Brachial plexus and peripheral nerve injuryinjury.pptx
- 1. BRACHIAL PLEXUS AND PERIPHERAL NERVE INJURY SYAZWANI SAEDI BINTI IDRIS SAEDI TAJUL ‘ATIQAH BINTI ZAULKAFALI NUR FATIHAH BINTI ZULKAFLI NUR DIYANA SAKINAH BINTI MUHAMAD RUSDI
- 2. OVERVIEW • Introduction • Pathogenesis • Classification • Examination techniques • Ulnar nerve paradox • Double crush syndrome • Investigation • Treatment
- 3. INTRODUCTION
- 5. PERIPHERAL NERVE MYELIN AXON NEURON SCHWANN CELL ENDONEURIUM FASCICLE EPINEURIUM PERINEURIUM BLOOD VESSEL NODES OF RANVIER
- 6. FUNCTION: • Myelin: coating axon • Axon: serving touch, pain, proprioception • Schwann cell: producing myelin • Nodes of Ranvier: where nerve impulses leap on
- 8. PATHOGENESIS
- 10. TRANSIENT ISCHEMIA • Acute nerve compression • Within: – 15 min: numbness + tingling – 30 min: Loss pain sensibility – 45 min: Muscle weakness • Relief of compression: – Intense paraesthesiae (5 min) – Restored sensation( 30 sec) – Full muscle power (10 min)
- 11. NEUROPRAXIA • Reversible • Nerve conduction block • Loss of some types of sensation and muscle power • Spontaneous recovery ( days – weeks)
- 12. AXONOTMESIS • Closed fracture and dislocations • Conduction loss ( axon ruptured, intact neural tubes) • Axonal regeneration within hours of nerve damage by Schwann cells • New axon grow join to end-organs can function
- 13. NEUROTMESIS • Nerve trunk ruptured, axonal continuity cannot be restored • Jumbled knot/neuroma produced • Fail to reach end-organs • Surgical intervention • Function adequate but never normal
- 14. CLASSIFICATION
- 15. * Based on Apley’s System of Orthopaedics and Fractures, 9th edition Seddon’s Neurapraxia Axonotmesis Neurotmesis
- 16. SUNDERLAND CLASSIFICATION 1ST DEGREE INJURY •Transient ischemia and neurapra xia •Reversibl e 2ND DEGREE INJURY •Correspond to Seddon’s axotnomesis •Axonal degeneration, endoneurium preserved regeneration complete/nearly complete •Without intervention 3RD DEGREE INJURY •Worse than axotnomesis •Endoneurium disrupt, perineurium intact, internal damage limit •Can reach end-organs •Limit recovery 4th DEGREE INJURY •Epineurium only intact •Continuity nerve trunk, severe internal damage •Need nerve repaired/gra fted 5th DEGREE INJURY •Nerve is divided •Need nerve repaired
- 18. WHY CLASSIFY?
