Peripheral nerve injuries

Reuben Kyui
Subject Lecturer
Structure of a nerve
 It has an outer covering
which forms a sheath
around the nerve, called
the epineurium.
 Nerve fibers, which are
axons, organize into
bundles known as fascicles
with each fascicle
surrounded by the
perineurium.
 Between individual nerve
fibers is an inner layer of
endoneurium.
 Peripheral nerve injury

Dermotome :
 is an area of skin supplied by a single spinal root

Myotome :
 Represents a muscle unit supplied by a single
spinal root
Seddon's classification
Neurapraxia -- temporary paralysis of a nerve caused
by lack of blood flow or by pressure on the affected
nerve with no loss of structural continuity.

Axonotmesis –
 neural tube intact, but axons are disrupted.
 nerves are likely to recover.

Neurotmesis –
 the neural tube is severed.
 Injuries are likely permanent without repair.
 Classification of Nerve Injuries

myelin axon endoneurium perineurium epineurium

Degree of Injury

I Neuropraxia +/-

II Axonotmesis yes yes no no no

III yes yes yes no no

IV yes yes yes yes no

V Neurotmesis yes yes yes yes yes

 Sunderland`s classification
 Grade I
 Same as Seddon's neuropraxia.
 Grade II
 Same as Seddon's axonotmesis.
 Grade III
 Neurotmesis with preservation of the perineurium.
 Grade IV
 Neurotmesis with preservation of the epineurium. Everything
else is disrupted.
 Nerve grossly appear edematous.
 Nerve grafting is required.
 Grade V
 Complete transection of the nerve trunk.
 Typical deformities :
 Wrist drop ---- radial nerve injury

 Claw hand ---- ulnar nerve injury

 Foot drop ---- lateral popliteal nerve injury

 Ape thumb ---- median nerve injury

 Winging of scapula ---- thoracodorsal nerve injury

 Pointing index ---- median nerve injury

 Simple screening tests
 Ulnar nerve injury :
 Loss of pain at tip of the little finger

 Medial nerve injury :

 Loss of pain at tip of index finger

 Radial nerve injury :

 Inability to extend thumb
Incidence of Peripheral nerve
injury
 Radial nerve ------ commonly injured

 Ulnar nerve ------- 30 %

 Median nerve ----- 15 %

 Lumbosacral plexus ---- 3 %

 Ulnar nerve injury
Causes :
General causes : metabolic diseases , collagen
diseases , malignancies , endogenous or exogenous
toxins , chemical or mechanical trauma , etc.
Local causes :
Causes in the axilla :
 Crutch pressure
 Aneurysm of the axillary vessels
Causes in the arm :
 # shaft of humerus
 Gunshot and penetrating injuries
 Cont ..
Causes at the elbow :
 Compression by the accessory muscles
 # lateral epicondyle of humerus
 Repeated occupational strains
 Recurrent subluxation of the nerve
 Compression by the osteophytes as in rheumatoid and
osteoarthritis
Causes in the forearm :
 # both bones forearm
 Incised wounds , gunshot wounds and penetrating injuries of
the forearm
 Cont ..
Causes at the wrist :
 Compression by osteophytes
 # hook of the hamate
 Compression by ganglion
 Wrist injuries
Causes in the hand:
 Blunt trauma
 Penetrating injuries

 Ulnar nerve injuries gives rise to claw hand

deformity
 Claw hand deformity
 It is a deformity with
hyperextension of the MCP
joints and flexion of the IP
joints of the fingers
( loss of flexon at MCP and
extension at IP joints )
 Clinical features
 Loss of sensation along the ulnar nerve
distribution

and

 Wasting of the hypothenar muscles ,

intrinsic muscles of the hand leading to
hollow intermetacarpal spaces on the
dorsum of the hand
.
 Levels of the lesion
High : above the level of elbow , entire nerve function
is lost

