The document discusses peripheral nerve injuries, including their structure, classification, mechanisms, and specific injuries related to the upper and lower limbs. It outlines Seddon's and Sunderland's classifications of nerve injuries, describing various conditions such as neuropraxia, axonotmesis, and neurotmesis, as well as the causes and treatment options for these injuries. Investigations like electromyography and nerve conduction velocity tests are mentioned, along with conservative and operative treatment methods.

1. PERIPHERAL NERVE
INJURIES
Presented by-
Pranjal Bagait
BPT IV Year

2. CONTENTS
●Introduction
●Structure of peripheral nerve
●Classification
●Patterns of injury
●Mechanism of injury
●ULE Nerve Injuries
●LLE Nerve injuries
●Investigations
●Treatment

3. INTRODUCTION
The Peripheral nerve injury means total or partial impairment
of nerve functioning as a result of traumatic insult. (2)
A peripheral nerve consist of various axons that carry
impulses to and from central nervous system. The impulses
regulate motor, sensory, autonomic activities. (1)
The PNS consists of spinal nerves and cranial
nerves(except CN I and CN II) .(2)

4. STRUCTURE OF PERIPHERAL NERVE (3)
●The nerve fibre is enclosed in
connective tissue covering called
endoneurium.
●A group of nerve fibres with
endoneurium are bound together by
fibrous tissue covering called
perineurium.
●A bundle of nerve fibres with
endoneurium and perineurium is
called fasciculus.
●A number of fasciculi are bound
together by a tissue sheath called
epineurium.

5. CLASSIFICATION OF NERVE INJURIES
1.SEDDON’S Classification(3)(7)
Neuropraxia-Physiological disruption of conduction of
nerves. Axons are intact and only demyelination of
sheath occur.
Complete and spontaneous Recovery within 21 days.
Axonotmesis -Complete interruption of axon and myelin
sheath but internal structure of nerve is preserved.
Wallerian degeneration occurs.
Recovery takes several months and may not be
complete
Neurotmesis- The structure of nerve is damaged due to
cutting of segment
Recovery only after nerve repair.

6. 2. SUNDERLAND’S Classification(6)(3)(7)
Neurapraxia Degree I Caused by applying
pressure on nerve over short period.
Temporary conduction block,
Axonotmesis Degree II Axon damaged with
intact endoneurium. Recovery in 18
months.
Neurotmesis Degree III Axon and
endoneurium damaged with intact
perineurium.
Neurotmesis Degree IV Axon, endoneurium,
and perineurium damaged with intact
epineurium.
Neurotmesis Degree V Complete nerve
transection.

7. PATTERNS OF INJURY(1)
Damage may occur to axon myelin sheath, cell body, and connective
tissue. There are 3 types of degeneration .
1.Wallerian 2.Segmental 3.Retrograde
Degeneration Degeneration
Degeneration

8. MECHANISM OF INJURY (3)
1. Direct injury -cut, laceration
2. Infections-Leprosy
3. Mechanical injury - traction, overstretching, compression
(CTS), friction, dislocations, avulsion
4. Cooling and freezing-frost bite
5. Thermal injuries
6. Electrical injuries-shock
7. Ischaemia -VIC
8. Radiation in cancer
9. RTA
10.External compression-orthosis, prosthesis, plaster cast

9. UPPER LIMB NERVE INJURIES
1. Brachial Plexus injury
● Erb's paralysis
● Klumpke's paralysis
● Axillary nerve
● Radial nerve
● Median nerve
● Ulnar nerve
LOWER LIMB NERVE INJURIES
1. Lumbo-sacral Plexus injury
● Femoral nerve
● Sciatic nerve
● Common peroneal nerve

10. BRACHIAL PLEXUS INJURY
Brachial plexus is network of nerves formed by anterior rami of lower 4
cervical nerves (C5 -C8) and 1 upper thoracic nerve (T1). It sends
signals to upper limb.(5)
Causes of injury(1)
● Birth trauma
● Fall on shoulder
● RTA
● Tumors
● Sports injuries
It consist mainly of 2 types of injury
● Erb's paralysis
● Klumpke’s paralysis

11. Erb’s paralysis(5)
Site of injury -Injury to upper trunk. (C5, C6)
Injury to erb’s point where 6 nerves meet,
*When damage to C5C6 is more proximal, nerve to
rhomboids and long thoracic nerve may be affected.
MOI- undue separation of head of humerus from
shoulder.
Muscles paralysed - Biceps , brachialis, deltoid,
supraspinatus, infraspinatus, shoulder adductors.
Deformity-Policeman’s tip hand or waiter’s tip hand.
Disability - Abduction & lateral rotation of arm at
shoulder.
-Flexion and supination of forearm.
-Biceps and supinator jerks lost.
- Sensory loss over lower deltoid.

12. Klumpke's paralysis(5)
Site of injury -Lower trunk of brachial plexus (partly C8 mainly
T1).
MOI - Forced abduction of arm at birth.
Trauma .
Muscles paralyzed - Intrinsic muscle of hand(T1).
Ulnar flexor of wrist and fingers (C8).
Deformity - claw hand (hyperextension of MCP joint & flexion of
IP joint)
Disability -loss of biceps & supinator jerk
Complete claw hand
Cutaneous anaesthesia
Horner syndrome

13. Axillary Nerve
Anatomy (5)
Derived from posterior cord of brachial plexus (C5C6).
Branches(5) -
Anterior -motor innervation to deltoid.
Posterior-motor innervation to teres minor.
Superior lateral cutaneous nerve - sensory innervation over inferior deltoid.
MOI (1)-
● Anterior & inferior shoulder dislocation
● FOOSH
● Contusion to deltoid
Result (1)
● Weakness of shoulder between 15-90 degrees .
● Sensory loss over outer aspect of shoulder .

