Orthopaedic Surgeon NERVE INJURY OUTLINE Relevant Physioanatomy Incidence Of Peripheral N Injury Aetiopathology Clinical Evaluation Electrophysiogical Assessment Imaging Techniques ID: 932574
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Slide1
DR. ANIPOLE O.ALecturer 1/ Consultant Orthopaedic Surgeon
NERVE INJURY
Slide2OUTLINERelevant Physio-anatomyIncidence Of Peripheral N. InjuryAetiopathologyClinical Evaluation
Electrophysiogical
Assessment
Imaging Techniques
Slide3OUTLINETreatmentsComplicationsNewer Techniques
Slide4Relevant Physio-AnatomyNerve is composed of neural and connective tissue. In both myelinated and non myelinated axons, each nerve fiber is surrounded by the
endoneurium
.
Groups of nerve fibers are surrounded by the
perineurium
to form fascicles.
Goups
of fascicles are surrounded by the internal and external
epineurium
.
Knowledge of motor and sensory fascicular topography within the nerve is essential to ensure correct alignment of the motor and sensory fascicles.
Slide5NERVE TRUNKPERINEURIUM
BLOOD VESSELS
EPINEURIUM
FASCICLE
NERVE FIBER
MYELIN SHEATH
AXON
ENDONEURIUM
Slide6A MOTOR NEURONE
Slide7Incidence Of Peripheral Nerve InjuryLimited reported data are available to determine incidence. In North America, data taken from a trauma population in Canada revealed that approximately 2-3% of patients had a major nerve injury.
Slide8Incidence Of Peripheral Nerve InjuryUlnar nerve inj: common ass with # medial humeral epicondyle and callus around the elbow,Median nerve inj: common in elbow dislocation
Slide9Incidence Of Peripheral Nerve InjuryAxillary nerve stretch inj. occur in ~ 5% of shoulder dislocationPeroneal nerve injury
common
in
fibular neck # or dislocation of knee
Slide10AetiopathophysiologyPeripheral nerve injuries may occur due to; Trauma ( blunt or penetrating wound): - Stab : from a knife, by a bullet, ragged end of fracture bone.Vascular Ischaemia
as in
Volkman’s
contracture of the forearm
Compression:
-Acute compression by
haemorrhage
or
oedema
: Compartment syndrome
-Chronic compression injuries.
Slide11Traction: E.g birth trauma→ Erb’s palsyChemical / Burn injuries; from injection of drugs, or adjacency of
methylmethacrylate
material to the sciatic nerve during total hip replacement.
Slide12AetiopathophysiologyInjury → Demyelination or axonal degeneration → disruption of the sensory and/or motor function Remyelination /axonal regeneration →
Reinnervation
of the sensory receptors, motor end plates, or both.
Slide13AetiopathophysiologyClassification Seddon in 1943 classified nerve injury as neurapraxia
,
axonotmesis
, and
neurotmesis
.
•
Sunderland
in 1951 expanded this classification system to 5 degrees of nerve injury.
Mackinnon
introduced the sixth degree.
Slide14Seddon,1943.Neuropraxia –Minor contusion or compression. Demyelination without axon disruption or degeneration. Conduction block .Transient loss of functionAxonotmesis –The axons are disrupted with distal Wallerian degeneration but the endoneurium
is intact
Neurotmesis
– Total division & disruption in continuity of axons, all supporting structures including
epineurium
.
Classification
Slide15Slide16
Slide17CLINICAL EVALUATIONHistory Taken Clinical Examination Inspection - Lesions of various nerve often results in a
xtic
limb attitude.
Slide18CLINICAL EVALUATIONMuscle toneReduced or abolished
Slide19CLINICAL EVALUATIONMuscle BulkProgressively atrophy to approximately 50% - 2 monthsMuscle Power
MRC method of grading muscle power – 0 – 5.
Slide20CLINICAL EVALUATIONSensory Assessment- Dermatones
Slide21CLINICAL EVALUATIONExamination of the nerve Local Tenderness - - Indicates an in complete lesion Tinel
sign
- Evidence of axon sprouts
- Sensation of pins & needles
Slide22Electrophysiogical Assessment (1) Nerve Conduction Studies (2) Electromyography
Slide23Nerve Conduction Studies Particularly useful in determining the anatomical site of compression of a nerve. .In cases of brachial plexus injury, can help to determine the presence of an avulsion injury.
Slide24ElectromyographyPerformed at least 4 weeks following nerve injury.Evidence of denervation is indicated by the presence of fibrillations
in the muscle.
Reinnervation
is noted by the presence of
motor unit potentials.
Slide25TREATMENTConservativeUse of splint or sling for supportPassive mobilizationMaintaining muscle strength in the unaffected muscles. No definitive studies have been done to support the use of electrical muscle stimulation to prevent muscle degeneration.
Slide26FORMS OF SURGICAL TREATMENTNERVE REPAIRNERVE GRAFTNERVE TRANSFERTENDON TRANSFER
Slide27Types of Nerve RepairPRIMARY 6 – 8 HOURSDELAYED PRIMARY 7 – 18 DAYSSECONDARY >18 DAYS
Slide28METHODS OF I ̊ REPAIREPINEURIALPERINEURIAL {FASCICULAR}Group Fascicular
Slide29Epineurial Repair
Slide30Fascicular (funicular) Repair
Slide31Nerve GraftingSural NerveAnt. br. of medial cut. n. of the forearmLat. Cut. n. of the forearm
Slide32POST OPT MGTCARE OF WOUNDSPLINTAGEPHYSIOTHERAPY/HAND THERAPISTFOLLOW-UP CARE
Slide33COMPLICATIONSInjury - RelatedPAINFUL NEUROMAPARALYSISJOINT STIFFNESSMUSCLE WASTINGREFLEX SYMPATHETIC DYSTROPHY
Slide34COMPLICATIONSOperation - Related:Infection, Hematoma, Seroma, and injury to surrounding structures, including vascular structures.
Further injury to the nerve.
Slide35THANKS FOR
LISTENING