Low :
Below the elbow at the junction of the middle and
lower third of forearm :
Spared :
- function of FDP and FUC
Lost :
 Motor : HTM ,Its, Lum ,PB
 Sensory : dorsal aspect of hand and one and half fingers
 Cont ..
Proximal to Guyon`s canal :
 Spared : FDP , FCU and
dorsal sensation
 Lost : same as above + loss
of volar sensation
 Cont ..
Distal to Guyon`s canal : -
 Spared : FDP , FCU , HTM , PB, dorsal and volar
sensation
 Lost : interossei and lumbricals

 FCU – flexor carpi ulnaris

 FDP – flexor digitorum profundus
 HTM – hypothenar muscles
 PB – palmaris brevis
 Lum – lumbricals
 Its - interossei
 Clinical tests :
 Froment's sign. When the patient
attempts to pinch with the thumb
and index finger, the long flexor of
the thumb is used to substitute for
the thumb adductor, resulting in
flexion of the thumb at the
interphalangeal joint.
 This characteristic appearance is
present in this patient's left hand,
caused by an ulnar nerve lesion at
the elbow
 Card test

 Inability to hold a card or paper in between fingers

due to loss of adduction by the palmar interossei

Pen test
 Unable to touch the pen due to the loss of action of
abductor pollicic brevis
Egawa test ( median nerve injury )
 With palm flat on the table the patient is asked to move
the middle finger sideways( test for the dorsal interossei
of middle finger )
 In total clawing median nerve is also injuried

Pointing index or oschner`s clasp test :

 When both the hands are clapsed together , index and
middle fingers , fail to flex due to the loss of action of
long finger flexors of the index and middle fingers
which are supplied by the median nerve .
 Treatment of ulnar nerve injury
 Unless there is a lot of muscle wasting,
(nonsurgical treatment )
Prevention
 Avoid frequent use of the arm with the
elbow bent
 If you use a computer frequently, make sure
that your chair is not too low. Do not rest the
Loosely wrapping a
elbow on the armrest. towel around the arm
 Avoid putting pressure on the inside of the with tape can help
arm (do not drive with the arm resting on the you to remember not
open window ). to bend the elbow
during the night
 Keep the elbow straight at night when you
are sleeping (done by wrapping a towel
around the straight elbow, wearing an elbow
pad backwards, or using a special brace )
 Nonsurgical Treatment
 If symptoms have only just
started,
 Anti – inflammatory drugs,
ibuprofen,( to reduce swelling
around the nerve ).
 Steroid (cortisone) injections
around the ulnar nerve are not With your arm forward and the elbow
generally used because there is straight, curl the wrist and fingers
a risk of damage to the nerve. toward the body, then extend them
away from you and then bend the
 Exercises ( prevents arm and elbow
wrist from stiffness ).

With the arm to the side, curl the wrist and fingers
toward the shoulder and then turn the palm up and
then stretch the neck to the other side.
 Surgical Treatment

 If the nerve is very compressed; or if there is muscle

wasting
Surgery :
 Around the elbow and the wrist or both
 More commonly, the nerve is moved from its place
behind the elbow to a new place in front of the
elbow. This is called an anterior transposition of
the ulnar nerve.
The nerve can be moved : -
 under the skin and fat (subcutaneous transposition),
 within the muscle (intermuscular transposition) or
 under the muscle (submuscular transposition).
 .

For anterior transposition of the ulnar nerve, an incision

along the inside of the elbow is used. Nerve moved from
behind the elbow to in front of it and will make sure that
it is not compressed by any other structures.
 .

Entrapment of the ulnar nerve at Guyon's canal.