14. Radial nerve injury
Anatomy(5)
Branch of posterior cord of Brachial plexus (C5-C8, T1)
Branches (5)
Before radial groove (post.cutaneous nerve of arm)-long
and medial head of triceps
After radial groove -lateral head of triceps, Anconeus,
Brachioradialis, ECRL
After crossing elbow before piercing supinator (deep
branch)-ECRB, Supinator
After piercing supinator(PIN) -extensor muscle of forearm
MOI (1)
● Humerus fracture
● Gunshot injury
● Crutch paralysis
● Stabbing
● Carcinomas

15. Types of injury(3)
High radial nerve palsy Low radial nerve palsy
Nerve injury in radial groove. All
muscles are paralysed except triceps
and anconeus brachioradialis,
Results (1)
● Weakness and wasting of muscles
supplies
● Deformity-wrist drop -finger
flexed (weak extensor)
● Sensory loss on dorsum of hand
and forearm
● Loss of tricep reflex
Nerve is injured around elbow
and the muscles supplied by
radial nerve in distal arm are
spare
ECRL, ECRB

16. Median Nerve injury
Anatomy(5)
Formed by joining lateral and medial cord of brachial
plexus (C7 C8)
Branches (5)
No branch in arm
Muscular branch -FCR, PL, FDS
AIN - proximal ⅓- All flexor muscle except FCU & medial
½ of FDP
Palmar cutaneous branch-Thenar muscle, 1 & 2
lumbricals
Articular branch & vascular branch
MOI(1)
● Dislocation in shoulder
● Compression in forearm (AIN Branch)
● Compression at wrist

17. Types of nerve injury
High median nerve palsy low median nerve palsy
Injury proximal to elbow,. All muscles are
paralysed of forearm and hand. There is sensory
deficit.
Result (1)
● Weakness of abduction & opposition of
thumb
● Weakness of pronation of forearm
● Ulnar deviation on wrist flexion
● Wasting of thenar muscle
● Sensory loss (mainly on index & middle
finger)
● Deformity - Ape hand deformity, hand of
benediction,
Common disease-
carpal tunnel syndrome
Injury in distal ⅓ of forearm causing
paralysis of hand muscles (sparring
forearm muscle). Sensory deficit.

18. Ulnar nerve injury
Anatomy(5)
Formed by medial cord of Brachial plexus (C7 C8)
Branches(5)
Forearm- proximal ⅓ FCU, FDP
Hand -superficial -hypothenar
Deep -Adductor pollicis, Interossei, medial 2
lumbricals
MOI (1)
Elbow injury -dislocation
Entrapment at elbow
Pressure on hand
Sensory supply

19. Types of nerve injury
High ulnar nerve palsy low ulnar nerve palsy
Injury proximal to elbow
Paralysis of all muscles of
forearm & hand
Sensory
deficit
Result(1)
● Ulnar claw hand - weakness of
muscles supplied
Injury to distal part of forearm
hand muscles paralysed with
sensory deficit

20. Lower limb nerves
1.Femoral nerve
Largest Branch of lumbar plexus L2,
L3,L4
Branches(5)

21. MOI(1)
● Fracture of upper femur
● CDH
● Hip surgery
Result(1)
● Weakness of hip flexion.
● Weakness of knee extension with wasting of thigh muscle.
● Sensory loss over anterior and medial aspect of thigh .
● Knee jerk lost .
● Difficulty in walking.

22. 2. Sciatic Nerve
Anatomy(5)
Largest Branch of sacral plexus (L4, L5 S1, S2, S3).
MOI (1)
● CDH, traumatic hip dislocation
● Penetrating injuries
● Entrapment at sciatic notch
Result (1)
● Weakness of hamstring with
loss of knee flexion .
● Tingling, burning sensation, pain,
numbness .
● Sensory loss at outer aspect of
leg.

23. 3. Common Peroneal Nerve
Anatomy(5)
Terminal branch of sciatic nerve (L4, L5, S1, S2).
It winds anteriorly with head of fibula and give deep
and superficial branches.
MOI(1)
● Trauma to head of fibula
● Pressure from kneeling
Results(1)
● Foot drop _weakness of dorsiflexion and eversion of
foot.
● Sensory loss involves dorsum and outer aspect of foot.
● Difficulty in lifting the foot.
● Dragging the foot on the floor as one walks.

24. Investigation
1.Electromyography -record electrical activity of muscle at
rest and during activity
2.NCV -suggest whether nerve is injured, whether it is
partial or complete
3.MRI
4.Special tests

25. Treatment(3)
1.Conservative
● Splintage of paralysed limb
● Joint mobility preservation
● Analgesic -NSAID -prednisolone
2. Operative
● Nerve repair
● Nerve suture
● Neurolysis
● Reconstructive surgery

26. References
1. Kenneth W. Lindsay
2. Suraj kumar
3. Maheshwari
4. K. Sembulingam
5. BD. Chaurasia -VOl. 1,VOL.2 Edition 7
6. https://pubmed.ncbi.nlm.nih.gov/
7. S. Sunder