Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions.

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Surgical Treatment Protocol for Peripheral Nerve Dysfunction of the Lower Extremity: A Systematic Approach.

To date, more than 150 surgical techniques have been described for the treatment of intractable nerve pain. However, owing to their technical complexity, as well as the lack of comparative studies in the literature, there is currently no consensus on the appropriate management of this often debilitating condition. Therefore, we present our surgical algorithm, based on Seddon's classification to differentiate the degree of nerve injury, and subsequent treatment course for the management of lower extremity neurogenic pain.

Anatomy of the median nerve and its clinical applications.

The median nerve is a mixed sensory and motor nerve. It is classically described as the nerve of pronation, of thumb, index finger, middle finger and wrist flexion, of thumb antepulsion and opposition, as well as the nerve of sensation for the palmar aspect of the first three fingers. It takes its name from its middle position at the end of the brachial plexus and the forearm. During its course from its origin at the brachial plexus to its terminal branches, it runs through various narrow passages where it could be compressed, such as the carpal tunnel or the pronator teres. The objective of this review is to summarize the current knowledge on the median nerve's anatomy: anatomical variations (branches, median-ulnar communicating branches), fascicular microanatomy, vascularization, anatomy of compression sites, embryology, ultrasonographic anatomy. The links between its anatomy and clinical, surgical or diagnostic applications are emphasized throughout this review.

Current concepts in peripheral nerve surgery.

The injuries of the peripheral nerves are relatively frequent. Some of them may lead to defects which cannot be repaired with direct end-to-end repair without tension. These injuries may cause function loss to the patient, and they consist a challenge for the treating microsurgeon. Autologous nerve grafts remain the gold standard for bridging the peripheral nerve defects. Nevertheless, there are selected cases where alternative types of nerve reconstruction can be performed in order to cover the peripheral nerve defects. In all these types of reconstruction, the basic principles of microsurgery are necessary and the surgeon should be aware of them in order to achieve a successful reconstruction. The purpose of the present review was to present the most current data concerning the surgical options available for bridging such defects.

High radial nerve palsy.

High radial palsy is primarily associated with humeral shaft fractures, whether primary due to the initial trauma, or secondary to their treatment. The majority will spontaneously recover, therefore early surgical exploration is mainly indicated for open fractures or if ultrasonography shows severe nerve damage. Initial signs of nerve recovery may appear between 2 weeks and 6 months. Otherwise, the decision to explore the nerve is based on the patient's age, clinical examination and electroneuromyography, as well as ultrasonography findings. If recovery does not occur, an autograft is indicated only in younger patients, before 6 months, if local conditions are suitable. Otherwise, nerve transfers performed by an experienced team give satisfactory results and can be offered up to 10 months post-injury. Tendon transfers are the gold standard treatment and the only option available beyond 10 to 12 months. The results are reliable and fast.

Effectiveness of the extended surgical approach to visualize the axillary nerve in the blind zone in an arthroscopic axillary nerve injury model.

INTRODUCTION: The aims of this study were to create a model of axillary nerve (AN) injury during an arthroscopic capsular plication to analyze the site for potential nerve injury and to determine the AN length that can be visualized through standard and extended anterior, axillary, and posterior approaches. MATERIAL AND METHODS: Six arthroscopic inferior capsular plications were performed in 3 human adult frozen cadavers. A nonabsorbable suture was used to plicate the inferior capsule aiming at capturing the AN (at a location closest to the joint capsule). We then attempted to explore the AN through 3 different surgical approaches (each approach was performed in 2 shoulders): a standard and an extended anterior, axillary, and posterior approach. Surgical clips were used to mark the AN length that was visualized through each approach. RESULTS: The AN injury was located in a range from 5.4 to 7.8 cm from its origin from the posterior cord. This location corresponds with the previously described AN injury zone B (blind) and zone C (circumflex). Compared to the standard approaches, the extended anterior, axillary, and posterior approaches improved the visualization of the AN by 3.6, 1.5, and 2.8 cm, respectively. None of these approaches independently was sufficient to expose the entire course of the AN. CONCLUSIONS: The blind zone is a potential location for AN injury after inferior capsular plication. On the basis of this study, a combination of a standard and an extended surgical approach may lead to better exposure of most of the AN length.

[LONG-TERM RESULTS OF DELAYED REPAIR OF MEDIAN NERVE INJURY].

