Nerve Injury
Nerve Injury
Nerve Injury
Axillary Nerve-Anatomy
Arises from posterior cord of brachial plexus and runs
alongside radial N behind Axillary A, separating the latter form
subscapularis muscle on the floor. At lower border of muscle, it
leaves radial N and turns posteriorly with the posterior humeral
circumflex artery through quadrangular space to posterior
aspect of humerus, where it divides into anterior and posterior
branches.
Posterior branch supplies to teres minor and posterior part of
deltoid before it curves around the posterior border of deltoid
to supply the skin over lower half of deltoid (upper lateral
cutaneous nerve of arm). The anterior branch proceeds
laterally and anteriorly beneath the deltoid and in contact with
surgical neck of humerus about 2 inches below upper
attachment of deltoid giving off numerous twigs to the muscle
throughout its course.
Axillary N injury-Treatment
Prophylaxis consists of avoiding unnecessary extension of
operative incisions and rough handling of deltoid muscle. If the
nerve is contused, spontaneous regeneration may take place in
4-6 months, during which time deltoid must be relaxed on
abduction splint and light massage and electric stimulation
given.
Daily active exercises are done to strengthen cuff muscles.
Operative repair of this nerve is exceedingly difficult and
frequently impossible. Conservative treatment is advised
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Axillary N injury-Arthrodesis
Complete deltoid paralysis, when not compensated by other
muscle action, requires arthrodesis of shoulder. Trapezius and
serratus anterior will raise the arm effectively.
Median N-Anatomy
Formed from lateral divisions of 5th, 6th and 7th cervical roots
and medial divisions of 8th cervical and 1st thoracic nerves.
Enters axilla lateral to Axillary artery and lies between MC N
laterally and ulnar N medially. It descends in arm with brachial
A and other nerves in a groove just medial to and slightly
behind the biceps muscle and gradually crosses over in front of
artery (rarely it crosses behind) until it lies medial to brachial A
before it reaches elbow.
No branches are given off in arm. At elbow it lies deep to
bicipital aponeuroses and median cubital vein. It enters
forearm by passing between larger humeral and smaller ulnar
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Median N-Treatment
In nerve suture, better results are obtained from early
intervention. Late repair leads to partial restoration,
particularly of sensation and paraesthesia. Nerve should be
explored and ends obtained and sutured in exact rotary
apposition. Gaps can be overcome in palm by flexing MCP joint.
Above wrist the nerve is freed and wrist is flexed. If elbow is
also flexed and nerve is gently pulled distally, a 3 ½ inch gap
can be overcome.
For larger gaps, dissect the nerve in upper arm and reroute it
superficial to elbow structures by detaching humeral head of
PT. A plaster cast maintains flexion of joints and later very
gradual extension is obtained over period of 1 month. If graft is
needed, Sural N may be used.
At exploratory operation in causalgia states, nerve displays a
lesion in continuity (intraneural scarring). Complete division of
nerve rarely causes causalgia. Treatment consists of
sympathectomy, preceded by procaine block of 2nd thoracic
ganglion. Complete anhidrosis and increase in warmth of hand
after 10 min of block. Pain is relieved for 1 to 3 hours. A
preganglionic sympathectomy is most effective. The white rami
communicates to 2nd and 3rd thoracic ganglia and sympathetic
trunk below 3rd are divided.
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Radial N-Anatomy
It is continuation of posterior cord formed by posterior
divisions of brachial plexus. In axilla it lies directly behind
Axillary A and runs on a floor formed by subscapularis muscle
proximally and latissimus dorsi and teres major distally. Axillary
(circumflex) N which originates form posterior cord, descends
alongside radial N, then leaves it at lower border of
subscapularis, where it passes backwards through
quadrangular space.
Beyond TM, it proceeds posterior to humerus by entering
interval between long and medial heads of triceps and
reaching spiral groove. It passes around back of humerus to
lateral side, where it pierces LIMS to reach anterior aspect of
arm. Here it lies in interval between brachialis medially and
brachioradialis and ECRL laterally.
At this level it gives off branches to lateral half of brachialis,
all of brachioradialis, ECRL and PIN. It then continues distally in
forearm under cover of BR till about 2” above wrist. It then
pierces deep fascia and turns laterally and dorsally, crossing
superficial to APL and EPB tendons and reaching dorsum of
hand where it supplies digital branches of sensation to dorsum
of thumb, index, middle and ring finger as far as MP.
In spiral groove radial N gives off posterior and lower lateral
cutaneous nerves of arm, posterior cutaneous nerve of
forearm, and muscular branches to triceps and anconeus.
