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Hand Nerve Injury Repair Workup

  • Author: Subhas Gupta, MD, PhD, CM, FRCSC, FACS; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
 
Updated: May 04, 2015
 

Laboratory Studies

Serum albumin test

  • The reason for ordering this test is to determine if the nutritional status of the patient is adequate to allow reconstructive surgery. If the values returned are less than normal, healing may be impaired and surgical repair compromised.
  • Generally, proceeding is acceptable when albumin levels are greater than or equal to 2.5 g/dL.
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Imaging Studies

Short tau inversion recovery MRI

  • This is a unique form of MRI that returns pictures that can highlight nerve trauma, although it is less sensitive than other diagnostic tests for determining the degree and location of injury.
  • The short tau inversion recovery MRI works by placing a phased array of surface coils on the body, thus allowing imaging of a smaller area with a more precise picture.
  • Both T1- and T2-weighted images can be used to view nerve pathology, which alters the nerve signal from its normally isodense state. T2-weighted images allow the hyperintense signal of nerve injury to be more apparent because of the ability to suppress the fat signal.
  • This type of test is indicated in patients with nonclassic symptoms, in those with ambiguous findings such as occur in patients with diabetes, for scar and nerve inflammation imaging after the addition of gadolinium, to visualize neuromas, and to determine the length of damaged nerve present.
  • This technology is not yet consistent enough to play a major role in diagnosis, but it can serve as a useful adjunct to other tests. [65, 13, 53]
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Other Tests

Sensory tests[4, 66, 67, 68]

  • Tinel test: The patient should feel a sensation when the tip of the severed nerve is tapped.
  • Two-point discrimination: Both moving (M2PD) and static (S2PD) are performed with the patient's eyes closed. Results should be consistent enough to exclude the patient guessing. This examination should be very thorough if a partial injury is suggested. S2PD is excellent if less than or equal to 6 mm, and M2PD is considered excellent if less than or equal to 3 mm. A lack of 2PD is poor.
  • Semmes-Weinstein test: This uses monofilaments, which allow the application of stimuli using constant force so that administration error is reduced. Findings should be similar to those from S2PD and M2PD.

Motor tests[4, 67, 68]

  • Grip and pinch strength: This is usually tested by having the patient squeeze a measuring device that can determine the amount of force the patient produces. Results may be compared to the unaffected hand to grade the deficiency. Testing intrinsic and extrinsic muscles separately can be helpful.
  • Muscle bulk: This test looks for atrophy of large muscles such as the first interosseous muscle.

Williams test: Denervated skin responds differently to stimuli. This allows clear demarcation of the affected area in the hand when the injured hand is placed in water. Innervated skin wrinkles when submerged, but denervated skin does not.

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Diagnostic Procedures

Electrodiagnostic techniques have been refined and help a great deal in testing and diagnosing neuromuscular lesions. The 2 most common tests are the nerve conduction study (NCS) or nerve conduction velocity test and electromyography (EMG). EMG is often understood to refer to both tests.[69, 13]

Table 4. Electrodiagnostic Characteristics of Nerve Injury (Open Table in a new window)

  Electromyography Nerve Conduction Study/Nerve Conduction Velocity
  Fibrillations Voluntary Muscle Unit Action Potential Sensory and Motor Latency Compound Motor Action Potential/Sensory Nerve Action Potential
Normal None Present Normal Normal
Nerve block/neurapraxia None None None across the block, normal above and below Normal above and below the block
Complete lesion/ axonotmesis, neurotmesis Present None Absent Absent
Incomplete Present Decreased in distribution of injury Normal or slightly prolonged (spread out) Reduced

 

NCSs use a percutaneous current to stimulate muscle and sensory nerves. This can result in a compound motor action potential or sensory nerve action potential, respectively. An active pickup generates the current that travels along the nerve and is read by another pickup a set distance away in either the efferent or afferent directions. This measures how fast the nerve conducted the stimulus (v = d/t). The current is gradually increased until a maximum response is obtained. This provides the basis for comparison of results over time. The distal ends of transected nerves have an NCS result that gradually falls over 7-9 days postinjury. This test can also help detect complete and partial nerve blocks.[69, 70, 13]

