PERIPHERAL NERVE INJURY - Assessment and Treatment pdf

Showing all the different type of nerve injury . Having all the type of nerve injury. Classification of nerve injury. Types . Clinical features. Signs and symptoms. And treatment

1. PERIPHERAL NERVE
INJURY
-DR. ISHITA GOSWAMI

2. CONTENT
•Introduction
•Mechanisms of nerve injury
•Nerve injury
•Classification of nerve injuries
•Recovery of nerve injuries
•Common sites of injury to peripheral nerves
•Injuries
•Assessment
•Management

3. INTRODUCTION
•Peripheralcomponentsoftheneuromuscularsystemincludethealpha
andgammamotorneurons,theiraxons,andtheskeletalmusclesthey
innervate;thesensoryneuronsandtheirreceptorslocatedinthe
connectivetissues,joints,andbloodvessels;andtheneuronsofthe
autonomicnervoussystem.
•Connectivetissuesurroundseachaxon(endoneurium)aswellas
fascicles(perineurium)andentirenervefibers(epineurium).

4. •Theaxolemmaisthesurfacemembraneofaxon.
•Schwanncellsliebetweentheaxolemmaandendoneurium;theyform
myelin,whichfunctionstoinsulatetheaxonaswellasspeedthe
conductionofactionpotentialsalongthenervefiber.
•Aperipheralnervemayconsistofasinglefascicleorconsistofseveral
fascicles

6. MECHANISMS OF NERVE INJURY
•Compression(sustainedpressureappliedexternallysuchastourniquet
orinternallysuchasfrombone,tumor,orsofttissueimpingement
resultinginmechanicalorischemicinjury)
•Laceration(knife,gunshot,surgicalcomplication,injectioninjury)
•Stretch(excessivetension,tearingfromtractionforces)
•Radiation
•Electricity(lighteningstrike,electricalmalfunction)

7. NERVE INJURY
•Peripheralnerveinjurymayresultinmotor,sensory,and/or
sympatheticimpairments.
•Inaddition,painmaybeasymptomofnervetensionorcompression
becausetheconnectivetissueandvascularstructuressurroundingand
intheperipheralnervesareinnervated.
•Knowingthemechanismofinjuryandtheclinicalsignsandsymptoms
helpthecliniciandeterminethepotentialoutcomeforthepatientand
developaplanofcare.

8. •Injurymaybecompleteorpartialandproducessymptomsbasedon
thelocationoftheinsult.
•Biomechanicalinjuriestotheperipheralnervoussystemresultmost
commonlyfromfriction,compression,andstretch.
•Secondaryinjurycanbefrombloodoredema.
•Compressiveforcescanaffectthemicrocirculationofthenerve,
causingvenouscongestionandreductionofaxoplasmictransport,thus
blockingnerveimpulses
•Ifsustained,itcancausenervedamage.

9. •Theinsultcanbeacutefromtraumaorchronicfromrepetitivetrauma
orentrapment.
•Siteswhereaperipheralnerveismorevulnerabletocompression,
friction,ortensionincludetunnels(softtissue,bony,fibro-osseus),
branchesofthenervoussystem(especiallyifthenervehasanabrupt
angle),pointswhereanerveisrelativelyfixedwhenpassingcloseto
rigidstructures(acrossabonyprominence),andatspecifictension
points.
•Responsetoinjurycanbepathophysiologicalorpathomechanical,
leadingtosymptomsderivedfromadversetensiononthenervous
system.Resultsmaybeintraneuraland/orextraneural.

10. CLASSIFICATION OF NERVE INJURIES
•Nerve injuries are classified using either the
Seddon or Sunderland classification
systems; both are based on structural and
functional changes that occur in the nerve
with various degrees of damage.
•These systems describe the degree of injury
to nerve substructures and the effect on
prognosis

11. SEDDON CLASSIFICATION
•Seddon’ssystemdescribesthreelevelsofpathology:neuropraxia,
axonotmesis,andneurotmesis.

13. SUNDERLAND CLASSIFICATION
1.Firstdegreeinjury(neuropraxia):minimalstructuraldisruption—
completerecovery
2.Seconddegree(axonotmesis):completeaxonaldisruptionwithwallerian
degeneration—usuallycompleterecovery;
3.Thirddegree(maybeeitheraxonotmesisorneurotmesis)—disruptionof
axon,andendoneurium—poorprognosiswithoutsurgery
4.Fourthdegree(neurotmesis):disruptionofaxon,endoneurium,and
perineurium—poorprognosiswithoutsurgery
5.Fifthdegree(neurotmesis)completestructuraldisruption—poor
prognosiswithoutmicrosurgery.

