PERIPHERAL NERVE INJURIES

STRUCTURE OF A PERIPHERAL NERVE

Peripheral nerve consists of masses of axis cylinders/axons, each with a neurilemmal tube.
Axon is a direct continuation of dorsal root ganglion cell. It is enclosed by its Schwann cell
sheath. Axons have a myelin sheath.
In unmyelinated fibres the Schwann cell alone acts as a sheath & in myelinated fibres it forms a
multi-laminated structure that encloses the myelin sheath.
The axon with its Schwann cell & myelin sheath is surrounded by a delicate fibrous tissue called
the endoneurium.
A bundle of such nerve fibres are further bound together by fibrous tissue to form a fasciculus.
Bundles of axons are grouped into fascicles by a dense connective tissue called perineurium.
Nerve fascicles are held together and surrounded by a connective tissue layer, termed the
epineurium. If the nerve contains more than one fascicle, the epineurium may be divided into
epifascicular epineurium surrounding.




CLASSIFICATION OF NERVE INJURIES

1. SEDDONS CLASSIFICATION
2. SUNDERLANDS CLASSIFICATION


SEDDONS CLASSIFICATION
NEUROPRAXIA
Minor contusion or compression of a peripheral nerve with preservation of the axis-cylinder.
Minor edema or breakdown of a localized segment of myelin sheath.
Transmission of impulses is physiologically interrupted for a time.
Recovery is complete in a few days or weeks.

AXONOTMESIS
More significant injury with breakdown of the axon and distal wallerian degeneration but with
preservation of the Schwann cell and endoneurial tubes.
Spontaneous regeneration with good functional recovery can be expected.


NEUROTMESIS
More severe injury with complete anatomical severance of the nerve or extensive avulsing or
crushing injury.
Axon, Schwann cell and endoneurial tubes are completely disrupted.
Perineurium and epineurium also are disrupted to varying degrees.
Significant spontaneous recovery cannot be expected.

SUNDERLANDS CLASSIFICATION
FIRST-DEGREE INJURY
Conduction along the axon is physiologically interrupted at the site of injury, but the axon is not
disrupted.
No wallerian degeneration occurs, and recovery is spontaneous and usually complete within a few
days or weeks.
Similar to Seddons classification Neuropraxia.
Motor function is more profoundly affected than sensory function.
Sensory modalities are affected in order of decreasing frequency as follows: proprioception,
touch, temperature, and pain.
Sympathetic fibers are the most resistant to this type of injury.
Electrical excitability of the nerve distal to the site of injury is preserved.
Return of motor function in the proximal and distal musculature occurs together.
No Tinel sign is present.
Complete restoration of function occurs.


SECOND-DEGREE INJURY
Disruption of the axon is evident
Wallerian degeneration distal to the point of injury and degeneration proximal for one or more
nodal segments.
Integrity of the endoneurial tube is maintained.
The neurological deficit is complete with loss of motor, sensory, and sympathetic function.
Motor reinnervation is accomplished in a progressive manner from proximal to distal in the order
in which nerve branches leave the parent trunk.
Advancing Tinel sign can be followed along the course of the nerve usually at the rate of 1 inch
per month, tracing the progression of regeneration.
Good functional return is achieved.
THIRD-DEGREE INJURY
Axons and endoneurial tubes are disrupted.
Perineurium is preserved.
Scar tissue within the endoneurium can obstruct certain tubes and divert sprouts to paths other
than their own.
Neurological loss is complete.
Duration of loss is more prolonged than in second-degree injury.
Returning motor function is evident from proximal to distal, but with varying degrees of
permanent motor or sensory deficit.
Advancing Tinel sign usually is present.
Complete return of neural function does not occur.

FOURTH-DEGREE INJURY
Axon and endoneurium are disrupted.
Some of the epineurium & perineurium are preserved.
Complete severance of the entire trunk does not occur.
Retrograde degeneration is more severe.
Nerve continuity is maintained only by scar tissue, preventing proximal axons from entering the
distal endoneurial tubes.
No advancing Tinel sign.
Prognosis for significant return of useful function is uniformly poor without surgery.
FIFTH-DEGREE INJURY
Nerve is completely transected, resulting in a variable distance between the neural stumps.
These injuries occur only in open wounds and identified at the time of early surgical exploration.
The likelihood of any significant bridging by axonal sprouts is remote, and the possibility of any
significant return of function without appropriate surgery is equally remote.


