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MAJ VIVEK MATHEW
RESIDENT
DEPT OF ORTHOPAEDICS
Nerve injuries
 Anatomy
 Causes
 Patterns of injury
 Examination
 Principles of Surgery
 Reconstructive surgery
ANATOMY
 Continuation of posterior cord of brachial plexus
 C5,C6, C7, C8,(T1)
 Primarily motor nerve
 Innervates
 Tr...
• Formed in front of
subscapularis;pass
anterior to lat dorsi to pass
through the triangular
interval
• accompanied by the...
upper arm
• enters posterior (extensor)
compartment
• supplies triceps
• re-enters anterior compartment of
arm by piercing...
• At the level of the lateral
epicondyle
• gives off posterior interosseous
nerve
• passes between two heads of
supinator
...
• The superficial radial nerve
continues into the forearm in
the anterior compartment deep
to brachioradialis
• terminates...
Causes:Radial Nerve injury
 Fractures of humeral shaft
 Gunshot wounds, lacerations of arm and proximal forearm
 Inject...
PIN ENTRAPMENT SYNDROME
 Two types of posterior interosseous nerve entrapment
(Spinner).
 Type I
 Complete paralysis of...
PIN ENTRAPMENT SYNDROME
 . posterior interosseous nerve :
 fracture-dislocations or dislocations of the elbow,
 fractur...
Radial Tunnel Syndrome
 Entrapment of the posterior interosseous nerve leading to
chronic and refractory tennis elbow (Ro...
Superficial Radial Nerve palsy
 Etiology:
 nerve may be caught in scar tissue at the wrist after
surgery or trauma.
 Co...
Examination
 Following muscles can be tested accurately because
their bellies or tendons can be palpated:
 triceps brach...
Diagnosis
 Inability to
 extend the elbow
 supinate the forearm
 wristdrop.
 An inexperienced examiner often may be m...
Examination
 by injuries of the nerve at the level of the middle of the
humerus or distally.
 triceps not seriously affe...
 Sensory examination
 no autonomous zone.
 If present : over the first dorsal interosseous muscle,
between the first an...
HIGH V/S LOW LESIONS
Treatment
 Methods of Closing Gaps
 Interfascicular nerve grafting:preferred method
 Mobilization techniques
 In axill...
Treatment
 Methods of Closing Gaps
 In middle third of arm,
 10 to 12 cm
 mobilizing the nerve from the elbow to the c...
Prognosis
 More favorable than for any other major nerve in
the upper extremity because
 it is predominantly a motor ner...
 Results of Suture of the Radial Nerve
 Only motor recovery is important in suture of the radial
nerve.
 89% obtain rec...
 Critical Limit of Delay of Suture (Zachary)
 Radial nerve
 15 months.
 posterior interosseous nerve
 9 months
TENDON TRANSFERS FOR
RADIAL NERVE PALSY
Tendon
transfered
Tendon
transferred
to
Pronator
Teres
Extensor
Carpi
Radialis
Brevis
Flexor
Carpi
Radialis
Extensor
Digit...
Anatomy
 Formed by junction of lateral and medial root of
median nerve from the medial and lateral cords of
the brachial ...
 After originating from the brachial
plexus in the axilla, the median nerve
descends down the arm, initially
lateral to t...
 The median nerve gives rise to two major
branches in the forearm:
 Anterior interosseous nerve -
Supplies the deep musc...
Causes
 Lacerations, usually in forearm or wrist.
 In the upper arm,
 relatively superficial lacerations
 excessively ...
 At the elbow, the nerve may be injured in
 supracondylar fractures
 posterior dislocations of the elbow.
 Pronator sy...
Examination
 Pronator Teres,
 Flexor Carpi Radialis,
 Flexor Digitorum Profundus (Index),
 Flexor Pollicis Longus,
 F...
 Usually, if the forearm
can be actively
maintained in
pronation against
resistance, the
pronator teres is
intact.
 If the wrist can be
actively maintained in
flexion, and a
contracting flexor
carpi radialis is
palpated, this muscle
is ...
 if the interphalangeal
joint of the thumb can
be maintained in flexion
against resistance with
the wrist in the neutral
...
 Although opposition
of the thumb can be
difficult to confirm, if
the thumb can be
actively maintained in
palmar abductio...
 The flexor digitorum
sublimis to each finger
is examined
separately, while the
remaining fingers are
held in full passiv...
 Sensory supply of the median nerve
 volar surface of thumb, index and middle fingers
 radial half of the ring finger
...
Tendon Transfers
Median Nerve Palsy
 Classification
1) High
 Above Origin Of Anterior Interosseous Nerve
 Pronator Tere...
TREATMENT
 If the onset of paralysis has been spontaneous, the
initial treatment is nonoperative.
 Surgical exploration
...
Results of Suture of the Median
Nerve
 Motor recovery is crucial after median nerve repair;
 Hand without median nerve s...
 50 %patients with recover sensitivity to pain and
touch and some stereognosis
 90% of these patients recover a useful d...
CRITICAL LIMIT OF DELAY OF SUTURE
 Motor recovery in the intrinsic muscles of the hand
 9 months in high lesions
 12 mo...