14. RECOVERY OF NERVE INJURIES
•Nervetissuethathasbecomeirritatedfromtension,compression,or
hypoxiamaynothavepermanentdamageandshowssignsofrecovery
whentheirritatingfactorsareeliminated.
•Whenthenervehasbeeninjured,recoveryisdependentonseveral
factorsincludingthe
-extentofinjurytotheaxonanditssurroundingconnectivetissue
sheath,
-thenatureandleveloftheinjury,
-thetimingandtechniqueoftherepair(ifnecessary),and
-theageandmotivationoftheperson

15. •Natureandlevelofinjury:
-Themoredamagetothenerveandtissues,themoretissuereactionand
scarringoccur.
-Also,theproximalaspectofanervehasgreatercombinationsofmotor,
sensoryandsympatheticfibers,affectingregeneration.
-Regenerationisoftensaidtooccuratarateof1inchperday,butratesfrom
0.5to9.0mmperdayhavebeenreportedbasedonthenatureandseverity
oftheinjury,durationofdenervation,conditionofthetissues,andwhether
surgeryisrequired

16. •Timingandtechniqueofrepair:
-Lacerationorcrushinjuriesthatdisrupttheintegrityoftheentirenerve
requiresurgicalrepair.
-Timingoftherepairiscritical,asistheskillofthesurgeonandtechnique
usedtoalignthesegmentsaccuratelyandavoidtensionatthesuturelinefor
optimalnerveregeneration.
-Differentregenerativepotentialoutcomesfollowingnerverepairhavealso
beenreportedbasedongroupingsofspecificnerves.
•Excellentregenerativepotential:radial,musculocutaneous,andfemoral
nerves
•Moderateregenerativepotential:median,ulnar,andtibialnerves
•Poorregenerativepotential:peronealnerve

17. •Ageandmotivationofthepatient.
-Thenervoussystemmustadaptandrelearnuseofthepathwaysonce
regenerationoccurs.
-Motivationandageplayaroleinthis,especiallyintheveryyoungand
theelderly.

18. COMMON SITES OF INJURY TO
PERIPHERAL NERVES
•BrachialPlexus
•UpperQuarter:
-AxillaryNerve:C5,6
-MusculocutaneousNerve:C5,6
-MedianNerve:C6-8
-UlnarNerve:C8,T1
-RadialNerve:C6-8,T1

19. •LumbosacralPlexus
•PeripheralNervesintheLowerQuarter:
-FemoralNerve:L2-4
-ObturatorNerve:L2-4
-SciaticNerve:L4,5,S1–3
-Tibial/PosteriorTibialNerve:L4,5,S1–3)
-CommonPeronealNerve:L4,5,S1,2

20. Brachial Plexus Injury
•Brachialplexusinjuriesrangeinseverityandcause.Theeffectsmay
bemildorsevere.
-Mechanismofinjury
•Injurytobrachialplexuscanoccurinmanyways.Theseincludethe
contactsports,roadtrafficaccident,motorvehicleaccidentorduring
birth.Grossly,itcanbedividedinto
•Traumatice.gmotorvehicleaccident,contactsports
•Nontraumatice.g.ObstetricpalsyandParsonage-TurnerSyndrome

21. •Thenetworkofnervesisfragileandcanbedamagedbystretching,
pressureorcutting.
•Stretchingcanoccurwhentheheadandneckareforcedawayfromthe
shoulder,suchasmighthappeninafallfromamotorcycle.Ifsevere
enough,thenervescanactuallyavulse,ortearoutoftheirrootsinthe
neck.
•Pressurecouldoccurfromcrushingofthebrachialplexusbetweenthe
collarboneandfirstrib,orswellinginthisareafrominjuredmusclesor
otherstructures
.
•Theformerexamplesofeventsarecausedbyoneoftwomechanisms
thatremainconstantduringtheinjury.

22. •Traction:Traction,alsoknownasstretchinjury,isoneofthe
mechanismsthatcausebrachialplexusinjury.Thenervesofthe
brachialplexusaredamagedduetotheforcedpullbythewideningof
theshoulderandneck.
•Impact:Heavyimpacttotheshoulderisthesecondcommon
mechanismtocausinginjurytothebrachialplexus.Dependingonthe
severityoftheimpact,lesionscanoccuratallnervesinthebrachial
plexus.