Sunderland Histopathic Changes Tinels Sign Prognosis
Axon Endoneurium Perineurium Epineurium
I Contusion Intact Intact Intact Not present Good
II Disrupted Intact Intact Intact Present Good/fair
III Disrupted Disrupted Intact Intact Present Fair/poor
IV Disrupted Disrupted Disrupted Intact No recovery Poor
V Disrupted Disrupted Disrupted Disrupted No recovery poor

NEURONAL DEGENERATION

Process of degeneration distal to a point of injury is called secondary, or wallerian, degeneration.
The reaction proximal to the point of detachment is called primary, traumatic, or retrograde
degeneration.
The time required for degeneration varies between sensory and motor segments and is related to
the size and myelinization of the fiber.
First 3 days after injury - definite morphologic changes become apparent in the axon.
Response to faradic stimulation can be obtained for periods of 18 to 72 hours.
After 2 or 3 days, the distal segment becomes fragmented, and with subsequent fluid loss the
fragments begin to shrink and to assume a more oval or globular appearance.


NEURONAL REGENERATION
As regeneration begins, the axonal stump from the proximal segment begins to grow distally.
If the endoneurial tube with its contained Schwann cells is intact, the axonal sprout may readily
pass along its primary course & re-innervate the end-organ.
Rate of recovery of axon is 1mm per day.
Muscle nearest to the site of injury recovers first, followed by others as the nerve reinnervates
muscles from proximal to distal called as motor march.
If the endoneurial tube is interrupted, the sprouts as many as 100 from one axonal stump may
migrate throughout the damaged areas into the epineural, perineural or adjacent tissues to form an
end neuroma or neuroma in continuity.
An end-neuroma may form when the proximal end is widely separated from the distal end.
A side neuroma indicates a partial nerve cut.

MECHANISM OF INJURY

Fractures & dislocations are the commonest cause of peripheral nerve injuries.
Other mechanisms by which a nerve may be damaged by:
Direct injury cut, laceration.
Infections leprosy.
Mechanical injury compression, traction, friction & shock wave.
Cooling & freezing frost bite.
Thermal injury
Electrical injury electric shock.
Ischaemic injury - Volkmanns ischaemia.
Toxic agents injection tetracycline resulting in radial nerve injury.
Radiation following cancer treatment.

MEDIAN NERVE
The median nerve controls coarse movements of the hand as it supplies most of the long muscles of the
front of the forearm. Therefore called the labourers nerve.
The median nerve, formed by the junction of the lateral and medial cords of the brachial plexus in the
axilla.
Root Value: C6, C7, C8, and T1.
Median nerve injuries often result in painful neuromas and causalgia. Median nerve injuries are more
disabling than injuries of the ulnar nerve because they involve the digits used in fine volitional activity.

CAUSES OF INJURY
1. In the axilla
Associated injury with ulnar &
musculocutaneous nerve & brachial
artery
2. In the arm
Superficial lacerations
Excessively tight tourniquets
Humeral fractures
Trapped by Ligament of Struthers
(fibrous band arising from a bony spur in
the humerus 5cm above the medial
epicondyle)

3. In the elbow
Supracondylar fractures
Posterior dislocations of the elbow
4. In the forearm
Lacerations
5. In the wrist
Compression syndromes (Carpal tunnel
syndrome)
Lacerations
Fractures of the distal radius
Fractures & dislocations of the carpal
bones
Median nerve deficits, as seen in the pronator syndrome, may result from compression of the nerve at the
pronator teres, the lacertus fibrosus, or the fibrous flexor digitorum sublimis arch or from anomalies
including a hypertrophic pronator teres, a high origin of the pronator teres, fibrous bands within the
pronator teres, the median nerve passing posterior to both heads of the pronator teres, or an accessory
tendinous arch of the flexor carpi radialis arising from the ulna.

