Pni
-
Upload
shruthi-savanth -
Category
Documents
-
view
111 -
download
1
Transcript of Pni
![Page 1: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/1.jpg)
“My countrymen should have nerves of steel, muscles of iron, and minds like
thunderbolt.”
-Vivekananda
![Page 2: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/2.jpg)
Management of Peripheral Nerve InjuriesDr.Obaidullah Khalid
P.G Orthopaedic surgery
DCMS
Under the guidance of
Dr.C.ShamSunderD.Ortho ,MS Ortho
Professor & HOD
DCMS
![Page 3: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/3.jpg)
Today we shall learn about :
Diagnostic Tests
Prognosis and Rehab
Equipment
General considerations
Factors affecting Neurorrhaphy
Surgery Proper
1
2
3
4
5
6
7
Indications and Time for Surgery
![Page 4: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/4.jpg)
Your own footer Your Logo
Diagnostic tests
The diagnostics give info on :
• Nerve Conduction
• Axon OR Myelin involvement
• To know Muscle recruitment
capability
![Page 5: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/5.jpg)
Nerve Conduction Velocity StudiesDiagnostic tests
![Page 6: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/6.jpg)
Nerve Conduction Velocity StudiesDiagnostic tests
•Should be done Proximal and distal to the
lesion
•Just after injury may show Normal study
•After 5-10 days when Wallerian degeneration is
fully settles in, the amplitude shows significant
decrease.
•If the amplitude recovers in 10 days ;
Neuropraxia
![Page 7: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/7.jpg)
ElectromyographyDiagnostic tests
•If a muscle loses its nerve supply, EMG will show denervation potentials by third week.•This excludes Neuro praxia but not Axonotmesis
![Page 8: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/8.jpg)
Tinel’s signDiagnostic tests
•Tingling sensation is felt all over the area supplied by the nerve
•A positive Tinels sign means Axonal Sprouts are progressing but are still
non myelinated
![Page 9: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/9.jpg)
Sweat testDiagnostic tests
Opthalmoscope
If sweating
occurs,
the test is inferred
positive
Inference : Complete
interruption of nerve conduction
hasn’t occurred.
Why ?
![Page 10: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/10.jpg)
Skin Resistant testDiagnostic tests
10 mA
10 mA
5 mA
9 mA
![Page 11: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/11.jpg)
Open WoundsGeneral Considerations
1Steel suture approximation,
Suturing to adjacent soft
tissue
EXCESS GAPING BETWEEN CUT ENDS
3-7 days after injury
Best time
3 Normal Saline
Lavage with
•Begin after stabilization of all vitals
and vital organs after a trauma in a
hospital set up
•Thorough Debridement and
Lavage of an open wound and
immediate repair if
personnel,expertise and equipment
is available
2
![Page 12: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/12.jpg)
Closed WoundsGeneral Considerations
•In closed wounds, a careful examination for discrete deficits.
Try to localize the site of lesion.PreGang ? Post Gang ?
•Once the wound is healed,splinting should be done in a way
that prevents muscle contactures.
•Begin joint mobilization so that muscles remain in soft state
and perform better during rehab following nerve repair
![Page 13: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/13.jpg)
Is it advisable to wait for any signs of improvement ?
Or should exploration be done ?
![Page 14: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/14.jpg)
• It is better to avoid early exploration.
• Wait till pain of (primary injury) subsides,
• Then do periodic EMGs,NCVstudies and
frequent clinical evaluation.
• BUT
• If examination reveals a transection,it is
preferrable to investigate then -> early
exploration.
![Page 15: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/15.jpg)
After Neurorrhaphy
Factors influencing Regeneration
More the gap,more
difficult to bring
ends together.
More the gap,
more different
fascicular patterns
Brooks : 90’
condition
Nicholson,Seddon,
Sakellarides: 2.5
cm gaping
Gap between Ends
1
Age Time factor
Better in Children
When compared to
Adults
32 It’s the delay
between time of
injury and repair
Affects motor
recovey
Sunderland : +12
Months later
showed significant
result
Kankaanpaa &
Bakalin : Within 3
months repair
showed better
results
Level of injury
More proximal
Bad outcome
Meticulous handling
Asepsis
Blood supply
Alignment of Fasciculi
After 4m, distal end shrinks
Condition of Nerve ends
4
5
![Page 16: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/16.jpg)
Indications for Surgical Exploration
• Sharp injury that has divided the nerve.
• Abrading/Blast wounds have made the condition of
nerve unknown.
• In closed #,when even after sufficient time, no
clinical/electrical evidence of regeneration observed.
• Low energy wounds with no evidence of regeneration.
![Page 17: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/17.jpg)
Surgical ExplorationWhen do we do it ?
• Exact time is multifactorial dependant
• But given a
-clean wound without any complications,
-experienced personnel and good
equipment ;
primary repair in 6-8 hours
secondary repair in 7-18 days
have shown good outcome.