23. Classification of injuries
•Leffertclassification
•IOpen(usuallyfromstabbing)
•IIClosed(usuallyfrommotorcycleaccident)
•IIaSupraclavicular
•Preganglionic:
•avulsionofnerveroots,usuallyfromhighspeedinjurieswithother
injuries.
•noproximalstump,noneuromaformation(negTinel's)
•pseudomeningocele,denervationofneckmusclesarecommon
•horner'ssign(ptosis,miosis,anhydrosis)

24. •Postgangionic:
•rootsremainintact;
•usuallyfromtractioninjuries;
•thereareproximalstumpandneuromaformation(posTinel's)
•deepdorsalneckmusclesareintact,andpseudomeningoceles
willnotdevelop;
•Infraclavicularlesion:
•usuallyinvolvesbranchesfromthetrunks(supraclavicular);
•functionisaffectedbasedontrunkinvolved

25. Millesiclassification of brachial plexus injury
•I: supraganglionic/preganglionic.
•II: infraganglionic/postganglionic
•III: Trunk.
•IV: Cord.

26. Classification on anatomical location of injury
•Upperplexuspalsy(Erb’spalsyintheOBPIcases)involvesC5-C6+/-
C7root
•Lowerplexuspalsy(Klumpke’spalsy)involvesC8-T1roots(and
sometimesalsoC7)
•TotalplexuslesionsinvolveallnerverootsC5-T1

27. Erb'sParalysis
•Siteofinjury
-TheregionoftheuppertrunkofthebrachialplexusiscalledErb's
point.Sixnervesmeethere.InjurytotheuppertrunkcausesErb's
Paralysis.
Causesofinjury
•Undueseparationoftheheadfromtheshoulder,whichiscommonly
encounteredinbirthinjury
•Fallonshoulder
•Duringanaesthesia

28. Nerve roots involved
Nerve roots involved
•Mainly C5
•Partly C6
•Muscles paralysed
•Mainly: biceps, deltoid, brachialis and brachioradialis.
•Partly: supraspinatus, infraspinatus and supinator

29. •Deformity
•Arm:Hangsbytheside,adductedandmediallyrotated
•Forearm:Extendedandpronated
•Thedeformityisknownas"Policeman'stiphand"or"Porter'stiphand
Disability
•Abductionandlateralrotationofthearm(shoulder)
•Flexionandsupinationofforearm.
•Bicepsandsupinatorjerksarelost.
•Sensationsarelostoverasmallareaoverthelowerpartofthedeltoid.

30. Klumpke'sParalysis
Siteofinjury
•InjurytotheLowertrunkofthebrachialplexusiscalled
Klumpke'sParalysis
Causeofinjury
•Undueabductionofthearm,orsometimesinabirthinjury.

31. Nerverootsinvolved
•MainlyT1
•PartlyC8
Musclesparalysed
•Intrinsicmusclesofthehand(T1)
•Ulnarflexorsofthewristandfingers(C8).

32. •Deformity
•Clawhand(positionofthehand)duetotheunopposedactionofthe
longflexorsandextensorsofthefingers.
•Inaclawhandthereishyperextensionatthemetacarpophalangeal
jointsandflexionattheinterphalangealjoints.

33. Disability
•Clawhand
•Cutaneousanaesthesiaandanalgesiainanarrowzonealongtheulnar
borderoftheforearmandhand.
•Horner'ssyndrome:ptosis,miosis,anhydrosis,enophthalmosandlossof
ciliospinalreflex-maybeassociated.Thisisbecauseofinjuryto
sympatheticfibrestotheheadandneckthatleavethespinalcordthrough
nerveT1.

34. •Vasomotorchanges:Theskinareaswithsensorylossiswarnerdueto
arteriolardilation.itisalsodrierduetotheabsenceofsweatingas
thereislossofsympatheticactivity.
•Tropicchanges:Longstandingcaseofparalysisleadstodryandscaly
skin.Thenailscrackeasilywithatrophyofthepulpoffingers.

35. Injury to lateral cord
Cause
•Dislocation of humerus associated with others
•Nerve involved-musculocutaneous, lateral root of median.
Muscles paralysed
•Biceps
•Coracobrachialis
•All muscles supplied by the median nerve, except those of hand

36. Deformityanddisability
•Midproneforearm
•Lossofflexionofforearm
•Lossofflexionofthewrist
•Sensorylossontheradialsideoftheforearm
•Vasomotorandtrophicchanges.

37. Injury to medial cord
Cause
•Subcoracoiddislocation of humerus
•Nerves involved
•Ulnar, Medial root of median
Muscles paralysed
•Muscles supplied bye ulnar nerve
•Five muscles of the hand supplied by the median nerve.