- 22. MECHANISM INJURY • Affect movement & cutaneous sensation in upper limb • ~ 95% due to traction/compression • Mechanism: – Stab wound – Traction (closed wound) • Supraclavicular (65%) • Infraclavicular (25%) • Combined (10%) – Others: - • Obstetrics –Erb & Klumpke • Postanaesthetic • Radiation • Tumour • Iatrogenic
- 23. TRACTION INJURY • Supraclavicular • roots or trunks -Usually d/t compression a/w fractures or dislocations of the shoulder • Infraclavicular • Cords and branches Upper brachial plexus injury ( C5, C6, C7) -d/t forcible widening of shoulder-neck angle Lower brachial plexus injury (C8, T1) -when upper limb is suddenly pulled superiorly
- 24. CLINICAL FEATURES • Based on: – Level of lesion – Pre or postganglionic lesion? – Type of lesion
- 25. LEVEL OF LESION UPPER PLEXUS INJURY (C5,C6,C7) •Paralysis: •Shoulder abductors •External rotators •Forearm supinator •Sensory loss (outer part of arm & forearm) LOWER PLEXUS INJURY (C8,T1) •Rare •Weak (wrist & finger flexor) •Paralysis ( intrinsic hand muscle) •Sensory loss ( ulnar forearm & hand) ENTIRE PLEXUS (C5 – T1) •Whole limb paralysed & numb
- 26. PRE OR POSTGANGLIONIC LESION? Disruption proximal to dorsal root ganglion Irreparable PREGA NGLION IC (ROOT AVULSI ON) Disruption distal to dorsal root ganglion Reparable POSTGA NGLION IC (AXONO TMESIS)
- 27. • Features of root avulsion: – Crushing/burning (anaesthetic hand) – Scapular muscle/diapragm paralysed – Horner’s syndrome: • Ptosis • Miosis • Enophthalmos • Anhidrosis – Severe vascular injury – Associated cervical spine fractures – Spinal cord dysfunction
- 28. TYPE OF LESION • To identify the severity of damage – Mild (1st /2nd degree injury) recover by 6/8 weeks – Severe (3rd /4th degree injury) – Neurotmesis early operative exploration needed • Based on: – Mechanism injury – Impact velocity
- 29. OBSTETRICAL BRACHIAL PLEXUS PALSY ER B’S PA LS Y •Upper root injury •Overweight babies with shoulder dystocia (delivery) •CF: •Loss finger extension •Arm •Held to the side •Internal rotate •pronated •Paralysis •Abductors , external rotators (shoulder) •supinators KL UM PK E’S PAL SY •Lower root injury •Breech delivery of small babies •CF: •Arm supinated •Elbow flexed •Loss intrinsic muscle power in hand •Absent reflex •Unilateral Horner’s syndrome
- 32. • Causes: i. Anterior-inferior shoulder dislocation ii. Fracture of humeral head • Clinical features: i. Cannot abduct the shoulder due to deltoid weakness ii. Numbness over deltoid (C5 dermatomes) • Treatment: i. Recovers spontaneously (If no sign of recovery by 8 weeks, nerve should explored and grafted) ii. If operation fails, consider shoulder arthrodesis or tendon transfer
- 33. Radial Nerve Injury • Radial nerve – All muscles of posterior compartments of arm & forearm – Skin of posterior & inferolateral arm, posterior forearm & dorsum of hand • Branches: – Superficial branch (innervate dorsum of hand) – Deep branch which become posterior interosseous nerve
- 34. • Can injured at elbow, upper arm and in axilla Low lesions •Fracture/ dislocation of elbow, open wound, surgical accident •Cannot extend metacarpophalang eal joints High lesions • Fracture of humerus, after prolonged torniquet pressure •Saturday night palsy •There is obvious wrist drop due to weakness of wrist extensors muscles Very High lesions •Due to pressure in axilla ( crutch palsy) •Spontaneous recovery • If there is no sign of recovery, nerve should be explored and repaired/grafted
- 35. Compression of the radial nerve at the upper arm while sleeping (Saturday night palsy) Compression of the radial nerve at axilla (crutch palsy)
- 36. Ulnar Nerve Injury • Ulnar nerve – Flexor carpi ulnaris & ulnar half of flexor digitorum profundus (forearm) – Most intrinsic muscles of hand – Skin of hand both dorsum and palmar of 5th and half of 4th digit • Branches: – Superficial branch of ulnar nerve – Deep branch of ulnar nerve
- 38. • Usually near the wrist or near the elbow Caused by pressure or laceration at wrist Claw hand, hypothenar wasting Weak finger abduction, loss thumb adduction and pinch difficult. Sensation loss at 5th digit and medial half of 4th digit Low lesions Caused by elbow fracture Less clawed due to half flexor digitorum profundus is paralysed. Motor and sensory loss same as low lesions High lesions
- 39. Ulnar Nerve Paradox • Ulnar paradox – More proximal the lesion, less is the claw. • This is due to paralysis of flexor digitorum profundus which reduces flexion of the interphalangeal joint. • If the lesion of the ulnar nerve occurs at the level of the wrist, the innervation of the medial half of the flexor digitorum profundus muscle (FDP), which is responsible for flexing the IP joints (the two distal joints of the fingers), is unaffected. • However, there will be paralysis of medial two lumbricals which function as to flex the MCP and to extend the IPJ. Thus creating the hyperextension of MCP joint in little and ring finger and flexion of IPJ forming the ‘claw hand’.
