Peripheral Nerve Injury

J. NAVIN KUMAR
 Peripheral nerves are bundles of axons
conducting afferent & efferent impulses.
Each axon is elongated process of a nerve
cell (neurons)
Cell bodies of
-motor neuron Ant horn cell
-sensory neuron dorsal root ganglia.
Single neuron may supply 10 1000
muscle fibres
 Connective tissue
- major tissue component
- epineurium, perineurium, endoneurium

Nerve tissue
- axon, schwann cell
Myelinated
All motor axons
Large sensory axons
touch, pain proprioception
Nodes of Ranvier
Faster conduction
Unmyelinated
Small diameter (crude touch )
Efferent sympathetic
No nodes
Slower conduction
 BLOOD S UPPLY OF NE R VE

Blood vessels run in the epineurium.

Become endoneurial Capillaries after
penetrating.
sympathetic supply to vessels by same
nerve
Mode of Nerve Injury
Ischemia
Compression
Traction
Laceration
burn
Classification
 Neuropraxia
the mildest form, reversible conduction
block
loss of function, which persists for hours
or days
direct mechanical compression, ischemia,
mild burn trauma or stretch
 Axonotmesis

axon continuity is disrupted

Axon disintegrates - phagocytosis
- Wallerian degeneration occurs
R egeneration at a rate of 1mm/day
 Neurotmesis
laceration from sharp or blunt forces
Division of nerve trunk
Endoneurinal tube destroyed to a
variable length
Will never recover without surgical
intervention
NE R VE INJURY AND RE
GENE R ATION
The distal part of the axon disintegrates and t
he myelin sheath breaks up
New axonal tendrils grow into the mass of pro
liferating S chwann cell
One of the tendrils will find its way into the old
endoneurial tube
Axon will slowly generate
 Clinical Signs
S ymptoms
Numbness
Paraesthesia
Muscle weakness

S igns
Abnormal posture
Weakness
Loss of sensation
 Tinels sign
performed by lightly tapping over the ner
ve to elicit a sensation of tingling or "pins
and needles" in the distribution of the nerv
e.
This distal sign of regeneration can be exp
ected during different stage of somato
sensory recovery
ASSESSMENT
Tinels sign
(advancing at rate of 1 mm/day)

E MG
Does not distinguish between
axonotmesis and neurontemesis
MRI
Treatment
Expectant

Dynamic splints

joints should be moved through their full

range twice daily to prevent stiffness and
minimize the work required of muscles wh
en they recover
Nerve Exploration
Indications
Type of injury suggest that nerve is
divided.
If recovery is delayed

Vascular injury, unstable fracture

contaminated soft tissue, tendon injury
are dealt before nerve injury.
Primary Repair

S ooner the better.

R agged ends pared.
Use microscope and10/0 suture.

S uture epineurium.
Avoid tension on suture line.

S plinting
Delayed Repair
Indications
Closed injury not improving at expected
time
Late presentation and missed diagnosis
F ailed primary repair

Nerve E xplored scarred segment re

sected /nerve mobilized - graft (if req.)
Epineural Repair
Nerve Grafting

Used to bridge gaps.

S ural nerve most commonly used.

Vascularised grafts also used.

 Nerve Graft

# leading cause of failure of nerve graft

Inadequate resection
Distraction of repair site
Nerve Transfer

Indicated for root avulsions of brachial

plexus

E xample..
S pinal accessory to suprascapular nerve.
Intercostal nerves to musculocutaneous
nerve
Tendon Transfer
R egenarating axons fail to reach muscle with
in 18 24 months after injury
Donor Muscle
E xpendable
Adequate power
R ecipient site
- mobile
- stable
Transferred tendon
R outed subcutaneously in a straight line of
PR OGNOS IS
DE PE NDS ON
TYPE OF LE S ION
LE VE L OF LE S ION
TYPE OF NE R VE
S IZE OF GAP
AGE
DE LAY IN S UTUR E
AS S OCIATE D LE S ION
S UR GICAL S KILL
RADIAL NERVE
 it originates from the posterior cord of the
brachial plexus with roots from C5, C6, C7,
C8 & T1
supplies muscles posterior compartment of the arm, posterior compartment of the forearm