EMG tests record the depolarization potentials of active and spontaneous muscle movement. This is recorded as a muscle unit action potential. Resting muscle is normally electrically silent. Muscle distal to an injury may appear normal for several days after the injury until wallerian degeneration has advanced far enough for the muscle to become denervated and fibrillations to start. This often requires 14-21 days; thus, the best time for EMG diagnosis is 3-4 weeks after injury. Denervated muscle displays positive sharp waves and fibrillations, in that order.[69, 70, 71, 12]

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Contributor Information and Disclosures
Author

Subhas Gupta, MD, PhD, CM, FRCSC, FACS Chief of Surgical Services, Professor of Surgery, Chairman, Department of Plastic Surgery, Director of Plastic Surgery Residency, Director of Comprehensive Wound Service, Department of Plastic Surgery, Loma Linda University School of Medicine

Subhas Gupta, MD, PhD, CM, FRCSC, FACS is a member of the following medical societies: American College of Phlebology, Canadian Society of Plastic Surgeons, College of Physicians and Surgeons of Ontario, Plastic Surgery Research Council, American Society of Plastic Surgeons, Royal College of Physicians and Surgeons of Canada, Wound Healing Society, California Society of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Medical Informatics Association, Canadian Medical Association, Canadian Society of Plastic Surgeons, Quebec Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Additional Contributors

Anthony E Sudekum, MD Consulting Staff, Department of Plastic Surgery, St John's Mercy Health Center of St Louis

Anthony E Sudekum, MD is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, Missouri State Medical Association

Disclosure: Nothing to disclose.

References
  1. Sunderland S, Bradley KC. The cross-sectional area of peripheral nerve trunks devoted to nerve fibers. Brain. 1949. 72:428-49.

  2. Majno G. The Healing Hand. Cambridge, Mass: Harvard University Press; 1975.

  3. Sunderland S. Advances in diagnosis and treatment of root and peripheral nerve injury. Adv Neurol. 1979. 22:271-305. [Medline].

  4. Mackinnon S, Dellon AL. Surgery of the Peripheral Nerve. New York, NY: Thieme Medical; 1988.

  5. Allan CH. Functional results of primary nerve repair. Hand Clin. 2000 Feb. 16(1):67-72. [Medline].

  6. Tubiana R. Evolution of the concepts and techniques used in the repair of peripheral nerves. Tubiana R, ed. The Hand. Philadelphia, Pa: WB Saunders; 1988. Vol 3: 367-82.

  7. Mitchell SW. Injuries of Nerves and Their Consequences. Philadelphia, Pa: Lippincott; 1872. 89-91.

  8. Seddon HJ. Three types of nerve injury. Brain. 1943. 66(4):238-88.

  9. Millesi H. Techniques for nerve grafting. Hand Clin. 2000 Feb. 16(1):73-91, viii. [Medline].

  10. Millesi H, Meissl G, Berger A. The interfascicular nerve-grafting of the median and ulnar nerves. J Bone Joint Surg Am. 1972 Jun. 54(4):727-50. [Medline].

  11. Dellon AL, Jabaley ME. Reeducation of sensation in the hand following nerve suture. Clin Orthop. 1982 Mar. (163):75-9. [Medline].

  12. Castaldo JE, Ochoa JL. Mechanical injury of peripheral nerves: fine structure and dysfunction. Terzis JK, ed. Microreconstruction of Nerve Injuries. Philadelphia, Pa: WB Saunders; 1987. 15-32.

  13. Carter GT, Robinson LR, Chang VH, Kraft GH. Electrodiagnostic evaluation of traumatic nerve injuries. Hand Clin. 2000 Feb. 16(1):1-12, vii. [Medline].

  14. Diao E, Vannuyen T. Techniques for primary nerve repair. Hand Clin. 2000 Feb. 16(1):53-66, viii. [Medline].

  15. Sunderland S. Nerves and Nerve Injuries. 2nd ed. New York, NY: Churchill Livingstone; 1978.

  16. Selecki BR, Ring IT, Simpson DA, et al. Trauma to the central and peripheral nervous systems. Part II: A statistical profile of surgical treatment New South Wales 1977. Aust N Z J Surg. 1982 Apr. 52(2):111-6. [Medline].

