ug class presentation

1. PERIPHERAL NERVE
INJURIES
DR SUPREETH
DR RAVI VARMA

2. ANATOMY OF THE SPINAL NERVES
• Each segmental spinal nerve is formed at or near its
intervertebral foramen by the union of its dorsal, or
sensory, root with its ventral, or motor, root.

3. • The somatic peripheral nervous system (PNS) is defined by the presence of Schwann cells
• This includes the primary roots, dorsal root ganglia, mixed spinal nerves, plexuses, nerve trunks,
autonomic nervous system, and cranial nerves III through XII

4. NOTE-
A single motor neuron supplies ten
to several thousand muscle fibres
the smaller the ratio, the finer the
movement

5. COMPONENTS OF SPINAL NERVE
• MOTOR
• SENSORY
• SYMPATHETIC

6. NEURONAL DEGENERATION AND REGENERATION
WALLERIAN DEGENERATION
RETROGADE DEGENERATION

7. CAUSES
1. LACERATION
2. COMPRESSION/ENTRAPMENT
3. TRACTION
4. BIRTH INJURIES
5. IATROGENIC
6. FRACTURE
7. METABOLIC DISTURBANCES
8. ISCHAEMIA
9. THERMAL /ELECTRICAL INJURIES

8. COMMON NERVE INJURIES
• UPPER LIMB
• Axillary nerve injury
• Radial nerve injury
• Median nerve injury
• Ulnar nerve injury
• LOWERLIMB
• Femoral nerve injury
• Sciatic nerve injury
• Peroneal nerve injury

9. NERVE INJURY & RECOVERY
Motor
Proprioception
Touch
Temperature
Pain
Sympathetic
Recovery
Injury

10. Seddon
BMJ
1942
Neurapraxia
(Transient Block)
Axonotmesis
(Lesion in Continuity)
Neurotmesis
(Division of a nerve)
Brain
1943
• Localised
degeneration of the
myelin sheaths
• Complete
interruption of axons
• Preservation of
supporting
structures (Schwann
tubes, endoneurium,
perineurium)
• All essential parts
destroyed
• Interruption can
occur without
apparent loss of
continuity

11. TRANSIENT ISCHAEMIA-
• Acute nerve compression causes numbness and tingling within 15 minutes
• loss of pain sensibility after 30 minutes and muscle weakness after 45 minutes
• Relief of compression is followed by intense paraesthesia lasting up to 5 minutes
• feeling is restored within 30 second
• TRANSIENT ENDONEURIAL ANOXIA AND THEY LEAVE NO TRACE OF NERVE DAMAGE.

12. NEURAPRAXIA
• ‘neurapraxia’ to describe a reversible block to nerve conduction
• minor contusion or compression of a peripheral nerve with preservation of the axis- cylinder
• Transmission of impulses is physiologically interrupted for a time
• recovery is complete in 3-6 weeks
• Tinel’s sign-negative

13. AXONOTMESIS
• designating more significant injury
• breakdown of the axon and distal wallerian degener-ation but with preservation of the Schwann cell
and endoneurial tubes.
• Spontaneous regeneration with good functional recovery can be expected
• Tinels sign-positive

14. NEUROTMESIS
• more severe injury
• complete anatomical severance of the nerve or extensive avulsing or crushing injury
• Axon,Schwann cell and endoneurial tubes , eperineurium and epineurium are disrupted to varying
degrees
• significant spontaneous recovery cannot be expected.

15. IN CLINICAL PRACTICE, HOW DO YOU DISTINGUISH?
AXONOTMESIS VERSUS NEUROTMESIS
• Nature of injury
• Serial observations
• Exploration
• Imaging

16. SUNDERLAND CLASSIFICATION
Sunderland
1951 I II III IV V
Focal
conduction
block
NO Wallerian
degeneration
Axonal
Disruption
Axon
+
Endoneurium
Disruption
Axon
+
Endoneurium
+
Perineurium
Disruption
Axon
+
Endoneurium
+
Perineurium
+
Epineurium
Disruption
Cross-innervation