- 40. Median Nerve Injury • Median nerve – Muscles of anterior compartment of forearm (except for flexor carpi ulnaris & half of flexor digitorum profundus) – 5 intrinsic muscles in thenar, half of palm and palmar skin • Branches: - anterior interosseous - palmar cutaneous
- 41. • Commonly injured near the wrist or high up the forearm Caused by cuts in front of wrist or carpal dislocations Wasting thenar muscle, weak thumb abduction and opposition Loss sensation over thumb, index,middle and half of 4th fingers Low lesions Due to forearm fractures or elbow dislocation Sign same as low lesion + paralysis of long flexors of thumb, index and middle fingers High lesions
- 42. Nerve Entrapment Syndromes When peripheral nerves tranverse fibro-osseous tunnels, they are at risk of compression if soft tissue increase in bulk. Condition increase in bulk: 1. Pregnancy 2. Myxodema 3. Rheumatoid arthritis 4. Local obstruction
- 43. Carpal Tunnel Syndrome • The most common site for nerve compression • Occur in median nerve compression
- 44. • Causes: Rheumatoid arthritis, diabetes,menopause, obesity,thyroid disorder, kidney failure, carpal fractures or dislocation • Signs and Symptoms: 1. Reduce sensation and tingling over the distribution. 2. Occur when wrist is held still in flexion or hyperextension (often at night when patient asleep) 3. Relief by changing posture or shaking hand to get the circulation going 4. Positive Tinel or Phalen sign
- 45. Double Crush Syndrome • Refers to a situation in which the compression of a peripheral nerve occurs at two sites at the same time • If a nerve is impaired at one location it makes that patient more susceptible to other entrapments along the same course • Examples: thoracic outlet syndrome and carpal tunnel syndrome
- 46. EXAMINATION OF PERIPHERAL NERVES OF UPPER LIMB AND LOWER LIMB Axillary nerve Radial nerve Median nerve Ulnar nerve Sciatic nerve Common peroneal nerve
- 47. Axillary nerve (C5,C6) •Commonly damaged during shoulder dislocations and displaced fractures of the proximal humerus. •Flattening over the lateral aspect of the shoulder result from muscle wasting. •Examination: • Deltoid contraction • Sensation over the “regimental badge” area
- 48. Radial nerve: innervates muscle of the posterior compartment of arm and forearm and the overlying skin Deep radial (became Posterior interosseous)- extensors of fingers and wrist except extensor carpi radialis longus Superficial radial-sensory/cutaneous
- 49. Radial nerve injury Sites of radial nerve injury Common mechanism of injury Motor deficit Sensory deficit Very high lesion ( at the axilla) •Crutch palsy •Saturday night palsy •Forearm extension, •Extension of finger and wrist, •Wrist drop •Weakness of supination •Lateral Arm •Posterior Forearm •Dorsum aspect of hand at the base of the thumb. high lesion (at the mid-arm) •Mid shaft humeral fracture •Extension of finger and wrist, •Wrist drop •Weakness of supination •Posterior Forearm •Dorsum aspect of hand at the base of the thumb. Low lesion (at the elbow) * Involved post.interosseous nerve, superficial intact •Fracture or dislocation at the elbow •Extension of finger at MCP joints •Weakness of wrist extension •Finger drop and partial wrist drop •None as it supplied by superficial radial nerve
- 50. Examination • Inspection: – Wrist drop – Wasting of forearm muscle – Wasting of triceps
- 51. • Muscle activity: – test the extensors of the wrist and fingers – the supinator muscle – the brachioradialis – the triceps (extension of elbow)
- 52. Sensory: Test sensory loss in the areas supplied by the nerve
- 53. Median nerve: Principle nerve of the anterior compartment of forearm. Anterior interosseous is its major branch
- 54. Median nerve injury sites of median nerve injury Common mechanism of injury Motor deficit Sensory deficit High median (forearm) Forearm fracture or elbow dislocation, tight cast •Wasting of thenar eminence •Thumb abduction •Thumb opposition •Flexion of thumb, index and middle fingers •Pronation of forearm Radial three and half and of digits and the lateral palmar surface Low median (wrist) or in the carpal tunnel Cuts in front of the wrist or carpal dislocation •Wasting of thenar eminence •Thumb abduction •Thumb opposition Radial three and half and of digits and the lateral palmar surface Anterior interosseous (proximal forearm) Tight cast, forearm bone fracture •Pronation of forearm •Flexion of thumb, index and middle fingers none
