Management of Nerve Injuries

Following points to be included in one's scheme .


A. Detailed Clinical History

               1.      Particular detatils of patient

                            Hand dominance

                             Profession

            2.    C/C




           3.   History of Present illness

                  Regarding

                 Site of Injury

                  mechanism of injury -blast , crush , tractrion ,

                                                     open wound with contamination

                                                      weakness , progressing or improving

                                                     consequences of weakness on daily life

                                                    abilities related to the organ affected

             
                                                   constitutional symptoms

                       Any other injuries on body


       4. Treatment history -


                              Emergency management

                                         dressing  , debridement , tag sutures any ?



                            Definitive Management

                                         end -end anastomosis , end to soft tissue to prevent contraction

                                        coverage of soft tissues

                           
                     
                         PT               document use of dynamic or static splints

                                             Active or passive motion ?

                         Its outcome

                                              any contractures , infection  ,

                                              improvement in motor function

                                              improvement in sensation
                       
                                               improvement in functions

                     



        5.  Past history

                 TT prohylaxis

                    drug allergy

                  DM and other medical illnesses


      6.   Expectation of Patient



B. Examination - Nerve examination mentioned in previous sections


C.Investigations

     1. Electrodiagnostic tests

          document injuries , location of inslt , severity of injury , recovery pattern , prognosis ,

        objective data for impairment documentation , pathology , selection of optimal muscles for

          tendon trasnsfers

  Nerve Conductions test (NCT ) and Electromyography (EMG )

         shows nerve conductivity , axon or myelin involvement  and muscles recruitment capability



Nerve Conduction test

        immediately after injury - interference of conduction but impossible to determine severity

        Proximal and distal to injury - Normal response

         Stimulation across injured segment varies

         5-10 days - Reduction in amplitude

                            - altered configuration of evoked potential

                          - Neuropraxia - conduction distal to lesion is normal .

       
Injury Pattern                     Porximal Stimulation              Immediately after injuries       after 10 days
                                          (conduction  distal to lesion)   (conduction across lesion )    (across lesion)

Neuropraxia                                  No response                       Normal response              Normal


Axonotemesis                            No response                            Normal                            No response
or neurotemesis

Proximal or central neurological lesions accessed using retrograde techniques (e.g. F-waves , SSEP )


EMGs
10-14 days after neural injury

 spontaneuous rest potentials + sharp waves appear in innervated myotomes with axonal injury



14 to 18 days

     fibrillation potentials

      denervation potential - last until innervated.


3 Weeks

            neural sprouting and increase in amplitude.

2 to 6 months

            large potentials remain until reinnervation completed.

Normal insertional activity present immediately after insertional activity.

Sharp waves


Amplitude - 100 - 400 microVoltage

 Duration 5 - 150ms

 Rate ; 2 - 40 Hz



wide body complexes

Fibrillation

Amplitude ; 5 - 1000 microvoltage
 Duration ;  0.5 - 2 ms

Rate;   2-3 Hz.


narrow body



onc can check the waves ;
https://www.researchgate.net/figure/Positive-sharp-waves-and-fibrillation-potentials-were-evident-in-all-four-limbs-upon_fig2_26881420

D.Treatment

Physiotherapy - ROM of the joints to prevent contracutre of joints

                           Splints

Nerve Repair -we will discuss later on different type of Nerve Repair. Upto now be able to examine

them properly from previous topics .

Tendon Transfer - be able to know different donor tendons  for different losses in different nerve

injuries more importantly in Upper Extremity. Radial Nerve examination and its losses is thoroughly

testested in examination.

Its equally important for median , ulnar nerves and brachial plexus injury.

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