PIN arises form radial N at level of lateral epicondyle. It
descends under cover of BR and gives branches to ECRB and
supinator. Then it penetrates supinator and passes obliquely
around lateral aspect of shaft to reach back of forearm and
travels distally of surface of APL under cover of EDL.
Then it lies on IM under cover of EPL and proceeds distally to
supply wrist joint. In back of forearm it supplies remainder of
extensor muscles and APL. Thus it supplies all muscles on
lateral and dorsal aspect of forearm except the BR and ECRL
which are supplied directly by radial N.
Radial N - Treatment
Regardless of level, affected muscles should be kept relaxed
by supportive splints and their tone maintained by galvanic
stimulation and light massage until nerve regenerates. Anterior
moulded splint counteracts wrist drop and should extend
beyond MCP joints to support PP. An additional extension from
splint holds thumb in complete extension and dorsal abduction.
If paralysis is immediate and complete, nerve should be
explored and sutured promptly. Good results are proportionate
to early repair. Nothing is lost by early exploration and finding
the nerve intact.
Gaps between nerve ends may be overcome by flexing the
elbow, externally rotating and adducting the arm and by
freeing various branches. If distance is extensive, nerve may
be transposed anteriorly. Shortening of humerus is sometimes
justified to aid approximation.
Compression injuries are generally temporary and almost
complete restoration of function is the rule.
Possibility of complete nerve tears and their serious
implications certainly warrant operative exposure of # site,
whereupon both nerve and bone injuries can be dealt with at
the same time.
Following complete cut of nerve, NCV begins to slow after 2-3
days and is maximum at 2 weeks. Therefore within 24-48 hours
eliciting this findings justifies surgical exploration. If no
conduction impairment develops by 1 week, nerve interruption
is physiological (neuropraxia) and non surgical treatment is
pursued. During this period electrical stimulation, heat and
massage to maintain tone, splinting to relax affected muscles
and range of motion exercises are started.
When causalgia occurs, an incomplete nerve lesion should be
suspected, the nerve explored, neuroma if any should be
resected, if necessary by removal of portion of nerve, F/B re
approximation, or adhesions if any are freed.
The Tinel sign may reveal the exact site of initiation of pain
impulses.
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Radial N - Prognosis
Prognosis of radial N repair is usually very good. Failure of
some portion to regenerate necessitates tendon
transplantations.
Triceps paralysis needs no compensation other than that
provided by gravity.
Supination of forearm may be restored by osteotomy of radius
and by rotating the distal fragment. Tubby operation
transplants the insertion of PT from volar to dorsal aspects of
radius.
Radial N - Treatment
Extension and abduction of thumb which stabilizes the thumb
at CMC joint is necessary for proper apposition. FCR may be
transplanted to APL and EPL and EPB.
FCU is transferred to EDC.
If no tendons are available, dorsiflexion of wrist is provided by
arthrodesis of wrist or by cutting tendons of EDC and
tenodesing the proximal ends of distal segment to dorsum of
radius.
Active flexion at MCP joints thereby tightens these tenodesed
tendons and automatically dorsiflexes the wrist. The CMC joint
of thumb may also be stabilized by arthrodesis.
Ulnar N - Anatomy
Largest branch of medial cord, arising under cover of PMn,
and descending along medial side of Axillary A and proximal
half of brachial A. At middle of humerus it leaves brachial A
and in company with UCA it passes backwards through the
MIMS to posterior aspect of arm. Then it descends along medial
head of triceps to back of medial epicondyle and passes
between heads of FCU to enter forearm. Under cover of FCU
(which it supplies) it lies on FDP (supplies its medial half) and is
immediately lateral to ulnar A.
Near pisiform bone it emerges through deep fascia lateral to
FCU and descends anterior to FR, where it divides into
superficial and deep branches. Deep branch passes medial to
hook of hamate and along with deep branch of ulnar A, enters
interval between ADM and FDM to gain the deep area of palm.
It supplies to hypothenar muscles and turns laterally across
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Ulnar N –Treatment
Repair should be done with care. Nerve contains both motor
and sensory fibers. Gaps are overcome by flexing wrist and
elbow. Nerve at elbow may be transposed anteriorly, and
branches freed, permitting mobilization distally. Recovery of
function requires > year in following order, forearm muscles,
sensations, hypothenar muscles, interossei and thumb
adductors.
During this period, hand is splinted with MCP joint in flexion
and IP joint in extension to keep paralyzed muscles relaxed and
prevent joint contractures.
When ulnar N paralysis is permanent, tendon transplantation
is the treatment of choice.
Pathophysiology
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Clinical Picture
H/O Cubitus valgus deformity, severe direct trauma or
repetitive trauma to ulnar groove.
Symptoms are related to severity of involvement. Minimal
nerve irritation causes subjective dysesthesias in ulnar
distribution and sensation of clumsiness.
