1. “My countrymen should have nerves of steel, muscles of iron, and minds like
thunderbolt.”
-Vivekananda
2. Management of Peripheral Nerve Injuries
Dr.Obaidullah Khalid
P.G Orthopaedic surgery
DCMS
Under the guidance of
Dr.C.ShamSunder
D.Ortho ,MS Ortho
Professor & HOD
DCMS
3. 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
4. Your own footer Your Logo
Diagnostic tests
The diagnostics give info on :
• Nerve Conduction
• Axon OR Myelin involvement
• To know Muscle recruitment
capability
6. Nerve Conduction Velocity Studies
Diagnostic 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
7. Electromyography
Diagnostic tests
•If a muscle loses its nerve supply, EMG will show
denervation potentials by third week.
•This excludes Neuro praxia but not Axonotmesis
8. Tinel’s sign
Diagnostic 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
11. Open Wounds
General Considerations
1
Steel 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
12. Closed Wounds
General 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
13. Is it advisable to wait for any signs of improvement ?
Or should exploration be done ?
14. • 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.
15. 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
16. 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.
17. Surgical Exploration
When 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.
18. Surgery Proper
Primary Repair
• Should be done as soon as possible
• ADVANTAGES :
Cut ends would not have retracted much
Rotation is usually undisturbed
No fibrosis
19. Surgery Proper
Secondary 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.
21. Anaesthesia
• General Anaesthesia Upper EX
• Spinal Anaesthesia Lower EX
VS
• Local anaesthesia ; advantage of allowing
evaluation of sensory impulses
22. 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
23. Technique of nerve repair
• Incision is the game changer.
• Never cross flexor crease of skin
Surgery proper
24. Surgery proper
• Do not hesitate to take a longer incision
• If nerve is dissected from a scar tissue, keep
stimulating 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
25. • 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.
26. Your own footer Your Logo
Partial Neurorraphy
Surgery Proper
• Generally done in
Sciatic nerve
• Advised when one
half of the nerve is
disrupted
27. • 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
31. Mobilization
Bridging 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
32. 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
33. • 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
Transpositioning
Bridging the gaps
34. • Avoid this procedure
• Only implicable when Humerus is already
fractured and a fragment is already
segmented provided, Transpositioning of
nerve is not sufficient.
Bone resection
Bridging the gaps
35. • 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 Grafting
Bridging the gaps
37. • 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
38. • 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
