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Peripheral

Nerve Injury

Neuropraxia:

Tinel’s Sign Negative
• It is temporary physiological disruption of nerve impulse
conduction. The loss of function is incomplete.
• Complete recovery takes place in 3 – 6 weeks and
it comes back like lightening, i.e. completely recovers
in one go.

Neuropraxia:

• No Wallerian degeneration takes place and Tinel’s
sign is negative.
– Crutch palsy — Pressure palsy (radial nerve or
part of brachial plexus injured)
– Saturday night palsy — Pressure palsy (radial nerve)
– Tourniquet palsy — Pressure palsy
• Few traumatic nerve injuries are neuropraxia

Axonotmesis:

• Tinel’s Sign Positive and Progressive
• • It is Axon breakdown, Tinel’s sign is
positive, Motor March is seen (recovery
of muscles takes place in the order of their
nerve supply from proximal to distal
direction).
• • Recovery is usually not complete.
• • Seen in closed fractures and dislocations

Neurotmesis:

• Tinel’s sign is positive and nonprogressive
• • Complete anatomic section of the nerve. Tinel’s
sign is positive and nonprogressive.
• • No recovery without surgical intervention. Even
with intervention may not have complete recovery.
• • Degeneration distal to injuries (Secondary or
Wallerian degeneration)
• • Degeneration in proximal segment (Primary or
retrograde degeneration)
• • At proximal end forms — Neuroma
• • At distal end forms — Glioma

• Order of Nerve Injuries

Neuropraxia
• Axonotmesis
• Neurotmesis

N AN

Autonomous Zone of Nerves:
• Exclusively Supplied by that Particular Nerve
• • Median Nerve — Tip of index finger, middle
finger.
• • Ulnar Nerve — Tip of little finger
• • Radial Nerve — 1 st web space on dorsum
of hand
• • Deep peroneal nerve — Dorsum of 1 st web space
on foot

Tinel’s Sign:

• (Records regeneration rate) by tapping on the
nerve course from distal to proximal direction
tingling is felt at the sprouting nerve ends
till the distal course of the nerve and it
disappears as myelinization takes place (Rate of
Recovery of Nerve is 1 mm/day)

Diagnostic Tests for Nerve Injuries:

• • EMG: Denervation fibrillation potentials. Appears at 2 –
3 weeks then spontaneous fibrillation.
• • EMG is the earliest indicator of nerve recovery.
• • Nerve conduction study:
• 1 . reduced in axonotmesis and neurotmesis but
cannot differentiate between the two.
• 2 . Normal nerve conduction velocity on day 10
goes toward neuropraxia.
• 3 . No conduction will indicate neurotmesis.

• • Sweat Test: In autonomous area, presence of

sweat rules out complete injury as sweat
fibers are most resistant to compression.
• • MRI: Value only in nerve root lesions (e.g.
Brachial plexus injuries).

Management:

• 1 . In closed Injury (Neuropraxia or
axonotmesis or :
• – Axillary N – Shoulder abduction splint
• – Radial N – Cock -up splint
• – Median N/Ulnar N – Knuckle bender
splint
• – Common peroneal N – foot drop splint
• – Brachial plexus injury – Aeroplane splint

• 2 . In open injuries

• – Primary repair: Within 6 – 8 hrs
• – Delayed primary repair: 7 – 18 days
• – Secondary repair: After 18 days

• 3 . Nerve that may be used as nerve donors: –

Sural nerve
• – Saphenous nerve
• 4 . Neurotization that is transfer of fibers of
an intact nerve to a damaged nerve
to augment its functions.
• 5 . If nerve recovery does not take place tendon
transfer can be carried out, e.g. modified jones
transfer for radial nerve palsy and tibialis
posterior transfer for foot drop. Most common tendon
for transfer is Palmaris Longus.

Good Prognostic Factors

• Growing age/Good repair
• Only motor
• Only sensory
• Distal Lesion
• Neuropraxia
Early repair
Radial
Vascularity maintained
End to end repair
GOOD NERVE

PERSENTATION

• PAIN
• LOSS OF SENSATION
• LOSS OF MOTION
• LOSS OF POWER
• LOSS OF REFLEXES
• WASTING
• TROPHIC CHANGES (skin,sc,neurovascular,bones,muscles)
• CONTRACTURES

CLINICAL EXAMPLES

• ERB’ PALSY
• CARPAL TUNNEL SYNDROME(MEDIAN NV)
• RADIAL NERVE INJURY
• ULNAR NERVE INJURY
• SCIATIC NERVE INJURY
• LATERAL POPLITEAL NERVE INJURY

ERB’S PALSY

• BIRTH INJURY (DIFFICULT LABOUR)
• TRACTION ON NERVE ROOTS C 5 -6
• STRETCH -RUPTURE -AVULSION
• UPPER LIMB IN EXTENSION
• MOTHER NOTICE NO MOTION
• 90 % GOOD RECOVERY
• ROLE OF SURGERY AFTER 3 MONTHS
• REMEMBER PROPER REHABILITATION

CARPAL TUNNEL SYNDROME

• MEDIAN NERVE ENTRAPMENT BY
FLEXOR RETINACULUM (TVS CARPAL
LIGAMENT)
• PAIN,NUMBNESS,NIGHT
• MANUAL WORKERS
• DIAGNOSIS
• CONS Rx
• SURGERY

CTS diagnosis

• History:
– Numbness and pain
– Often at night
– Volar aspect → thumb - index - long - radial half of ring
– Risk factors

Risk Factors

• obesity
• pregnancy
• diabetes
• thyroid disease
• chronic renal failure
• Others  RA, storage diseases, alcoholism, acromegaly,
advanced age.
• Repetitive strain injury

CTS diagnosis

• Physical examination:
– Durkan’s test → Most sensitive

– Tinel’s test

– Phalen’s test

CTS - Differential diagnoses

• cervical radiculopathy
• brachial plexopathy
• pronator syndrome
• ulnar neuropathy
• peripheral neuropathy of multiple etiologies

CTS Treatment

• Nonoperative
– Activity modification
– Night splints
– NSAIDs
– Steroid injection
• Operative

CTS – Operative

• Can be:
– Open
– Endoscopic

RADIAL NERVE INJURY

SCIATIC NERVE INJURY

The End


رفعت المحاضرة من قبل: Ahmed monther Aljial
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