Motor

Muscles of the posterior forearm. All the labeled muscles are innervated by the radial nerve,
and represent all muscles innervated by the radial nerve except for the supinator.
Muscular branches of the radial nerve:
Triceps brachii
Anconeus
Brachioradialis
E xtensor carpi radialis longus
Deep branch of the radial nerve:
E xtensor carpi radialis brevis
Supinator
Posterior interosseous nerve
E xtensor digitorum
E xtensor digiti minimi
E xtensor carpi ulnaris
Abductor pollicis longus
E xtensor pollicis brevis
E xtensor pollicis longus
E xtensor indicis
 sensory innervation to much of the back of the hand,
including the web of skin between the thumb and index
finger.
 Low lesions # or dislocations at elbow, ope
n wound or surgical accident. Cannot extend
metacarpophalangeal joint

High lesions occur wt # of the humerus or aft p

rolonged tourniquet pressure . Also seen wt ptnt
s fall asleep wt hand dangling down ( S
aturday night palsy)

Very high lesions due to pressure in axilla

(crutch palsy)
E XAMINATION:
Decreased ability to extend the arm at the elbow
Decreased ability to rotate the arm outward (sup
ination)
Difficulty lifting the wrist or fingers (extensor muscle we
akness)
Muscle loss in the forearm
Weakness of the wrist and finger
Wrist or finger drop
Tests for nerve dysfunction may include:

E MG
MR I
Nerve conduction test
 Open wounds explored
- the nerve repaired or grafted

If associated wt # humerus, function even

tually returns. If no signs of recovery by 8-12 we
eks, it should be repaired / grafted

Most of the cases recovery is waited, wrist spli

nted in extension and fingers kept moving.
 No recovery disability can be largely overco
me by tendon transfers
ULNAR NE R VE
The ulnar nerve originates from the C7-
T1 nerve roots which form part of the
medial cord of the brachial plexus

it gives off the following branches:

- S uperficial branch of ulnar nerve
- Deep branch of ulnar nerve
SUPPLIES MUSCLE -

flexor carpi ulnaris

flexor digitorum profundis
lumbrical muscles
opponens digiti minimi
flexor digiti minimi
abductor digiti minmi
interossi
adductor pollicis
 Low lesions by pressure or laceration at wri
st. Hypothenar wasting and hand clawed due t
o paralysis of muscle. F inger abduction weak an
d loss of thumb adduction. S ensation los
s over one and half fingers.

High lesion with elbow # / malunion produces

nmarked cubitus valgus with tension over the n
erve less clawed because supply to flexor digit
orum profundus sensory loss same
Test
Interosseous muscle weakness. Ask ptnts spr
ead fingers than strongly as possible force his ha
nd together

Froments sign ptnt asked to grip a card firmly bet

ween thumbs and index finger
normal using thumb adductors and
interphalangeal joint held extended
abnormal - adductor pollicis is weak, grip the card
by acutely flexing interphalangeal joint (flexor p
ollicis longus supplied by median nerve)

Typical area of sensory loss

 E xploration and suture for ulnar nerve ea
sily achieved than other nerve.

If recovery does not occur hand function is

significantly impaired.

Tendon transfers only restore the modest le

vel of function
MEDIAN NERVE
Anterior compartment of the forearm (with two exc
eptions), Thenar eminence, Lumbricals

Superficial group:
Pronator teres
Flexor carpi radialis
Palmaris longus
Intermediate group:
Flexor digitorum superficialis muscle
The anterior interosseus branch of the median nerve sup
plies the following muscles:
Deep group:
Flexor digitorum profundus (only the lateral half)
Flexor pollicis longus
Pronator quadratus
 supply the:
a) lateral (radial) three and a half digits on the
palmar side
b) index, middle and ring finger on dorsum of the
hand
 Low lesions cuts in front of wrist or by carp
al dislocations thenar eminence is wasted ,
thumb abduction and opposition weak, wt typ
ical sensation lost

High lesions forearm # / elbow dislocation s

ame as low lesions addition of long flexors to the
thumb, index and middle fingers are paralyse
d.
Tests