- 55. Inspection: • Thenar wasting • Atrophy pulp of index • Cracking of the nails
- 56. Muscles: • Pronator teres • Test power of flexor pollicis longus in the thumb • Flexor digitorum profundus in index finger • Ask patient to form circle with index and thumb and press their tips tightly • Test abductor pollicis brevis
- 57. Sensory: Test sensory loss in the areas supplied by the nerve
- 58. Carpal tunnel syndrome Median nerve, sensitive structure in the carpel tunnel • Inflammation of the synovial sheaths • Wasting of thenar muscle • Loss of coordination and strength in thumb • Loss of sensory at radial three and half and of digits except central palm. (*palmar cutaneous branch of the median nerve)
- 59. Examination: • Apply very firm, steady pressure with both thumbs for 30 sec. over the median nerve in the carpal tunnel • Note the onset of numbness, pain or paraesthesia • Phalen test – Hold both wrists fully flexed for 1-2 min – Noted exacerbation of paraesthesia
- 61. Low ulnar injury •Injury to the nerve in the distal part of the forearm, denervates most intrinsic hand muscles. •Hypothenar wasting •Weak finger abduction •Loss of thumb adduction ( froment’s sign) •Loss of sensation
- 62. • Claw hand, the person cannot extend the interphalangeal joints when trying to straighten the fingers. • This results from atrophy of the interosseous muscles of the hand. • The claw is produced by the unopposed action of the extensors and FDP
- 64. Common peroneal nerves • Motor distribution: – Muscles of anterior compartment of the leg: • Tibialis anterior • Extensor hallucis longus • Extensor digitorum longus • Peroneus tertius – Muscle of peroneal(lateral) compartment of the leg: • Peroneus brevis and longus – On the foot, extensor digitorum brevis
- 65. • Sensory distribution the first web space (deep peroneal) the dorsum of the foot and the front and lateral half of the leg (superficial peroneal)
- 66. Common peroneal nerve injury • At the fibular neck, trauma in lateral ligament injuries of the knee or pressure from a splint or plaster cast.
- 67. Examination: o Look for deformity of foot drop and abnormal gait. (either leg lifted high or foot slid along the ground) o Test the dorsiflexion of the foot (deep peroneal) o Evert the foot (superficial peroneal) o Test the sensation in the area of distribution o Note muscle wasting of the anterior and lateral half of the leg
- 68. Sciatic nerve(L4-S3) Losses include those seen in both tibial and common peroneal nerve palsies
- 69. Sciatic nerve injury Common mechanism of Injury Sensory loss Muscle deficit Posterior hip dislocation •Entire sole of the foot •Dorsum of the foot •Lateral aspect of the leg and lateral half of the calf Wasting of muscle: The posterior thigh The calf Sole of the foot Drop foot Trophic ulceration Absent ankle jerk Loss of muscle power: Hamstring muscles of the calf Muscles of anterior and lateral compartment of the leg
- 70. Investigation and management of Brachial Plexus Injury
- 71. INVESTIGATIONS Radiography 1. Chest x-ray : - Fracture of 1st and 2nd ribs 2. Cervical spine - transverse process fracture indicate root avulsion 3. Shoulder x-ray - Fracture of clavicle - Dislocation of shoulder
- 72. MRI • Standard imaging for non-traumatic brachial plexopathies. • Can differentiate pre/post-ganglionic injury • Non-invasive, no radiation • Diagnostic accuracy is relatively high • Able to detect tumors that are invading the plexus from the area adjacent to it but difficult to distinguish the tumors since their features are non-specific. • MRI has been shown to be less accurate in detecting nerve root avulsions compared to CTM and MRM
- 74. Magnetic Resonance Myelography (MRM) • Diagnosis of traumatic meningoceles and nerve root avulsion • Non-invasive, does not employ radiation, and is superior in the assessment of psuedomeningoceles compared to CTM. • Diagnostic accuracy of 92% in root avulsion Figures 2 & 3: CT myelogram showing a normal brachial plexus (left) and injured brachial plexus (right)
