PERIPHERAL NERVE

LESION

Classification
Seddons Classification
xx Neuropraxia: It is temporary physiological paralysis of
nerve conduction. Here recovery is complete. There is no
reaction of degeneration.
xx Axonotmesis: It is division of nerve fibres or axons with
intact nerve sheath. There is reaction of degeneration distally
with near complete recovery. Patient can present with
sensory loss, paralysis of muscles or causalgia.
xx Neurotmesis: Here complete division of nerve fibres with
sheath occurs. Degeneration occurs proximally up to the
first node of Ranvier as well as distal to the injury. Recovery
is incomplete even after nerve suturing. There is complete
loss of motor and sensory functions with loss of reflexes.
If the nerve is mixed type other than pure motor or sensory
recovery is still poorer.
Injuries may be incised or lacerated or crushed one.
Cut end of the nerve forms proximally neuroma and distally
glioma.
Neuromas may be:
xx True neuroma or false neuroma.
xx End neuroma or side neuroma.
Sunderlands classification
I: Conduction blocktemporary neuronal block
II: Axonotmesis but endoneurium is preserved
III: Axonotmesis with disruption of endoneurium, but perineurium
is preserved
IV: Here disruption of endo and perineurium has occurred but
epineurium is intact
V: Neurotmesis with disruption of endo, peri and epineurium
has occurred
Clinical Features
xx Loss of sensory, motor, autonomous and reflex functions.
xx Secondary changes in the skin and joint.
Primary nerve suturing is done if it is a clean incised wound.

Secondary nerve suturing is done after 3 weeks if it is a

crushed wound.
Management
xxAssociated injuries like fracture, vessel injury, injuries in
other systems should be looked for.
xxAssessment of nerve injury is done by checking sensation,
muscle power, reflexes.
xxNerve conduction studies.
xx Investigations relevant for associated injuries.
xx Exploration of the wound.
Debridement of the area is done. If injury is incised one, then
nerve is sutured with 8-0 to 10-0 nonabsorbable
interrupted
sutures (polypropylene).

TINELS SIGN
It is the clinical sign (prognostic indicator) used to assess the
level of regeneration. It is elicited 3 weeks after the nerve injury
(Regeneration begins after the completion of nerve degeneration).
Tapping over the course of the nerve is done from distal to
proximal to elicit a sensation of pins and needles or hyperaesthesia.
If sensation is felt at the site as well as distally along the
distribution of the nerve, that means good recovery can be
expected. If sensation is felt only at the site of tapping, then
result is equivocal. If no sensation is felt it means no recovery.
Causes of peripheral nerve lesions
. Traumatic: Either closed or open injury
. Inflammatory: Leprosy, herpes zoster, diphtheria
. Compression neuropathies
. Lead poisoning
. Arsenical poisoning
. Alcoholism
. Diabetes mellitus
. Vitamin B1 deficiency
. Porphyria
. Neurofibroma and other neural tumours
. Idiopathic
BRACHIAL PLEXUS INJURIES It can be:

xx Supraclavicular injury 65%

xx Infraclavicular injury 25%
xx Combined 10%
It can also be:
xxUpper plexus injury.
xx Lower plexus injury.
It can be:
Pre-ganglionic injury Post-ganglionic injury
Avulsion injury Usually less severe
More dangerous Better recovery
Extends into the spinal cord
Investigations
. Nerve conduction studies.
. CT/MRI.
. Electromyogram.
. X-ray cervical spine and part.
Treatment
xx Conservative, nerve repair.
xx Tendon transfer, physiotherapy.
Osteotomy of coracoid process proximal to the attachment
of pectoralis minor, short head of biceps and coracobrachialis
is done to improve abductionSevers operation.
CAUSALGIA
It is severe burning pain and hyperaesthesia in the distribution
of a peripheral nerve due to incomplete injury to the nerve.
Features of upper and lower plexus injuries
Upper plexus injury (Erb-Duchenne paralysis) Lower plexus injury
(Klumpkes paralysis)
1. It is due to depression of shoulder by trauma 1. Forcible
hyperabduction of shoulder causes this injury
2. After difficult labour in newborn 2. In newborn it result due to
difficult breech delivery
3. Here C5 and C6 roots are injured 3. Here C8 and T1 are injured
4. Muscles affected are deltoid, biceps brachioradialis
and supinator
4. Intrinsic muscles of the hand are involved
5. Effects are: 5. Effects are:

