Peripheral Nerve Injury (Part-I)
- 1. Peripheral Nerve Injuries (Part-I) Dr. Anshu Sharma Assistant Prof. Dept. of Orthopaediscs, GMC&H.
- 2. • Peripheral nerves are formed from nerves arising from the spinal cord (spinal nerves). • There are 31 pairs of spinal nerves in the body. • These, either through a direct branching or through a network of nerves (plexus), give rise to Peripheral nerves. • So, Peripheral nerves are bundles of axons conducting efferent impulses from cells in anterior horn of the spinal cord to the muscles, and afferent impulses from peripheral receptors via cells in the posterior root ganglia to the cord. Introduction
- 3. • All motor axons and sensory axons are coated with myelin sheath, interrupted with nodes of Ranvier. • Outside Schwann cells, axon is covered by a connective tissue stocking called Endoneurium. • The axons that make up a nerve are separated into bundles (fascicules) by fairly dense membranous tissue, the Perineurium. • The group of fascicules that make up a nerve trunk are enclosed in an even thicker connective tissue coat, the Epineurium.
- 5. Mechanisms of Injury Fracture & Dislocations (most common) Thermal injury (Burns) Direct Injury (Cut and Laceration) Electrical injury (Electrical shock) Infection- Leprosy. Ischemic injury (Volkmann’s Ischemia) Mechanical Injury (Compression , Traction, Friction and shock wave) Toxic agents: IM Injections. (Tetracycline) Cooling and freezing (Frost bite) Radiation Exposure (Following Radiotherapy)
- 6. Primary injury:- Results from same trauma that injures a bone or joint. Radial nerve is the most commonly injured. In Humeral shaft fractures, 14 % is complicated by radial nerve injuries -Displaced osseous fragments -Stretching of nerve -Following Manipulation Secondary injury :- Results from involvement of nerve by infection, scar, callous or vascular complications which may be hematoma, AV fistula, Ischemia or aneurysm.
- 7. Neuronal Degeneration & Regeneration:- Any part of neuron detached from its nucleus, degenerates & is destroyed by phagocytosis. ○ Distal part Secondary / Wallerian Degeneration. ○ Proximal Primary /Retrograde Degeneration for a single node. Time required for degeneration varies between sensory and motor fibers and is also related to size & myelination of fibers.
- 8. • As the regeneration begains, the axonal stumps from the proximal segment begins to grow distally. • If the endoneural tube with its contained schwann cells is intact, the axonal sprouts may readily pass along its primary course and re-innervate the end organ. this will form Neuroma in continuity. • An end neuroma may form when the proximal end is widely separated from distal end. • A side neuroma indicates a partial nerve cut. • Advancing Tinel sign ( 1mm/day) and presence of Motor march phenomena are signs of regeneration.
- 10. Classification of Nerve injury:- Seddon’s classification 1. Transient ischaemia 2. Neurapraxia 3. Axonotmesis 4. neurotmesis
- 11. Transient ischemia:- • Due to transient endoneurial anoxia (due to acute nerve compression) • Reversible condition • Within 15 min: numbness and tingling • After 30 min: loss of pain sensibility • After 45 min: muscle weakness • Relief of compression is followed by intense paresthesia upto 5 min. • Feeling restored within 30 seconds and full muscle power after 10 minutes.
- 12. Neurapraxia:- • Physiological interruption, anatomically normal. • No proximal or distal degenration and neuroma formation. • Seen in crutch palsy, Saturday night palsy, tourniquet palsy. • Recovery is Complete and Excellent.
- 13. Axonotmesis • Due to axonal interruption but the nerve is in continuity and the neural tubes are intact. • Wallerian degeneration distal to the lesion and few millimeters retrograde. • Neuroma in continuity will formed. • Axonal regeneration occurs within hours of nerve damage (1-2 mm/day), and recover in few weeks. • Seen in Tardy Ulnar nerve palsy. • Recovery is usually Good.
