If nerves are damaged during surgery, they will recover. Bruises and injuries to peripheral nerves

A damaged nerve fiber is unable to heal. However, simultaneously with the denervation process, restoration processes begin, which can go in three directions.
(1) Nerve regeneration: the proximal stump forms axonal outgrowths (influxes of axoplasm, or “growth flasks”), which begin to move distally and grow into the endoneurial tubes (of course, only in cases where the latter have retained their integrity). The myelin sheath of the newly formed fiber is formed from strands of lemmocytes. The rate of axonal regeneration is approximately 1.5-2 mm per day. Individual nerve conductors have different abilities to regenerate: among peripheral nerves The function of the radiation and musculocutaneous nerves, and the ulnar and peroneal nerves have the worst regenerative abilities [Karchikyan S.I., 1962; Weber R., 1996J. To achieve good repair, growing axons must connect to the distal nerve stump before it develops significant peri- and endoneurial scarring. In cases where a connective tissue scar is formed along the sprouting fiber, some of the axons do not spread in the distal direction, but randomly deviate to the sides, forming a traumatic neuroma.
At full anatomical damage of the nerve trunk, 2-3 weeks after the injury, an amputation neuroma forms at the central end.
Regeneration of the nerve trunk can occur heterogeneously: part of the motor fibers grows into the sensory membranes, and the same fibers grow into bundles innervating opposite parts of the limb [Gaidar B.V., 1997].
(2) In cases where not all, but only part of the nerve fibers in the nerve trunk are affected, restoration of muscle function is possible due to the branching of the surviving axons and their “capture” of those muscle fibers that were innervated by the dead axons; in this case, the motor units of the muscle are enlarged. Due to this mechanism, a muscle can maintain its performance in cases of loss of up to 50% of the axons that innervated it (and for muscles that do not develop significant efforts - even up to 90%), however, it takes about a year to complete the process of compensatory innervation restructuring.
(3) In some cases (usually with a nerve trunk injury such as a bruise), restoration or improvement of functions is associated with the reversibility of certain pathomorphological processes: with the disappearance of reactive inflammatory phenomena, with resorption of minor hemorrhages, etc. For mild injuries, nerve conduction, even after complete loss, is restored within the first days or weeks.

7.2.2. Factors that determine the recovery forecast

The main factors that determine the speed and degree of spontaneous recovery of impaired functions in peripheral neuropathies and plexopathies (and, consequently, the volume and direction of therapeutic interventions) include the following:
- degree of damage to the nerve conductor;
- level of damage;
- the nature of the damaging agent.

7.2.2.1. Degree of damage to nerve conductors (with local injury)

Rehabilitation specialists most often determine the degree of nerve damage in 3 categories according to the H. Seddon classification. Sometimes the classification of S. Sunderland is also used, which distinguishes 5 degrees of nerve damage; this classification is based on H.Seddon's classification, detailing it. According to H. Seddon’s classification, all local damage to nerve trunks is divided, depending on the safety of the axon and connective tissue structures, into three groups: (1) neurapraxia; (2) axonotmesis; (3) neurotmesis. (1) Neurapraxia is a nerve injury that does not lead to axon death. Often observed with nerve compression (eg, Saturday night palsy due to compression of the radial nerve), with minor injury nerve. Clinically characterized by a decrease in vibration, proprioceptive, and sometimes tactile sensitivity. Pain sensitivity is less affected. Motor disturbances and paresthesia are often observed. Conduct block nerve impulse, observed due to local damage to the myelin sheath, is transient and regresses as myelin is restored. Restoration of motor and sensory functions can last up to 6 months.
(2) Axonotmesis (axonotmesis, English) - damage to the nerve, leading to the death of the axon while the epineurium, perineurium, endoneurium and Schwann cells are preserved. It is often observed with closed fractures or dislocations of the bones of the extremities, as well as with compression of the nerve trunks. The motor, sensory and sudomotor functions of the nerve are impaired. Functional restoration occurs due to axon regeneration. The speed and extent of recovery depends on the level of damage, age (in young people regeneration occurs faster) and general condition sick. In cases where axon growth is slow, scarring of the endoneurial tube into which the axon grows may occur and repair does not occur. For the same reason, an unfavorable prognosis occurs in cases where the nerve trunk defect is of significant length. Under favorable conditions, gradual neurotization of the distal part of the damaged nerve occurs, which continues for many months, sometimes a year or more. There is a restoration of lost functions, but not always complete.
O) Neurotmesis (neurotmesis, English) - rupture of a nerve with the intersection of the axon and connective tissue sheaths of the nerve. Due to the fact that the endoneurial tubes are damaged, it becomes impossible for axons to grow into them; axonal regeneration leads to the formation of a traumatic neuroma. The prognosis for recovery is unfavorable. This classification based on microscopic changes in the nerve trunk. It is almost impossible to discern the degree of damage macroscopically. Diagnosis is based on dynamic clinical and electrophysiological observation. In this regard, with closed injuries of the nerve trunks, domestic authors often use a different classification based on the identification of the following 4 forms of damage to the nerve trunk [Makarov A.Yu., Amelina O.A., 1998]: concussion, bruise, compression, traction. A concussion is not accompanied by morphological changes in the nerve; nerve dysfunction is short-term (no more than 1-2 weeks) and completely reversible. Nerve contusion is characterized by the occurrence of small hemorrhages, areas of crushing of nerve fibers and bundles, which leads to complete or partial disruption of conductivity, long-term and persistent loss of functions. When a nerve is compressed, the degree of conduction disturbance depends primarily on the duration of the intervention: with timely removal of the substrates compressing the nerve (hematoma, foreign body, bone fragment, etc.), a rapid and complete restoration of conductivity can be observed, whereas with long-term compression develop in the nerve trunk degenerative changes. Failure to restore function within 2-3 months is a criterion for complete anatomical interruption of the nerve. Traction (for example, traction of the branches of the brachial plexus during reduction of a dislocated shoulder) is usually accompanied by partial dysfunction, but restoration of conduction along the nerve takes a long time (within several months).