38. Deformity and disability
•Claw hand
•Sensory loss on the ulnar side of the forearm and hand
•Vasomotor and tropic changes as a bone.

39. Axillary Nerve Injury
•TheAxillarynerve(circumflexnerve),isanupperextremitynerve,
whichispartoftheposteriorcord(C5-C6),andprovidesmotor
innervationtothedeltoidandteresminormuscles.
Mechanismofinjury:
•Anteriororinferiordislocationofhumeralhead
•Fractureofsurgicalneckorthehumerus
•ForcedAbductionoftheshoulder
•Fallingonoutstretchedhand(FOOSHinjury)

40. •Generalizedmild,dull,andachypaintothedeeporlateraloranterior
shoulder,withoccasionalradiationtotheproximalarm.
•Numbnessandtinglingofthelateralarmand/orposterioraspectofthe
shoulder(C5-C6nerverootterritory)insomecases,persisting2-4
weekspost-injury.
•Feelingofinstabilityoftheshoulder.
•Weakness,especiallywithflexion,abduction,andexternalrotation.

41. •Fatigue, especially with overhead activities, heavy lifting, and/or
throwing.
•May/or may not reveal a history of trauma to theshoulder region.
•History of dislocation with soreness persisting ~1week post-injury.

42. MEDIAN NERVE
•TheMedianNervecanbecompressedatmanypointsalongitscourse
tothewrist.Dependingonthesiteofinjuryandthesymptoms.
CarpalTunnelSyndrome
•Commonconditionthatcausesatinglingsensation,numbnessand
sometimespaininthehandandfingers.Thesesensationsusually
developgraduallyandstartoffbeingworseduringthenight.

43. Theytendtoaffectthethumb,indexfinger,andmiddlefinger.Other
symptomsofcarpaltunnelsyndromeinclude:
•PinsandNeedles(Paraesthesia)
•ThumbWeakness
•Dullacheinthehandorarm

44. Anterior Interosseous Syndrome
•Apuremotorneuropathy,astheanteriorinterosseousnervecontains
nosensoryfibers;dullforearmpainishoweversometimesmentioned
bypatients.
•Typically,patientsfailtomakean“OKSign",asflexionofthe
interphalangealjointofthethumbandthedistalinterphalangealjoint
oftheindexfinger,areimpaired

45. Pronator Teres Syndrome
•Itisaresultofthetothepositionofthismusclethatsitsoveryour
mediannerve,thepressureonthenervecanelicitpainwhilehindering
yourforearmmovement.
•Itoccurswhenyourpronatorteresmusclebecomestightor
overworked,compressingthemediannerve.
•Hammering,repeatedlyusingascrewdriver,cleaningfishcanleadto
overuseofthepronatorteres.Symptomsincludepainandreduced
mobility

46. •Motor signs of a median nerve lesion include;
•Weak pronation of the forearm
•Weak flexion and radial deviation of wrist
•Thenar atrophy
•Inability to oppose or flex the thumb;

47. •Sensorysignsofamediannervelesioninclude;
•sensorydistributionincludesthumb,radial21/2fingers,andthe
correspondingportionofpalm.
•withintactnerve,thumbcanbepronated,liningupnailsatornear
180deg;
•withmediannervepalsy,thumbcannotbepronated&nailis<100
deg

48. Ulnar Nerve
•Ulnarnerveentrapmentoccurswhentheulnarnerveiscompressed.
Thistypicallyoccursattwomainsites:theelbowandthewrist.Ulnar
nerveentrapmentattheelbowisusuallyatthecubitaltunnel(Cubital
TunnelSyndrome.
•Ulnarnerveneuropathyattheelbowisthesecondmostcommon
entrapmentneuropathy(thefirstmostcommonisthemediannerveat
thewrist)

49. Cause
•Ulnarnerveentrapmentattheelbow(CubitalTunnelSyndrome)and
wrist(Guyon'sCanalSyndrome)occurduetorepetitivecompression,
fromleaningontheelbowsorwrists(cyclist'spalsy)andprolonged
elbowflexion.Itcanalsooccurfromtrauma,swelling,fractures,and
vascularandbonypathologies/abnormalities.
•Guyon’scanalsyndromeoccurswhentheulnarnervebecomes
entrappedbetweenthehookofthehamateandthetransversecarpal
ligament.

50. •Guyon’scanalsyndromeisconsideredanoveruseinjurywhichis
commonlycausedbydirectpressureonahandlebar(i.e.bicycle
handlebar,weightlifting,constructionequipment)andtherefore,is
sometimesreferredtoas“handlebarpalsy”.
•Itcanalsoresultfromexcessivegripping,twisting,orrepeatedwrist
andhandmotions.Also,entrapmentmaydevelopifthehandisflexed
andulnardeviatedforprolongedperiodsoftime.