- 14. Neurotmesis:- • Division of nerve trunk (Axons as well as nerve). • Rapid wallerian degeneration. • End or side neuroma will formed. • Destruction of endoneurial tubes over a variable segment and scarring prevents regeneration of axons. • Surgical repair required • Recovery/Function may be adequate but is never normal (poor).
- 17. • Diagnosis:- The diagnosis of a peripheral nerve lesion depends primarily on a precise history and an exact clinical examination. • Investigations are just to confirm the diagnosis.
- 18. History • c/c= Inabilty to move a part of limb • Weakness and Numbness • Duration of symptoms • Cause may or may not be obvious. • When cause is obvious: nerve affected and its level is easy to decide. • When cause is not obvious: history of injection in nerve proximity, any medical causes like leprosy, diabetes should be asked.
- 19. Examination • Following observation should be made: 1. Attitude and deformity: Some peripheral nerve injuries present with classic attitude and deformity of limb. Wrist drop Foot drop Winging of scapula Claw hand Ape-hand deformity Pointing index Policeman-tip deformity
- 20. 2. Wasting of muscles: - Will become obvious some time after paralysis. -Compare opposite sound side. Slight wasting may go missed. 3.Skin changes: - Dry( No sweating), glossy and smooth. -Pallor or cyanosis -Trophic changes such as ridged and brittle nails, shiny atrophic skin, trophic ulcersetc
- 21. 4.Temperature: Paralysed part is usually colder and drier due to loss of sweating. Always compare with normal side. 5.Sensory examination: Different forms of sensation to be tested in suspected case of nerve palsy. 6.Sweat test: To detect sympathetic function in the skin supplied by a nerve. -Presence of sweating within an autonomous zone of an injured peripheral nerve reassures that complete inteurrption of the nerve has not occurred. -Starch test or Ninhydrin print test. 7.Motor examination
- 22. Regional Nerve Injuries: Brachial Plexus injuries:- Most commonly: 1. Erb’s palsy 2. Klumpke’s palsy
- 23. Erb’s palsy • Injury of C5, C6 and (sometimes) C7. (Erb’s point) • Common in overweight babies with shoulder dystocia at delivery • The abductors and external rotators of the shoulder and the supinators are paralyzed. • Arm held to the side, internally rotated and pronated
- 24. Erb’s palsy
- 25. Klumpke’s palsy • Injury of C8 and T1. • Usually after Breech delivery. • Baby lies with the arm supinated and the elbow flexed • Loss of intrinsic muscle power in the hand.
- 27. Long Thorasic Nerve • Roots C5, 6, 7. • Supplies serratus anterior muscle. • Injury cause paralysis of the muscle causing winging of scapula (Medial border becomes prominent). • Test by pushing against the wall.
- 28. Test for long thoracic nerve injury (winging of right scapula)
- 29. Axillary Nerve • Root value (C5, 6). • Supplies Deltoid and Teres Minor muscles. • Cutaneous branch supplies the skin over the lower half of the deltoid (landmark: 5 cm below the tip of acromion). • Injury caused shoulder weakness and wasting of the deltoid muscles. • Extension of the shoulder with the arm abducted to 900 is impossible. • Small area of numbness over the deltoid.
- 30. RADIAL NERVE - Continuation of the posterior cord of the brachial plexus. - Root value: C5- C8 , T1.
- 32. Motor branches • Before the radial groove: -Long and Medial heads of Triceps. • After the radial groove, before crossing the elbow: -Lateral head of Triceps, Anconeous, Brachioradialis, Extensor carpi radialis longus. • After crossing the elbow: -Extensor carpi radialis brevis, the supinator. • After piercing the supinator: other extensor muscles of the forearm and hand
- 33. Low lesions • Due to # or dislocation at the elbow or to a local wound • Complain of clumsiness , not being able to extend the MCP joints of the hand • In thumb, weakness of extension and retroposition • Wrist extension is preserved
- 34. High lesions • Due to # of the humerus or after prolonged tourniquet pressure • Wrist drop due to weakness of the radial extensors of the wrist • Inability to extend MCP joints or elevate the thumb. • Sensory loss to a small patch on the dorsum around the anatomical snuff box
- 35. Very high lesions • Due to trauma or operations around shoulder. • Also common in Saturday night palsy or crutch palsy • In addition to high lesions, the triceps is paralysed and the triceps reflex is absent.
