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PATHOLOGY
Nerves can be injured by ischaemia ,compression, traction, laceration or burning. Aetiology:-Direct trauma -Systemic causes-DM,leprosy,lead poisoning - Entrapment neuropathies e.g.,carpal tunnel,cubital tunnel,supinator syndromes
Neurapraxia
A reversible physiological nerve conduction block followed by spontaneous recovery after a few weeks. It is due to mechanical pressure causing segmental demyelination and is seen typically in crutch palsy, Saturday night palsy,tourniquet palsy.
Axonotmesis
There is loss of conduction but the nerve is in continuity and the neural tubes are intact. The denervated target organs (motor end-plates and sensory receptors) gradually atrophy, and if they are not re- in nervated within 2 years they will never recover.
Neurotmesis
In Seddon's original classification, neurotmesis meant division of the nerve trunk
BRACHIAL PLEXUS
C8T1 Lower trunk Median Medial cord C8T1 Lower trunk Median OP Thumb opp Medial cord ----Median Sensory loss Median claw hand-loss of lat 2 lumbricals Oschners clasp test(pointing index) Ape thumb deformity Pen test
Median Nerve
Plexus* POST C
POST C POST C Post C ---
PN Radial
Radial Radial Radial Radial
Finding Wr drop
Triceps, med hd
Superficial Radial
Post
Brachioradialis ECRL ECRB Supinator sens Ext Digit Abd Pol Longus Interosseous Ext Pol Longus
Ulnar nerve
Elbow Flexor carpi ulnaris
Adductor Pollicus
Opponens
Digiti Minimi
Flexor
Flex Pollicus Br
Dorsal/palmar Interosseous
3rd/4th lumbricals
PRINCIPLES OF TREATMENT
Treating underlying cause Oral corticosteroids-to reduce inflammation & edema Active and passive physiotherapy to muscles Galvanic stimulation Dynamic splints To prevent contracture of the affected muscle
PRINCIPLES OF TREATMENT
Nerve exploration . Exploration is indicated: (1) if the nerve was seen divided and needs to be repaired; (2) type of injury (e.g. a knife wound or a high energy injury) suggests that the nerve has been divided or severely damaged; (3) if recovery is inappropriately delayed and the diagnosis is in doubt.
Epineurial neurorrhaphy
Nerve grafting
Free autogenous nerve grafts can be used to bridge gaps too large for direct suture. The sural nerve is most commonly used Neurotization
recovery is awaited the skin must be protected from friction damage and bums. The joints should be moved through their full range twice daily to prevent stiffness and minimize the work required of muscles when they recover. 'Dynamic' splints may be helpful.
Tendon transfers
Motor recovery may not occur if the axons, regenerating at about 1mm per day, do not reach the muscle within 1824 months of injury. The principles can be summarized as follows:
Tendon transfers
The donor muscle should be expendable Have adequate power Be an agonist or synergist The recipient site should be stable Have mobile joints and supple tissues The transferred tendon shouldbe routed subcutaneously Have a straight line of pull Be capable of firm fixation
CLAW HANDULNAR&MEDIAN
Boyds transfer Riordan transfer Fowlers technique