7.2.2.2. Damage level

The more proximal the damage to the nerve trunk or plexus (i.e., the greater the distance from the site of damage to the peripheral endings), the worse the prognosis for restoration of function, since the longer it takes for the nerve fiber to grow and the greater the likelihood of irreversible development in the endoneurial tube of the peripheral segment of the nerve. Scar changes. So, for example, according to S.I. Karchikyan, with injuries to the sciatic nerve in the upper third of the thigh, the first movements of the foot and fingers appear only 15-20 months or later after the application of the nerve suture, and with injuries to the same nerve in the lower third of the thigh - 10-15 months after surgery.
The worst prognosis is observed for damage at the radicular level, since the roots of the spinal nerves do not regenerate and cannot be restored surgically. Damage to the roots (usually a separation of the root at the cervical level), in contrast to damage to the plexus, is characterized by the following symptoms:
- intense burning pain radiating along the corresponding dermatome;
- paralysis of paravertebral muscles innervated by the posterior branches of the spinal nerves;
- paralysis of the scapula muscles due to dysfunction of the short nerves of the shoulder girdle (pterygoid scapula);
- Horner's syndrome (with damage to the C8 roots);
- trophic disorders and rapidly progressing muscle atrophy with severe secondary contractures.

7.2.2.3. Nature of the damaging agent

Peripheral neuropathies and plexopathies can have the most various etiologies(Table 7.2). In peacetime, the most common form of peripheral nerve damage is tunnel neuropathies, accounting for about 30-40% of all diseases of the peripheral nervous system. Tunnel neuropathy is a local lesion of the nerve trunk caused by its compression and ischemia in the anatomical canals (tunnels) or due to external mechanical influence [Leikin I.B., 1998]. Factors predisposing to the development of tunnel neuropathies include the genetically determined narrowness of the natural nerve receptacles, the acquired narrowness of these receptacles due to edema and connective tissue hyperplasia during various diseases(For example, diabetes mellitus, hypothyroidism, collagenosis), prolonged overstrain of the muscular-ligamentous apparatus in persons of certain professions, the effects of herbs, muscular-tonic and neurodystrophic disorders in reflex syndromes of spinal osteochondrosis, iatrogenic traumatic effects (incorrect application of a plaster cast, hemostatic tourniquet). Nerve dysfunction occurs due to both demyelination and axonal damage (deterioration of neurotrophic control due to failure of axonal transport).
Tunnel nerve lesions are manifested primarily by pain, sensory and autonomic disorders. Movement disorders develop in only one third of patients and consist, as a rule, in a decrease in muscle strength, muscle wasting, and the development of contractures. The prognosis for functional restoration with early treatment is usually favorable, but this restoration can take quite a long time, up to several months. In addition, the prognosis depends on the underlying disease against which the neuropathy developed, and on whether occupational overload of the limb persists. In 30-40% of cases, tunnel neuropathies recur [German A.G. et al., 1989].
In second place in frequency are traumatic neuropathies. Among the causes of traumatic neuropathies, the most prognostically favorable are incised wounds, in which timely surgical intervention provides a good outcome. Traction and gunshot injuries have a worse prognosis, since in them the central segment of the nerve and the neuron of the spinal centers are often changed, which significantly complicates nerve regeneration. Destruction of the nerve trunk over a long distance can also be observed due to electrical trauma or chemical damage (accidental injection of various medicinal substances into the nerve). A very unfavorable condition accompanying nerve damage is circulatory disturbance in the limb (bleeding or prolonged application of a hemostatic tourniquet, thrombosis of the main artery), which can lead to the development of an atrophying sclerosing process in the muscles, tendons, joint capsules, skin and subcutaneous tissue with the formation of contractures. Secondary changes in the joints and tendons, which develop as a result of stretching of the ligaments and joint capsules during passive hanging of the limbs in the case of flaccid paralysis or paresis, can also prevent the restoration of movements.
For neuro- and plexopathies that have developed against the background of somatic diseases, due to immune, neoplastic, infectious, toxic lesions and effects, the prognosis depends on the nature of the course of the underlying disease or process.

