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Peripheral
                        Nerve
                        Injuries

Dr.Prateek Singh
intern
Dept. of Orthopaedics
B...
Peripheral Nerve
Coverings
Internal topography
Fascicular arrangement constantly change throughout
                     the course
Etiology of peripheral nerve injuries

1.   Metabolic or collagen disease
2.   Malignancy
3.   Endo or exo-toxins
4.   Isc...
Primary injury
 – Results from same trauma that injures a bone or
   joint
 – Radial nerve is the most commonly injured. O...
Classification of nerve injuries
Seddon Classification
     1.Neuropraxia:
      1.Minor contusion or compression with pre...
Sunderland Classification
   Each degree of injury suggesting a greater anatomical
    disruption with its correspondingl...
Neuronal degeneration and regeneration
• Any part of neuron detached from its
  nucleus, degenerates & is destroyed by
  p...
Diagnosis of Peripheral nerve
                 injuries
• History
  –   Which nerve ?
  –   What level ?
  –   What is the...
Diagnosis of Peripheral nerve
                 injuries

1. Motor:
  –    All muscles distal to the injury – paralyzed
   ...
2.   Sensory :

• Sensory loss usually follows a definite
  anatomical pattern, although factor of
  overlap from adjacent...
(3) Reflex


• Abolishes all reflexes transmitted by that
  nerve, either afferent or efferent arc.
• Complete & incomplet...
(5)   Others:

 • Trophic Changes
          • Esp. hand and feet
          • Skin – thin, glistening, breaks easily to for...
Test for peripheral nerves of upper limb
• Radial nerve injury
  – very high / high / low injury
  – Wrist drop / finger d...
• Ulnar nerve
  – High / low palsy –ulnar paradox
  – Test for FCU / Abd. digiti minimi / Interossei (dorsal -
    Egawa’s...
Electrodiagnostic studies
• Electromyography
• Nerve conduction velocity
• Strength duration curve
Time of Surgery
• Primary repair : First 6 – 8 hours

• Delayed primary repair : First 7 – 18 days

• Secondary repair : >...
Indications for surgery
1. When a sharp injury has obviously divided a
   nerve.
2. When abrading, avulsing or blast wound...
Types of Nerve Repair :

1. Endoneurolysis
2. Partial Neurorrhaphy
3. Neurorrhaphy
  1. Epineural
  2. Epi-perineural
  3....
Method of closing gap between nerve ends
1. Mobilization ( critical nerve gap distance – value
   of Grantham)
2. Position...
Factors that influence regeneration after
neurorrhaphy

 1.   Age of patient
 2.   Gap between nerve ends
 3.   Delay betw...
Options
•   Orthoses
•   Tendon transfers
•   Bony blocks
•   Arthrodesis
Thank You
Peripheral nerve injury
Peripheral nerve injury
Peripheral nerve injury
Peripheral nerve injury
Peripheral nerve injury
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Peripheral nerve injury Slide 1 Peripheral nerve injury Slide 2 Peripheral nerve injury Slide 3 Peripheral nerve injury Slide 4 Peripheral nerve injury Slide 5 Peripheral nerve injury Slide 6 Peripheral nerve injury Slide 7 Peripheral nerve injury Slide 8 Peripheral nerve injury Slide 9 Peripheral nerve injury Slide 10 Peripheral nerve injury Slide 11 Peripheral nerve injury Slide 12 Peripheral nerve injury Slide 13 Peripheral nerve injury Slide 14 Peripheral nerve injury Slide 15 Peripheral nerve injury Slide 16 Peripheral nerve injury Slide 17 Peripheral nerve injury Slide 18 Peripheral nerve injury Slide 19 Peripheral nerve injury Slide 20 Peripheral nerve injury Slide 21 Peripheral nerve injury Slide 22 Peripheral nerve injury Slide 23 Peripheral nerve injury Slide 24 Peripheral nerve injury Slide 25 Peripheral nerve injury Slide 26 Peripheral nerve injury Slide 27 Peripheral nerve injury Slide 28 Peripheral nerve injury Slide 29
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Peripheral nerve injury