  17. Noble J, Munro CA, Prasad VS, Midha R. Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries. J Trauma. 1998 Jul. 45(1):116-22. [Medline].

  18. Birch R, Raji AR. Repair of median and ulnar nerves. Primary suture is best. J Bone Joint Surg Br. 1991 Jan. 73(1):154-7. [Medline].

  19. Wilgis EF, Brushart TM. Nerve repair and grafting. Green DP, ed. Operative Hand Surgery. Toronto, Canada: Churchill Livingstone; 1993. Vol 2: 1315-40.

  20. Kline DG, Hudson AR. Selected recent advances in peripheral nerve injury research. Surg Neurol. 1985 Oct. 24(4):371-6. [Medline].

  21. Ducker TB, Kempe LG, Hayes GJ. The metabolic background for peripheral nerve surgery. J Neurosurg. 1969 Mar. 30(3):270-80. [Medline].

  22. Bushnell BD, McWilliams AD, Whitener GB, Messer TM. Early clinical experience with collagen nerve tubes in digital nerve repair. J Hand Surg [Am]. 2008 Sep. 33(7):1081-7. [Medline].

  23. Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen conduits. J Hand Surg Am. 2011 Sep. 36(9):1441-6. [Medline].

  24. Cabaud HE, Rodkey WG, Nemeth TJ. Progressive ultrastructural changes after peripheral nerve transection and repair. J Hand Surg [Am]. 1982 Jul. 7(4):353-65. [Medline].

  25. O'Daly JA, Imaeda T. Electron microscopic study of Wallerian degeneration in cutaneous nerves caused by mechanical injury. Lab Invest. 1967 Dec. 17(6):744-66. [Medline].

  26. Terzis J, Faibisoff B, Williams B. The nerve gap: suture under tension vs. graft. Plast Reconstr Surg. 1975 Aug. 56(2):166-70. [Medline].

  27. Mira JC. The biology of regeneration in peripheral nerves. Tubiana R, ed. The Hand. Philadelphia, Pa: WB Saunders; 1988. Vol 3: 383-404.

  28. Chaudhry V, Cornblath DR. Wallerian degeneration in human nerves: serial electrophysiological studies. Muscle Nerve. 1992 Jun. 15(6):687-93. [Medline].

  29. Drago J, Kilpatrick TJ, Koblar SA, Talman PS. Growth factors: potential therapeutic applications in neurology. J Neurol Neurosurg Psychiatry. 1994 Dec. 57(12):1445-50. [Medline].

  30. Colditz JC. Splinting the hand with a peripheral nerve injury. Hunter GM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. St. Louis, Mo: Mosby; 1995. 679-92.

  31. Rafols FJ, Orenstein HH. Hand II: Peripheral Nerves and Tendon Transfers. Selected Readings in Plastic Surgery. 1999. 8 (33):1-40.

  32. Weis P. The technology of nerve regeneration: A review, sutureless tubulation and related methods of nerve repair. J Neurosurg. 1944. 1:400-50.

  33. Weis P, Taylor C. Further experimental evidence against 'neurotropis' in nerve regeneration. J Exp Zoo. 1944. 95:233-57.

  34. Yamada KM, Spooner BS, Wessells NK. Ultrastructure and function of growth cones and axons of cultured nerve cells. J Cell Biol. 1971 Jun. 49(3):614-35. [Medline].

  35. Brushart TM, Gerber J, Kessens P, et al. Contributions of pathway and neuron to preferential motor reinnervation. J Neurosci. 1998 Nov 1. 18(21):8674-81. [Medline].

  36. Varon S, Adler R. Trophic and specifying factors directed to neuronal cells. Adv Cell Neurobiol. 1981. 2:115-63.

  37. Lundborg G, Dahlin LB, Danielsen N, et al. Nerve regeneration across an extended gap: a neurobiological view of nerve repair and the possible involvement of neuronotrophic factors. J Hand Surg [Am]. 1982 Nov. 7(6):580-7. [Medline].

  38. Lundborg G, Longo FM, Varon S. Nerve regeneration model and trophic factors in vivo. Brain Res. 1982 Jan 28. 232(1):157-61. [Medline].

