“My countrymen should have nerves of steel, muscles of iron, and minds like

thunderbolt.”

-Vivekananda

Management of Peripheral Nerve InjuriesDr.Obaidullah Khalid

P.G Orthopaedic surgery

DCMS

Under the guidance of

Dr.C.ShamSunderD.Ortho ,MS Ortho

Professor & HOD

DCMS

Today we shall learn about :

Diagnostic Tests

Prognosis and Rehab

Equipment

General considerations

Factors affecting Neurorrhaphy

Surgery Proper

1

2

3

4

5

6

7

Indications and Time for Surgery

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Diagnostic tests

The diagnostics give info on :

• Nerve Conduction

• Axon OR Myelin involvement

• To know Muscle recruitment

capability

Nerve Conduction Velocity StudiesDiagnostic tests

Nerve Conduction Velocity StudiesDiagnostic tests

•Should be done Proximal and distal to the

lesion

•Just after injury may show Normal study

•After 5-10 days when Wallerian degeneration is

fully settles in, the amplitude shows significant

decrease.

•If the amplitude recovers in 10 days ;

Neuropraxia

ElectromyographyDiagnostic tests

•If a muscle loses its nerve supply, EMG will show denervation potentials by third week.•This excludes Neuro praxia but not Axonotmesis

Tinel’s signDiagnostic tests

•Tingling sensation is felt all over the area supplied by the nerve

•A positive Tinels sign means Axonal Sprouts are progressing but are still

non myelinated

Sweat testDiagnostic tests

Opthalmoscope

If sweating

occurs,

the test is inferred

positive

Inference : Complete

interruption of nerve conduction

hasn’t occurred.

Why ?

Skin Resistant testDiagnostic tests

10 mA

10 mA

5 mA

9 mA

Open WoundsGeneral Considerations

1Steel suture approximation,

Suturing to adjacent soft

tissue

EXCESS GAPING BETWEEN CUT ENDS

3-7 days after injury

Best time

3 Normal Saline

Lavage with

•Begin after stabilization of all vitals

and vital organs after a trauma in a

hospital set up

•Thorough Debridement and

Lavage of an open wound and

immediate repair if

personnel,expertise and equipment

is available

2

Closed WoundsGeneral Considerations

•In closed wounds, a careful examination for discrete deficits.

Try to localize the site of lesion.PreGang ? Post Gang ?

•Once the wound is healed,splinting should be done in a way

that prevents muscle contactures.

•Begin joint mobilization so that muscles remain in soft state

and perform better during rehab following nerve repair

Is it advisable to wait for any signs of improvement ?

Or should exploration be done ?

• It is better to avoid early exploration.

• Wait till pain of (primary injury) subsides,

• Then do periodic EMGs,NCVstudies and

frequent clinical evaluation.

• BUT

• If examination reveals a transection,it is

preferrable to investigate then -> early

exploration.

After Neurorrhaphy

Factors influencing Regeneration

More the gap,more

difficult to bring

ends together.

More the gap,

more different

fascicular patterns

Brooks : 90’

condition

Nicholson,Seddon,

Sakellarides: 2.5

cm gaping

Gap between Ends

1

Age Time factor

Better in Children

When compared to

Adults

32 It’s the delay

between time of

injury and repair

Affects motor

recovey

Sunderland : +12

Months later

showed significant

result

Kankaanpaa &

Bakalin : Within 3

months repair

showed better

results

Level of injury

More proximal

Bad outcome

Meticulous handling

Asepsis

Blood supply

Alignment of Fasciculi

After 4m, distal end shrinks

Condition of Nerve ends

4

5

Indications for Surgical Exploration

• Sharp injury that has divided the nerve.

• Abrading/Blast wounds have made the condition of

nerve unknown.

• In closed #,when even after sufficient time, no

clinical/electrical evidence of regeneration observed.

• Low energy wounds with no evidence of regeneration.

Surgical ExplorationWhen do we do it ?

