orthopedics,peripheral nerve injury.(dr.baxtiar rasul)
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Transcript of orthopedics,peripheral nerve injury.(dr.baxtiar rasul)
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Peripheral nerve injuries
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Structure of the nerve
Axon
myeline sheath
Schwann cell layer
Endoneurium
Perineurium
Epineurium
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Pathology
The nerve is injured by:
Ischaemia
Compression
Traction
Laceration
burning
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Types of injury
•Transient ischaemia
•Neurapraxia
•Axonotmesis
•Neurotmesis
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Transient ischaemia
Acute nerve compression →
Acute endoneural anoxia →
Temporary numbness + muscle wasting
Recovery by 10 minutes
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Neurapraxia
Chronic mechanical pressure →
Demyelination of axon
Spontaneous recovery after few days or weeks
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Axonotmesis
• Segmental interruption of the axons
• Loss of conduction
• But the neural tubes are intact
• Seen in closed fractures and dislocations
• Distal to the lesion → Wallerian degeneration
• Axonal regeneration occurs by formation of the new axonal processes which grow at a speed of 1-2 mm per t
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Neurotmesis
Division of the nerve trunk
Occurs in open wounds
Neural tubes are destroyed
A Neuroma is formed( regenerating fibers + Schwann cells + fibroblasts)
Function may be adequate but is never normal even after surgical repair.
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Diagnosis
Symptoms: (1) Numbness (2) Tingling (3) Weakness
Signs: (1) Abnormal posture ( wrist drop) (2) Atrophy of the muscles (3) Change in sensibility
Tinels sign: shows progression in nerve recovery
Electrodiagnostic tests (1) level of injury (2) Severity (3) progress of nerve recovery
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Obstetric brachial plexus injuries
Caused by excessive traction on the brachial plexus during childbirth.C5+C6+C7+C8+T1
Clinical features:•Difficult delivery•Flail arm.
•Further examination reveals one of the following: (A) Erb’s palsy (B) klumpke’s palsy
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Erb’s palsy:
Injury of C5+ C6
The arm is held to the side, internally rotated, and pronated.
(i.e paralysis of the abductors and external rotators of the shoulder + the supinators)
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Klumpke’s palsy:
Less common
The arm is flail and pale
All muscles of the fingers are paralyzed
± Ipsilateral Horner’s syndrome
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Treatment:
If there is no biceps recovery by 3 months, surgery is performed:
If the roots are not avulsed: Nerve graft
If the roots are avulsed : Nerve transfer
If severe internal rotation : Subscapularis release ± tendon transfer OR Rotation osteotomy of the humerus
Physiotherapy in all cases
Prognosis in Klumpke’s palsy is poor.
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Axillary nerve injury (C5)
Supplies (1) Deltoid (2) Skin over the lower ½ of the deltoid.
Injured in (1) Shoulder dislocation (2) # of humeral neck
Clinically (1) Loss of abduction (2) Numbness over the deltoid.
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Treatment:
Spontaneous recovery during 8 weeks. If not:
Exploration + repair OR graft. If failed:
Tendon transfer OR Shoulder arthrodesis. .