7.2.3. Clinical and electrophysiological signs of restoration of nerve conductors

Determining the degree of restoration of the function of nerve conductors is based on data from a comprehensive clinical and electrophysiological examination conducted over time. The most complete description of the clinical patterns of restoration of the function of nerve conductors is presented in works summarizing the experience in the treatment of traumatic neuropathies accumulated during the Great Patriotic War (Karchi kyan S.I. Traumatic damage to peripheral nerves. - L.: Medgiz, 1962; Astvatsaturov M.I. Guide to military neuropathology. - L., 1951; Experience of Soviet medicine in the Great Patriotic War, 1952. - T.20). Below we will consider the patterns of functional restoration after a complete nerve break in the case of favorable regeneration or after timely neurosurgical intervention.
The earliest clinical symptoms of recovery are usually changes in the sensitive area, which long precede signs of recovery motor function[Karchikyan S.I., 1962]:
- paresthesia that occurs in the anesthesia zone with pressure on the nerve area immediately below the damage zone, i.e. to the area of ​​regenerating young axons;
- the appearance of sensitivity to sharp compression of the skin fold in the anesthesia zone;
- pain when pressure is applied to the nerve trunk distal to the site of injury with irradiation of pain in the distal direction along the nerve; as the axon grows, this pain is obtained from levels located more and more towards the periphery.
Restoration of sensitivity occurs earlier in more proximal sections, starting from the edges of the central zone of anesthesia. First, protopathic (primitive) pain and temperature sensitivity is restored: the ability to perceive only sharp pain and temperature irritations without accurately recognizing the quality and precise localization of the applied irritation. Therefore, painful and temperature irritations of the skin cause sensations that have the properties of hyperpathy (diffuse, difficult to localize, very unpleasant). This may be due to insufficient myelination of newly formed regenerating fibers, which leads to widespread irradiation of excitation to neighboring fibers. Then tactile sensitivity begins to recover, and only then fine temperature sensitivity, muscle-joint sense, and stereognostic sense. As epicritic (more subtle) sensitivity is restored, the hyperpathic features of perception of pain and temperature stimuli begin to disappear.
It must be remembered that a narrowing of the zone of sensitivity disorder can occur not only as a result of the beginning of regeneration, but also due to compensatory phenomena (overlapping of branches of neighboring nerves); it is important to distinguish between these processes.
The earliest signs of restoration of motor function include a slight increase in the tone of paralyzed muscles and a decrease in atrophy. Then, starting from more proximal sections, active muscle contractions appear. 5-6 months after a nerve injury, active movements occur, which are initially characterized by weakness, rapid exhaustion, and awkwardness. The restoration of small differentiated isolated movements (for example, in the interphalangeal joints) takes a particularly long time. Reflexes are the last to be restored; they often remain lost even with complete restoration of sensitivity and motor functions. In general, a damaged axon, when the cause that impedes axonal growth is eliminated, is restored within a period of 1.5-2 to 8-10 months [Lobzin V.S. et al., 1988].
Even without regeneration partial restoration Lost movements may occur due to compensatory contraction of muscles innervated by intact nerves. On the other hand, the lack of movement recovery may not be due to a lack of nerve regeneration, but to concomitant damage to the tendons, muscles and joints.
