PERIPHERAL NERVE INJURY

POST GRADUATE SEMINAR

TOPIC:- PERIPHERAL NERVE INJURY

Date- 02-03-2016

Presenter- Moderator-
Dr. Baharul Islam Choudhury Dr. C.R.Buragohain
PGT, Orthopedics Asst. Proff
Date – 08- 06- 2016
MICRO ANATOMY
NERVE DEGENERATION & REGENERATION
HOW TO DIAGNOSE
 TREATMENT
• Careful assessment of vital function.
• Clean Open wound where nerve is sharply incised
Immediate primary repair is preferred.
If patient condition does not permit it may be delayed.

• Severe contaminated open wound

If Nerve end is identified, loose end to end apposition.
If gap, suture the ends to soft tissue to prevent retraction.
Repair after healing of spoft tissue.
• Closed injury
Careful assessment of discrete deficit
Active movement of joints started after pain subsides.
Gentle passive exercises.
Dynamic & static splinting to prevent contracture.
Periodic EMG, NCVS, clinical evaluation.

• If nerve injury is after manipulation or casting, early exploration is favored

SURGERY
 METHOD OF CLOSING GAP

• Mobilization.
• Positioning of extremity.
• Transposition.
• Bone resection.
• Nerve stretching.
• Nerve grafting.
• Tendon transfer
BRACHIAL PLEXUS INJURY
 RADIAL NERVE INJURY
• It is continuation of post cord of brachial plexus.
• It is primarily motor nerve.
Very high lesion
caused by –
Trauma or operation around shoulder.
Compression in axilla ( Crutch palsy , Saturday night palsy).
Triceps is also paralysed in addition to wrist & hand.

High lesion
Caused by—
# of SOH, # S/C & # Lat condyle humerus.
Prolonged tourniquet pressure.
Wrist drop & sensory loss over dorsum around anatomical snuff box.

Low lesion
Caused by—
#, dislocation around elbow.
Operation of proximal radius.
Finger extension at MP joint is lost.
• Treatment—
Open injuries should be explored & repaired as soon as possible.
Closed injuries are 1st to 2nd deg lesion & function eventually returns.
Wrist should be splinted.
Large disability can be overcomed by tendon transfer.
 ULNAR NERVE INJURY
• Arises from medial cord of brachial plexus.
• Injuries usually occur near the elbow or wrist by—
# dislocation at elbow.
Med condyle # or S/C # humerus.
Cubitus valgus deformity.
L/W or cut wound around wrist.
Direct pressure or prolonged flexion of elbow.

C/F—
• Treatment—
If nerve is divided it should be explored & repaired.
Anterior transposition at the elbow.
Tendon transfer.
Hand physiotherapy.
 MEDIAN NERVE INJURY

• The nerve is formed by junction of lateral & medial cord of brachial plexus.
• Injuries are caused by—
Cut wound in front of elbow.
Carpal dislocation.
forearm # or elbow dislocation.
Stab or gunshot wound.

C/F—
• Treatment—
If nerve is divided, suture or nerve grafting should be attempted.
Post operatively wrist is splinted in flexion.
Tendon transfer is indicated if disability is severe.
 LONG THORACIC NERVE INJURY

> Root value C5, 6, 7.

> Damaged in shoulder or neck injuries, carrying loads, first rib resection,
radical mastectomy, viral infection.
> Paralysis of serratus anterior causes winging of scapula.
> Test is done by asking the patient pushing forward against wall.

> Recovers spontaneously, over a year or longer except direct injury or

division.
> Persistent winging requires stabilization by transferring pect. Minor or
major to the lower part of the scapula.
 SPINAL ACCESSORY NERVE INJURY
• Root value C2-6.
• Supplies sternomastoid & upper half of trapezius.
• Injured by stab wounds, operation in the post. triangle of neck.
• C/O severe pain & stiffness of shoulder, asymmetry or drooping of
shoulder, weakness on abduction of arm, mild winging of scapula

• .
• Stab injuries should be explored immediately & nerve repaired.
• If cause is uncertain, wait for 8 wks keeping the arm in sling for sign of
recovery.
• No sign of recovery after 8 wks nerve should be explored & repaired by
direct suturing or grafting.
 SUPRASCAPULAR NERVE INJURY
• Arises from upper trunk of BP ( C5,6).
• Supplies supra & infra spinatus muscle.

• Injured in # scapula, shoulder dislocation, sudden traction, direct blow,

carrying heavy load.
• C/O unexplained pain, diminished power of abduction & ext rotation.
• EMG establish the diagnosis.

• Injury is usually axonotmesis, which clears up spontaneously after 3

months.
• In the absence of trauma, nerve entrapment should be suspected &
decompression by division of suprascapular ligament.
 AXILLARY NERVE INJURY
• Arises from post. Cord of BP.( C5, 6).
• Supplies deltoid & teres minor. & also skin over deltoid.
• Nerve is injured by
fracture or dislocation around shoulder,
penetrating wounds,
direct blows,
quadrilateral space syndrome.
post approach to shoulder,
Shoulder arthoscopy.
• C/O weakness & wasting of deltoid, unable to abduct beyond 15 deg, loss
of sensation over lower half of deltoid.

• Injury associated with # or dislocation recover spontaneously.

• If no sign of recovery by 8 wks > EMG advised > if suggests denervation
> exploration & grafted.
 FEMORAL NERVE INJURY

• Formed by union of post division of L2,3,4 roots.

• The nerve is injured by
Penetrating wound of lower abdomen.
Hematomas of the abdominal wall.
Pelvic fracture.
During operation.

C/F—
Atrophy of thigh muscle.
Difficult to go up a hill or stairs.
Numbness to ant thigh & medial aspect of leg.

Treatment of clean cut of nerve done by-

Suturing
Grafting
Tendon transfer from hamstrings to quadriceps.
 SCIATIC NERVE INJURY
• The nerve is formed by L4,5 & S1,2,3.
• Largest nerve of the body of diameter 2 – 2.5 cm.
• Supplies muscle of entire leg & foot & post part of thigh.
• Nerve is injured by-
Gunshot wound
#, Dislocation of hip.
Penetrating wound & # SOF.
I/M injection.
Surgery around hip.
Long standing THR.

C/F—
In complete lesion hamstring & all muscle below knee are paralysed.
Loss of sensation below knee except medial side & foot.
Walks with high stepping gait due to foot drop.
Wasting of the limb muscle.
Trophic ulcer on the sole.
• Treatment –
If nerve is divided suture or nerve grafting is done.
Recovery may take more than a year.
Foot drop splint is fitted,
Care of skin of sole.
Counteract foot drop by transfering tibialis post to the front.
Amputation may be preferred in deformed & insensitive limb.
 PERONEAL NERVE INJURY
• Injured by—
Rupture of LCL.
#, dislocation head of fibula.
By casts.
Crossing the legs.

C/F—
Significant pain.
Foot drop.
Loss of sensation over front & outer aspect of leg & dorsum of foot.

Treatment –
If there is division it is explored & repaired.
Foot drop splint is fitted.
Tendon transfer.
THANKING YOU