- 36. Radial Nerve Tests:. • From proximal to distal, following muscles can be examined: 1.Triceps: Ask to extend his elbow against resistance Where other hands feel for triceps contraction. 2. Brachioradialis: Ask to flex his elbow from 90 degree onwards, keeping the forearm in mid-prone and against resistance,brachioradialis stands out and can be felt.
- 37. 3.Wrist extensors: “Wrist drop” occur in paralysis of wrist extensors (Brachioradialis, ECRL, ECRB, Extensor digitorum, Extensor carpi ulnaris).
- 39. 4. Extensor digitorum -Function: extension at MCP Joint. -“finger drop” 5. Extensor pollicis longus: -Function: extension at IPJ of thumb. -Examined by stabilising the MCP Joint of thumb while patient is asked to extend IPJ. - “thumb drop”
- 40. PIN PALSY • PIN is a branch of the radial nerve. • Purely motor innervation to the extensor compartment. 1. Finger metacarpal extension weakness. 2. Wrist extension weakness. -inability to extend wrist in neutral or ulnar deviation -the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent ECU (PIN).
- 41. Median nerve • Formed by joining of branches from Lateral and Medial cords of brachial plexus.
- 43. MOTOR BRANCHES OF MEDIAN NERVE In the Arm Nil In the forearm: 1. Proximal 1/3 All flexors of forearm (except FCU and Medial half of FDP) 2. Distal 1/3 Nil In the hand: Thenar muscles (Except Adductor Pollicis) 1st twolumbricals
- 44. Low Median Nerve Lesions: • Due to injury in the distal 1/3rd of forearm. • Sparing of Forearm muscles. • Unable to abduct the thumb (Thenar Muscles). • Sensation lost over the radial three and a half digits. • Long standing condition, atrophy of thenar eminence.
- 45. High Median Nerve lesions: • Due to injury in proximal 2/3rd of forearm or elbow dislocation. • Signs: In addition to low lesions, paralysis of long flexors to the thumb, index and middle fingers, radial wrist flexors and the forearm pronator muscles. • There will be sensory deficit in the skin of hand.
- 46. • Tests: from proximal to distal, following muscles can be examined:- 1.Flexor pollicis longus: -fn: flexion at IP Joint of thumb. -asked to flex distal phalynx of thumb against resistance while proximal phalanx is steady by examiner. 2. Flexor digitorum superficialis and lateral half of flexor digitorum profundus: “pointing index sign”
- 47. -Pointing Index :-on asking pt to make a fist, index finger remains straight. -Occurs due to paralysis of both flexors (FDS &FDP) of index finger due to median nerve palsy at level proximal to elbow.
- 48. 3.Flexor carpi radialis: -In a patient with paralysis of this muscles, the wrist deviates to ulnar side while palmar flexion occurs.
- 49. 4. Muscles of thenar eminence: -Abductor pollicis brevis, Opponens pollicis, Flexor pollicis brevis. -Only two can be examined for their isolated action. a) Abductor pollicis brevis: - fn: abduction of thumb - “Pen test” - pt is asked to lay his hand flat on the table with palm facing the ceiling, and a pen is held above the thumb and asked him to touch the pen with tip of his thumb.
- 50. Pen test
- 51. b) Opponens pollicis: - fn: to appose the tip of the thumb to other fingers. (Apposition is a swinging movement of thumb across the palm and not a simple adduction)
- 52. Thumb is in same plane as wrist .
- 53. To be Continued in Part II…