Among the electrophysiological methods used for dynamic control to monitor the processes of restoration of nerve conduction, needle and stimulation electromyography (EMG), as well as the method of evoked potentials (Chapter 2 of the first volume) are currently used. Let us recall that a partial disruption of nerve conduction during stimulation EMG recording is characterized by a decrease in the speed of excitation, a decrease in the amplitude and frequency of action potentials of the nerve and muscle, and a change in the structure of the M-response; During registration needle EMG a change in the structure of action potentials of the motor units of the corresponding muscles is observed. With demyelinating processes, nerve conduction velocity decreases to a greater extent, while with axonopathies, a predominant decrease in the nerve action potential and a change in the M-response are observed, and changes in conduction velocity may not be observed. When the nerve is completely interrupted, the distal segment continues to conduct impulses for up to 5-6 days. Then there is a complete absence of electrical activity in the affected nerves and muscles. After the first three weeks, spontaneous muscle activity at rest (denervation potentials of fibrillations and positive sharp waves) usually appears, recorded using needle electrodes. The first signs of reinnervation after complete denervation of the muscle are detected when recording needle EMG in the form of the occurrence of a series of low-voltage polyphasic potentials lasting 5-10 ms during an attempt to voluntarily contract [Popov A.K., Shapkin V.I., 1997]. As muscles are reinnervated, the appearance of polyphasic motor units and an increase in their amplitude and duration are also observed (the appearance of giant motor unit potentials is associated with the capture of additional muscle fibers by the remaining axons). Reinnervation potentials can sometimes be detected 2-4 months before the first clinical signs of recovery [Zenkov J1.P., Ronkin M.A., 1991].
The earliest judgments about the dynamics recovery processes can be obtained by recording evoked potentials (EP). Peripheral EPs are caused by stimulation of the peripheral nerve (magnetic or electrical) and are recorded in the form of waves above different areas nerve. 7 or more days after the injury, peripheral EPs are compared with those observed immediately after the injury, or with their values ​​on the unaffected contralateral side. In this case, they focus not only on the amplitude of the VP, but also on the area under the VP wave. With the reversible nature of the disorders (neurapraxia), 7 or more days after the injury, sensory and motor EPs caused by stimulation of the peripheral nerve below the level of the lesion continue to be recorded in the distal part of the nerve. With axonotmesis and neurotmesis, after this period, a decrease in the amplitude and a change in the shape of VPs distal to the site of damage is observed, and after the completion of Wallerian degeneration, VPs in the peripheral segment of the nerve are not caused.
Electrodiagnostic methods make it possible to distinguish neurapraxia from axonotmesis and neurotmesis, but do not allow one to distinguish between axonotmesis and neurotmesis; This requires the use of magnetic resonance imaging.
In plexopathies, the BII method can help in the differential diagnosis of pre- and postganglionic lesions, which is important when determining indications for neurosurgical intervention. With postganglionic damage to the trunks of the plexus, the distal end loses connection with the cell body of the spinal ganglion, therefore, both sensory and motor action potentials upon irritation of the peripheral segment of the nerve are absent at any point below the site of damage. With preganglionic lesions, motor peripheral EPs are not evoked while sensory EPs are preserved in the same segments of the nerve (despite anesthesia in the corresponding innervation zones). This is explained by the following: with a preganglionic lesion, the central process of the bipolar cell is damaged, which disrupts the transmission of sensitive impulses to the cerebral cortex and, accordingly, is accompanied by anesthesia. However, the peripheral segment does not lose connection with the cell body of the spinal (sensitive) ganglion, remains viable and normally conducts sensory impulses. In this regard, with preganglionic damage, sensory action potential is recorded along the entire course of the nerve fiber up to the level of injury. Erroneous conclusions, however, can be drawn with multifocal trauma, when there is both pre- and postganglionic radicular damage; in this case, sensory peripheral EPs are not evoked, “masking” the preganglionic damage. The detection of preganglionic lesions indicates an extremely unfavorable prognosis, since, as already indicated, root regeneration is impossible and surgical intervention is not available.
Predicting the possible spontaneous recovery of impaired functions determines the direction and scope of further rehabilitation measures.