51. Clinical Presentation
•Symptomsofulnarnerveentrapmentincludetinglinginfingers4and
5
•Weakgrip
•Strength
•Pain
•Sensitivityontheulnarsideoftheforearm,wristandhand,muscle
atrophy,clawingofdigits4and5

52. Cubital Tunnel Syndromecan present in different grades of severity:
Grade I: Mild symptoms including:
•Intermittent paresthesia
•Minor hypoesthesia of the dorsal and palmar surfaces of the fifth and
medial aspect of fourth digits
•No motor changes
Grade II: Moderate and persistent symptoms including:
•Paresthesia
•Hypoesthesia of the dorsal and palmar surfaces of the fifth and medial
aspect of fourth digits
•Mild weakness of ulnar innervated muscles
•Early signs of muscular atrophy

53. •GradeIII:Severesymptomsincluding:
•Paresthesia
•Obviouslossofsensationofthedorsalandpalmarsurfacesofthefifth
andmedialaspectoffourthdigits.
•Significantfunctionalandmotorimpairment
•Muscleatrophyofthehandintrinsics
•Possibledigitalclawingoffourthandfifthdigits(SignofBenediction)

54. •Guyon'sCanalSyndromesymptomsinclude:
•Muscularatrophy-Primarilythehypothenarmusclesandinterosseiwith
muscle-sparingofthethenargroup:
•weakenedfingerabductionandadduction(interossei)
•weakenedthumbadductor(adductorpollicis)
•Sensorylossandpainwhichmayinvolvethepalmarsurfaceofthefifth
digitandmedialaspectofthefourthdigit&thedorsumofmedialaspect
ofthefourthfingerandthedorsumofthefifthfingerdon’thavesensory
loss.
•UlnarClawmaypresent(signofBenediction)

55. Radial nerve injury
•Radialnerveinjuriesareassociatedwiththepathittravelsclosetothe
humerus.
•Mechanismsofinjurycanbe:humerusfracture,adirectblowor
sustainedpressure(i.e.fromincorrectuseofacrutch).
•Motorfunctionofthetricepsareusuallypreservedastheyare
innervatedsuperiorlywhereaswristanddigitextensorsareoften
paralysedleadingtothedroppedwristdeformity.

56. •Alossofsynergicactionbetweenwristflexorsandextensorscauses
excessiveandunwantedwristflexion.
•Weakness:
•Wristextension
•Abductionofthumb
•Diminishedsensation:
•Backofthumb,index,middle,and1/2ringfinger
•backofforearm
•Abnormalreflexes
•Triceps
•Brachialradialis

57. Musculocutaneous nerve
•IsolatedinjuriesoftheMusculocutaneousNervearerare.Itmay
becomeinjuredby
•BrachialPlexusdamage
•Compressioninjuryegweightliftingorsportsinvolvinglotsofforarm
flexingandsupination.Thebicepsaponeurosisandtendoncompress
againstthefasciaofthebrachialismusclecausingsensorylossbelow
theelbowonthelateralsideoftheforearm.
•Dislocationoftheshoulder
•Shouldersurgery
•Entrapmentofthenerveattheelbow

58. •Check strength ofBiceps Brachii, CorocobrachialisandBrachialis
muscles .
•Check sensation on lateral forearm
•SeeNerve Entrapement

59. Lumbar Plexus
•Thelumbarplexusisacomplexneuralnetworkformedbythelower
thoracicandlumbarventralnerveroots.
•Damagetothelumbarplexusornervesproximalanddistaltoitcan
resultinseveralpathologies.
•Lumbardischerniationcancauseocclusionoftheintervertebral
foramen,compressinglumbarspinalnervesneartheirentrytothe
lumbarplexus.Thissyndromecancauseparesthesiaandweakeningin
thelumbarplexusnerves'innervatedlocations.

60. •Thelateralfemoralcutaneousnerve,whichisabranchofthelumbar
plexus,cancauseacommonandseriousnervecompressioncondition.
Thisisknownasmeralgiaparestheticaandiscausedbythenerve
becomingtrappedasitpassesbeneathorthroughtheinguinal
ligament.