- 75. Electrodiagnostic studies 1) Electromyography (EMG) • Diagnostic procedure to assess the health of muscles and the nerve that control the muscles. • EMG results can reveal nerve dysfunction, muscle dysfunction or problems with nerve-to-muscle signal transmission. • For closed injuries can best be performed 4 to 6 weeks after the injury because to look for spontaneous recovery
- 76. 2) Nerve conduction study • Measures sensory nerve action potential (SNAPs) • Use electrode to detect nerve conduction • Only reliable after one week • Can distinguish between pre/ postganglionic
- 77. MANAGEMENT 1) Non-operative - observation alone waiting for recovery Indications • most managed with closed observation • guns shot wounds (in absence of major vascular damage can observe for three months) Signs of neurologic recovery • advancing Tinel sign
- 78. 2) Operative Immediate surgical exploration (< 1 week) Indications • sharp penetrating trauma • Iatrogenic injuries • open injuries • progressive neurologic deficits • expanding hematoma or vascular injury Techniques • nerve repair • nerve grafting • neurotization
- 79. Early surgical intervention (3-6 weeks) Indications - near total plexus involvement and with high mechanism of energy Delayed surgical intervention (3-6 months) Indications • partial upper plexus involvement and low energy mechanism • plateau in neurologic recovery • best not to delay surgery beyond 6 months Techniques • usually involves tendon/muscle transfers to restore function
- 80. Surgical Technique for Brachial Plexus Injury 1) Nerve exploration 2) Primary repair 3) Late repair 4) Nerve guides 5) Nerve graft 6) Nerve transfer 7) Tendon transfer
- 81. Nerve exploration • Indications : – To explore if there are any divided nerve that needs repair. – To explore the causes of delayed recovery – To explore when in doubt of diagnosis.
- 82. Nerve repair
- 83. Primary repair • Performed within 7 days of injury • Indications : sharp clean wound Delayed Repair - weeks/months after the injury Indicated if i) closed injury does not show any recovery ii) misdiagnosed, and patient presented late iii) failed primary repair
- 84. Nerve guide • Give guides (tube) for nerve gaps to grow back • Example silicone • Simple way avoiding nerve graft as it is limited. • It is an artificial means of guiding axonal regrowth to facilitate nerve regeneration • Prevent painful neuroma as nerve end goes hair-wired
- 85. Nerve graft • When gaps too large for suturing • Sural nerve most commonly used • Attached by fine suture or fibrin glue
- 86. Nerve graft • Transplanting a nerve from the leg to reconnect damaged nerves Nerve transfer • Sewing an adjacent, functioning nerve or part of a nerve into a non functioning nerve in an attempt to restore function in a paralyzed muscle
- 87. Tendon transfer • A functioning tendon is shifted from its original attachment to a new one • To restore the action that has been lost. • The origin of the muscle is left in place ; the tendon insertion (attachment) onto bone is detached and re-sewn into a different place. • Restore function
- 88. Investigation and Management : Peripheral Nerve Injury Investigation: • EMG and nerve conduction study – characteristic findings • denervation of muscle • neurogenic lesions
- 89. MANAGEMENT Non-operative Operative • Observation with sequential EMG for 3 months •Medication : NSAID, • Physiotherapy -Developing gross and fine motor skills -Re-educating normal movement patterns -Stretching -Strengthening If there’s no progression of nerve healing After 3 months. -Surgical repair Indication : Neurotmesis (3rd degree) - Nerve grafting Indication : Nerve defects > 2.5 cm
- 90. Axillary nerve injury Investigation • Radiography • Electrodiagnostic study ( EMG, NCS) Management Non-operative : • NSAIDs, arm sling, physiotherapy • Usually recovers spontaneously Operative : • If no sign of recovery by 8 weeks and investigation of electrodiagnostic study show denervation. • Nerve should be explored and grafted. • Good result if surgery done within 12 weeks. • If surgery failed, consider tendon transfer.