TENDON TRANSFERS
Median Nerve Palsy
 Reconstructive Goals
 Thumb Opposition
 FPL Function
 Index FDP Function
 Sensat...
Tendon Transfers
Low Median Nerve Palsy
 Deficit And Deformity
 Abduction And Opposition Frequently Retained
 Due To Di...
Tendon Transfers: Opponenspalsty
 Standard Opponensplasties
1) FDS Opponensplasty
 Royle-Thompson Technique
 Bunnell Te...
Tendon Transfers
Low Median Nerve Palsy
1) FDS Opponensplasty – Royle-Thompson
 FDS Brought Around Ulnar Border Of Palmar...
Tendon Transfers
Low Median Nerve Palsy
1) FDS Opponensplasty – Bunnel Technique
 Ring Finger FDS Divided
 FCU Exposed
...
Tendon Transfers
Low Median Nerve Palsy
2) Extensor Indicis Proprius Opponensplasty
 Popular In High Median Nerve Palsy
...
3. Huber Transfer
Tendon Transfers
Low Median Nerve Palsy
4) Camitz Procedure
 Tfr of PL to APB
 Performed At Same Time As Carpal Tunnel R...
Tendon Transfers
High Median Nerve Palsy
 Deficit
 All Flexor Compartment Forearm Muscles
 Apart From Ulnar-Innervated ...
Tendon Transfers
High Median Nerve Palsy
 Extrinsic Transfers
 Restoration Of Index
Function
 ECRL  Index FDP
 Side-T...
Tendon Transfers
High Median Nerve Palsy
 Extrinsic Transfers
 Restoration Of Thumb
Function
 Brachioradialis  FPL
Tendon Transfers
High Median Nerve Palsy
 Thumb Opposition
 Early Transfer
 Allows Pronation Of Hand
 Compensates For ...
ANATOMY
 continuation of medial cord
 C7, C8, T1
 no branches in the upper
arm.
 enters the posterior
compartment of t...
ANATOMY
 Gives articular branch to
elbow
 descends to the wrist
deep to flexor carpi
ulnaris.
 supplies flexor carpi
ul...
ANATOMY
 Just proximal to the
wrist it gives off a
dorsal cutaneous
branch that supplies
the skin over the
dorsal aspect ...
ANATOMY
 crosses into the palm superficial
to the flexor retinaculum in
Guyon's canal.
 It divides into a
 motor branch...
Anatomy
Anatomy
Causes
 Axilla / upper arm :
 usually accompanied by other nerves and brachial artery
 Midarm :
 relatively protected
...
Other causes
 Traction on nerve
 Subluxation or dislocation of nerve
 Entrapment syndrome
 Displaced fractures of medi...
TYPES
 High ulnar nerve palsy:
 All extrinsic and intrinsic muscles affected
 Sensory loss over palmar and dorsal aspec...
High ulnar palsy
LOW ULNAR NERVE PALSY
Examination
 “ Claw hand “ deformity : Benediction hand
 Flattened palm and wasting of hypothenar region
 Shallow midpa...
Patho-anatomy of deformity
 Paralysis of interossei and lumbricals
Unopposed MCP joint extension & IP joint flexion by
d...
Specific signs and tests for motor dysfunction
Duchenne's sign : Hyperextension at MCP joints &
flexion at IP joints of u...
 Pitres-Testut sign : Inability to actively move long
finger in radial and ulnar deviation with palm placed
flat
 Cross ...
 Jeanne’s sign : Hyperextension of MP joint of thumb
during key pinch or gross grip
Froment’s sign : Thumb IP joint flex...
Examination
Examination
Examination
Examination
ANOMALOUS INNERVATION PATTERNS
 5 -10 % cases : FCU
innervated by C7
 Martin- Gruber
anastomosis :
 Between median and
...
ANOMALOUS INNERVATION PATTERNS
 Richie – Cannieu
anastomosis :
 Anomalous connection
between motor branch of
ulnar nerve...
PRINCIPLES OF SURGERY
 Sensation recovers earlier than motor power after
suturing
 Critical limit of delay :
 motor :
...
 Nerve repair
 Transposition
 Medial epicondylectomy
 Reconstructive surgery
PRINCIPLES OF SURGERY
INCISION
 Nerve repair :
,
 Incision given over tendon of
pectoralis ,curving over natural
folds of axilla and then over...
Principles of Surgery
 Transposition :
 With arm abducted and
externally rotated .
Incision made on
posteromedial surfac...
Principles of Surgery
 Transposition :
 Identify branches to FCU
and FDP and dissect
them intraneurally
 nerve freed fr...
Medial Epicondylectomy
Entire medial epicondyle and part of supracondylar ridge removed
RECONSTRUCTIVE SURGERY
 Deformities and deficiencies correctable by surgery
 Claw hand
 Unstable thumb
 Flattened or r...
Reconstruction
 Capsulodesis
 Prevent MCP
Hyperextension
 Dynamic
Procedures
 Static Tenodesis (Parkes)
 Prevents MCP...
