Traumatic Peripheral Nerve

Injury

TJOK MAHADEWA, M.D.

Presented in Block Neuroscience
27th May 2009

Introduction
Degradation and regeneration of peripheral nerves
is distinct from that of nerves in the central
nervous system
Prognosis of peripheral nerve injury is dependant
upon age, the nerve injured, the level of the
injury, the degree of injury and the timing of
repair
A sophisticated degradation process occurs
following injury, before regeneration of a nerve
can take place
Management of peripheral nerve injuries has
remained largely unchanged over the last century
Management of peripheral nerve injuries requires
a multi-disciplinary team

Signs and Symptoms

Pain
Abnormal Sensations
Weakness
Loss of motor function
Loss of active ROM

Radiculopathy
Process affecting the nerve root,
most commonly by a herniated disc
Weakness in muscles supplied by
the nerve root (myotome)
Sensory loss in the area of the skin
supplied by the nerve root
(dermatome)

Mononeuropathy
Dysfunction of a single peripheral
nerve
Weakness in muscles supplied by
the nerve
Sensory loss in the area of the skin
supplied by the cutaneous
branches of the nerve

Brachial Plexopathy
Can refer to involvement of the
entire plexus, or parts of the plexus
Trunk lesion
Cord lesion
Distribution of weakness and
numbness depends upon the part of
the plexus affected

Sensory Supply to the Arm

Because fibers from different nerve
roots come together and then split
apart in the plexus
A dermatome may include areas of
the skin supplied by different
peripheral nerves
A single nerve may supply sensation
to skin covered by more than one
dermatome

Sensory Supply to the Arm

Because of the pattern of root
contribution to the plexus:
An upper trunk lesion has sensory loss
in the combined C5,6 dermatomes
A middle trunk lesion has sensory loss
in the C7 dermatome
A lower trunk lesion has sensory loss
in the combined C8T1 dermatomes

Dermatomes of the Posterior Arm

Dermatomes of the Anterior

Arm

Principles of Localization
Certain sites are prone to nerve
entrapments/injuries
Nerve opposing bone
Ulnar nerve at the elbow

Closed spaces
Carpal tunnel

Adjacent structures
Median nerve at the elbow, adjacent to
the brachial artery

Order in which branches arise

Movements at specific joints
Single nerve
Elbow extension
Radial

Multiple nerves
Elbow flexion
Musculocutaneous
Radial

Diagnosis
EMG
NCS
MRI

Treatment
OBSERVATION
Medication
SURGERY FOR NERVE REPAIR

Case
A 38 yo woman was the restrained
passenger in a car struck head on
She braced her hands on the dashboard
immediately prior to impact
She suffered bilateral fractures of the
humerus at the spiral (radial) groove
She complains of diffuse aches in her
arms and neck and weakness in her
arms

Case
On exam she has:
Bilateral wrist and finger drop (ie profound
weakness of wrist and finger extension at the
MCPs)
Weakness of supination
Weakness of elbow flexion with forearm held so
that thumb is toward shoulder, but not with hand
held in supination
Remainder of strength exam is normal
She has numbness in the posterior forearm
extending into dorsum of hand into thumb and
proximal index finger

Triceps, long head

Triceps, lateral head

Triceps, med hd

Brachioradialis
ECRL
ECRB Superficial
Supinator
Radial sens
Ext Digit
Abd Pol Longus Post Interosseous
Ext Pol Longus
Ext Pol Br
Ext Indicies

Bilateral radial nerve palsies at the spiral (radial) groove related to fractures

Examples
Superficial radial neuropathy secondary to handcuffs

C6 Radiculopathy secondary to a
herniated disc

On exam :
Weakness of shoulder abduction
Weakness of elbow flexion
Mild weakness of pronation
Sensory loss in her lateral forearm
and thumb both posteriorly and
anteriorly

Ulnar neuropathy at the wrist

Ulnar sensory loss in an ulnar lesion proximal to the
midforearm

Ulnar nerve

Elbow
Flexor carpi ulnaris

Flex Dig Prof III/IV

Dorsal uln cut
Wrist
Adductor Pollicus Abductor
Flex Pollicus Br
Opponens
Flexor
Dorsal/palmar
Interosseous
3rd/4th lumbricals

Digiti Minimi

Related to Trauma
Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs <
1%
Habitual Non traumatic dislocation may present
as Multi directional dislocation due to generalized
ligamentous laxity and is Painless

Anterior Shoulder dislocation

Usually also inferior
Usually Indirect fall on Abducted and extended
shoulder

May be direct when there is a blow on the shoulder

from behind

Clinical Picture
Patient is in pain
Holds the injured
limb with other hand
close to the trunk
The shoulder is
abducted and the
elbow is kept flexed
There is loss of the
normal contour of
the shoulder