  1. 1. Peripheral Nerve Injuries Dr.Prateek Singh intern Dept. of Orthopaedics BPKIHS
  2. 2. Peripheral Nerve
  3. 3. Coverings
  4. 4. Internal topography Fascicular arrangement constantly change throughout the course
  5. 5. Etiology of peripheral nerve injuries 1. Metabolic or collagen disease 2. Malignancy 3. Endo or exo-toxins 4. Ischaemia 5. Radiation * infection:leprosy 6. Trauma  Thermal  Chemical  Mechanical
  6. 6. Primary injury – Results from same trauma that injures a bone or joint – Radial nerve is the most commonly injured. Of humeral shaft fractures, 14 % is complicated by radial nerve injuries – Displaced osseous fragments – Stretching – Manipulation Secondary injury – Results from involvement of nerve by infection, scar, callous or vascular complications which may be hematoma, AV fistula, Ischemia or aneurysm
  7. 7. Classification of nerve injuries Seddon Classification 1.Neuropraxia: 1.Minor contusion or compression with preservation of axis – cylinder of myelin sheath. 2.Impulse transmission physiologically interrupted. 3.Complete recovery in a few days to weeks 2.Axonotemesis : 1.More significant injury 2.Breakdown of axon and distal Wallerian degeneration but with preservation of schwann cell & endoneurial tubes 3.Spontaneous regeneration with good functional recovery can be expected 3. Neurotmesis 1.More severe injury 2.Complete anatomical severance, avulsion or crushing of nerve 3.Axon, Schwann cell & endoneurial tubes are completely disrupted 4.Spontaneous recovery cannot be expected unless surgically intervened
  8. 8. Sunderland Classification  Each degree of injury suggesting a greater anatomical disruption with its correspondingly altered prognosis  Anatomically various degrees (1st – 5th) represent injury to  Myelin  Axon  Endoneurial tube & it’s content  Perineurium  Entire nerve trunk  Sixth degree (Mackinson) or mixed injuries occur in which a nerve trunk is partially severed and remaining part of trunk sustains 1st to 4th degree injury.  Mixed recovery pattern depending on degree of injury to each portion of nerve.
  9. 9. 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 between sensory and motor fibers and is also related to size & myelination of fibers • Advancing Tinel sign and presence of motor march phenomena are signs of regeneration
  10. 10. Diagnosis of Peripheral nerve injuries • History – Which nerve ? – What level ? – What is the cause ? – What degree of injury ? – Old or fresh injury ?
  11. 11. Diagnosis of Peripheral nerve injuries 1. Motor: – All muscles distal to the injury – paralyzed & atonic – Atrophy : 50 -70 % in 1st two months – Striations & motor end plate configurations retained for 12 – 18 months (critical limit of delay)
  12. 12. 2. Sensory : • Sensory loss usually follows a definite anatomical pattern, although factor of overlap from adjacent nerves may be present • Autonomous zone • Weber 2 point discrimination test • Tinel’s sign
  13. 13. (3) Reflex • Abolishes all reflexes transmitted by that nerve, either afferent or efferent arc. • Complete & incomplete lesion. So , not a reliable guide to injury severity. (4) Autonomic : • Loss of sweating • Loss of pilomotor response and • Vasomotor paralysis in autonomous zone
  14. 14. (5) Others: • Trophic Changes • Esp. hand and feet • Skin – thin, glistening, breaks easily to form ulcers that heal slowly • Fingernails • Ridged, distorted and brittle • Osteoporosis (Reflex sympathetic dystrophy)
  15. 15. Test for peripheral nerves of upper limb • Radial nerve injury – very high / high / low injury – Wrist drop / finger drop / thumb drop – Test for triceps/ /Brachioradialis/ wrist extensors / extensor digitorum / EPL • Median nerve – High / low injury – Test for FPL / FDS / FDP (lat. half) / FCR / Abd. Pollicis brevis ( pen test) / Oppenens pollicis – See for pointing index / complete claw hand
  16. 16. • Ulnar nerve – High / low palsy –ulnar paradox – 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
  17. 17. Electrodiagnostic studies • Electromyography • Nerve conduction velocity • Strength duration curve
  18. 18. Time of Surgery • Primary repair : First 6 – 8 hours • Delayed primary repair : First 7 – 18 days • Secondary repair : > 3 weeks
  19. 19. Indications for surgery 1. When a sharp injury has obviously divided a nerve. 2. When abrading, avulsing or blast wounds have rendered the condition of nerve unknown 3. When a nerve deficit follows a blunt or closed trauma & no clinical or electrical evidence of regeneration has occurred after an appropriate time 4. When a nerve deficit follows a penetrating wound as stab or low velocity gunshot wound, part observed for evidence of nerve regeneration for appropriate time.
  20. 20. Types of Nerve Repair : 1. Endoneurolysis 2. Partial Neurorrhaphy 3. Neurorrhaphy 1. Epineural 2. Epi-perineural 3. Perineural 4. Nerve grafting
  21. 21. Method of closing gap between nerve ends 1. Mobilization ( critical nerve gap distance – value of Grantham) 2. Positioning of extremity – Flex knee and elbow < 90° – Flex wrist < 40° 1. Transposition 2. Bone resection 3. Nerve stretching & bulb sutures 4. Nerve grafting 5. Nerve crossing ( pedicle grafting )
  22. 22. Factors that influence regeneration after neurorrhaphy 1. Age of patient 2. Gap between nerve ends 3. Delay between time of injury and repair 4. Level of injury 5. Condition of nerve ends 6. Experience & technique of surgeon
  23. 23. Options • Orthoses • Tendon transfers • Bony blocks • Arthrodesis
  24. 24. Thank You
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