OBJECTIVE: To review and analyze the long-term results of delayed repair of median nerve injury. METHODS: Between January 2004 and December 2008, 228 patients with median nerve injury undergoing delayed repair were followed up for more than 4 years, and the clinical data were retrospectively analyzed. There were 176 males (77.19%) and 52 females (22.81%), aged 2-71 years (median, 29 years). The main injury reason was cutting injury in 159 cases (69.74%); 203 cases had open injury (89.04%). According to the injury level, injury located at area I (upper arm) in 38 cases (16.67%), at area II (elbow and proximal forearm) in 53 cases (23.25%), at area III (anterior interosseous nerve) in 13 cases (5.70%), and at area IV (distal forearm to wrist) in 124 cases (54.39%). The delayed operations included delayed suture (50 cases, 21.93%), nerve release (149 cases, 65.35%), and nerve graft (29 cases, 12.72%). RESULTS: For patients with injury at area I and area II, the results were good in 23 cases (25.27%), fair in 56 cases (61.54%), and poor in 12 cases (13.18%) according to modified Birch and Raji's median nerve grading system; there was significant difference in the results between 3 repair methods for injury at area II (χ2 = 6.228, P = 0.044), but no significant difference was found for injury at area I (χ2 = 2.241, P = 0.326). Twelve patients (13.18%) needed musculus flexor functional reconstruction. Recovery of thenar muscle was poor in all patients, but only 5 cases (5.49%) received reconstruction. Thirteen cases of nerve injury at area III had good results, regardless of the repair methods. For patients with injury at area IV, the results were excellent in 6 cases (4.84%), good in 22 cases (17.74%), fair in 72 cases (58.06%), and poor in 24 cases (19.35%) according to Birch and Raji's grading system; there was significant difference in the results between 3 repair methods (χ2 = 12.646, P = 0.002), and the result of delayed repair was better. CONCLUSION: The results of delayed repair is poor for all median nerve injuries, especially for high level injury. The technique of repair methods vary with injury level. For some delayed median nerve injuries, early nerve transfer may be a better choice for indicative patients.

Traumatic injuries of peripheral nerves: a review with emphasis on surgical indication.

Traumatic peripheral nerve injury is a dramatic condition present in many of the injuries to the upper and lower extremities. An understanding of its physiopathology and selection of a suitable time for surgery are necessary for proper treatment of this challenging disorder. This article reviews the physiopathology of traumatic peripheral nerve injury, considers the most used classification, and discusses the main aspects of surgical timing and treatment of such a condition.

Traumatic injuries of peripheral nerves: a review with emphasis on surgical indication / Lesoes traumaticas de nervos perifericos: uma revisao com enfase na indicacao cirurgica

Traumatic peripheral nerve injury is a dramatic condition present in many of the injuries to the upper and lower extremities. An understanding of its physiopathology and selection of a suitable time for surgery are necessary for proper treatment of this challenging disorder. This article reviews the physiopathology of traumatic peripheral nerve injury, considers the most used classification, and discusses the main aspects of surgical timing and treatment of such a condition.

Traumatismos dos nervos periféricos resultam em lesões incapacitantes e estão presentes em muitas das lesões dos membros. A compreensão da fisiopatologia dessas lesões e a seleção do momento operatório mais adequado são imprescindíveis para que o tratamento seja adequado. Neste artigo revisamos a fisiopatologia das lesões traumáticas dos nervos periféricos, apresentamos a classificação mais utilizada dessas lesões e discutimos os principais aspectos relacionados ao momento da cirurgia e às formas de reparo cirúrgico.

Nerve physiology: mechanisms of injury and recovery.

Peripheral nerve injuries are common conditions, with broad-ranging groups of symptoms depending on the severity and nerves involved. Although much knowledge exists on the mechanisms of injury and regeneration, reliable treatments that ensure full functional recovery are scarce. This review aims to summarize various ways these injuries are classified in light of decades of research on peripheral nerve injury and regeneration.

Peripheral nerve injuries in sports-related surgery: presentation, evaluation, and management: AAOS exhibit selection.

Peripheral nerve injuries during sports-related operative interventions are rare complications, but the associated morbidity can be substantial. Early diagnosis, efficient and effective evaluation, and appropriate management are crucial to maximizing the prognosis, and a clear and structured algorithm is therefore required. We describe the surgical conditions and interventions that are commonly associated with intraoperative peripheral nerve injuries. In addition, we review the common postoperative presentations of patients with these injuries as well as the anatomic structures that are directly injured or associated with these injuries during the operation. Some examples of peripheral nerve injuries incurred during sports-related surgery include ulnar nerve injury during ulnar collateral ligament reconstruction of the elbow and elbow arthroscopy, median nerve injury during ulnar collateral ligament reconstruction of the elbow, axillary nerve injury during Bankart repair and the Bristow transfer, and peroneal nerve injury during posterolateral corner reconstruction of the knee and arthroscopic lateral meniscal repair. We also detail the clinical and radiographic evaluation of these patients, including the utility and timing of radiographs, magnetic resonance imaging (MRI), ultrasonography, electromyography (EMG), and nonoperative or operative management. The diagnosis, evaluation, and management of peripheral nerve injuries incurred during sports-related surgical interventions are critical to minimizing patient morbidity and maximizing postoperative function. Although these injuries occur during a variety of procedures, common themes exist regarding evaluation techniques and treatment algorithms. Nonoperative treatment includes physical therapy and medical management. Operative treatments include neurolysis, transposition, neurorrhaphy, nerve transfer, and tendon transfer. This article provides orthopaedic surgeons with a simplified, literature-based algorithm for evaluation and management of peripheral nerve injuries associated with sports-related operative procedures.