Clinical Picture
Loss of the contour of the
shoulder may appear as a
step
Anterior bulge of head of
humerus may be visible or
palpable
A gap can be palpated
above the dislocated head
of the humerus

X Ray anterior Dislocation of

Shoulder

Associated injuries of anterior

Shoulder Dislocation
Injury to the neuro vascular bundle
in axilla ( rare )
Injury of the Axillary or Circumflex
Nerve ( Usually stretching leading to
temporary neuropraxia )
Associated fracture

Axillary Nerve Injury

Also called circumflex
nerve
It is a branch from
posterior cord of Brachial
plexus
It hooks close round neck
of humerus from posterior
to anterior
It pierces the deep surface
of deltoid and supply it
and the part of skin over it

Axillary nerve injury

Management of Anterior Shoulder

Dislocation
Is an Emergency
It should be reduced in less than 24
hours or there may be Avascular
Necrosis of head of humerus
Following reduction the shoulder
should be immobilised strapped to
the trunk for 3-4 weeks and rested in
a collar and cuff

Methods of Reduction of
anterior shoulder Dislocation
Hippocrates Method ( A form of
anesthesia or pain abolishing is
required )
Stimpsons technique ( some
sedation and analgesia are used but No
anesthesia is required )
Kochers technique is the method
used in hospitals under general
anesthesia and muscle relaxation

Hippocrates Method

Stimpsons technique

Kochers Technique

Complications of anterior Shoulder Dislocation

Neuro vascular injury ( rare )

Axillary nerve injury
Associated Fracture of neck of humerus or
greater or lesser tuberosities
Avascular necrosis of the head of the Humerus
(high risk with delayed reduction)
Heterotopic calcification ( used to be called
Myositis Ossificans )
Recurrent dislocation

Fractures of The Humerus

Proximal Humerus (includes surgical and
anatomical neck )
Shaft of Humerus
Distal humerus ( includes Supra Condylar
fracture in children )
Commonly Indirect injury
Indirect injury results in Spiral or Oblique
fractures
Direct injuries results in transverse or comminuted
fracture
May be associated with Radial Nerve injury

Fracture Proximal and Shaft

Humerus

Radial Nerve Injury

Results in Wrist drop
Associated with fracture humerus in up to
12% of fractures
2/3 ( 8%) of Radial injury are Neuropraxia
1/3 ( 4%) are nerve lacerations or
transection

Sciatic Nerve

Composed from roots of L4 to S3.

Peroneal and tibial components differentiate early,
sometimes as proximal as in pelvis.
Passes posterior to posterior wall of acetabulum.
Generally passes inferior to piriformis muscle, but
occasionally the piriformis will split the peroneal
and tibial components

Hip Dislocation: Mechanism of Injury

Almost always due to high-energy trauma.

Most commonly involve unrestrained occupants
in MVAs.
Can also occur in pedestrian-MVAs, falls from
heights, industrial accidents and sporting
injuries.

Posterior Dislocation

Generally results from axial load applied to

femur, while hip is flexed.
Most commonly caused by impact of
dashboard on knee.

Type of Posterior Dislocation

depends on:
Direction of applied force.
Position of hip.
Strength of patients
bone.

Clinical Management:
Emergent Treatment
Dislocated hip is an emergency.
Goal is to reduce risk of AVN
Evaluation and treatment must be streamlined.
Allows restoration of flow through occluded or
compressed vessels.
Literature supports decreased AVN with earlier
reduction.
Requires proper anesthesia.
Requires team (i.e. more than one person).

Sciatic Nerve Injury

Occurs in up to 20% of patients with hip dislocation.
Nerve stretched, compressed or transected.
With reduction:

40% complete resolution

25-35% partial resolution

If No Improvement after 34 Weeks:

EMG and Nerve Conduction Studies for baseline information and
for prognosis.
Allows localization of injury in the event that surgery is required.
For Foot Drop:
Splinting (i.e. ankle-foot-orthosis):
Improves gait
Prevents contracture

SURGERY
NERVE GRAFT
NERVE TRANSFER

REHABILITATION
Brace or Splints
Electrical Stimulator
Physical and Occupational therapy

U Shaped slab

Functional brace Fracture Shaft

of Humerus

Questions?

CONCLUSION
When present in open fractures ; immediate
exploration and repair
In closed injuries treated conservatively after close
reduction-immobilization of the bone ; initial
management is doing Nerve Conduction Studies
( NCS ) and Electromyography ( EMG ) and awaiting
for spontaneous recovery
Recovery usually starts after few days but may take
up to 9 months for full recovery
If No spontaneous recovery occurs in 12 weeks
confirmed by NCS and EMG ;then exploration of the
nerve should be carried out