61. Femoral nerve
•Femoralnervedamage(alsoreferredtoasfemoralnervedysfunction
orneuropathy),canoccurfromaninjuryorprolongedcompression.
Typically,damageanddysfunctionofthefemoralnerveareassociated
withthelegweaknessandsensationchanges.
•Injury:Injuryofthefemoralisuncommonbutmaybeinjuredbya
stab,gunshotwounds,orapelvicfracture.
•Thefemoralnervecanbedamagedduringpenetratingtraumatothe
thigh.Itcanalsobedamagedduringhipreplacementoperations,
particularlytheanteriorapproach(notcommonlyused)wherethe
nervecanbestretchedanddamaged

62. •MotorLoss
•Poorflexionofthehip,becauseofparalysisoftheiliacus,psoasand
sartoriusmuscles.
•Inabilitytoextendtheknee,becauseofparalysisofthequadriceps
femoris.
Sensoryimpairment
•Sensorydeclineovertheanteriorandmedialaspectsofthethigh,asa
resultofengagementoftheintermediateandlateralcutaneousnerves
ofthethigh.
•Sensorylossonthemedialsideofthelegandfootuptotheballofthe
greattoe(firstmetatarsophalangealjoint),becauseofengagementof
thesaphenousnerve

63. OBTURATOR NERVE
•Injurytothenerveisrareasitliesdeepwithinthepelvisandmedial
thigh.Itcanbedamagedthroughdirectinjurytothenerveorto
surroundingmuscletissue.Milddamagetotheobturatornervecanbe
treatedwithphysiotherapy.Moreseverecasesmayrequiresurgery
•Injurymaybecausedby:
•Nervebeingstretchedduringsurgery
•Thenervecanbecomeentrappedattheexitoftheobturatorcanalor
moredistallybyfascia

64. •Entrapment of the obturator nerve causes exercise-induced medial
thigh pain, typically in athletes.
•Athletes may present with pain that may be brought on by exercise,
often sports involving a lot or running and twisting.Hip abduction and
extension aggravate the pain, andresisted adduction does not elicit
pain.
•Compression during pregnancy
•Car or household accident
•Abdominalsurgery

65. •Symptoms
•Pain & paresthesiasmay extend from hip to knee along the medial
aspect of the thigh
•Extension or lateral leg movement can increase pain
•May have troublewalking or experience leg weakness due to problems
adducting the ipsilateral hip

66. •Signs
•Weak hip adductors on affected side
•Wasting of medial thigh
•Abnormal abduction ofhipduring ambulation resulting in a
circumduction, wide-basedgait
•Area of sensory loss or alteration in the mid and lower third of the
medial thigh which sometimes may extend below theknee
•Ipsilateral loss of thehip adductor tendonreflex (test against
asymptomatic leg as is not always present in healthy population)

67. •Sciaticnerveinjuryoccursduetotrauma(pressure,stretchingorcutting)to
thenerveandcancausesymptomssuchasparesthesia,lossofmuscle
powerandpain.
•Thesesymptomsaresimilartothosecausedbysciatica.
•Trauma-hipdislocation,acetabularfracture
•Iatrogeniccauses-
•Directsurgicaltrauma
•Faultypositioningduringanaesthesia
•Injectionofneurotoxicsubstances
•Tourniquets
•Dressings,castsorfaultyfittingorthotics
•Radiation
SCIATIC NERVE INJURY

68. •Thecommonsymptomsarepainandabnormalgaitpattern.
•However,painintensityisdifficulttoquantifyorrateparticularlyin
thepaediatricpopulationbutfacialexpressionisquitehelpful.Other
clinicalsignsinclude:
•Footdrop
•Externalrotationandabductioncontractureofthehip
•EquinovarusorEquinusdeformity
•Muscularweakness/atrophy
•Motorandsensorydeficitsuchasparaesthesiaandnumbness

69. Tibial Nerve injury
•Thetibialnerveisthelargerterminalbranchofthetwomainmuscular
branchesofthesciaticnerve
•Injurytothetibialnervecancausemotorlossandalteredsensation
andpaintoanyoftheareasitsupplies,dependingonsiteof
involvement.
•Poplitealfossaregion.Injurymayoccurduetoe.g.
•Spaceoccupyinglesion
•Lacerationinjury
•Posteriordislocationoftheknee

70. •Entrapmentinsoleusarch:Soleusarchentrapmentneuropathycan
occurwithsportsthatmakespecialdemandsonthecalfmuscles.
Swellingandhypertrophyofthesoleusmusclemaycauseits
tendinousarchtocompressthepoplitealarteryandveinaswellasthe
tibialnerve.
•Thiscancausechronicmechanicaldamagetothenerveandtheartery
andveinmaybecomeoccluded.Thisrequiressurgicalreleaseandhas
agoodoutcome.
•Fracturesofthetibiaandfibula.
•Localtraumatotheposteriorlowerleg