In the last 20 years, due to the progress of general biological and technical knowledge, significant achievements have been noted in the surgery of peripheral nerves. Nerve damage is one of the most common and severe types of injuries that cause complete or partial disability, force patients to change professions and often become a cause of disability. In everyday life clinical practice Unfortunately, a significant number of diagnostic, tactical and technical errors are made.

Diagnosis of damage to nerve trunks

Peripheral nerve damage can be closed or open.

Closed injuries occur due to a blow with a blunt object, compression of soft tissues, damage from bone fragments, tumors, etc. Complete disruption of the nerve in such cases is rarely observed, so the outcome is usually favorable. Lunate dislocation, fracture radius in a typical location often lead to compression injuries of the median nerve in the area of ​​the carpal tunnel; a fracture of the hamate bone can cause a break in the motor branch of the ulnar nerve. Open injuries in peacetime are most often the result of injuries from glass fragments, a knife, sheet iron, circular saw etc. The oncoming changes manifest themselves depending on the nature and duration of exposure to the traumatic agent by various syndromes of functional disorders.

Loss of sensitivity is almost always observed when a peripheral nerve is damaged. The prevalence of disorders does not always correspond to the anatomical zone of innervation. There are autonomous zones of innervation in which loss of all types of skin sensitivity is noted, i.e. anesthesia. This is followed by a zone of mixed innervation, in which, if one of the nerves is damaged, areas of hypoesthesia alternate with areas of hyperpathy. In the additional zone where innervation occurs neighboring nerves and only a slightly damaged nerve, it is not possible to determine a sensitivity disorder. The size of these zones is extremely variable due to the individual characteristics of their distribution. As a rule, the diffuse zone of anesthesia that appears immediately after a nerve injury is replaced by hypoesthesia after 3-4 weeks. Yet the process of substitution has its limits; If the integrity of the damaged nerve is not restored, then loss of sensitivity remains. Loss of motor function manifests itself in the form of flaccid paralysis of muscle groups innervated by branches extending from the trunk below the level of nerve damage. This is important diagnostic sign, making it possible to determine the area of ​​nerve damage.

Secretory disorders manifest themselves in disruption of the activity of the sweat glands; Anhidrosis of the skin occurs, the area of ​​which corresponds to the boundaries of impaired pain sensitivity. Therefore, by determining the presence and size of the anhidrosis zone, one can judge the boundaries of the anesthesia area.

Vasomotor disturbances are observed approximately within the same limits as secretory ones: the skin becomes red and hot to the touch (hot phase) due to paresis of vasoconstrictors. After 3 weeks, the so-called cold phase begins: the limb segment deprived of innervation is cold to the touch, the skin acquires a bluish tint. Often in this area there is increased hydrophilicity and pastiness of soft tissues. Trophic disorders are expressed by thinning of the skin, which becomes smooth, shiny and easily wounded; turgor and elasticity are noticeably reduced. There is clouding of the nail plate, transverse striations and indentations appear on it, and it fits tightly to the pointed tip of the finger. In the long term after injury, trophic changes spread to tendons, ligaments, and joint capsules; joint stiffness develops; Osteoporosis of the bones appears as a result of forced inactivity of the limb and poor circulation.

The severity of nerve damage leads to varying degrees of impairment of its function.

When a nerve is concussed, anatomical and morphological changes in the nerve trunk are not detected. Motor and sensory disorders are reversible; complete restoration of function is observed 1.5-2 weeks after the injury. In the case of a bruise (contusion) of a nerve, the anatomical continuity is preserved, there are isolated intra-tremular hemorrhages and a violation of the integrity of the epineural sheath. Functional impairments are more profound and persistent, but after a month they are always completely restored.

Nerve compression can occur from various reasons(long-term exposure to a tourniquet, in case of injuries - bone fragments, hematoma, etc.). Its degree and duration are directly proportional to the severity of the lesion. Accordingly, prolapse disorders can be transient or persistent, in which case surgical intervention is required.

Partial defeat nerve is manifested by loss of functions according to those intra-trunk formations that are injured. Often there is a combination of symptoms of loss with symptoms of irritation. Spontaneous healing in similar situations rarely observed.

A complete anatomical break is characterized by the death of all axons and the disintegration of myelin fibers along the entire perimeter of the trunk; there is a division of the nerve into peripheral and central or they are connected by a strand of scar tissue, the so-called “false continuity”. Restoring lost functions is impossible; trophic disorders develop very quickly, and atrophy of paralyzed muscles in the denervated zone increases. Clinical diagnosis. Staging correct diagnosis nerve injuries depend on the sequence and systematicity of the studies performed.

