26. Restore
the continuity of fascicles
Internal topography
Intra-operative nerve stimulation
Neurolysis with the eyes
Priority to the motor recovery(radial and
peroneal nerve)
27.
28.
29. Tension at site of repair
Need of postural positioning
Alignment of sensory & motor components
Maximize number of axons
Reversal of graft
Exclusion of expendable nerve
30. Sural nerve
› 30-40cm
› Lateral peroneal communicating br : 10-20cm
Lateral antebrachial cutaneous nerve(LABC)
› 8cm
Medial antebrachial cutaneous nerve (MABC)
› Anterior & posterior division
› 20 cm
Expendable nerves(peroneal and radial)
Sensory branches of ulnar and median nerves
Distal anterior interosseous nerve and so on…
37.
Motor nerve transfer
› Pure motor axons
› Close proximity
› expendable
› Synergistic supply
Sensory nerve transfer
› pure sensory axons
› Innervates non critical area
› Expendable and lying in close proximity
38. elbow flexion
Shoulder abduction
Ulnar-innervated intrinsic hand function
Forearm pronation
Radial nerve function
Accompanying artery and vein give off the blood supply of the nerves via vesa nervorum passing along the nerve into their epineurium which further give off smaller branches
Proximally : axons retract and undergo quiescence & then regenrate their multiple daughter axons that regrow towards their sensory or motor target organs…Once a functioning synapse is made,all other daughter axons degenerate.Distally: injured nerve segment undergoes degenrative changes and tissue debris are phagocytosed by macrophages..all these changes collectively make what’s known as wallerian degenration
Ten test for quality of sensationStatic and moving two point descrimination that measures no of fibres innervating it yet
Nerves have an intrinsic elastic property which makes the nerve to have horizontal or spiral bands along its length known as bands of fontana by which they can be moved to certain extent..these bands disappear when the nerve is compressed
In order to restore the sensory and motor modalities of a nerve..stitch the sensory & motor fascicles of proximal segment to those of distal segment if the internal topography of a nerve is clear..every nerve has a specific internal organization and u must know all of them before going into that micro repair..usually nerves r more monofascicular proximally and are polyfascicular distally and there is plexus formation in between these fascicles that diminish distally
Alignment is a challengeThen no of max axons…u can even reverse a long graft to have maximum axons at the distal siteExclusion of non essential nerve components..n their distal sensory ends joined to nearby sensory nerves by end to side anastomosis
Due to partial injury or a previous repairProper assessment of functioning fascicles by nerve stimulation testsIf neuroma is circumferential and normally functioning components are difficult to be separated then
Criteria for motor n sensory donor nerves
Limited use
Challenging as they can evoke immune system leading to graft rejection