71. Medialmalleoluslevel:
•Compressionofthetibialnerveintheosseofibroustunnelbelowthe
flexorretinaculumoftheanklecausestarsaltunnelsyndrome.On
examinationitpresentsaspainandparesthesiainthesoleofthefoot.
•Tibialnerveblockdoneforcertainoperationsofthefoot.
•Soleoffoot:Abnormalpressureattheballofthefootcanirritatethe
firstplantardigitalnervecausingMorton'sneuroma/Metatarsalgia

72. Common peroneal nerve
•Thecommonperonealnerveisthesmallerandterminalbranchof
thesciaticnerve.
•Thecommonperonealnerveisinaparticularlyvulnerablepositionas
itwindsaroundtheneckofthefibula.Itmaybedamagedatthissite
by
•Traumaorinjurytotheknee
•TKA
•Compressionofthefibulaheadduringsurgerye.g.tourniquet
•Fractureofthefibula
•Fracturetotibialplateau

73. •Useofatightplastercastofthelowerleg
•Crossingthelegsregularly
•Pressuretothekneefrompositionsduringdeepsleeporcoma
•Patellardislocations(33%chanceofnervedamage)

74. •Damagetothisnerveisfollowedbyfootdrop(duetoparalysisofthe
ankleandfootextensors)andinversionofthefootduetoparalysisof
theperonealmuscleswithunopposedactionofthefootflexorsand
invertors).
•Thereisalsoanaesthesiaovertheanteriorandlateralaspectsoftheleg
andfoot,althoughthemedialsideescapes,sincethisisinnervatedby
thesaphenousbranchofthefemoralnerve.
•Neuropathicpaincanalsobeacommonsymptomtoperonealnerve
neuropathywhichcanbemanagedwithanalgesia.
[

75. ASSESMENT
•Demographics:
•Chiefcomplains:
-fullnessintheupperextremity;afeelingofswelling,tingling,pain,
coldness,ornumbness;ordroppingthings.
•History:
-historyoftrauma,repetitiveactivities,sustainedstaticortension
postures,suchascomputerkeyboardwork,orphysicalactivities
performedwithahighlevelofcognitivedemand,asseeninapianist.

76. •theprogressionofthesymptomsorcomplaintsandthelevelof
irritabilityshouldbedetermined.
-Pasthistory:
-Medicalhistory:
•Thehistoryshouldincludeadiscussionofgeneralhealth,including
anypotentiallyrelevantmedicalconditions(e.g.,asthma,diabetes,
hypothyroidism).
-Drughistory:
-Surgicalhistory:
-Personalhistory:
-Socio-economichistory:
-Occupationhistory:

77. •Environmentalhistory:
•Educationalhistory:
•Rehabilitationhistory:

78. ON OBSERVATION
•Body Built
•Posture
•Deformity
•Attitude of limb
•Skin changes
•Swelling
•External aids
•Gait
•Breathing pattern

79. ON PALPATION
•Temperature (Cool, cyanotic skin can be an indication of arterial
insufficiency or sympathetic dysreflexia in the area, whereas swelling
can be an indication of inflammation and venous or lymphatic
insufficiency)
•Swelling
•Tenderness
•Spasm

80. ON EXAMINATION
•Vitals –Pulse examination
•Sensory examination
-cortical level: abnormal tactile localization, graphesthesia, and
stereognosis.
•Reflex examination
•Motor examination:
-Range of motion
-MMT

81. •Pain examination:
-Site of pain
-Nature
-Pattern
-Duration
-Aggravating factors
-Reliving factors
-Intensity of pain

83. •Gait examination
•Balance examination

84. PHYSIOTHERAPY MANAGEMENT

85. Acute phase:
•Immobilization: time dictated by surgeon
-Movement: amount and intensity dictated by type of injury and
surgical repair
-Splinting or bracing: may be necessary to prevent deformities
-Patient education: protection of the part

86. •Patient education. The patient
must learn to protect the extremity
to avoid injury due to loss of
sensation.