  39. Birch R, Bonney G, Wynn Parry CB. Surgical Disorders of the Peripheral Nerves. Toronto, Canada: Churchill Livingstone; 1998.

  40. Breidenbach W, Terzis JK. The anatomy of free vascularized nerve grafts. Clin Plast Surg. 1984 Jan. 11(1):65-71. [Medline].

  41. Politis MJ. Specificity in mammalian peripheral nerve regeneration at the level of the nerve trunk. Brain Res. 1985 Mar 4. 328(2):271-6. [Medline].

  42. Lundborg G. The hand and the brain. Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 3-10.

  43. Frykman GK. Nerve regeneration after injury: newer approaches to improving nerve regeneration. Hunter JM, Schneider LH, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 26-30.

  44. Tubiana R. Clinical examination and functional assessment of the upper limb after peripheral nerve lesions. Tubiana R, ed. The Hand. Philadelphia, Pa: WB Saunders; 1988. Vol 3: 453-88.

  45. Omer GE Jr. Physical diagnosis of peripheral nerve injuries. Orthop Clin North Am. 1981 Apr. 12(2):207-28. [Medline].

  46. Varitimidis SE, Sotereanos DG. Partial nerve injuries in the upper extremity. Hand Clin. 2000 Feb. 16(1):141-9. [Medline].

  47. Taylor GI, Ham FJ. The free vascularized nerve graft. A further experimental and clinical application of microvascular techniques. Plast Reconstr Surg. 1976 Apr. 57(4):413-26. [Medline].

  48. Townsend PL, Taylor GI. Vascularised nerve grafts using composite arterialised neuro-venous systems. Br J Plast Surg. 1984 Jan. 37(1):1-17. [Medline].

  49. Weber RA, Breidenbach WC, Brown RE, et al. A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg. 2000 Oct. 106(5):1036-45; discussion 1046-8. [Medline].

  50. Trumble TE, McCallister WV. Repair of peripheral nerve defects in the upper extremity. Hand Clin. 2000 Feb. 16(1):37-52. [Medline].

  51. Jabaley ME. Internal anatomy of the peripheral nerve. Hunter JM, Schneider LH, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 19-25.

  52. Smith KL. Anatomy of the peripheral nerve. Hunter JM, Schneider LH, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 11-8.

  53. Jarvik JG, Kliot M, Maravilla KR. MR nerve imaging of the wrist and hand. Hand Clin. 2000 Feb. 16(1):13-24, vii. [Medline].

  54. Allieu Y, Bonnel F. Surgical anatomy of the peripheral nerves. Tubiana R, ed. The Hand. Philadelphia, Pa: WB Saunders; 1988. Vol 3: 405-23.

  55. Sunderland S. The internal topography of the radial, median, and ulnar nerves. Brain. 1945. 64(4):243-99.

  56. Sunderland S. Nerve Injuries and their Repair. New York, NY: Churchill Livingstone; 1991.

  57. Chow JA, Van Beek AL, Meyer DL, Johnson MC. Surgical significance of the motor fascicular group of the ulnar nerve in the forearm. J Hand Surg [Am]. 1985 Nov. 10(6 Pt 1):867-72. [Medline].

  58. Bjorkman A, Weibull A, Rosen B, Svensson J, Lundborg G. Rapid cortical reorganisation and improved sensitivity of the hand following cutaneous anaesthesia of the forearm. Eur J Neurosci. 2009 Feb. 29(4):837-44. [Medline].

  59. Kilinc A, Ben Slama S, Dubert T, Dinh A, Osman N, Valenti P. [Results of primary repair of injuries to the median and ulnar nerves at the wrist]. Chir Main. 2009 Apr. 28(2):87-92. [Medline].

  60. Werdin F, Schaller HE. [Combined flexor tendon and nerve injury of the hand]. Orthopade. 2008 Dec. 37(12):1202-9. [Medline].

  61. Lampe EW. Surgical anatomy of the hand. With special reference to infections and trauma. Clin Symp. 1988. 40(3):1-36. [Medline].

  62. Hobbs RA, Magnussen PA, Tonkin MA. Palmar cutaneous branch of the median nerve. J Hand Surg [Am]. 1990 Jan. 15(1):38-43. [Medline].