Zancolli
Capsulodesis
Volar MP joint Capsulodesis
 A1 pulley release with MP
joint volar plate advancement
 Complicated...
METHODS OF CLAW HAND RECONSTRUCTION
Static procedures :
 To maintain MP joint in some degree of flexion
or to limit MP jo...
Proximal Phalangeal Flexion Static Techniques
 Fasciodermadesis ( Zancolli )‡
 Excision of 2 cm of the palmar skin (derm...
Dorsal Methods (Howard; Mikhail)
To provide bony block to proximal phalangeal
extension
Enables long extensors to extend...
Static Tenodesis Techniques
 Riordan
One half of ECRL and ECU tendons made use of
as “grafts” to prevent hyperextension o...
Dynamic procedures:Integration of
Finger Flexion
Fowler tenodesis
 Incorporates active wrist motion
to tension static ten...
Tendon Transfers
Ulnar Nerve Palsy
 Wrist Motors For Proximal Phalanx Power
 Muslces Available
 ECRL
 ECRB
 Brachiora...
Tendon Transfers
Ulnar Nerve Palsy
 Thumb-Index Key Pinch
 Requires Thumb Adduction And Flexion
 Loss Of Adductor And I...
Tendon Transfers
High Ulnar Nerve Palsy
 Significant Deficit
 FCU And FDP Paralysis
 Decreased Power Grip
 Options
 F...
Tendon Transfers
Ulnar Nerve Palsy
 Preferred Transfers
1) Thumb Adduction
 ECRB  Adductor Tubercle Thumb
 FDS (Long) ...
Tendon Transfers
Ulnar Nerve Palsy
 Preferred Transfers
3) Clawed Fingers
 ECRL – Four Tailed Tendon Graft
 FCR – If Wr...
BROWN’S 4 TAILED ECRL TFR
Sciatic Nerve
Sciatic Nerve
 Analogous to brachial
plexus.
 anterior primary rami of
L5, S1, S2, and S3
 trunk formed by the
posterio...
 leaves pelvis through sciatic notch
 common peroneal part laterally and tibial part
medially
 descends deep to the glu...
Mode of injury
 Hip
 gunshot wound to the thigh or buttock.
 posterior dislocation and fracture-dislocation of the hip,...
Examination
 Muscles supplied by the peroneal component
include the anterior tibial and the long extensors of
the toes (d...
 Foot drop:
 equinus deformity of the foot, clawing of the toes, and
atrophy of the muscles innervated by the nerve,
dep...
 The autonomous zone of the
sciatic nerve includes
 metatarsal heads and over the
heel,
 the lateral and posterior
aspe...
Treatment
Methods of Closing Gaps
 Mobilizing the nerve : 15 cm
 flexing the knee
 hyperextending the hip.
 When the f...
After treatment
 immobilized in a double spica cast extending from the
nipple line to the toes
 Critical Limit of Delay of Suture
 12 to 15 months
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
peripheral nerve injuries
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brachial plexus, radiAL, MEDIAN ,ULNAR,LUMBOSACRAL PLEXUS,SCIATIC , peroneal ,tibial nerves

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peripheral nerve injuries

  1. 1. MAJ VIVEK MATHEW RESIDENT DEPT OF ORTHOPAEDICS
  2. 2. Nerve injuries  Anatomy  Causes  Patterns of injury  Examination  Principles of Surgery  Reconstructive surgery
  3. 3. ANATOMY  Continuation of posterior cord of brachial plexus  C5,C6, C7, C8,(T1)  Primarily motor nerve  Innervates  Triceps  Supinators of the forearm  Extensors of the wrist, fingers, and thumb.
  4. 4. • Formed in front of subscapularis;pass anterior to lat dorsi to pass through the triangular interval • accompanied by the profunda brachii artery
  5. 5. upper arm • enters posterior (extensor) compartment • supplies triceps • re-enters anterior compartment of arm by piercing lateral intermuscular septum.
  6. 6. • At the level of the lateral epicondyle • gives off posterior interosseous nerve • passes between two heads of supinator • enters the extensor compartment of the forearm.
  7. 7. • The superficial radial nerve continues into the forearm in the anterior compartment deep to brachioradialis • terminates by supplying the skin over the posterior aspect of the thumb, index, middle and radial half of the ring finger
  8. 8. Causes:Radial Nerve injury  Fractures of humeral shaft  Gunshot wounds, lacerations of arm and proximal forearm  Injection injuries  Entrapment syndromes  in the arm : fibrous arch of the lateral head of the triceps muscle.
  9. 9. PIN ENTRAPMENT SYNDROME  Two types of posterior interosseous nerve entrapment (Spinner).  Type I  Complete paralysis of all muscles supplied by the nerve  include  extensor digitorum communis,  extensor indicis proprius,  extensor digiti quinti,  extensor carpi ulnaris,  abductor pollicis longus,  extensor pollicis brevis.  Type II  only one or a few of these muscles are paralyzed.