a. Elbow will be extended, pronated and upper limb

is internally rotated (Policeman receiving tip)
a. Combined median and ulnar claw hand
b. Sensory deficit over the lateral aspect of arm and
upper part of the lateral forearm
b. Horners syndrome
c. Sensory deficit over the medial aspect of forearm, hand,
and medial 1 finger
Sites
Common in upper limb.
Commonly seen in median nerve, also often in brachial
plexus injuries. In the lower limb it is seen in sciatic nerve or
tibial nerve injuries.
Pathology
Incomplete nerve injury produces abnormal impulse towards
sensory nerve ending causing vasomotor instability and pain.
Clinical Features
Hyperaesthesia with severe disabling and burning pain.
Skin becomes red, shiny and glossy which sweats
profuselyWeir-Mitchells skin.
Eventually skin becomes atrophic, cyanotic, cold and
blotchy.
Skin is less sensitive to heat, cold, and pin prick, but
hypersensitive to touch and tender to pressure.
Nails are rigid, brittle with change in colour.
Investigation
Nerve conduction studies.
Treatment
xxAnti-inflammatory drugs, steroids, physiotherapy.
xx IV guanethidine regionally.
xx If not improved, sympathectomycervical for upper limb,
lumbar for lower limb.
MEDIAN NERVE INJURY
xxMedian nerve arises from lateral (C5, 6, 7) and medial cord
(C8 and T1) of the brachial plexus. It is initially lateral to the
axillary artery and becomes medial in the lower part of the

arm and in the cubital fossa. It passes through the pronator

teres, descends in relation to flexor muscles and enters the
palm through the carpal tunnel at the wrist.
xx It supplies pronator teres, flexor carpi radialis, palmaris
longus and flexor digitorum superficialis. Anterior interosseous
branch of the median nerve supplies pronator teres,
lateral half of the flexor digitorum profundus, flexor pollicis
longus and pronator quadratus.
xx In the wrist, it supplies abductor pollicis brevis, flexor
pollicis and opponens pollicis of thenar eminence
and lateral
two lumbricals. It gives sensory supply to lateral three and
half fingers of the hand.
Median nerve is affected in:
. Injuries
Supracondylar fracture of the elbow
Fracturedislocation of the elbow
Direct cut injuries
. Leprosy
. Carpal tunnel syndrome
. As a part of brachial plexus injury
Clinical Features of Median Nerve Palsy
In high median nerve palsy
xxWasting of the thenar eminence. Loss of sensation on lateral
three and half fingers.
xxOchsners clasping test shows pointing index because of the
inactivity of lateral two divisions of the profundus.
xx Ape or Simian thumb deformity is due to overaction of
the adductor pollicis which is supplied by the deep branch
of ulnar nerve. As all other thenar muscles are paralysed,
thumb comes in the same plane of the metacarpals.
xx Pen test: In median nerve injury, pen held in front of
the hand cannot be touched by thumb as abduction is not
possible due to paralysis of the abductor pollicis brevis.
In low median nerve palsy profundus is not paralysed and
so pointing index is not seen.
Investigations

xxNerve conduction studies.

xxX-ray of the part in case of fracture.
xx Electromyogram.
Treatment
xxNerve suturing or nerve graft.
xx Tendon transfer.
xx Treat the cause like carpal tunnel syndrome.
CARPAL TUNNEL SYNDROME
xx It is the compression neuropathy of median nerve in the
carpus, deep to flexor retinaculum.
xx Flexor retinaculum (transverse carpal ligament) maintains
the concavity of wrist and extends laterally from trapezium
and scaphoid to pisiform and hook of the hamate medially.
Carpal tunnel is formed by carpal bones behind and flexor
retinaculum in front. It contains median nerve and long flexor
tendons of fingers and thumb. Ulnar nerve lies superficially,
not in the carpal tunnel.
Median nerve gets compressed if space of the carpal tunnel
gets reduced.
Causes
xx Lunate dislocation, malunited Colles fracture.
xx Radiocarpal arthritis, flexor tendon tenosynovitis.
xxMyxoedema, acromegaly, pregnancy.
Clinical Features
xx Common in females.
xx Tingling, numbness, paraesthesia and burning sensation in
the lateral three and half fingers supplied by median nerve.
Burning sensation gets aggravated at night.
xxApe thumb deformity, wasting of thenar muscles, weakness
of opponens pollicis and abductor pollicis brevis, i.e.
features of low median nerve palsy.
xxWhen BP cuff is inflated patient feels
CLAW HAND
xx It is the hyperextension of the metacarpophalangeal
joint
with flexion of the interphalangeal joints of the hand.
xx Extension of MCP joint is due to unopposed action of