The anterior interosseous nerve may be injured in fractures and lacerations or may be compressed or
entrapped by any of the following: the tendinous origins of the flexor digitorum sublimis or the pronator
teres, variant muscles such as the palmaris profundus and flexor carpi radialis brevis, accessory muscle
slips and tendons from the flexor digitorum sublimis to the flexor pollicis longus, an accessory head of
the flexor pollicis longus (Gantzer muscle), an aberrant radial artery, thrombosis of the ulnar collateral
vessels, enlargement of the bicipital bursa, or a Volkmann ischemic contracture.

LEVELS OF LESION
1. High median nerve palsy (injury proximal to elbow)
Paralysis of all the muscles supplied by the median nerve
Sensory deficit in skin of the hand
2. Low median nerve palsy (injury in the distal-third of forearm)
Sparing of forearm muscles
Muscles of the hand are paralyzed
Anaesthesia over the median nerve distribution of the hand

Median nerve injured above the elbow
1. Muscles supplied by the median nerve in the cubital fossa, forearm and hand are paralyzed
2. Motor loss:
Pronators Pronator teres, Pronator quadratus
Wrist and finger flexors Flexor Carpi Radialis, Flexor Digitorum Superficialis, Palmaris
Longus, Flexor Pollicis Longus, and Flexor Digitorum Profundus (Lateral Half)
Thenar eminence Abductor Pollicis Brevis, Flexor Pollicis Brevis, Opponens Pollicis
Lumbricals 1
st
& 2
nd

3. Cutaneous loss:
Lateral two-thirds of palm
Loss of sensation on lateral three and half digits including dorsum of distal phalanges.
4. Ape like deformity/ ape-thumb deformity
5. Paralysis of the short muscles of the thumb
6. Wasting of thenar muscles
7. Thumb is adducted & laterally rotated so that 1
st
metacarpal lies in the same plane as the other
metacarpals
8. Opposition of the thumb is lost
9. Vasomotor changes
Odema, pigmentation of skin, nails get friable, dryness of skin.
10. Trophic changes
Flattening of forearm muscles except on medial side
Flattening of thenar eminence leading to ape like deformity

CLINICAL FEATURES
Injury of this nerve at a level above elbow joint results in loss of pronation and a decrease in
flexion of the hand at the wrist joint.
In the hand, thenar muscles are paralysed and atrophy in time. Opposition and flexion movements
of thumb are lost, and thumb and index finger are arrested in adduction and hyperextension
position. This appearance of the hand is collectively referred as ape hand deformity.
In addition, in palmar side of the hand sensation of lateral part of hand, first three fingers and
lateral half of the fourth finger and in dorsal side sensation of distal portions of first three
fingers and lateral half of distal portion of fourth finger is lost.



Injury to median nerve at the wrist
1. Median nerve is most commonly injured at the wrist than at the elbow, this is due to the
superficial position of the nerve at this site.
2. Muscles of the forearm are spared.
3. Muscles of the hand are paralyzed
4. The median nerve controls coarse movement of the hand and is the nerve of grasp. Patient is
unable to pick up a pin with the thumb & index finger. Inability to oppose the thumb is the chief
disability of median nerve lesions at the wrist
5. Ape like deformity/ ape-thumb deformity
6. Paralysis of the short muscles of the thumb
7. Thenar muscles are wasted
8. Thumb is adducted & laterally rotated so that 1
st
metacarpal lies in the same plane as the other
metacarpals
9. Loss of thumb opposition.
10. Paralysis of 1
st
& 2
nd
lumbricals makes the index & middle finger lag behind while making a fist.


Thenar muscle wasting Ape-thumb deformity

DIAGNOSTIC TESTS
1. PEN TEST - Patient keeps his hand flat on the table with palm facing the ceiling. A pen is held
above the thumb & the patient is asked to touch the pen with the tip of his thumb patient is
unable to touch the pen due to the loss of action of abductor pollicis brevis.

2. POINTING INDEX OR OSCHNERS CLASP TEST - if the patient is asked to clasp both the
hands together, index and middle fingers remain straight & fail to flex due to the loss of action of
flexor digitorum superficialis & flexor digitorum profundus (lateral half).
3. BENEDICTION TEST - for the same reason as above patient is unable to flex the index and
middle finger on lifting the hand (this is the position a clergyman uses to bless the couple during
marriage. Hence called benediction test).