- 91. Radial nerve injury Investigation : • Radiography • Electrodiagnostic study ( EMG, NCS) Management (depends on causes) Non-operative : • NSAIDS, bracing and splinting, physiotherapy Operative : • Open wounds : explored, nerve repaired or grafted • Closed wounds : observe, if there is no sign of recovery by 8-12 weeks, nerve explored and repaired or grafted
- 92. Ulnar Nerve Injury Investigation • Electrodiagnostic test (Electromyography, Nerve Conduction Study to locate the site of lesion) • Imaging: radiography : to look for bone spurs, arthritis, or other places that the bone may be compressing the nerve. Management Non Operative : NSAID , Bracing or splinting, Physiotherapy Operative : – Exploration and suture of a divided nerve – Transposing the nerve to the front of the elbow (due to cubital tunnel syndrome) – Cubital tunnel release – Medial epicondylectomy
- 93. Median Nerve Injury Investigation • Electrodiagnostic test (Electromyography, nerve conduction study) • Imaging: radiography (to look for fracture that cause impaired range of movement) Management Non Operative : NSAID , Bracing or splinting, Activity changes (use different hand, less burden on the hand, make way for healing process. Operative : – Exploration and suture of a divided nerve – Divide transverse ligament to make more space (decompression)
- 94. Musculocutaneous nerve injury Investigation • Radiography • Electrodiagnostic test (EMG, NCS) Management • Spontaneous recovery is possible but may take several months • Surgical decompression is indicated as first-line treatment if there is paraesthesia, as this suggests that the affected nerve still has some function • Repair and nerve grafts
Editor's Notes
- #4: PNS: bundles of axon – conduct efferent impulse (cell in ant horn muscle) – afferent impulse ( peripheral rc cell in post root ganglia cord)
- #6: Blood vs: epi endo (endoneurial capillaries) : can damage by overstrecthing
- #7: Eg of PNS
- #10: - Dt transient endoneurial anoxia
- #11: Dt mechanical pressure segmental demyelination Eg : crutch palsy ( paralysis of UL dt brachial plexus damage)
- #12: - Neural tube (epi n peri)
- #15: - Seddon’s : useful but many cases fall in btwn axonotmesis n neurotmesis
- #27: ptosis:dropping eyelid Miosis:> pupil contraction Enophthalmos:backward displacement of eyeball into orbit Anhidrosis:x sweatg
- #47: skin covering the inferior region of the deltoid muscle - the "regimental badge" area (which is innervated by the Superior Lateral Cutaneous Nerve branch of the Axillary nerve).
- #49: Saturday night palsy from falling asleep with one's arm hanging over the arm rest of a chair, compressing the radial nerve at the spiral groove.
- #51: Extend wrist: elbow flex, hand prone, support wrist ask patient to straighten fingers and extend wrist Supinator: elbow extend eliminate supine action by biceps, ask pt. to prone(turn his hand) Brachioradialis: elbow flex, midprone position, feel contraction of muscle. Triceps: extend shoulder, extend elbow,first against gravity.
- #60: Other than tht, manoeuvere by extend the elbow, dorsiflex the wrist Test thenar muscle And lastly sensory
- #61: Froment sign: ask pt grasp a sheet of paper btwn thumbs and sides of index finger Thumb will flex at interphalangeal joint in contrast to good side.