extensor digitorum.
xx Flexion of MCP joint and extension of interphalangeal
joints are by extensor hood of interossei and lumbricals.
So extensor hood is functioning mainly by ulnar nerve and
also by median nerve. In ulnar or median nerve palsies,
these actions are paralysed and so patient develops claw
hand.
xx It is actually intrinsic minus deformity.
Causes
. Leprosy
. Trauma
. Entrapment neuropathies
. Tardy ulnar palsy
. Klumpkes palsy
Clinical Features
xx Typical claw hand.
xx Loss of sensation along the distribution of the nerve.
xx Inability to grasp card between the fingers.
xxWhile holding the book between the thumb and fingers,
thumb will be flexed in ulnar claw hand (positive Froments
test).
Types
xxUlnar claw hand: Only medial two fingers are involved.
Low ulnar palsy: Here lesion is in the wrist (at Guyons
canal). Here deformity is more because of the overaction
of the FDP.
.
Ulnar paradox: Higher the lesion lesser the deformity, lower
the lesion more the deformity.
xxMedian claw hand: Only lateral two fingers are involved.
It is less common.
xx Combined median and ulnar claw hand: Here all four
fingers of the hand are involved.
Investigations
xx Electromyogram.
xxNerve conduction studies.
Treatment
xx Paul Brands operation: Extensor carpi radialis longus or
brevis (ERCB) is transferred with a graft to the extensor
hood through the lumbrical canal. Graft is taken from
palmaris longus or plantaris muscle.
xx Stye-Bunnells operation: Flexor digitorum superficialis
of index finger is used (only in ulnar claw hand) to transfer

to extensor hood.
xx Fowlers operation: Extensor digitorum is used to transfer
to extensor hood.
xx Riordan operation: Flexor carpi radialis is used for tendon
transfer.
xx Anterior transpositioning of the ulnar nerve in case of tardy
ulnar palsy.
RADIAL NERVE INJURY
xx Radial nerve is derived from the posterior cord of the
brachial plexus (C5, 6, 7, 8 and T1). It descends behind the axillary
artery in front of the subscapularis,
latissimus dorsi and
teres major. It passes through the medial and lateral heads
of the triceps muscle, winds round the humerus through the
radial groove and enters the forearm in front of the lateral
epicondyle in relation to brachioradialis,
brachialis and
extensor carpi radialis longus muscles.
xx In the arm it supplies triceps, anconeus, brachioradialis,
extensor carpi radialis longus and part of brachialis. It gives
posterior and lower lateral cutaneous nerves of the arm and
posterior cutaneous nerve of the forearm.
xx Superficial branch of the radial nerve from the elbow runs
in the forearm in relation to supinator and brachioradialis
and ends by forming five digital nerves which gives sensory
supply to lateral three and half fingers on the dorsal aspect
except skin over the distal phalanges.
xxDeep branch also called as posterior interosseous nerve
winds round the radius supplying supinator and extensor
carpi radialis brevis. It gives 3 short branches to extensor
digitorum, extensor digiti minimi and extensor carpi ulnaris.
It also gives two long branchesone to abductor pollicis
longus and extensor pollicis brevis; another to extensor
pollicis longus and extensor indicis.
B
Conditions where radial nerve is affected
In the axilla
. Crutch palsy. It is neuropraxia
. Fracture upper end of the humerus
. Bony or soft tissue growth
In the radial groove
. Pressure on the arm from the edge of the operating table
. Saturday night palsyan individual with excessive alcohol