  10. 10. PIN ENTRAPMENT SYNDROME  . posterior interosseous nerve :  fracture-dislocations or dislocations of the elbow,  fractures of the forearm,  Volkmann ischemic contracture, ,  aneurysms,  rheumatoid synovitis of elbow
  11. 11. Radial Tunnel Syndrome  Entrapment of the posterior interosseous nerve leading to chronic and refractory tennis elbow (Roles and Maudsley).  Four potentially compressive anatomical structures:  (1) the origin of the extensor carpi radialis brevis,  (2) adhesions around the radial head,  (3) the radial recurrent arterial fan, and  (4) the arcade of Frohse as the posterior interosseous nerve enters the supinator.  Presentation:  Pain in the region of the radial nerve beneath the extensor mass at and just distal to the radial head,  pain on resistance to supination of the forearm,  electrodiagnostic measures
  12. 12. Superficial Radial Nerve palsy  Etiology:  nerve may be caught in scar tissue at the wrist after surgery or trauma.  Constricting jewelry  Presentation:  pain in forearm  sensory impairment on the dorsum of the thumb.
  13. 13. Examination  Following muscles can be tested accurately because their bellies or tendons can be palpated:  triceps brachii,  brachioradialis,  extensor carpi radialis,  extensor digitorum communis,  extensor carpi ulnaris,  abductor pollicis longus,  extensor pollicis longus.
  14. 14. Diagnosis  Inability to  extend the elbow  supinate the forearm  wristdrop.  An inexperienced examiner often may be misled by the patient's ability to extend the wrist merely by flexing the fingers.
  15. 15. Examination  by injuries of the nerve at the level of the middle of the humerus or distally.  triceps not seriously affected  In injuries of the nerve at its bifurcation into the deep and superficial branches,  the brachioradialis and the extensor carpi radialis longus continue to function;  the arm can be supinated, and the  wrist can be extended.  The nerve is especially susceptible to electrical stimulation in situ just proximal to the elbow
  16. 16.  Sensory examination  no autonomous zone.  If present : over the first dorsal interosseous muscle, between the first and second metacarpals.  too inconsistent  confirmatory evidence of complete interruption of the nerve proximal to its bifurcation at the elbow.
  17. 17. HIGH V/S LOW LESIONS
  18. 18. Treatment  Methods of Closing Gaps  Interfascicular nerve grafting:preferred method  Mobilization techniques  In axilla & proximal arm on medial side proximal to the point of emergence of branches to triceps,  6 to 7 cm  without sacrificing the branches to the triceps  Resecting humerus not feasible at this level.
  19. 19. Treatment  Methods of Closing Gaps  In middle third of arm,  10 to 12 cm  mobilizing the nerve from the elbow to the clavicle  widely stripping the branches of the nerve, by  Flexing & externally rotating shoulder, adducting arm across the chest,  sacrificing branch to brachioradialis (if biceps is functioning).  Transposing the nerve beneath the biceps anterior to the humerus,  3 to 4 cm of humerus resection in presence of nonunited fracture humerus
  20. 20. Prognosis  More favorable than for any other major nerve in the upper extremity because  it is predominantly a motor nerve  muscles innervated by it are not involved in the finer movements of the fingers and hand.
  21. 21.  Results of Suture of the Radial Nerve  Only motor recovery is important in suture of the radial nerve.  89% obtain recovery of proximal muscles  63% regain useful function of all muscles supplied by the radial nerve,  36% regain some fine control of the extensors of the fingers and thumb.
  22. 22.  Critical Limit of Delay of Suture (Zachary)  Radial nerve  15 months.  posterior interosseous nerve  9 months
  23. 23. TENDON TRANSFERS FOR RADIAL NERVE PALSY
  24. 24. Tendon transfered Tendon transferred to Pronator Teres Extensor Carpi Radialis Brevis Flexor Carpi Radialis Extensor Digitorum Communis Palmaris Longus Extensor Pollicis Longus
  25. 25. Anatomy  Formed by junction of lateral and medial root of median nerve from the medial and lateral cords of the brachial plexus in the axilla  Composed of fibers from( C5), C6, C7, C8, and T1.  From the sensory standpoint, they are more disabling than injuries of the ulnar nerve because they involve the digits used in fine volitional activity
  26. 26.  After originating from the brachial plexus in the axilla, the median nerve descends down the arm, initially lateral to the brachial artery.  Halfway down the arm, the nerve crosses over the brachial artery, and becomes situated medially.  The median nerve enters the anterior compartment of the forearm via the cubital fossa.  In the forearm, the nerve travels between the flexor digitorum profundus and flexor digitorum superficialis muscles.
  27. 27.  The median nerve gives rise to two major branches in the forearm:  Anterior interosseous nerve - Supplies the deep muscles in the anterior forearm.  Palmar cutaneous nerve - Innervates the skin of the lateral palm.  The median nerve enters the hand via the carpal tunnel, where it terminates by dividing into two branches:  Recurrent branch – Innervates the thenar muscles.  Palmar digital branch – Innervates the palmar surface and fingertips of the lateral three and half digits. Also innervates the lateral two lumbrical muscles.