ULNAR NERVE
The ulnar nerve is called musicians nerve because it controls fine movements of the fingers through its
extensive motor distribution to short muscles of the hand.

Root Value: C8, T1

CAUSES OF INJURY
1. Causes in the axilla
Crutch pressure
Aneurysm of the axillary vessels
2. Causes in the arm
Fracture shaft of humerus
Gunshot & penetrating injuries
3. Causes at the elbow
Compression by the accessory
muscle
Fracture lateral epicondyle of
humerus
Repeated occupational strains
Recurrent subluxation of the nerve
Compression by the osteophytes
Cubitus valgus deformity


4. Causes in the forearm
Fracture both bones forearm
Incised wounds, gunshot wounds &
penetrating injuries of the forearm
5. Causes at the wrist
Compression by osteophytes
Fracture hook of the hamate
Compression by ganglion
Wrist injuries
6. Causes in the hand
Blunt trauma
Penetrating injuries
Occupational causes

LEVELS OF LESION
1. High ulnar nerve palsy (Above the level of elbow)
Entire nerve function is lost
Sensory deficit in the skin of the hand

2. Low ulnar nerve palsy
Below the elbow at the junction of middle & lower third of forearm
Spared: Flexor Digitorum Profundus & Flexor Carpi Ulnaris
Motor loss hypothenar muscles, Interossei, lumbricals, palmaris brevis
Sensory loss dorsal aspect of hand (medial border) & one and half fingers





3. Proximal to Guyons canal
Spared: Flexor Digitorum Profundus & Flexor Carpi Ulnaris + dorsal sensation
Motor loss hypothenar muscles, Interossei, lumbricals, palmaris brevis
Sensory loss loss of volar sensation

4. Distal to Guyons canal
Spared: Flexor Digitorum Profundus & Flexor Carpi Ulnaris + Hypothenar muscles +
palmaris brevis + dorsal and volar sensations
Motor loss: Interossei and lumbricals

Clinical features of Ulnar Nerve Injury
1. Loss of sensation along the distribution of ulnar nerve
2. Motor loss depending on the type of lesions
3. Wasting of hypothenar muscles, intrinsic muscles of the hand
4. Leading to hollow intermetacarpal spaces on the dorsum of the hand
5. Ulnar claw hand deformity


Hollowing of intermetacarpal spaces

















CONFIRMATORY/DIAGNOSTIC TESTS

1. FROMENTS SIGN/BOOK TEST patient is asked to grasp a book between the thumb &
index finger. Normally, a person will grasp the book firmly with thumb extended using the
adductor pollicis & the first dorsal interosseous muscles. If ulnar nerve is injured, the adductor
pollicis will be paralysed & the patient will hold the book by using the flexor pollicis longus. This
produces flexion at the IP joint of the thumb. This becomes more pronounced if the examiner tries
to pull the book out while the patient tries to hold it.



2. EGAWAS TEST (FOR DORSAL INTEROSSEI) with palm flat on the table the patient is
asked to move the middle finger sideways.



3. CARD TEST it is the inability to hold a card or paper in between the fingers due to loss of
abduction by the palmar interossei.









CLAW HAND DEFORMITY

It is a deformity with hyperextension of the MCP joints & flexion of the IP joints of the fingers.

Types & causes of claw hand:
1. True claw hand
Involvement of ulnar & median nerve
2. Ulnar claw hand
Involvement of ulnar


Complete claw hand Ulnar claw Hand

Features of Claw Hand Deformity:
1. Called as intrinsic minus hand.
2. Loss of intrinsic muscle function due to ulnar nerve injury results in loss of flexion at MCP joints
& extension at IP joints of the fingers.
3. Hyperextension at MCP joint & flexion at the IP joint involving the ring & little fingers more
than the index & middle fingers.
4. The thumb is also adducted by its long extensors because the intrinsics & the abductors are
paralysed.
5. The intermetacarpal spaces are hollowed out due to wasting of the interosseous muscles.
6. Sensory loss medial one and half fingers including their nail beds, medial one-third of palm.
7. Trophic changes long standing cases of paralysis lead to dry & scaly skin. Nails crack easily
with atrophy of pulp of fingers.