consumption compresses his arm over the chair or by fall. It

is neuropraxia
. Prolonged tourniquet applicationtourniquet
palsy
. Fracture of the shaft of the humerus
. Rarely intramuscular injection of drugs can cause radial
nerve palsy
In the elbow
. Dislocation or fracture neck of the radius
Clinical Features
xxWrist drop because of inability of extending the wrist.
xx Inability to extend metacarpophalangeal joint, but extensions
of the interphalangeal joints are normal.
xx Inability to extend the forearm.
xx Inability to extend the thumb.
xx Flexion of the elbow against resistance with forearm in
mid-prone position is difficult because of the weakness of
the brachioradialis muscle.
xx Loss of sensation in back of the arm, forearm, hand and
lateral three and half fingers.
Posterior interosseous nerve is purely motor and so sensation
is intact when it gets injured. It causes only dropped fingers.
Investigations
xxX-ray of the part.
xxNerve conduction studies.
Treatment
xxNerve suturing or nerve graft.
xx Tendon transfer.
COMMON PERONEAL NERVE INJURY
This nerve supplies the extensor and peroneal group of muscles
and sensory supply to the skin over the front and lateral aspect
of the leg and dorsum of the foot.
Common peroneal nerve is affected in:
. Fracture neck of the fibula
. Leprosy
. Lead poisoning
. Iatrogenic
Clinical Features
xx Foot drop with high stepping gait.
xx Talipes equinovarus deformity.
xx Loss of sensation on the lateral side of the leg and dorsum
of the foot.
Management

xx Treating the foot drop.

xxMCR chappals.
FOOT DROP
Inability to dorsiflex and evert the foot due to paralysis of the
peroneal and extensor group of muscles, as a result of common
peroneal nerve injury.
Causes
. Fracture neck of the fibula
. Leprosy
. Lead poisoning
. Iatrogenic
. Direct incised wound
Clinical Features
xxHigh stepping gait.
xx Loss of sensation over lateral and dorsum of the foot.
Treatment
Tendon transfer using tibialis posterior muscle. Tendon of
the muscle is detached from its navicular insertion and with
a tendon graft (from plantaris) it is transferred to cuboid and
cuneiform bones to get dorsiflexion and eversion.
a. Obers procedure.
b. Barrs procedure.
MEDIAL POPLITEAL NERVE INJURY
It supplies the soleus, gastrocnemius, popliteus, plantaris,
tibialis posterior, flexor digitorum longus and flexor hallucis
longus.
Medial popliteal nerve is rarely involved by any disease
process. Trauma can cause medial popliteal nerve palsy.
Clinical features
. Inability to plantar flex the foot
. Claw toes
. Sensory loss in the sole of the foot
AXILLARY NERVE INJURY
Axillary nerve supplies the deltoid and teres minor muscle and
also sensory supply to the skin over the upper lateral aspect
of the arm.
Axillary nerve is affected in:
xx Fracture neck of the humerus.
xxDislocation of humeral head.
xx Following IM injection into the deltoid.
Clinically there will be loss of abduction of the shoulder and
anaesthesia of the skin over the lateral part of the arm.

LONG THORACIC NERVE INJURY

(NERVE OF BELL)
It supplies serratus anterior muscle. It arises from C5, 6, 7
cervical roots.
The nerve is injured commonly in malignancy, during breast,
axillary or chest wall surgeries.
Clinically, when outstretched (elbow extended) arm is pushed
against the wall, the inferior angle of the scapula will become
prominent (Winging of the scapula).
MERALGIA PARAESTHETICA
xx It is entrapment neuropathy of lateral cutaneous nerve of
thigh. Nerve gets compressed while passing through the
inguinal ligament. It arises from posterior divisions of
lumbar plexus (L2, 3); runs over the quadrates lumborum
and iliacus muscles; emerges behind the lateral part of
the inguinal ligament; divides into anterior and posterior
branches, supplying skin over anterolateral part of the thigh
and anterior part of the gluteal region.
xx It causes hyperaesthesia, tingling over upper lateral aspect
of the thigh along the distribution of the nerve. Symptoms
get worsened on standing or walking; it is relived
by sitting.
xx It mimics disc prolapse or Hansens disease or neuropathies.