1. Peripheral Nerve Injury
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Peripheral Nerve Injury
同济医院骨外科 黄仕龙

2. Contents General topic Specific injury radial nerve introduce
definition
classification
pathological change
outcomes
diagnosis
treatments
Specific injury
radial nerve
median nerve
ulnar nerve
femoral nerve
tibial nerve
peroneal nerve

3. What is peripheral nerve?
It is a structures which connects central nerve system and terminal orgnas, and transmits electronic potential.
Moter nerve
Sensory nerve
Mixed nerve
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6. Functions & Characteristics
Transmit electronic information
Features
1. conductivity
2. reproducibility

7. How many? Who are they? 31 pairs C1-4 cervical plexus
C4-Th1 brachial plexus
Th1-Th12 thoracic nerve
Th2-L4 lumbar plexus
L4-S5 sacral plexus：

8. Classification
Neuropraxia
Axonotmesis
neurotmesis

9. Histopathological change
Neuropraxia
Most minor damage, such as slight tension…
Appearance is intact, may have cell or molecular change;
Lose conductivity temporary;
A movement disorder, but without atrophy;
B sensory disorder, but still exist;
C with biological potential

10. histopathological change
Axonotmesis
medium damage, such as contusion..
Appearence: looks good, bead-shape, or hollow feeling;
Histological: epineurium intact, but fiber rupture, or tract damage with inner haemorrhagia and scar;
Lose moter, sensory, and electronic reaction.

11. Histopathological change
Neurotmesis
Severe damage, such as shape damage, avulsion..
Continuity was totally broken;
Without any moter, sensory, vegetative nervous reaction, muscle begin atrophy;
Without any potential.

12. Pathological outcome During w1-w4：
Wallerians’ Degeneration: axon & myelin sheath shrinking, smash, broken.
Then Macrophage coming...
Schwann’s effect: rest Schwann’s cell proliferation, form hollow pipe, then new axons coming.

14. Results Repair timely and properly 2-3w, axon regenerate
4w, get through new Schwann’s membrane pipe
NGF, E. stimulation induce the axon heading to terminal organs
1mm per day

15. Results Repair too late or improperly
pressure, scar or poor blood supply
impede axon growth
>6w, Schwann’s membrane smash to pieces
Endplate degeneration and disappear, muscle atrophy;
nonreversible

16. Diagnosis ①movement dysfunction; History: Symptom： Tinel sign
②sensory disfuction ;
③vegetative nervous dysfuction;
Tinel sign
Electrophysiologic study (EPS)

17. Movement dysfunction
active movement
myodynamia

18. Sensory disfuction Lose algesia, thermal sense, pselaphesia
How to test:
use a pin: healthyside first, then the wounded side
use some soft subjects, such as cotton swab;
use cold water(5-10℃), or warm water(40-45 ℃);
feel different shape when blindly; twopoint discrimination test; normally 2-4mm

20. Vegetative nervous dysfuction
Skin: smooth, adiapneustia;
Iodostarch reaction:
Nail: cracking

21. Tinel’s test Use finger or small hammer
Over inductance means N. regeneration.
Positive site

22. Electrophysiologic study(EPS)
Normal action potential: 40～70m/sec
fibrillation potential(2～4w): om/sec

23. Treatments
strategies of treatment
Diagnose properly
Operate early

24. Treatments Neuropraxia or closed Axonotmesis
Conservative Treatment for 3m;
Physiotherapy;
acusector;
Nerve growth factor

25. Treatments Neuropraxia or closed Axonotmesis
>3m without recover or improve
Nerve relieve or neurolysis

27. Treatments Opening Neroirgure Gompletly
1. primary repair: immediately;
2.Extension repair: during w1-w3;
3.Secondary repair: during m1-m2;
4.Delayed repair: poor outcome

28. Treatments Operational construction 1. neurorrhaphy
①end-to-end anastomosis
②end-to-side anastomosis
2. Nerve Brisement
3. nerve grafting
4. nerve implantation

36. Treatments Deal with Neurolesion
1. Dissociate proximal and distal(<5cm);
2. Flax the joint;
3. Neural inversion;
4. Remove some bone;
5. Transplantation;
6. gap bridging;
7. replacement.

41. Specific topic

42. Median nerve injury Constitution:
Innervated: nearly all flexor of forearm;
Injure at wrist: Ape hand deformity,..
At elbow: flexor of thumb, index, middle finger;
At upper arm:

44. Ulnar nerve injury Constitution:
Innervated: flexor of ring finger and little finger
Injure at wrist: clawhand deformity, intrinsic muscle atrophy..
At elbow: flexor of ring finger, little finger;

46. Radial nerve injury Constitution: superficial & deep branch
Innervated: all extensor
Injure at wrist: Tucks area,
At elbow: extensor of finger
At upper arm: extensor of wrist

49. Femoral nerve injury Constitution: L2，3，4
Innervated: quadriceps femoris, sartorius
Injure: knee extension dysfunction

50. Tibial nerve injury
Constitution: come from sciatic nerve; anterior & posterior branch
Innervated: all flexor of ankle, sense of the sole
Injure at thigh: most common caused by supracondylar fracture of femur;

51. Peroneal nerve injury Constitution: come from sciatic nerve;
Innervated: the lateral crus muscle group, sensory of the lateral crus & dorsum of foot
Injure at thigh: Pedal deformity, drop toe; sensory disturbance.

52. The ends !