  28. 28. Causes  Lacerations, usually in forearm or wrist.  In the upper arm,  relatively superficial lacerations  excessively tight tourniquets  humeral fractures,  when injured near axilla, the ulnar and musculocutaneous nerves and the brachial artery also are commonly injured.  In the arm, the median nerve may be compressed by the ligament of Struthers.
  29. 29.  At the elbow, the nerve may be injured in  supracondylar fractures  posterior dislocations of the elbow.  Pronator syndrome  At the wrist, the median nerve may be injured by  fractures of the distal radius  fractures and dislocations of the carpal bones.
  30. 30. Examination  Pronator Teres,  Flexor Carpi Radialis,  Flexor Digitorum Profundus (Index),  Flexor Pollicis Longus,  Flexor Digitorum Sublimis,  Abductor Pollicis Brevis.  Substitution movements  caused by action of intact muscles may cause confusion during the examination.
  31. 31.  Usually, if the forearm can be actively maintained in pronation against resistance, the pronator teres is intact.
  32. 32.  If the wrist can be actively maintained in flexion, and a contracting flexor carpi radialis is palpated, this muscle is intact.
  33. 33.  if the interphalangeal joint of the thumb can be maintained in flexion against resistance with the wrist in the neutral position and the thumb adducted, the flexor pollicis longus is functioning.
  34. 34.  Although opposition of the thumb can be difficult to confirm, if the thumb can be actively maintained in palmar abduction and a contracting abductor pollicis brevis is palpated, this muscle is functioning.
  35. 35.  The flexor digitorum sublimis to each finger is examined separately, while the remaining fingers are held in full passive extension.
  36. 36.  Sensory supply of the median nerve  volar surface of thumb, index and middle fingers  radial half of the ring finger  dorsal surfaces of the distal phalanges of the index and middle fingers are supplied by the median nerve.  autonomous zone  dorsal and volar surfaces of the distal phalanges of the index and middle fingers  Autonomic changes  Iodine starch test  Ninhydrin print test.
  37. 37. Tendon Transfers Median Nerve Palsy  Classification 1) High  Above Origin Of Anterior Interosseous Nerve  Pronator Teres And Quadratus, FCR, FDS (II – V), FDP(II & III) And FPL Paralyzed 2) Low  Thenar Intrinsic Muscles Paralyzed  Abductor Pollicis Brevis, Opponens Pollicis, And Superficial Head Of Flexor Pollicis Brevis
  38. 38. TREATMENT  If the onset of paralysis has been spontaneous, the initial treatment is nonoperative.  Surgical exploration  indicated in absence of clinical or EMG improvement after 12 weeks.  If nerve injury is caused by a penetrating wound, primary repair is recommended.  In irreparable injury to the nerve, tendon transfers are indicated
  39. 39. Results of Suture of the Median Nerve  Motor recovery is crucial after median nerve repair;  Hand without median nerve sensory supply is almost useless.  Even with the best sensory recovery, the patient probably will have difficulty with stereognosis.
  40. 40.  50 %patients with recover sensitivity to pain and touch and some stereognosis  90% of these patients recover a useful degree of motor function in the long flexors of the forearm  In more distal lesions, about two thirds attain some useful motor recovery
  41. 41. CRITICAL LIMIT OF DELAY OF SUTURE  Motor recovery in the intrinsic muscles of the hand  9 months in high lesions  12 months in low ones.  Sensory recovery  9 months in high lesions  12 months in low ones  may occur when suture has been delayed 2 years.  Sensory return in children is possible, however, after longer delays.
  42. 42. TENDON TRANSFERS Median Nerve Palsy  Reconstructive Goals  Thumb Opposition  FPL Function  Index FDP Function  Sensation  Prime Determinant In Hand Function
  43. 43. Tendon Transfers Low Median Nerve Palsy  Deficit And Deformity  Abduction And Opposition Frequently Retained  Due To Diverse Innervation Of Intrinsics  Median And Ulnar Nerves
  44. 44. Tendon Transfers: Opponenspalsty  Standard Opponensplasties 1) FDS Opponensplasty  Royle-Thompson Technique  Bunnell Technique 2) Extensor Indicis Proprius Opponensplasty 3) Huber Transfer  Abductor Digiti Minimi 4) Camitz Procedure  Palmaris Longus
  45. 45. Tendon Transfers Low Median Nerve Palsy 1) FDS Opponensplasty – Royle-Thompson  FDS Brought Around Ulnar Border Of Palmar Aponeurosis  FDS Has A Large Potential Excursion  Adjusting Tension Not As Critical  Margin For Error
  46. 46. Tendon Transfers Low Median Nerve Palsy 1) FDS Opponensplasty – Bunnel Technique  Ring Finger FDS Divided  FCU Exposed  4cm Proximal To Pisiform Insertion  Tendon Split Into Two Halves  Free End Looped Back Onto Its Base  Ensure Loop Not Too Tight
  47. 47. Tendon Transfers Low Median Nerve Palsy 2) Extensor Indicis Proprius Opponensplasty  Popular In High Median Nerve Palsy  Ring And Middle FDS Unavailable  Does Not Weaken Grip  Tendon Must Be Superficial To FCU  Avoid Compression To Ulnar Nerve