ULNAR PARADOX
Higher the lesion of the median & ulnar nerve injury, the less prominent is the deformity & vice versa.
This is because in higher lesions the long finger flexors are paralysed. Loss of finger flexion makes the
deformity look less obvious.

TARDY ULNAR PALSY
1. It is late onset ulnar nerve palsy.
2. Causes:
Malunion or non-union of lateral condyle fracture of humerus
Cubitus valgus
Dislocation of elbow
Recurrent subluxation due to previous trauma
3. Treatment Anterior transposition of the ulnar nerve


RADIAL NERVE INJURY

Radial nerve is the thickest branch of brachial plexus.

Root Value: C5 C8, T1

Causes for Radial Nerve Injury
1. In the axilla
Aneurysm of the axillary vessels
Crutch palsy
2. In the shoulder
Proximal humeral fractures
Shoulder dislocation
3. In the spiral groove (5S)
Shaft fracture
Saturday night palsy
Syringe palsy
Surgical positions
S march (Esmarch) tourniquet
palsy


4. Between spiral groove & lateral epicondyle
Fracture shaft of humerus
Supracondylar fracture of humerus
Penetrating & gunshot injuries
Cubitus valgus deformity
5. At the elbow
Posterior dislocation of elbow
Fracture head of humerus
Monteggia fractures
6. Causes in the forearm
Fracture both bones forearm
Penetrating & gunshot injuries

LEVELS OF LESION

1. Very high radial nerve palsy (in the axilla/above spiral groove) total palsy
2. High radial nerve palsy (at the spiral groove)
Spared: Triceps & Anconeus
3. Low type I:
Between the spiral groove & lateral epicondyle
Spared: Elbow extensor
Motor loss - Wrist, thumb, fingers extensors
Sensory loss dorsum of first web space

4. Low type II:
Below the elbow
Spared: Elbow extensors & Wrist extensors
Motor Loss thumb & finger extensor
Sensory Loss - Sensation of first web space

Clinical features of Radial Nerve Injury:
If the lesion is high, the patient will present with wrist drop, thumb drop & finger drop. Unable to
extend the elbow.
If lesion is low, elbow extension is spared; but the wrist, thumb and finger extension is lost.
Sensation along the posterior surface of the arm & forearm is lost in high lesions and in low
lesions the above sensations are spared. But there is loss of sensation over the dorsal web space.


MANAGEMENT OF PERIPHERAL NERVE INJURIES

ELECTRODIAGNOSTIC TESTING
1. Electromyography (EMG) graphic recording of the electrical activity of a muscle at rest &
during activity.
Immediately after section/injury normal insertional activity
5 10 days after injury denervation changes
5 14 days after section/injury positive sharp waves with denervation
Within 12 days denervation, fibrillation potentials
As Wallerian degeneration progresses (15 30 days) spontaneous fibrillation potentials
Regeneration polyphasic potentials initially
As regeneration progresses low amplitude biphasic or triphasic potentials
2. Strength Duration Curve (S-D curve)
3. Nerve Conduction Studies
4. Tinels Sign
5. Sweat Test
CONSERVATIVE MANAGEMENT
I. During stage of paralysis
1. To prevent or decrease oedema
Positioning
Elevation
Massage
Exercises
2. To maintain circulation of affected area
Active movements
Massage & passive movements (if paralysis is present)
3. To prevent contractures
Passive movements to maintain ROM
Splinting (static)
Stretching
4. To maintain activity and power of unaffected muscles
5. To improve power of affected muscles after wallerian degeneration is over.
6. To maintain function
7. Care of anaesthetic areas

II. Stage of recovery
1. Motor re-education
Initiation of contraction PNF, quick stretch, tendon tapping
Muscle strengthening
Muscle coordination
2. Splinting changed to dynamic splint
3. Sensory re-education
4. Functional activities

SPLINTING IN NERVE PALSIES

Median Nerve Palsy
1. C-splint
a. Maintains thumb in abduction & partial rotation under the second metacarpal and supports
it.
b. Stretches the first web space.
c. Indications - Median nerve injury

2. Short Opponens splint
a. Maintains thumb in abduction & partial rotation under the second metacarpal. The wrist
and fingers are free.
b. Function
Immobilization of the thumb
Improves prehension by providing a stable position against which the fingers can
pinch.
Protects the joint from pain
Stretches the web space
c. Indications
Low median nerve injury
Opponens transfer (6 weeks after surgery post-op)