  63. Leibovic SJ, Hastings H 2nd. Martin-Gruber revisited. J Hand Surg [Am]. 1992 Jan. 17(1):47-53. [Medline].

  64. McCabe SJ, Kleinert JM. The nerve of Henle. J Hand Surg [Am]. 1990 Sep. 15(5):784-8. [Medline].

  65. West GA, Haynor DR, Goodkin R, et al. Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury. Neurosurgery. 1994 Dec. 35(6):1077-85; discussion 1085-6. [Medline].

  66. Weinstein S, Drozdenko R, Weinstein C. Evaluation of sensory measures in neuropathy. Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 63-76.

  67. Bell-Krotoski JA. Sensibility testing: current concepts. Hunter GM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. St. Louis, Mo: Mosby; 1995. 109-28.

  68. Vanderhooft E. Functional outcomes of nerve grafts for the upper and lower extremities. Hand Clin. 2000 Feb. 16(1):93-104, ix. [Medline].

  69. Bralliar F. Electromyography: its use and misuse in peripheral nerve injuries. Orthop Clin North Am. 1981 Apr. 12(2):229-38. [Medline].

  70. Van Beek A, Hubble B, Kinkead L, et al. Clinical use of nerve stimulation and recording techniques. Plast Reconstr Surg. 1983 Feb. 71(2):225-40. [Medline].

  71. Terzis JK, Publicover N. Clinical electrophysiologic peripheral nerve recordings. Clin Plast Surg. 1984 Jan. 11(1):47-52. [Medline].

  72. Fakin RM, Calcagni M, Klein HJ, et al. Long-term clinical outcome after epineural coaptation of digital nerves. J Hand Surg Eur Vol. 2015 Mar 31. [Medline].

  73. Highet WB, Sanders FK. The effects of stretching nerves after suture. Br J Surg. 1943. 30:355-69.

  74. Rodkey WG, Cabaud HE, McCarroll HR Jr. Neurorrhaphy after loss of a nerve segment: comparison of epineurial suture under tension versus multiple nerve grafts. J Hand Surg [Am]. 1980 Jul. 5(4):366-71. [Medline].

  75. Rinker BD, Ingari JV, Greenberg JA, et al. Outcomes of Short-Gap Sensory Nerve Injuries Reconstructed with Processed Nerve Allografts from a Multicenter Registry Study. J Reconstr Microsurg. 2015 Apr 20. [Medline].

  76. Mackinnon SE, Dellon AL. Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plast Reconstr Surg. 1990 Mar. 85(3):419-24. [Medline].

  77. Strauch B. Use of nerve conduits in peripheral nerve repair. Hand Clin. 2000 Feb. 16(1):123-30. [Medline].

  78. Rinker B, Liau JY. A prospective randomized study comparing woven polyglycolic Acid and autogenous vein conduits for reconstruction of digital nerve gaps. J Hand Surg Am. 2011 May. 36(5):775-81. [Medline].

  79. Nath RK, Mackinnon SE. Nerve transfers in the upper extremity. Hand Clin. 2000 Feb. 16(1):131-9, ix. [Medline].

  80. Bertelli JA, Ghizoni MF. Very distal sensory nerve transfers in high median nerve lesions. J Hand Surg Am. 2011 Mar. 36(3):387-93. [Medline].

  81. Scholz T, Krichevsky A, Sumarto A, Jaffurs D, Wirth GA, Paydar K, et al. Peripheral Nerve Injuries: An International Survey of Current Treatments and Future Perspectives. J Reconstr Microsurg. 2009 Mar 19. [Medline].

  82. Dahlin LB. Techniques of peripheral nerve repair. Scand J Surg. 2008. 97(4):310-6. [Medline].

  83. Taras JS, Jacoby SM. Repair of lacerated peripheral nerves with nerve conduits. Tech Hand Up Extrem Surg. 2008 Jun. 12(2):100-6. [Medline].

  84. Smith KL. Nerve response to injury and repair. Hunter GM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. St. Louis, Mo: Mosby; 1995. 609-27.