- #69: a pressure ulcer caused by external trauma to a part of the body that is in poor condition because of disease, vascular insufficiency or loss of afferent nerve fibres
- #71: Paralyzed diaphragm : indicate upper nerve root injury (C3,C4,C5) : pre-ganglionic lesions During the initial assessment of the patient, plain films of the clavicle and cervical spine may identify bony injuries and raise the clinical suspicion for a brachial plexus injury e.g. displaced fracture of the transverse process of the cervical spine, fracture of the 1st and 2nd ribs Plain X-rays can be useful to diagnose hemidiaphragm paralysis from phrenic nerve involvement, or fractures of the clavicle or humerus. •chest radiograph -fractures to the first or second ribs suggest damage to the overlying brachial plexus cervical spine series -transverse process fracture likely indicates a root avulsion • scapular and shoulder series -scapulothoracic dissociation is associated with root avulsion and major vascular injury • clavicle -fracture may indicate brachial plexus injury
- #72: MR scanning is useful in the investigation of non-traumatic lesions, pathology that may be responsible for non-traumatic brachial plexus dysfunction; infiltrating tumors/compressive tumors 87.2% for traumatic brachial plexus injuries Brachial plexus commonly affected by breast CA, lung CA Inability to differentiate neurofibroma from schwannoma
- #74: MRM is the imaging method that achieves myelogram-like images with MRI MRI 52% CTM 85% CTM is the gold standard, Eg in case of large meningoceles, some nerve roots may not be clearly visualized.
- #75: not used anymore..bcoz unsure the reasons why results different btw pre/post ganglionic lesion
- #83: Repair as soon as possible within 7 days in sharp clean wound Advantages : Nerve ends not retracted much Nerve orientation undisturbed No fibrosis yet Suture at epineurium, make sure no tension Put splint for 3 weeks, then exercise
- #84: Secondary suture This can be carried out when the skin wound is healed and up to 6 months after the injury. The scarred and thickened junction is excised and again the nerve is mobilized and the sheath sutured. Secondary suture may require more excision of the nerve, but operative conditions and expertise may be more favourable. After both methods of suture the repair is protected by immobilizing the joints for several weeks
- #85: commonly used due to traction injuries (postganglionic) preferable to graft lesions of upper and middle trunk allows better chance of reinnervation of proximal muscles before irreversible changes at motor end plate donor sites include sural nerve, medial brachial nerve, medial antebrachial cutaneous nerve vascularized nerve graft includes ulnar nerve when there is a proven C8 and T1 avulsion (mobilized on superior ulnar collateral artery)
- #87: Motor recovery may not occur if regenerating axons fail to reach the muscles within 18-24 hrs. So Tendon transfer is prefered.
- #92: Nonsurgical Treatment Non-steroidal anti-inflammatory medicines. If your symptoms have just started, your doctor may recommend an anti-inflammatory medicine, such as ibuprofen, to help reduce swelling around the nerve. Steroid injections. Steroids, like cortisone, are very effective anti-inflammatory medicines. Injecting steroids around the ulnar nerve is generally not used because there is a risk of damage to the nerve. Bracing or splinting. Your doctor may prescribe a padded brace or split to wear at night to keep your elbow in a straight position. Nerve gliding exercises. Some doctors think that exercises to help the ulnar nerve slide through the cubital tunnel at the elbow and the Guyon's canal at the wrist can improve symptoms. These exercises may also help keep the arm and wrist from getting stiff. Cubital tunnel release. In this operation, the ligament "roof" of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve. After the procedure, the ligament begins to heal and new tissue grows across the division. The new growth heals the ligament, and allows more space for the ulnar nerve to slide through. Cubital tunnel release tends to work best when the nerve compression is mild and the nerve does not slide out from behind the bony ridge of the medial epicondyle when the elbow is bent. Ulnar nerve anterior transposition. More commonly, the nerve is moved from its place behind the medial epicondyle to a new place in front of it. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). Moving the nerve to the front of the medial epicondyle prevents it from getting caught on the bony ridge and stretching when you bend your elbow.
- #93: Surgical technique. In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia. During surgery, a cut is made in your palm. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve. Once the skin is closed, the ligament begins to heal and grow across the division. The new growth heals the ligament, and allows more space for the nerve and flexor tendons. Endoscopic method. Some surgeons make a smaller skin incision and use a small camera, called an endoscope, to cut the ligament from the inside of the carpal tunnel. This may speed up recovery.