If ulnar nerve is compressed at the wrist, make an incision
and free the nerve where it is compressed.
 Ulnar paradox
 The higher the lesion of the median and ulnar
nerve injury , the less prominent is the deformity
and vice versa, because in higher lesions the long
finger flexors are paralysed .
 The loss of finger flexion makes the deformity
look less obvius
 Radial nerve injury
Causes : -
General causes : metabolic diseases , collagen
diseases , malignancies , endogenous or
exogenous toxins , chemical or mechanical
trauma , etc.
Local causes : -
In the axilla :
 Aneurysm of the axillary vessels
 Crutch palsy
In the shoulder:
 Proximal humeral #
 Shoulder dislocation
Cont..
In the spiral groove ( 5 `s )
 Shaft #
 Saturday night #
 Syringe palsy
 `S ` march`s tourniquet palsy
Between spiral groove and lateral epicondyle :
 # shaft humerus
 Supracondylar # humerus
 Lateral epicondyle # of humerus
 Penetrating and gunshot injuries
 Cubitus valgus deformity
Cont …

At the elbow :
 Posterior dislocation of elbow
 # head of radius
 Monteggia #

Causes in the forearm :

 # both bones of forearm
 Penetrating and gunshot injuries
Levels of lesion
High above spiral groove---- total palsy

Low :

Type 1 (Between the spiral groove and the lateral

epicondyle ) : -

Spared : - elbow extensor

Lost : -
 Motor : wrist extensor , thumb extensor , finger extensor
 Sensory : dorsum of first web space
 Cont ..
Low

 Type 2 ( below the elbow ) :

Spared :
 Elbow extensor
 Wrist extensor

Lost :
 Motor : thumb extensor , finger extensor
 Sensory :
 First web space
 Clinical features

Depend upon the site of the injury: -

Lesions in or above the axilla :
 Paralysis and wasting of all the muscles innervated.
 Clinically, this is manifest as:
 weakness of forearm extension and flexion - triceps and
brachioradialis
 wrist drop and finger drop - paralysis of the extensors of
the wrist and digits
 weakness of the long thumb abductor and extensor muscles
Cont ..
 Sensory loss on the dorsum of hand and forearm
appropriate to the cutaneous distribution
 Lesions around the humerus
 spare brachioradialis and
 extensor carpi radialis longus.
 Posterior interosseous palsy (due to a dislocation or
fracture of the elbow ).
 weakness of finger extension, and of thumb extension and
abduction.
 little or no wrist drop, and usually, no sensory loss.
 Fig : - Wrist drop
 .
 Tests
Muscles supplied by the radial nerve and how to test each:

 C7,8: triceps - ask patient to extend elbow against resistance.

 C5,6: brachioradialis - ask patient to flex elbow with forearm half way between pronation and
supination.

 C6,7: extensor carpi radialis longus - ask patient to extend wrist to radial side with fingers
extended.

 C5,6: supinator - with arm by side, ask patient to resist hand pronation.

 C7,8: extensor digitorum - ask patient to keep fingers extended at MCP joint.

 C7,8: extensor carpi ulnaris - ask patient to extend wrist to ulnar side.

 C7,8: abductor pollicis longus - ask patient to abduct thumb at 90° to palm.

 C7,8: extensor pollicis brevis - ask patient to extend thumb at MCP joint.

 C7,8: extensor pollicis longus - ask patient to resist thumb flexion at IP joint.
 Sensation:
 The cutaneous branches of
the radial nerve supply the
dorsal aspect of the
forearm from below the
elbow down over the
lateral part of the hand to
include the thumb to the
interphalangeal joint and
the fingers to the distal
interphalangeal joint.
Exams and Tests
An examination of the arm, hand, and wrist identify radial
nerve dysfunction.
 Decreased ability to extend the arm at the elbow
 Decreased ability to rotate the arm outward (supination)
 Difficulty lifting the wrist or fingers (extensor muscle
weakness)
 Muscle loss (atrophy) in the forearm
 Weakness of the wrist and finger
 Wrist or finger drop

Tests for nerve dysfunction :

 EMG
 MRI of the head, neck, and shoulder
 Nerve biopsy
 Nerve conduction tests
Treatment
Closed fracture

CONTROL OF SYMPTOMS
 Analgesics ( to control pain neuralgia)
 Phenytoin, carbamazepine, or tricyclic antidepressants
(amitriptyline) to reduce stabbing pain
 Steroids (prednisone) to reduce swelling
Other treatments include:
 Braces, splints,
 Physical therapy to help maintain muscle strength
 Occupational therapy, or job counseling
 Surgery : -
 Failure of conservative by 12 to 18 months
 Surgery ( open # )
Clean wound :
Primary repair , splint , physiotherapy