Testing of abductor power hand remain flat, pal

m upwards ptnt told to point the thumb towar
ds the ceiling against the examiners resistant

Wasting of the thenar eminence

Typical loss of sensation

 If the nerve divided suture shld alwys be at
empted

If recovery does not occur.... Disability is bec

ause of loss of sensory
Long thoracic nerve
 supplies the S erratus anterior. This nerve ch
aracteristically arises by three roots from the f
ifth, sixth, and seventh cervical nerves (C5-C
7)
 Injury damaged in shoulder or neck injuries or
by carrying heavy loads on the shoulder

Classic sign winging of scapula ask ptnt pus

h forward forcefully against wall

Usually this nerve recovers spontaneously, tho

ugh this may take a year or longer
AXILLARY NERVE
 Brachial plexus c5
It supplies three muscles
- deltoid
- Teres minor
- long head of the triceps brachii
sensory
- shoulder joint
- skin covering the inferior region of the deltoi
d muscle - the "regimental badge" area
 Injured during shoulder dislocation or # of the hum
eral neck.

Ptnt cannot abduct shoulder deltoid weakness.

Nerve usually recovers spontaneously by 8 wee
ks, if no signs of recovery, the nerve shld be explor
ed and grafted.
Good results from surgery can be expected after 12
weeks.
If surgery fails, shoulder athrodesis or tendon tra
nsfer should be considered.
NERVE INJURIES AFFECTING THE
LOWER LIMB
FE MOR AL NE R VE
 largest branch of the lumbar plexus, arises from the
dorsal divisions of the ventral rami of the 2nd, 3r
d, and 4th lumbar nerves.
suplies the anterior compartment of thigh.
It contains the following five muscles:
- sartorius
- quadriceps (rectus femoris, vastus lateralis,
vastus intermedius, vastus medialis)
 Injured by a gunshot wound, traction during ope
ration or by bleeding into thigh

Weakness - knee extension

Numbness of ant thigh and medial aspect of leg

 Disabling lesion early treatment essential
Thigh hematoma must be evacuated
Clean cut may be treated successfully by car
eful suturing or grafting
SCIATIC NERVE
 large nerve fiber in humans.

The sciatic supplies nearly the whole of the skin

of the leg, the muscles of the back of the thigh,
and those of the leg and foot.

spinal nerves L4 through S 3.

articular and muscular branches.
The articular branches supply the hip-joint

The muscular branches

- biceps femoris
- semitendinosus
- S emimembranosus
- adductor magnus.

The muscular branch eventually gives off the tibial nerv

e and common peroneal nerve
 Injury gunshots or iatrogenic or #
F oot drop, numbness and paraesthesia of th
e leg and foot.
Late features are- wasting of the calf and trop
hic ulcers
Open # - nerve explored and repaired
F oot drop splint fitted till recovery
Chances of recovery is poor, delayed and
incomplete
 Partial lesions can be managed by tendon
transfer
If no recovery, amputation preferred for fla
il, deformed insensitive limb
COMMON PERONEAL NERVE
divides beneath the muscle into
-superficial peroneal nerve
-deep peroneal nerve).
 anterior compartment of leg, lateral
compartment of leg, extensor digitorum brev
is

supplies the skin on the posterior and lateral

surfaces of the leg.
 Injury lateral ligament injuries - knee forced
into varus foot-drop ( dorsiflexion and
eversion is weak) sensation over front outer
half and the dorsum of the foot.

S uperficial branch involved peroneal mus

cles paralysed eversion lost but dorsifle
xion intact wt loss of sensation over outer side
of the leg and foot
 Deep branch usually due to compartment
syndr pain, abnormal sensation, weakness of
dorsiflexion and sensory loss around the first
web space on the dorsum of foot

Open wound explored and sutured

S plint worn to control foot drop

If no recovery, disability can be improved by

tendon transfer or foot stabilization.
 Thanks to Dr Badrul.... F or his kind guid
ance in this preparation of this slides..............
.
 Diagnosis is not the end, but the b
eginning of practice.
Martin H. Fischer (physcision)