary Not retracted much No fibrosis Relative rotation undisturbed ◦ Delayed Left with no recovery Missed/delay presentation Failed primary repair Nerve graft Nerve transfer Tendon transfer
- 24. Intra-op ◦ Expertise ◦Patience ◦ Adequate lighting ◦ Surgeon should be relaxed ◦ Vascular injuries, unstable fractures, contaminated soft tissues and tendon divisions should be dealt with before the nerve lesion ◦ Dissection from normal to abnormal, long incision
- 25. ◦ Neuroma excision,debridement ◦ Sling sutures ◦ Tensionless repair: rerouting of nerves flexion of joints ◦ Operating loops ◦ Nerve stimulation ◦ Bipolar diathermy ◦ No shame in referral !!
- 26. Post op ◦POP at least 6 wks ◦ Protect parts at risk of injury ◦ Early physiotherapy ◦ Dynamic splinting
- 27. Early repair ADVANTAGES Early return to fxn Better fuscicular visualization Better realignment Decreased tension on suture line
- 28. DISADVANTAGES Notall injuries amenable to repair No advantage in fxnal outcome Potential for suture line dehiscence due to delayed necrosis Epineurium more friable
- 29. Delayed repair Indicated in major trauma or contamination Adv Epineural hypertrophy Demarcation of injured nerve elements Disadv Stump retraction Neuroma debridement
- 30. The graftis no substitute to nerve loss It is a guiding rail, yet better than any alloplastic material Double coaptation required Autograft is superior
- 31. Source -sural -saphenous -posterior auricular Alternatives to nerve graft -alloplastic nerve conduit -venous grafts
- 32. Nil tension Positioning/splints/Immobilization for 7-14 days Gradual mobilization 3wk- 3mon range of motion exercises 3-6mon strengthen exercises 6mon-1yr Sensory re-education
- 33. General: anesthetic,wound infxn Insensate limb Failure of repair Collateral injury to surrounding structures Volkmanns ischemia Tension at the site of repair/ dehiscence Pain due to neuroma Infection
- 34. Though notlife threatening, morbidity could be far reaching. A good knowledge of the peripheral nerve injuries is essential Where expertise is lacking referral should be done after the initial treatment of associated injuries
- 35.