Periphe

ral
Nerve
Injuries

Peripheral Nerve

Coverings

Internal topography
Fascicular arrangement constantly change throughout the course

Etiology of peripheral nerve

injuries
1.
2.
3.
4.
5.
6.

Metabolic or collagen disease

Malignancy
Endo or exo-toxins
Ischaemia
Radiation
* infection:leprosy
Trauma

Thermal
Chemical
Mechanical

Primary injury

Results from same trauma that injures a bone or

joint
Radial nerve is the most commonly injured. Of
humeral shaft fractures, 14 % is complicated by
radial nerve injuries

Displaced osseous fragments

Stretching
Manipulation

Secondary injury

Results from involvement of nerve by infection,

scar, callous or vascular complications which may
be hematoma, AV fistula, Ischemia or aneurysm

Classification of nerve injuries

Seddon Classification
1.Neuropraxia:

Minor contusion or compression with preservation of axis

cylinder of myelin sheath.
2. Impulse transmission physiologically interrupted.
3. Complete recovery in a few days to weeks
1.

2.Axonotemesis

More significant injury

2. Breakdown of axon and distal Wallerian degeneration but
with preservation of schwann cell & endoneurial tubes
3. Spontaneous regeneration with good functional recovery
can be expected
1.

3.

Neurotmesis
More severe injury
2. Complete anatomical severance, avulsion or crushing of
nerve
3. Axon, Schwann cell & endoneurial tubes are completely
disrupted
4. Spontaneous recovery cannot be expected unless surgically
intervened
1.

Sunderland
Classification

Each degree of injury suggesting a greater anatomical

disruption with its correspondingly altered prognosis
Anatomically various degrees (1 st 5th) represent
injury to

Myelin
Axon
Endoneurial tube & its content
Perineurium
Entire nerve trunk

Sixth degree (Mackinson) or mixed injuries occur

in which a nerve trunk is partially severed and
remaining part of trunk sustains 1 st to 4th degree
injury.
Mixed recovery pattern depending on degree of
injury to each portion of nerve.

Neuronal degeneration and

regeneration
Any part of neuron detached from its
nucleus, degenerates & is destroyed by
phagocytosis.

Distal
Secondary / Wallerian Degeneration
Proximal - Primary / Traumatic / Retrograde
Degeneration

Time required for degeneration varies

between sensory and motor fibers and is also
related to size & myelination of fibers
Advancing Tinel sign and presence of motor
march phenomena are signs of regeneration

Diagnosis of Peripheral
nerve injuries

History
Which nerve ?
What level ?
What is the cause ?
What degree of injury ?
Old or fresh injury ?

Diagnosis of Peripheral
nerve injuries
1.

Motor:

All muscles distal to the injury

paralyzed & atonic
Atrophy : 50 -70 % in 1st two months
Striations & motor end plate
configurations retained for 12 18
months (critical limit of delay)

2.

Sensory :

Sensory loss usually follows a definite

anatomical pattern, although factor of
overlap from adjacent nerves may be
present
Autonomous zone
Weber 2 point discrimination test
Tinels sign

(3) Reflex

Abolishes all reflexes transmitted by that

nerve, either afferent or efferent arc.
Complete & incomplete lesion. So , not a
reliable guide to injury severity.

(4)

Autonomic :

Loss of sweating
Loss of pilomotor response and
Vasomotor paralysis in autonomous zone

(5)

Others:

Trophic Changes

Fingernails

Esp. hand and feet

Skin thin, glistening, breaks easily to
form ulcers that heal slowly
Ridged, distorted and brittle

Osteoporosis (Reflex sympathetic

dystrophy)

Test for peripheral nerves of upper

limb

Radial nerve injury

very high / high / low injury

Wrist drop / finger drop / thumb drop
Test for triceps/ /Brachioradialis/ wrist
extensors / extensor digitorum / EPL

Median nerve

High / low injury

Test for FPL / FDS / FDP (lat. half) / FCR /
Abd. Pollicis brevis ( pen test) / Oppenens
pollicis
See for pointing index / complete claw hand

Ulnar nerve

High / low palsy ulnar paradox

Test for FCU / Abd. digiti minimi / Interossei
(dorsal - Egawas test ; palmar card test ) /
lumbricals /Add. Pollicis (Froments sign /
book test )
Ulnar claw hand

Electrodiagnostic studies

Electromyography
Nerve conduction velocity
Strength duration curve

Time of Surgery

Primary repair : First 6 8 hours

Delayed primary repair : First 7 18

days

Secondary repair : > 3 weeks

Indications for surgery

1.

2.

3.

4.

When a sharp injury has obviously divided a

nerve.
When abrading, avulsing or blast wounds have
rendered the condition of nerve unknown
When a nerve deficit follows a blunt or closed
trauma & no clinical or electrical evidence of
regeneration has occurred after an appropriate
time
When a nerve deficit follows a penetrating
wound as stab or low velocity gunshot wound,
part observed for evidence of nerve
regeneration for appropriate time.

Types of Nerve Repair :

1.
2.
3.

Endoneurolysis
Partial Neurorrhaphy
Neurorrhaphy
1.
2.
3.

4.

Epineural
Epi-perineural
Perineural

Nerve grafting

Factors that influence regeneration after

neurorrhaphy
1.
2.
3.

4.
5.
6.

Age of patient
Gap between nerve ends
Delay between time of injury and
repair
Level of injury
Condition of nerve ends
Experience & technique of surgeon

Options

Orthoses
Tendon transfers
Bony blocks
Arthrodesis

Thank You