Moderate involvement produces pronounced subjective pain
and paraesthesia and IO weakness and atrophy. FCU & FDP to
DP of little and ring fingers are rarely affected. Nerve may be
tender and palpably enlarged at post condylar groove.
Severe N lesions are rare. Interossei are very weak and
atrophied. FCU & ulnar half of FDP are partially weakened.
Sensory loss varies from marked hypoesthesia to anesthesia.
Sweating in reduced, although hyperhydrosis is not infrequent.
Cubital tunnel syndrome caused by compression of N by
arcuate ligament is provoked by prolonged flexion attitudes of
elbow, such as during sleep. Sometimes symptoms can be
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Diagnosis
Traumatic ulnar neuritis at elbow must be differentiated from
ulnar N compression at wrist. Dorsal cutaneous branch of ulnar
N leaves parent N beyond elbow. So sensory impairment in
dorsal ulnar aspect of hand localizes lesion proximally.
Contrariwise, absence of this finding does not necessarily
implicate ulnar N lesion at wrist, because N may be only
partially involved at elbow.
Electro diagnostic studies will reveal slowing of conduction at
elbow, and differentiate whether N is involved proximally (at
thoracic outlet) or distally at wrist. Preoperatively it is
important to determine compressive bone lesion about ulnar
groove. In addition to routine x-rays, special view is taken to
outline groove. The externally rotated arm is placed against
cassette, while elbow is acutely flexed, and central x-ray beam
is directed vertically.
Prognosis
Depends largely on degree of N involvement and time interval
between onset of symptoms and surgical intervention. In
minimal involvement, anterior transposition of N leads to
immediate relief of local discomfort and peripheral
paraesthesia. With moderate sensory and motor impairment,
following surgery, hand becomes stronger, but variable
weakness and sensory impairment persist in some. In
advanced paralysis, surgery results in partial recovery of motor
power in some but sensory recovery is better, normal function
is never regained.
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Treatment
Nerve must be transposed anteriorly. Sites of potential kinking
should receive proper attention. MIMS extending proximally
from epicondyle must be adequately resected. Aponeurotic
band is released. N should not be laid in groove cut in muscle,
because scarring and IMS become adherent to N. Origin of
common flexor pronator tendon should be elevated, the N
placed beneath the muscle mass, and tendon origin restored.
Occasionally, it may be possible to remove local compressing
lesion like ganglion or osteophyte without need for anterior
transposition.
Pathology
Ganglion produce largest number of compressive lesions at
wrist.
Often H/O blunt trauma over hypothenar area by single
severe blow from using hand as hammer or by fall on
outstretched hand or repetitive trauma. Pisiform appear to
sustain the brunt of injury, and OA changes develop at
pisotriquetral joint.
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Clinical Picture
Dependant on site and degree of injury.
2 anatomical patterns; lesion proximal to pisohamate
ligament that causes both sensory and motor involvement and
lesion deep in palm distal to pisohamate ligament that affects
interossei and ulnar lumbricals but spares hypothenar muscles
and ulnar volar sensations.
Compression at level of Guyon’s canal presents following
features :-
Compressive tissue (ganglion, RA pannus, bone fragment) is
sometimes palpable.
Sensory loss over volar ulnar distribution but spares dorsal
area except over DP.
Motor involvement affects hypothenar, ulnar 2 lumbricals and
interossei.
Clawing of little and ring fingers.
Compressive lesions that exerts pressure only on deep branch
produces purely motor weakness of interossei but spares
hypothenar muscles. Abducted attitude of little finger results
from unopposed action of ADM. Clawing of little and ring finger
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Diagnosis
Muscle weakness and wasting are seen but is common to
whole lot of neurological and myopathic conditions.
When symptoms suggest distal ulnar N involvement, inquire
about injury such as laceration, despite a time lapse.
Detailed sensory examination to distinguish between nerve
compression at elbow from injury to distal portion. When
sensation is lost over volar ulnar area, but intact over dorsal
ulnar area, injury is localized distal to point of origin of dorsal
sensory branch (6 to 8 cm above wrist).
Muscle examination must be detailed.
EMG studies of 1st dorsal interossei may show fibrillation
potentials S/O involvement of deep branch.
NCV studies between wrist and 1st DI or adductor pollicis, is
highly diagnostic and any delay must be clearly demonstrated
before surgical intervention. When fibrillation potentials are
already present on EMG studies, denervation is far advanced.
X-rays of wrist and hand, including special carpal tunnel and
pisiform views are necessary to determine presence of OA, #
and neoplasm.
Treatment
Immediate decompression of ulnar N is mandatory. Nerve is
isolated adjacent to FCU tendon in distal forearm and then
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