![Page 18: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/18.jpg)
Surgery ProperPrimary Repair
• Should be done as soon as possible
• ADVANTAGES :
Cut ends would not have retracted much
Rotation is usually undisturbed
No fibrosis
![Page 19: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/19.jpg)
Surgery ProperSecondary Repair
• It is Late repair as
Closed injury was treated but showed no signs
of recovery in elapsed time.
• Diagnosis was missed.
• Primary repair Failure.
![Page 20: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/20.jpg)
Surgery Proper
Equipment
![Page 21: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/21.jpg)
Anaesthesia
• General Anaesthesia Upper EX
• Spinal Anaesthesia Lower EX
VS
• Local anaesthesia ; advantage of allowing
evaluation of sensory impulses
![Page 22: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/22.jpg)
Preparation and Draping
• Full extremity till Plexus location should be
prepared
• Pneumatic torniquet
• Mark incision along the course of the nerve
• ? Advisable to keep hand exposed .To check
contractions of muscles of hand
![Page 23: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/23.jpg)
Technique of nerve repair
• Incision is the game changer.
• Never cross flexor crease of skin
Surgery proper
![Page 24: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/24.jpg)
Surgery proper
• Do not hesitate to take a longer incision
• If nerve is dissected from a scar tissue, keepstimulating to make sure what all branches are still functioning
• Before mobilization, suture the epineurium proximal and distal to the lesion so that orientation is unaltered by rotation.
• Releasing torniquet releases ischaemia and surgeon can notice the msucle contraction upon stimulation
Technique of nerve repair
![Page 25: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/25.jpg)
• If NEUROMA confronts, stimulate the nerve and
record.
Inject saline and check the proximal and distal
spread.If positive (spread present), better leave
it alone.
![Page 26: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/26.jpg)
Your own footer Your Logo
Partial NeurorraphySurgery Proper
• Generally done in
Sciatic nerve
• Advised when one
half of the nerve is
disrupted
![Page 27: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/27.jpg)
• Completely severed nerve
• Methods of closing gap ends
Mobilization
Positioning of Extremity
Transpositioning
Bone Resection
Nerve Guides
Nerve Grafting
Nerve crossing
Neurorrhaphy and Nerve grafting
![Page 28: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/28.jpg)
Epineural Neurorraphy
![Page 29: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/29.jpg)
Fascicular Neurorraphy
![Page 30: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/30.jpg)
• Mobilization begins in ten days
InterFascicular NeurorraphyBridging the gaps
![Page 31: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/31.jpg)
MobilizationBridging the gaps
• Little mobilization takes place in almost all
Neurorraphies
• Excess may lead to vascular comprimise
• Cut off are :
• Care should be taken to avoid stripping
small vessels
![Page 32: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/32.jpg)
Positioning of Extremity
• Neurorapphy with too much flexion will
lead to traction upon extension that leads
to intraneuronal fibrosis.
• 90’ should be the cut off for Elbow flexion
• 40’ flexion of wrist
• After wound healing, arithmetic increase in
extension of 10’ per week is adviced.
Bridging the gaps
![Page 33: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/33.jpg)
• Changing anatomical course to shorten
the distance between cut ends.
• Eg Ulnar Nerve at elbow.
Median nerve - anterior to Pronator Teres
Proximal Radial Nerve to ant. of Humerus
TranspositioningBridging the gaps
![Page 34: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/34.jpg)
• Avoid this procedure
• Only implicable when Humerus is already
fractured and a fragment is already
segmented provided, Transpositioning of
nerve is not sufficient.
Bone resectionBridging the gaps
![Page 35: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/35.jpg)
• Described by Seddon and Millesi
• SURAL NERVE is nerve of choice for graft
40 cms can be taken from each leg
• Lat. Antebrachial cutaneous nerve –
20cms from each arm (situated lateral to
BicepsTend)
• Vascularized nerve grafts, Trunk grafts,
allografts have not been described.
Nerve GraftingBridging the gaps
![Page 36: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/36.jpg)
Nerve Guides
Autogenous vien
Freeze dried muscle
![Page 37: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/37.jpg)
• Neuropraxia : Almost 100% recovery
• Higher the lesion,worser the prognosis
• Pure nerve recovery > Mixed nerve recovery
• Children recover better than adults
• Time taken
• Associated lesions
• Surgical technique
Prognosis
![Page 38: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/38.jpg)
• Immobilize 4 weeks with plaster cast/splint
• Followed by 3 weeks of plastic brace that can be
gradually extended.
• Dressing shouldn’t be done till 7th day
• Lower Limb – 6 weeks spica
• For Interfasicular types,Cast is put in the surgical
position itself and is opened on the 10th day
when mobilization is encouraged.
Rehab
![Page 39: Pni](https://reader030.fdocuments.net/reader030/viewer/2022020116/559780741a28ab25218b4752/html5/thumbnails/39.jpg)
THANK YOU!
Your Logo