87. •Movement.Beginrangeofmotion(ROM)tominimizejointand
connectivecontracturesandadhesions.Thisisdictatedbythesurgeon
andtypeofsurgery.
•Splintingorbracing.Splintingorbracingmaybenecessarytoprevent
deformitiesduetostrengthimbalances(useofaradialnervesplintto
preventwristdrop,amediannervesplinttopositionthethumbin
opposition,aplantarflexionsplinttopreventfootdrop)andtoprevent
unduestressonthehealingnervetissue

88. Recovery phase
•Recoveryphase:signsofreinnervation(musclecontraction,increased
sensitivity)
•Motorretraining:muscle“hold”intheshortenedposition
•Desensitization:multipletexturesforsensorystimulation;
•Vibration
•Discriminativesensoryreeducation:identificationofobjectswith,
thenwithout,visualcues

89. •Motorretraining:Whensignsofvolutionalmusclecontractionoccur,
themuscleispositionedinitsshortenedposition;thepatientisasked
tohold.
•Electricalstimulationmaybeusedtoreinforcethisactiveeffort.
•Whenthemusclesdemonstratecontrolofsomerange,begingravity-
eliminated,active-assistiveROM.
•Continuetoprotecttheweakmuscleswithasplintorbrace.Asnerves
regenerate,thepersonexperiencesincreasedsensitivity
(hypersensitivity)intheareathathadpreviouslybeenwithout
sensation.Useagradedseriesofmodalitiesandproceduresto
decreasetheirritabilityandincreaseawareness

90. •Usemultipletypesoftexturesorcontactforsensorystimulation
(cotton,roughmaterial,sandpaperofvariousgrades,Velcro).
•Thetexturescanbewrappedarounddowelrodsforfinger
manipulationorstrokingalongskin.
•Contactparticlessuchascottonballs,beans,macaroni,sand,orother
materialwithvariousdegreesofroughnesscanbeplacedintubsor
canswherethepatientcanrunthehandorfootthroughthematerial.

91. •Havethepatientbeginmanipulatingorplacingtheextremityinthe
leastirritatingtexturefor10minutes.
•Astoleranceimproves,progresstothenexttextureofslightlymore
irritatingbuttolerablestimulus.
•Maximumprogressoccurswhenthemostirritatingtextureistolerated
Vibration:
•Canalsobeused.Patternofrecoveryafternerveinjuryispain
(hypersensitivity),perceptionofslowvibration(30cps),moving
touch,constanttouch,rapidvibration(256cps),andawarenessfrom
proximaltodistal.

92. •Discriminativesensoryre-education:
-Thisistheprocessofretrainingthebraintorecognizeastimulusonce
thehypersensitivitydiminishes.
-Beginbyusingamovingtouchstimulus,suchastheeraserendofa
pencil,andstrokeoverthearea.Thepatientfirstwatches,thencloses
hisorhereyesandtriestoidentifywheretouchoccurred.
-Progressfromstrokingtousingconstanttouch.Whenthepatientis
abletolocalizeconstanttouch,progresstoidentificationoffamiliar
objectsofvarioussizes,shapes,andtextures.

93. -Forthehand,usefamiliarhouseholdandpersonalcareobjects,suchas
keys,eatingutensils,blocks,toothbrush,andsafetypins.
-Forthefeet,havethepatientwalkonvarioussurfaces,suchasgrass,
sand,wood,pebbles,andunevensurfaces
•Patienteducation.Instructthepatienttoresumeuseoftheextremity
graduallywhilemonitoringpain,swelling,oranydiscoloration;if
necessary,modifyortemporarilyavoidanyaggravatingactivities.
•Whilethenerveisrecoveringorifnerverecoveryisincomplete,teach
thepatientpreventivecaretoavoidin

94. Chronic phase
•Reinnervationpotentialpeakedwithminimalornosignsof
neurologicalrecovery
•Compensatoryfunction:compensatoryfunctionisminimizedduring
therecoveryphasebutisemphasizedwhenfullneurologicalrecovery
doesnotoccur
•Preventivecare:emphasisonlifelongcaretoinvolvedregion
•Thepersonwillprobablyhavetocontinuetowearthesupportive
splintorbrace,andpreventivecaremustcontinueindefinitely

95. Pain Management
•Massage
•TENS
•Relaxation techniques
•Low level laser therapy

96. Muscle Strength
•Whenmusclestrengtheningexercisescancommenceitisimportant
nottodamagethehealingnervoustissue:ifpinsandneedles,
numbnessorincreasedpainoccurstheexerciseistoohardandcan
haveanegativeeffectonhealing.
•Musclestrengtheningexercisesareemployedasappropriate,eg
isometric,gradedweightprogression,open-closechain,andUseof
supportslingsmaybeemployedtoassistthemovementandtakethe
weightofthelimb.

97. Prevention of contracture
•Splintstopreventdeformitiesdeveloping,oreventoovercome
establishedcontracturesandimprovefunction,andinthiswayaidthe
patient'srecovery
.
•Staticanddynamicsplintscanhelptorestparalysedmusclesin
optimumpositioningtoavoidoverstretchingandorcontractures.

98. THANKYOU