17. • In this classification, peripheral nerve
injuries are arranged in ascending
order of severity
• Anatomically, the various degrees
represent injury to
• (1) myelin,
• (2) axon,
• (3) the endoneurial tube and its
contents,
• (4) perineurium, and
• (5) the entire nerve trunk

18. VI type-mackinnon or mixed injuries

19. DIAGNOSIS
• NOTE-Always test for nerve injuries following any significant trauma. And test
again after manipulation or operation, in case the nerve has been damaged
during treatment!
acute chronic

21. MUSCLE POWER
• Muscles supplied by the nerve
should be tested repeatedly
• Nerve regenaration at 1mm per
day
• MOTOR MARCH

22. SENSORY EXAMINATION
• Sensory loss usually follows a definite anatomical pattern,
• area supplied exclusively by the severed nerve and is
called the AUTONOMOUS ZONE
• Axonometesis –cross innervation

24. • RELEXES
• AUTONOMIC- SWEATING
• TROPHIC CHANGES
• NAIL CHANGES
• OSTEOPOROSIS

25. TINEL’S SIGN
• A classic sign of progressive nerve recovery is
peripheral tingling provoked by percussing
the nerve at the site of injury
• NOTE- where regenerating axons are most
sensitive

26. DIAGNOSTIC TESTS
• EMG-earliest indicator
• NERVE CONDUCTION STUDY
• SWEAT TEST
• MRI

27. TREATMENT
• Conservative
• surgical

28. PREREQUISITES FOR NERVE REPAIR
• Skeletal stability
• Healthy tissue bed
• Healthy nerve ends
• No undue tension
• Adequate soft tissue coverage

29. FACTORS
•AgePatient factor
• Level of injury (distal vs proximal)
• Type of nerve (pure vs mixed
functions)
• Condition of nerve ends
Injury factors
• Delay to repair
• Length of gap
Surgical
factors

30. INDICATION FOR SURGERY
• Sharp injury dividing a nerve
• Blast injury
• In a closed injury when no signs of recovery by appropriat time

31. TIME OF OPERATION
Open injury
Primary repair(6-8
hours)
Delayed primary
repair(7-18 days)
Secondary
repair(after 18 days)
Closed
injury
Conservative(splints)
Delayed intervention

32. GOOD PROGNOSTIC FACTORS
• G-growing age
• O-only motor
• O-only sensory
• D-distal lesion
• N-neuropraxia
• E-early repair
• R-radial nerve
• V-vascularity
• E-end to end repair
GOOD NERVE

33. TREATMENT OPTIONS
• PARTIAL NEURORRHAPHY
• NEURORRHAPHY
• NERVE GRAFTING(sural nerve and saphaneous nerve)
• TENDON TRANSFERS

34. CARE OF PARALYSED PARTS
While recovery is awaited,
• the skin must be protected from friction damage and burns.
• The joints should be moved through their full range twice daily to prevent stiffness and minimize the
work required of muscles when they recover.
• SPLINTS-both dynamic and static alternatively

35. • A newly born child, delivered by full term vaginal delivery- shoulder presentation,birth weight-4 kg,born
to a gestational diabetes mother presented with deformity of left upper limb,with hand held in
pronation of forearm and hand held close to the body

40. • A patient with a past history of shoulder
dislocation,which was reduced in phc
and c/o weakness in abduction and loss
of sensory supply of lateral aspect of arm

41. • A patient came to jss hospital with c/o
inability to grip things and ride a
motor bike
• Past history of surgery to fracture of
humerus

43. CRUTCH PALSY

44. • A jss ug student residing in hostel came to opd with c/o weakness in fingers and deformity after socials
of their batch

45. RADIAL NERVE
• Wrist drop
• Fingerdrop
• Splints-cock up splint

46. • A software engineer presented with
tingling and numbness of radial side
of hand with thenar atrophy

47. MEDIAN NERVE
• Labourers hand
• Oschner clasp sign
• Ape thumb deformity
• Pen test
• Carpal tunnel syndrome
• Ok sign or kiloh nevin sign

53. ULNAR NERVE
• Musician nerve
• Card test
• Froments sign
• Ulnar paradox
• Claw hand