ULNAR NERVE INJURY
1. Knuckle bender splint
a. Maintains the MCP joint in 90
0
flexion & IP joint in extension
b. Function
Immobilization of fingers
It provides support and stabilizes the wrist in extension
It maintains the transverse palmar arch
It assists in prehension
c. Indication
Total claw hand
Ulnar claw hand
Klumpkes Paralysis
d. Hand position
This splint comprises of a light padded bar across the dorsal aspect of the proximal
phalanges of the third and fourth fingers and a similar one over the upper end of the
metacarpals. These are attached to another padded bar in the palm of hand by a small
spring which pulls the MCP joints into flexion but allows the patient to extend them. The
IP joints of fingers are placed in extension. This splint uses the three-point principle.




2. Hand orthosis with MCP block
a. Prevents clawing of the ring & small fingers while allowing full digital flexion and IP joint
extension.



RADIAL NERVE PALSY

1. Static Cock-up Splint keeps the wrist in dorsiflexion (15
0
- 20
0
) and it extends to keep the MCP
joint in neutral position. Prevents active movements
2. Dynamic Cock-up Splint - Provides mild compression and firm support to the wrist and palm
keeping the fingers available for movement.



SURGICAL MANAGEMENT
Operative procedures for nerve injuries consist of:
1. Nerve repair
2. Neurolysis
3. Tendon transfers
Nerve repair
It may be performed within a few days of injury (primary repair) or later (secondary repair).

Primary repair:
It is indicated when the nerve is cut by a sharp object, and the patient reports early. In such cases
an immediate primary repair is the best.
In case the wound is contaminated or the patient reports late, a delayed primary repair is better.
In the first stage the wound is debrided and the two nerve ends approximated with one or two fine
silk sutures so as to prevent retraction of the cut-ends.
After two weeks, once the wound heals, a definitive repair is made.

Secondary repair:
Indications:
a. Nerve lesions presenting some time after injury: Often nerve injuries are missed at the time of
injury, or it may not have been possible to treat them early for some other reason such as poor
general condition of the patient.
b. Syndrome of incomplete interruption: If no definite improvement occurs in 6 weeks in cases with
an apparently incomplete nerve injury, nerve exploration, and if required secondary repair should
be carried out.
c. Syndrome of irritation: Cases with signs of nerve irritation need exploration and sometimes a
secondary repair.
d. Failure of conservative treatment: If a nerve injury is treated conservatively and no improvement
occurs within 3 weeks, one should proceed to electrodiagnostic studies and explore the nerve, if
required.


Techniques of nerve repair: Nerve repair can be either end-to-end or by using a nerve graft.
a. Nerve suture: When the nerve-ends can be brought close to each other they may be sutured by
one of the following techniques:
Epineural suture
Epi-perineural suture
Perineural suture
Group fascicular repair

Methods of closing nerve gaps: In many cases, the loss of nerve tissue is so much that an end-to-end
suture cannot be obtained. In such a situation, the following measures are adopted to gain length and
achieve an end-to-end suture:
Mobilisation of the nerve on both sides of the lesion.
Relaxation of the nerve by temporarily positioning the joints in a favourable position.
Alteration of the course of the nerve, e.g. the ulnar nerve may be brought in front of the medial
epicondyle.
Stripping up the branches from the parent nerve without tearing them.
Sacrificing some unimportant branch if it is hampering nerve mobilisation.

b. Nerve grafting: When the nerve gap is more than 10 cm or end-to-end suture is likely to result in
tension at the suture line, nerve grafting may be done. In this, an expandable nerve (the sural
nerve) is taken and sutured between two ends of the original nerve.

Neurolysis
1. This term is applied to the operation where the nerve is freed from enveloping scar (perineural
fibrosis). This is called external neurolysis.
2. In many cases, the nerve sheath may be dissected longitudinally to relieve the pressure from the
fibrous tissue within the nerve (intra-neural fibrosis). This is called internal neurolysis.