  85. Lundborg G, Rydevik B. Effects of stretching the tibial nerve of the rabbit. A preliminary study of the intraneural circulation and the barrier function of the perineurium. J Bone Joint Surg Br. 1973 May. 55(2):390-401. [Medline].

  86. Clark WL, Trumble TE, Swiontkowski MF, Tencer AF. Nerve tension and blood flow in a rat model of immediate and delayed repairs. J Hand Surg [Am]. 1992 Jul. 17(4):677-87. [Medline].

  87. Liu CT, Benda CE, Lewey FH. Tensile Strength of human nerves. Arch Neurol Psych. 1948. 59:322-36.

  88. Jabaley ME, Wallace WH, Heckler FR. Internal topography of major nerves of the forearm and hand: a current view. J Hand Surg [Am]. 1980 Jan. 5(1):1-18. [Medline].

  89. Young L, Wray RC, Weeks PM. A randomized prospective comparison of fascicular and epineural digital nerve repairs. Plast Reconstr Surg. 1981 Jul. 68(1):89-93. [Medline].

  90. Bratton BR, Kline DG, Coleman W, Hudson AR. Experimental interfascicular nerve grafting. J Neurosurg. 1979 Sep. 51(3):323-32. [Medline].

  91. Hudson AR, Hunter D, Kline DG, Bratton BR. Histological studies of experimental interfascicular graft repairs. J Neurosurg. 1979 Sep. 51(3):333-40. [Medline].

  92. Moneim MS. Interfascicular nerve grafting. Clin Orthop. 1982 Mar. (163):65-74. [Medline].

  93. Kiel JH. Basic Hand Splinting. Boston, Mass: Little Brown; 1983.

  94. Fess EE. Splinting peripheral nerve injuries. Hunter JM, Schneider LH, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis, Mo: Mosby; 1994. 95-9.

  95. Jabaley ME, Burns JE, Orcutt BS, Bryant M. Comparison of histologic and functional recovery after peripheral nerve repair. J Hand Surg [Am]. 1976 Sep. 1(2):119-30. [Medline].

  96. Wiech K, Preissl H, Lutzenberger W, et al. Cortical reorganization after digit-to-hand replantation. J Neurosurg. 2000 Nov. 93(5):876-83. [Medline].

  97. Cheng AS, Hung L, Wong JM, et al. A prospective study of early tactile stimulation after digital nerve repair. Clin Orthop. 2001 Mar. (384):169-75. [Medline].

  98. Florence SL, Boydston LA, Hackett TA, et al. Sensory enrichment after peripheral nerve injury restores cortical, not thalamic, receptive field organization. Eur J Neurosci. 2001 May. 13(9):1755-66. [Medline].

  99. Callahan AD. Methods of compensation and reeducation for sensory dysfunction. Hunter GM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. St. Louis, Mo: Mosby; 1995. 701-14.

  100. Waylett-Rendall J. Desensitization of the traumatized hand. Hunter GM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. St. Louis, Mo: Mosby; 1995. 693-700.

  101. Fu SY, Gordon T. Contributing factors to poor functional recovery after delayed nerve repair: prolonged denervation. J Neurosci. 1995 May. 15(5 Pt 2):3886-95. [Medline].