  48. 48. 3. Huber Transfer
  49. 49. Tendon Transfers Low Median Nerve Palsy 4) Camitz Procedure  Tfr of PL to APB  Performed At Same Time As Carpal Tunnel Release  Restores Palmar Abduction  Palmaris Longus Usually Scarred
  50. 50. Tendon Transfers High Median Nerve Palsy  Deficit  All Flexor Compartment Forearm Muscles  Apart From Ulnar-Innervated FCU And FDP  Aim Of Tendon Transfers  Flexion Of Index And Thumb  Opposition  Potential Motors  Brachioradialis  FPL  ECRL  Index FDP
  51. 51. Tendon Transfers High Median Nerve Palsy  Extrinsic Transfers  Restoration Of Index Function  ECRL  Index FDP  Side-To-Side Suturing Of Profundus Tendons  Restores Range Of Motion  Strength Is Not Restored
  52. 52. Tendon Transfers High Median Nerve Palsy  Extrinsic Transfers  Restoration Of Thumb Function  Brachioradialis  FPL
  53. 53. Tendon Transfers High Median Nerve Palsy  Thumb Opposition  Early Transfer  Allows Pronation Of Hand  Compensates For Loss Of Sensation  Possible Transfers  EIP  EPL  Extensor Digiti Minimi  FCU – Eliminates Only Functioning Wrist Flexor
  54. 54. ANATOMY  continuation of medial cord  C7, C8, T1  no branches in the upper arm.  enters the posterior compartment of the upper arm midway down its length by piercing the medial intermuscular septum,  passes behind the medial epicondyle of the humerus to enter the forearm
  55. 55. ANATOMY  Gives articular branch to elbow  descends to the wrist deep to flexor carpi ulnaris.  supplies flexor carpi ulnaris and the ulnar half of flexor digitorum profundus.
  56. 56. ANATOMY  Just proximal to the wrist it gives off a dorsal cutaneous branch that supplies the skin over the dorsal aspect of the little finger and the ulnar half of the ring finger
  57. 57. ANATOMY  crosses into the palm superficial to the flexor retinaculum in Guyon's canal.  It divides into a  motor branch, which supplies the  hypothenar muscles,  the intrinsic muscles of the hand (apart from the radial two lumbricals)  adductor pollicis, and  cutaneous branches,  supply the skin of the palmar aspect of the little finger and the ulnar half of the ring finger
  58. 58. Anatomy
  59. 59. Anatomy
  60. 60. Causes  Axilla / upper arm :  usually accompanied by other nerves and brachial artery  Midarm :  relatively protected  Distal arm , elbow :  Dislocation of elbow  Supracondylar fractures  Distal forearm/wrist :  Gunshot , laceration , fractures or dislocations
  61. 61. Other causes  Traction on nerve  Subluxation or dislocation of nerve  Entrapment syndrome  Displaced fractures of medial humeral epicondyle  Tardy ulnar nerve palsy  Shallow ulnar groove on posterior aspect of medial humeral epicondyle  Hypoplasia of humeral epicondyle  Inadequate fibrous arch  Prolonged flexion at elbow  Direct pressure during surgery
  62. 62. TYPES  High ulnar nerve palsy:  All extrinsic and intrinsic muscles affected  Sensory loss over palmar and dorsal aspect of medial third of hand , sensory loss over palmar and dorsal aspect of whole of little finger and ulnar half of ring finger  Low ulnar nerve palsy :  Only deep intrinsic muscles affected  No sensory loss over proximal and middle phalynx of little and ring finger due to sparing of dorsal cutaneous branch
  63. 63. High ulnar palsy
  64. 64. LOW ULNAR NERVE PALSY
  65. 65. Examination  “ Claw hand “ deformity : Benediction hand  Flattened palm and wasting of hypothenar region  Shallow midpalmar receptacle distal to thenar and hypothenar eminences  Longitudinal palmar furrows between prominent long flexors ( wasting of lumbricals )  Concavities in intermetacarpal spaces  Loss of sensation over the little finger and ulnar half of ring finger  Trophic changes , ulceration , brittle nails
  66. 66. Patho-anatomy of deformity  Paralysis of interossei and lumbricals Unopposed MCP joint extension & IP joint flexion by digital extensors & flexors  Without stabilization of MCP joints in neutral/slight flexed position, long extensor function “blocked” at MP joint by diversion of this tension to sagittal band, producing hyperextension and effectively blocking the extensor's ability to extend PIP joint.‡
  67. 67. Specific signs and tests for motor dysfunction Duchenne's sign : Hyperextension at MCP joints & flexion at IP joints of ulnar two fingers  Bouvier’s maneuver : Dorsal pressure over proximal phalanx to passively flex MP joint results in straightening of distal joints and temporary correction of claw deformity  Extensor digitorum tendon can extend middle and distal phalanges when proximal phalanx stabilized Andre-Thomas sign : On palmar -flexon of wrist exaggeration of deformity