Contaminated wound :
Delayed primary repair and secondary repair

Late cases :
 Tendon transfers
 Arthrodesis
Splints
Complications

 Mild to severe deformity of the hand

 Partial or complete loss of feeling in the
hand
 Partial or complete loss of wrist or hand
movement
 Recurrent injury to the hand
Brachical plexus injuries
 Causes
Closed injury :
 Due to birth or
 Due to bike trauma

Open injury :
 Due to penetrating or gunshot injuries
 Others ( less common )
 Traction injuries
 Tumor removal
 Shoulder dislocations
 Surgical excision of cervical ribs
 Abnormal pressures due to faulty posture
Types of lesions
 Supraclavicular lesion:

1 . Preganglionic lesion :
 Cause could be either birth or bike trauma

Characteristic feature :
 Presence of Horner`s syndrome.

2 . Postganglionic lesion : -
- absence of Horner`s syndrome
- prognosis is slightly better than the preganglionic lesion
- positive Tinel`s sign ( tapping above the clavicle ,
produces tingling sensation in the anaesthetic limb )
 Horner`s syndrome
Remember ( 5 P`s ) : -
 Ptosis of the eyelid
 Pupils which are small and
constricted
 Protrusion of the eyeball
which is slight
 Pain even at rest
 Poor prognosis
 Assessment of brachial plexus
injury
In preganglionic lesion In postganglionic lesion
 Horner`s syndrome ---present  Horner`s syndrome ----absent
 Unable to elevate scapula  Able to elevate scapula

 Tinel`s sign --- present in the

later stages
 Investigation
 X – ray ( to rule out # )

 CT scan ( study cross – section anatomy )

 MRI ( study the soft tissue damages )

 Electromyogram (EMG or electromyography)

 Nerve conduction study

Treatment

1 . Splinting
 Aeroplane splint
 Cont ..
2 . For pain control :

 TENS method ( 'Transcutaneous

Electrical Nerve Stimulation‘ )
 Mild electrical impulses are
transmitted through the skin
 Cause body to release endorphins,
the body’s own pain-relieving
hormones.
 These 'positive signals' to the brain
block the slower-moving pain
messages.
 Surgical measures
 Types of surgery
Nerve graft : -
 the damaged part of
the brachial plexus is
removed and replaced
with sections of
nerves cut from other
parts of body
Nerve transfers

 Done in the most serious

types of brachial plexus
injuries, called
avulsions, when the
nerve root has been torn
out of the spinal cord.
 Muscle transfers
 Needed if arm
muscles have
atrophied from
lack of use.
ERBS PALSY
 Erb's palsy
 paralysis of the muscles in a baby's
arm, caused by injury of the nerves
in the shoulder at birth (during
delivery).
 The baby lies with one arm and
hand twisted backward and does
not move the arm as much as the
other.
 If the full range of motion of the
arm is not kept through regular
exercise, contractures will develop
.
 Clinical features
At the shoulder :
 Loss of shoulder abduction and external rotation ( due to
paralysis of the deltoid , supra and infraspinatus and teres minor
muscles )
At the elbow :
 Loss of flexion of the elbow joint ( due to paralysis of the biceps
and brachialis )
At the forearm :
 Loss of supination of the forearm

 May be sensory loss on the outer aspects of the arm and

forearm both in the front and back .
Policeman or Waiter`s tip
 Shoulder ---
internally
rotated
 Elbow -----
extension
 Forearm ---
pronated
 Wrist ------
flexion
 Treatment
1 . Splinting
 Aeroplane splint
2 . For pain control :
 TENS method
 Types of surgery
- Nerve graft .
- Nerve transfers .
- Muscle transfers .
- release of soft tissue contractures .
With the baby, start range-of-
motion exercises 2 times a day.
When the child is old, have him do exercises himself, for
range of motion and to increase strength.
Cont ..
Cont ..