1. This document discusses principles of peripheral nerve repair, including making an accurate diagnosis, determining the injury mechanism, timing of repair, adequate debridement of nerve stumps, use of microsurgery, and postoperative management. 2. Specific techniques are presented, such as cable grafts to bridge nerve gaps and nerve transfers to restore shoulder function. Complications from various injuries like gunshot wounds and traumatic false aneurysms compressing nerves are also reviewed. 3. Hereditary conditions like Hereditary Neuropathy with Liability to Pressure Palsies that increase susceptibility to nerve injuries are mentioned.

1. Peripheral nerve Injuries
Upper extremity
Somsak Leechavengvongs, M.D.
Institute of Orthopedics - Lerdsin Hospital
Bangkok, Thailand

2. Principle of peripheral nerve repair
1. Make the diagnosis
- History and Physical exam
- Preop assessment of motor and sensory systems
- Electrophysiological studies may be indicated in
the patient who is not cooperative

3. 2. Determine the mechanism of injury
- Crushed injury
- Avulsion injury
- Oscillating saw
- Sharp transection
“Unless a peripheral nerve is cut” with a surgical blade,
there will be a zone of injury requiring debridement”
Principle of peripheral nerve repair

4. 3. Timing of repair related to injury
- Primary nerve repair (within 7 days) when
clinical and surgical judgement permit (clean
sharp cut wound)
- Secondary nerve repair (2-3 weeks) when the
zone of injury is indeterminate at initial
exploration
Principle of peripheral nerve repair

5. 4. Adequate debridement of both stumps
- Determine the Zone of injury
- Scar will inhibit the growth of the axons across
the repair site and inhibit recovery
- Trimming until normal fascicular mushrooming
or “snail eyes” are seeing
- Softness o the nerve and presence of bands of Fontana
Principle of peripheral nerve repair

6. 5. Microsurgical technique
- The Microscope should be used whenever possible
for advantage of visualization
- Nerve repair should be performed with
either 9-0 or 10-0 nylon, interrupted
- Any tension at the nerve repair site must be avoided
Principle of peripheral nerve repair

7. 6. Postoperative management
- Immobilization by splinting to allow tension healing 3-
4 weeks
- Sensory re-education to understand the new “language”
- Postoperative monitoring of nerve function to provide
the basis for determine of re-operation
Principle of peripheral nerve repair

8. Stab wound at the neck with
C5 root injury

9. Distal stump
Proximal stump

10. Suture site

11. 9 months after the operation

14. Penetrating injury to the terminal
branches of the posterior interosseous
nerve

18. Penetrating injury of
the median, ulna radial nerve

20. Cable nerve grafts
Radial nerve
Median n
Ulnar nerve

21. 7months after surgery

23. Stab wound with C5 –C6 injury
and vascular injury 10 months

24. Transfer of the Ulnar Fascicle
to branch to Biceps (Oberlin’s Technique)

25. Nerve transfer for shoulder reconstruction

26. N to long head
of Triceps
Anterior branch
of Axillary n
Perfect size matching between donor and recipient nerve

29. Gunshot wound with nerve injuries
Disagreement in treatment
Leffert recommended conservative if no vascular
injury is present
Surgery if no recovery by 3 months
Armine and Sugar recommended primary repair
of the brachial plexus when there is an
associated vascular injury needed exploration
and repair

30. Recent advance Gunshot
injuries to the nerves
C. Oberlin a,*, M. Rantissi b
Chirugie de la main 30(2011) 176-182
War injuries in the Gaza strip
Early exploration (within 1 week) in case of
paralysis of a peripheral nerve after a bullet injury
Direct suture must be performed whenever possible

31. Partial nerve injury from GSW injury

32. Illustrating
positions
previously used
to overcome
nerve gaps

33. Gun shot wound at the left elbow
Entry wound

34. Claw hand deformity

35. Ulnar nerve

36. Primary repair of the ulnar fascicle
and anterior transposition

37. Nerve compression Injuries due to
traumatic false aneurysm
Most patients were seen soon after the initial
trauma, the diagnosis of major arterial disruption
was not made at that time
No neurological deficit initially
Sign of arterial injury may be missed if the
diagnosis is not carefully considered

44. Nerve compression Injuries due
to traumatic false aneurysm
Degree and extent of neurological injury are the rate
at which duration and rate of compression
Possible role of epineurial fibrosis and neurolysis
Signs of ishemia rarely occur due to rich collateral
network

45. Nerve compression Injuries due
to traumatic false aneurysm
Sign of arterial injury may be missed if the diagnosis
is not carefully considered
Arteriography should be performed
- presence of a distal deficit
- local hematoma
- bruit or anatomically related nerve injury

47. Ipsilateral

51. DB + Revised EF &
K-wire

52. 2 teams

53. Donor (Lt. side)
Esmarch tourniquet ~ 1 hr

54. Recipient (Rt. side)

55. Post-operative (MM)
Weakness & numbness both upper extremities
More past history
Normal delivery with LP anesthesia :
Weakness both lower ext ~ 1 month

56. Investigate
Film C-spine + MRI : normal
EMG
Severe degree brachial plexitis

57. Hereditary neuropathy
with liability to pressure
palsies (HNPP)
Autosomal dominant
Demyelinating motor-sensory neuropathy
The hall- mark of the disease is recurrent focal
compression neuropathies, which tend to improve
in hours to months.
Under expression of the Peripheral myelin
protein-22 gene on chromosome 17 (17p11.2)

58. Tourniquet paralysis
Incidence 1:7000
Excessive pressure
Keeping tourniquet too long
Should be cautioned in congenital susceptible to
nerve compression and very thin patient
Spontaneous recovery within 3-4
months