  68. 68.  Pitres-Testut sign : Inability to actively move long finger in radial and ulnar deviation with palm placed flat  Cross your fingers test : Inability to cross middle finger dorsally over index finger, or index over middle finger Masse's sign: Flattened metacarpal arch and loss of hypothenar elevation  Wartenberg's sign : Inability to adduct extended little finger to extended ring finger
  69. 69.  Jeanne’s sign : Hyperextension of MP joint of thumb during key pinch or gross grip Froment’s sign : Thumb IP joint flexion while attempting to perform lateral pinch Bunnell’s O sign : Combined hyperextension at MP joint and hyperflexion of IP joint (noticed when patient makes a pulp to pulp pinch with thumb and index finger)
  70. 70. Examination
  71. 71. Examination
  72. 72. Examination
  73. 73. Examination
  74. 74. ANOMALOUS INNERVATION PATTERNS  5 -10 % cases : FCU innervated by C7  Martin- Gruber anastomosis :  Between median and ulnar Nerve  Marinacci Communication  b/w ulnar and median in forearm
  75. 75. ANOMALOUS INNERVATION PATTERNS  Richie – Cannieu anastomosis :  Anomalous connection between motor branch of ulnar nerve and recurrent branch of median nerve near wrist  Berretini anastomosis  b/w common digital brs of median & ulnar nerve
  76. 76. PRINCIPLES OF SURGERY  Sensation recovers earlier than motor power after suturing  Critical limit of delay :  motor :  6-9 months for lesions at elbow  12 -15 months for lesions at wrist  Sensory :  2 years  Vascularity of the limb should be adequate , joints should be fully mobile and power of muscles to be transferred should be adequate  No contractures permissible
  77. 77.  Nerve repair  Transposition  Medial epicondylectomy  Reconstructive surgery PRINCIPLES OF SURGERY
  78. 78. INCISION  Nerve repair : ,  Incision given over tendon of pectoralis ,curving over natural folds of axilla and then over medial aspect of arm  6-8 cm proximal to elbow , curve incision slightly posteriorly  Continue incision and dissection along ulnar side of volar aspect of forearm  free it from FCU at its origin at humeral epicondyle or resect epicondyle 2 cm in wrist and 4 cm at elbow can be overcome by transposition 11 -15 cm by flexion of elbow , wrists Posterior splint or slab needed for 2 -4 weeks
  79. 79. Principles of Surgery  Transposition :  With arm abducted and externally rotated . Incision made on posteromedial surface of elbow , 7 cm proximal to epicondyle  Reflect skin flap anteriorly and identify nerve in its groove  Free FCU from its humeral origin
  80. 80. Principles of Surgery  Transposition :  Identify branches to FCU and FDP and dissect them intraneurally  nerve freed from Arcade of Struthers till the point where nerve lies between 2 heads of FCU  Divide the tendinous origin or medial epicondyle for submuscular transfer
  81. 81. Medial Epicondylectomy Entire medial epicondyle and part of supracondylar ridge removed
  82. 82. RECONSTRUCTIVE SURGERY  Deformities and deficiencies correctable by surgery  Claw hand  Unstable thumb  Flattened or reversed distal transverse arch  Loss of strong adduction of 1st metacarpal  Loss of abduction of index finger  Abnormal abduction of little finger  Loss of sensibility in autonomous area of little finger  Weakness of flexion in ulnar deviation of wrist  Wasting of intermetacarpal spaces
  83. 83. Reconstruction  Capsulodesis  Prevent MCP Hyperextension  Dynamic Procedures  Static Tenodesis (Parkes)  Prevents MCP Hyperextension  Provides IP Extension  Tendon transfers
  84. 84. Zancolli Capsulodesis Volar MP joint Capsulodesis  A1 pulley release with MP joint volar plate advancement  Complicated claw hands with MP joint contracture Zancolli incorporated collateral ligament release on both sides of MP joint with volar capsuloplasty
  85. 85. METHODS OF CLAW HAND RECONSTRUCTION Static procedures :  To maintain MP joint in some degree of flexion or to limit MP joint hyperextension  claw posture reversed by functioning long extensors  Flexion of MP joint unrestricted in static procedures
  86. 86. Proximal Phalangeal Flexion Static Techniques  Fasciodermadesis ( Zancolli )‡  Excision of 2 cm of the palmar skin (dermadesis) at MP joint level combined with shortening of pretendinous band of palmar aponeurosis (fasciodermadesis) to correct claw hands with weak extensors
  87. 87. Dorsal Methods (Howard; Mikhail) To provide bony block to proximal phalangeal extension Enables long extensors to extend IP joints and correct deformity. Mikhail inserted bone block on dorsum of the metacarpal head
  88. 88. Static Tenodesis Techniques  Riordan One half of ECRL and ECU tendons made use of as “grafts” to prevent hyperextension of MP joint while remaining half continue to actively extend wrist
  89. 89. Dynamic procedures:Integration of Finger Flexion Fowler tenodesis  Incorporates active wrist motion to tension static tendon grafts  Free tendon grafts sutured to extensor retinaculum of wrist and passed in a dorsal to palmar direction through the intermetacarpal spaces, volar to the DTML, through the lumbrical canals, and onto the lateral bands of dorsal extensor expansion of 4 fingers