• Exact time is multifactorial dependant

• But given a

-clean wound without any complications,

-experienced personnel and good

equipment ;

primary repair in 6-8 hours

secondary repair in 7-18 days

have shown good outcome.

Surgery ProperPrimary Repair

• Should be done as soon as possible

• ADVANTAGES :

Cut ends would not have retracted much

Rotation is usually undisturbed

No fibrosis

Surgery ProperSecondary Repair

• It is Late repair as

Closed injury was treated but showed no signs

of recovery in elapsed time.

• Diagnosis was missed.

• Primary repair Failure.

Surgery Proper

Equipment

Anaesthesia

• General Anaesthesia Upper EX

• Spinal Anaesthesia Lower EX

VS

• Local anaesthesia ; advantage of allowing

evaluation of sensory impulses

Preparation and Draping

• Full extremity till Plexus location should be

prepared

• Pneumatic torniquet

• Mark incision along the course of the nerve

• ? Advisable to keep hand exposed .To check

contractions of muscles of hand

Technique of nerve repair

• Incision is the game changer.

• Never cross flexor crease of skin

Surgery proper

Surgery proper

• Do not hesitate to take a longer incision

• If nerve is dissected from a scar tissue, keepstimulating to make sure what all branches are still functioning

• Before mobilization, suture the epineurium proximal and distal to the lesion so that orientation is unaltered by rotation.

• Releasing torniquet releases ischaemia and surgeon can notice the msucle contraction upon stimulation

Technique of nerve repair

• If NEUROMA confronts, stimulate the nerve and

record.

Inject saline and check the proximal and distal

spread.If positive (spread present), better leave

it alone.

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Partial NeurorraphySurgery Proper

• Generally done in

Sciatic nerve

• Advised when one

half of the nerve is

disrupted

• Completely severed nerve

• Methods of closing gap ends

Mobilization

Positioning of Extremity

Transpositioning

Bone Resection

Nerve Guides

Nerve Grafting

Nerve crossing

Neurorrhaphy and Nerve grafting

Epineural Neurorraphy

Fascicular Neurorraphy

• Mobilization begins in ten days

InterFascicular NeurorraphyBridging the gaps

MobilizationBridging the gaps

• Little mobilization takes place in almost all

Neurorraphies

• Excess may lead to vascular comprimise

• Cut off are :

• Care should be taken to avoid stripping

small vessels

Positioning of Extremity

• Neurorapphy with too much flexion will

lead to traction upon extension that leads

to intraneuronal fibrosis.

• 90’ should be the cut off for Elbow flexion

• 40’ flexion of wrist

• After wound healing, arithmetic increase in

extension of 10’ per week is adviced.

Bridging the gaps

• Changing anatomical course to shorten

the distance between cut ends.

• Eg Ulnar Nerve at elbow.

Median nerve - anterior to Pronator Teres

Proximal Radial Nerve to ant. of Humerus

TranspositioningBridging the gaps

• Avoid this procedure

• Only implicable when Humerus is already

fractured and a fragment is already

segmented provided, Transpositioning of

nerve is not sufficient.

Bone resectionBridging the gaps

• Described by Seddon and Millesi

• SURAL NERVE is nerve of choice for graft

40 cms can be taken from each leg

• Lat. Antebrachial cutaneous nerve –

20cms from each arm (situated lateral to

BicepsTend)

• Vascularized nerve grafts, Trunk grafts,

allografts have not been described.

Nerve GraftingBridging the gaps

Nerve Guides

Autogenous vien

Freeze dried muscle

• Neuropraxia : Almost 100% recovery

• Higher the lesion,worser the prognosis

• Pure nerve recovery > Mixed nerve recovery

• Children recover better than adults

• Time taken

• Associated lesions

• Surgical technique

Prognosis

• Immobilize 4 weeks with plaster cast/splint

• Followed by 3 weeks of plastic brace that can be

gradually extended.

• Dressing shouldn’t be done till 7th day

• Lower Limb – 6 weeks spica

• For Interfasicular types,Cast is put in the surgical

position itself and is opened on the 10th day

when mobilization is encouraged.

Rehab

THANK YOU!

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