PERIPHERAL NERVE INJURIES

Anatomy
Endoneurium -surrounds myelinated and unmyelinated axons -protects the nerve when it is elongated/ stretched Perineurium -made up of collagen fibrils -encircles the fascicle Epineurium (collagen,elastic fibers) -encases the nerve trunk mesoneurium (interfascicular epineurium) -epineural extension between fascicles

 Peripheral nerves -regenerate approximately 1mm/day(about 1 inch per month) -long distances(12 inches) may result in fibrosis of the muscle

Injury classification (Seddon)

1.Neuropraxia -physiologic transection(temporary disruption of nerve conduction) -local ischemic demyelination -no Wallerian degeneration -basement membrane is intact -axonal transport is impaired -recovery (average=6-8 wks)

Injury classification (Seddon)

2.Axonotmesis -complete interruption of axons and myelin sheaths -stroma remains in continuity -Wallerian degeneration occurs -endoneural remain intact,allowing regeneration

Injury classification (Seddon)

3.Neurotmesis -nerve completely severed or disorganized scar tissue -spontaneous regeneration impossible

Sunderland Classification of nerve injury

Gr.1 = loss of axonal conduction Gr.2 = loss of continuity of axons with intact endoneurium Gr.3 = transection of nerve fiber(axon and sheath)with intact perineurium Gr.4 = loss of perineurium and fascicular continuity Gr.5 = loss of continuity of the entire nerve trunk

Common mechanism of Injury

Lacerations Contusive injury (GSW) Stretch Compression-Ischemia Electrical injury Drug injection

Response of axons to injury

-connective tissue response-proliferative -basal lamina-guidance system of the distal stump -Schwann cells proliferate close to the growth cones-elongating neurite -Cytoskeleton proteins(tubulin,neurofilament CHON)-building blocks for axonal regrowth

Management
Progressive deficit is usually due to vascular inj.-immediate exploration Clean,sharp,relatively fresh lacerating inj. -explored acutely and repaired within 72 hours Penetrating inj.-explored as soon as the primary wounds heal

Management
Gunshot wounds to the brachial plexus rarely divides the nerve -axonotmesis,neurotmesis -surgery is of little benefit (lower trunk, medial cord,or C8/T1 roots) Traction inj. -incomplete postganglionic inj.tend to improve spontaneously Neuromas in continuity-neurolysis,resection, grafting

Specific nerve Injuries

Brachial plexus inj. Median nerve entrapment -Carpal Tunnel Syndrome -Pronator Teres Syndrome Ulnar entrapment -Tardy ulnar palsy Radial nerve inj. -Saturday night palsy

Specific nerve Injuries

Axillary nerve injuries Femoral nerve Peroneal nerve

Repair techniques
Epineural repair Fascicle repair Interfascicular nerve grafting-Nerve grafts Donor sites: 1.sural nerve(most common) 2.superficial radial nerve graft 3.medial or lateral cutaneous nerve(forearm) 4.lateral cutaneous nerve(femur) 5.medial cutaneous nerve(arm)

Electrophysiologic testing
Electromyography -demonstrate denervation(fibrillations,denervation potentials,insertion activity) Nerve conduction velocities Somatosensory evoked potentials