PROGNOSIS
The following factors dictate recovery following a nerve repair:
1. Age: The lower the age, the better the prognosis.
2. Tension at the suture line: The more the tension, the poorer the prognosis.
3. Time since injury: After 18 months only sensory functions can be expected.
4. Location of injury: The more proximal the injury, the worse the prognosis.
5. Type of nerve: A primarily motor nerve, like radial nerve, has a better prognosis than a mixed
nerve.
6. Condition of the nerve ends: The more the crushing and infection, the poorer the prognosis.
7. Associated conditions: Infection, ischaemia etc. indicate poor prognosis.

Reconstructive surgery
1. These are operations performed when there is no hope of the recovery of a nerve, usually after 18
months. Operations included in this group are tendon transfers, arthrodesis and muscle transfer.
Rarely, an amputation may be justified for an anaesthetic limb or the one with causalgia.




TYPES OF TENDON TRANSFERS IN NERVE INJURIES

Criteria for tendon transfer:
1. The tendon should have muscle power Grade 5 or Grade 4 because after the transfer it loses
muscle power by one grade.
2. It should have its own nerve and blood supply
3. Transfer should be done from a synergistic group.
4. The tendon should be routed in a straight line.
5. Tendon should be sutured in moderate tension.
6. Prior to tendon transfer, joint stiffness, contractures and malunion of bones should be corrected.
7. Age of the patient should be minimum 5 years.
8. The disease should be non-progressive.
9. Any infection of bones and joint should be controlled.
10. Good range of passive movements is available at the joints

Median Nerve Palsy

Opponensplasty - a tendon transfer operation where tendon of flexor digitorum superficialis of the ring
finger is rerouted so that it passes through a pulley created at the flexor carpi ulnaris tendon, and is
attached to the thumb.

Ulnar Nerve Palsy
For Claw Hand Deformity

Principles of treatment
All treatment measures aim at blocking hyperextension at metacarpophalangeal (MCP) joint.
Once MCP joint is stabilised, the long extensors will bring about the extension of IP joints. The
long flexors will help in flexion of the MCP joints along with their action of finger and wrist
flexion.

Methods of stabilisation of MCP joints
Active method involves tendon transfer.
Passive method involves arthrodesis, capsulodesis or tenodesis

Active method this is by tendon transfers.

Types of surgery
1. Modified Bunnels Operation
When finger flexors are strong, wrist flexors and extensors are strong, Modified S. Bunnell
operation is performed.
In this flexor digitorum superficialis of the ring finger is transferred through the lumbrical
canal into the dorsal digital expansion.
2. Riordans operation
When flexion of the wrist is habitual or if there is a flexion contracture of the wrist
In Riordans operation the flexor carpi radialis muscle is removed and transferred with a
free tendon graft leaving behind the flexor carpi ulnaris to bring about the wrist flexion.

3. Brands Operation
When the finger flexors are weak, the wrist flexors are also weak and when the wrist
extensors are strong, extensor carpi radialis longus or brevis is transferred by a free tendon
graft.

4. Fowlers Operation
When finger flexors, wrist extensors are not available for transfer, extensor digitorum
longus tendon of the index and little fingers are transferred by the fowlers technique.

Radial Nerve Palsy

Treatment of late cases (>1 year):
Principles of treatment
1. Active treatment tendon transfers
2. Passive treatment tenodesis, wrist arthrodesis in functional positions is done.

Choice of tendons in active treatment
1. From wrist flexors Flexor carpi ulnaris, Palmaris longus
2. From the pronators pronator teres
3. From the finger flexors flexor digitorum superficialis (rarely chosen)

Tendon Transfer Techniques
1. High Lesions
For elbow extension latissimus dorsi or pectoralis major to the triceps muscle can be
done
2. Low lesions Type I
For wrist extension pronator teres
For finger extension flexor carpi ulnaris split into four slips & transferred dorsally into
four fingers
For thumb extension and abduction palmaris longus
3. Low Lesions Type I I (wrist extension is spared)
For finger extension flexor carpi ulnaris split into four slips & transferred dorsally into
four fingers
For thumb extension palmaris longus
For thumb abduction pronator teres

4. Omers Technique consists of splitting flexor carpi ulnaris into five slips and transferring into
all the five fingers instead of four.

5. Boyes technique - Flexor digitorum superficialis is used instead of flexor carpi ulnaris to bring
about extension of four fingers.