 
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Hand nerve injury repair. Crushed median nerve at the elbow.
Hand nerve injury repair. Epineural repair of median nerve.
Hand nerve injury repair. Partial transection of ulnar nerve in the forearm.
Hand nerve injury repair. Posttraumatic neuroma.
Hand nerve injury repair. Excision of posttraumatic neuroma.
Hand nerve injury repair. Algorithm for the treatment of nerve injuries.
Table 1. Clinical Progression Based on Degree of Injury
Degree Severity Description Tinel Sign Progress Distally Recovery Pattern Rate of Recovery Surgery
First Neurapraxia Demyelination with restoration in weeks Fast Complete Fast (days to 12 wk) None
Second Axonotmesis Disruption of axon with regeneration and full recovery + + Complete Slow (3 cm/mo) None
Third   Disruption of axon and endoneurium causing disorganized regeneration + + Varies* Slow (3 cm/mo) Varies
Fourth   Disruption of axon, endoneurium, and perineurium, with intact epineurium and no regeneration + None None Yes
Fifth Neurotmesis Transection of the nerve + None None Yes
Sixth Neuroma-in-continuity Mixture of one or more of the above conditions Varies by fascicle, depending on injury
*Recovery is at least as good as nerve repair but varies from excellent to poor, depending on the degree of endoneurial scarring and the amount of sensory and motor axonal misdirection within the injured fascicle.
Table 2. Pathophysiology of Degeneration and Regeneration*
Timing Degeneration Regeneration
6 hours Nucleus becomes displaced and Nissl bodies break up, turning the cell basophilic.[15] Axon spikes appear briefly at the proximal end.
1 day Macrophages begin entering the site of degeneration. This stimulates Schwann cell proliferation[19] Nerve function drops off with rupture of the blood-nerve barrier.[20] Distal stump begins to swell. Growth cones that contain a cytoskeleton form at the end of axon sprouts. Cell bodies of severed axons begin to enlarge as the cells become activated. The nucleus must become hypochromatic before elongation can occur.[21]
2 days   Mitochondria in the axoplasm for distal transport.
3 days Degenerative process involves all myelinated axons. Perineurial cells become enlarged and active. Axons shrink, and myelin begins to disintegrate. This is cleaned up by macrophages and Schwann cells and can take as many as 3 months.[14] Schwann cell proliferation peaks.[19]  
4 days   RNA production increases in the cell body. Axon sprouting may begin at day 4 in a clean transection.[21]
1 week Infiltration of inflammatory cells and RBCs occurs, along with myelin fragmentation. Schwann cells are activated and dividing. Growth cones can occasionally be seen within a Schwann cell, depending on the injury type. Swelling of axoplasm occurs in myelinated fibers, caused by mitochondria.
2 weeks Schwann cell proliferation has peaked, and endoneurial clearance is proceeding. As the contents of the tubes are removed, they shrink; if collagen is laid down, the reduced size can become permanent.[19, 22, 23] Schwann cells near regenerating axons stop myelin destruction and surround axons.[24]
3 weeks The distal portion of the axon is finishing the degenerative processes, and the myelin is fragmenting.[21] The axon is surrounded completely by myelin, and the organelle count in the Schwann cell drops. Most of the regenerating axons are found outside the degenerating endoneurial tubes.[24] Metabolic changes in the axon peak.[20] Axon sprouting usually starts and can cross the anastomoses.[21]
4 weeks   Remyelination starts, and perineurial cells decrease in size once the nerve is remyelinated.
*Times can vary extensively with the type and extent of damage.[25, 24, 14]
Table 3. Selection of Operative Procedure
Surgery Ends Can Approximate Vascularized Bed Graft Possible Proximal Portion Intact Distal Portion Intact
End-to-end closure Yes Yes Yes Yes Yes
Nerve graft No Yes Yes Yes Yes
Vascularized graft No No Yes Yes Yes
Conduit No No No Yes Yes
Nerve transfer No No No No Yes
Table 4. Electrodiagnostic Characteristics of Nerve Injury
  Electromyography Nerve Conduction Study/Nerve Conduction Velocity
  Fibrillations Voluntary Muscle Unit Action Potential Sensory and Motor Latency Compound Motor Action Potential/Sensory Nerve Action Potential
Normal None Present Normal Normal
Nerve block/neurapraxia None None None across the block, normal above and below Normal above and below the block
Complete lesion/ axonotmesis, neurotmesis Present None Absent Absent
Incomplete Present Decreased in distribution of injury Normal or slightly prolonged (spread out) Reduced
Table 5. Common Donor Sites
Graft Donor Site Length Obtained Sensory Deficit
Distal posterior interosseous nerve 15-20 cm Dorsal wrist joint
Lateral antebrachial cutaneous nerve 15 cm Lateral forearm surface
Medial antebrachial cutaneous 20 cm Medial and anterior surface of forearm
Superficial radial 25 cm Dorsal radial hand surface
Lateral femoral cutaneous 30 cm Lateral and thigh
Anterior femoral cutaneous 40 cm Medial and anterior thigh
Sural 40 cm Lateral foot surface and a portion of the heel
Saphenous 25-40 cm Medial foot surface
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