  90. 90. Tendon Transfers Ulnar Nerve Palsy  Wrist Motors For Proximal Phalanx Power  Muslces Available  ECRL  ECRB  Brachioradialis  FCR  Gross Grip Power Improved
  91. 91. Tendon Transfers Ulnar Nerve Palsy  Thumb-Index Key Pinch  Requires Thumb Adduction And Flexion  Loss Of Adductor And Interossei  FPL And EPL Contribute  Lesser Extent  75 – 80% Loss With Ulnar Nerve Palsy Arthrodesis Of MCP & IP Joints Of Thumb An Option
  92. 92. Tendon Transfers High Ulnar Nerve Palsy  Significant Deficit  FCU And FDP Paralysis  Decreased Power Grip  Options  FDP Paralysis  Tenodesis Of Profundus Tendons  FCU Paralysis  Consider Transfer FCR To FCU
  93. 93. Tendon Transfers Ulnar Nerve Palsy  Preferred Transfers 1) Thumb Adduction  ECRB  Adductor Tubercle Thumb  FDS (Long)  Adductor Tubercle Thumb 2) Thumb-Index Tip Pinch  APL  First Dorsal Interosseous & Arthrodesis Thumb MP  EPB  First Dorsal Interosseous & Arthrodesis Thumb MP
  94. 94. Tendon Transfers Ulnar Nerve Palsy  Preferred Transfers 3) Clawed Fingers  ECRL – Four Tailed Tendon Graft  FCR – If Wrist Flexion Contracture 4) Distal Finger Flexion (High Palsy)  FDP (Long) Tenodesed To FDP (Ring & Little) 5) Radial Wrist Flexion (High Palsy)  FCR  FCU
  95. 95. BROWN’S 4 TAILED ECRL TFR
  96. 96. Sciatic Nerve
  97. 97. Sciatic Nerve  Analogous to brachial plexus.  anterior primary rami of L5, S1, S2, and S3  trunk formed by the posterior divisions form common peroneal part  trunk formed by the anterior divisions becomes the tibial part of the sciatic nerve  diameter 2 to 2.5 cm
  98. 98.  leaves pelvis through sciatic notch  common peroneal part laterally and tibial part medially  descends deep to the gluteus maximus to the level of the inferior gluteal fold  follows a more superficial course to the distal third of the thigh  supplies articular branches to the hip joint& hamstrings  In apex of popliteal fossa, common peroneal part leaves laterally to supply the short head of the biceps femoris & deviates laterall  larger tibial nerve, which continues distally in the midline of the limb.
  99. 99. Mode of injury  Hip  gunshot wound to the thigh or buttock.  posterior dislocation and fracture-dislocation of the hip,  intramuscular injection into the buttock  surgery around the hip joint.  Compression of the sciatic nerve by wear debris from long- standing total hip replacements  Compression caused by anatomical variations in the relationship of the nerve to the gluteal and piriformis muscles and to the sciatic notch may cause sciatic pain.  Thigh  penetrating wounds and fractures of the femoral shaft.  Peroneal half of the nerve is injured much more often than is the entire nerve.
  100. 100. Examination  Muscles supplied by the peroneal component include the anterior tibial and the long extensors of the toes (deep peroneal nerve) and the peroneus longus and the peroneus brevis (superficial peroneal nerve).
  101. 101.  Foot drop:  equinus deformity of the foot, clawing of the toes, and atrophy of the muscles innervated by the nerve, depending on the level of the injury.  Profound weakness of flexion of the knee,  inability to dorsiflex the foot or extend the toes,  inability to plantar flex and evert the foot,  inability to flex the toes may be seen.  Peroneal part: sensory loss primarily over the lateral aspect of the leg and dorsum of the foot.  When the tibial nerve is involved, the sensory deficit is primarily over the plantar aspect of the foot.  Autonomic disturbances and chronic pain may follow an injury to the sciatic or tibial nerve..
  102. 102.  The autonomous zone of the sciatic nerve includes  metatarsal heads and over the heel,  the lateral and posterior aspects of the sole of the foot,  the dorsum of the foot as far medially as the second metatarsal,  a narrow strip up the lateral aspect of the leg.
  103. 103. Treatment Methods of Closing Gaps  Mobilizing the nerve : 15 cm  flexing the knee  hyperextending the hip.  When the femur has been fractured and the sciatic nerve divided, it is very important, even in the presence of draining sinuses, to operate on the nerve before the femur has united because, aside from the effect of time on the nerve ends and muscles, the knee may stiffen, and it may be impossible to flex it enough to close large defects.  Resecting a part of the femur may be necessary to help close the gap. When a fracture is present, such a resection may be justified and can be done with ease.  autogenous interfascicular nerve grafting  especially in young patients.
  104. 104. After treatment  immobilized in a double spica cast extending from the nipple line to the toes
  105. 105.  Critical Limit of Delay of Suture  12 to 15 months
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brachial plexus, radiAL, MEDIAN ,ULNAR,LUMBOSACRAL PLEXUS,SCIATIC , peroneal ,tibial nerves

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