Survey. The time, circumstances and mechanism of injury are established. Based on the referral documents and the patient’s words, the duration and volume of first aid provided are determined. medical care. The nature of the pain and the occurrence of new sensations that have appeared in the limb since the moment of injury are clarified.

Inspection. Pay attention to the position of the hand or foot, fingers; the presence of their typical settings (positions) can serve as a basis for judging the nature and type of damage to the nerve trunk. The color of the skin and the configuration of muscle groups in the affected area of ​​the limb are determined in comparison with a healthy one; They note trophic changes in the skin and nails, vasomotor disorders, the condition of the wound or skin scars resulting from trauma and surgery, and compare the location of the scar with the course of the neurovascular bundle.

Palpation. They obtain information about the temperature of the skin of the hand or foot, its turgor and elasticity, and the moisture content of the skin. Pain in the area of ​​the postoperative scar upon palpation is usually associated with the presence of a regenerative neuroma of the central end of the damaged nerve. Valuable information is provided by palpation of the area of ​​the peripheral segment of the nerve, which, with a complete anatomical break, can be painful, and in the case of projection pain, partial damage to the nerve or the presence of regeneration after neurorrhaphy (Tinel's symptom) can be assumed. Sensitivity study. When conducting the study, it is desirable to exclude factors that distract the patient’s attention. He is asked to close his eyes in order to concentrate and not control the doctor’s actions with his eyes. It is necessary to compare sensations from similar irritations in symmetrical areas that are known to be healthy.

1. Tactile sensitivity is examined by touching with a ball of cotton wool or a brush.
2. The feeling of pain is determined by pricking with the point of a pin. It is recommended to alternate painful stimulation with tactile stimulation. The subject is given the task to define an injection with the word “Sharp”, a touch with the word “Dull”.
3. Temperature sensitivity is examined using two test tubes - with cold and hot water; Skin areas with normal innervation are distinguished by a temperature change of 1-2°C.
4. Feeling the localization of irritation: the subject indicates the location of the skin prick with a pin (the prick is applied with the eyes closed).
5. The feeling of discrimination between two one-dimensional stimuli is determined using a compass (Weber’s method). The normal value of discrimination is taken to be the result of a study on a symmetrical area of ​​a healthy limb.
6. Feeling of two-dimensional stimulation: letters are written on the skin of the area under study or figures are drawn, which must be named by the patient without visual control.
7. Articular-muscular feeling is determined by giving the joints of the limbs different positions that the subject must recognize.
8. Stereognosis: the patient, with his eyes closed, must “recognize” the object placed in his hand, based on the analysis of diverse sensations (mass, shape, temperature, etc.). Determination of stereognosis is especially important for injuries to the median nerve. Based on the results obtained, a functional assessment is given: if stereognosis is preserved, the human hand is suitable for performing any work.

Electrophysiological research methods. Clinical tests to assess the state of peripheral nerve functions should be combined with the results of electrodiagnostics and electromyography, which allow us to determine the state of the neuromuscular system of the injured limb and clarify the diagnosis. Classical electrodiagnostics is based on the study of excitability - the reaction of nerves and muscles in response to irritation by faradic and direct electric current. Under normal conditions, in response to irritation, the muscle responds with a fast, live contraction, but with injury to the motor nerve and degenerative processes, worm-like flaccid contractions are recorded in the corresponding muscles. Determining the threshold of excitability on healthy and diseased limbs allows us to draw a conclusion about quantitative changes electrical excitability. One of the significant signs of nerve damage is an increase in the nerve conduction threshold: an increase in the strength of current pulses in the affected area in comparison with a healthy one to produce a muscle contraction response. Long-term results using this method have shown that the data obtained are not reliable enough. Therefore in last years electrodiagnostics in its traditional version is gradually being replaced by stimulation electromyography, which includes elements of electrodiagnostics.

Electromyography is based on recording the electrical potentials of the muscle being studied. The electrical activity of muscles is studied both at rest and during voluntary, involuntary and caused by artificial stimulation muscle contractions. The detection of spontaneous activity - fibrillations and slow positive potentials at rest - are undoubted signs of a complete break of the peripheral nerve. Electromyography (EMG) allows you to determine the degree and depth of damage to the nerve trunk. Using the method of stimulation EMG (a combination of electrical stimulation of nerves with simultaneous recording of the resulting oscillations in muscle potential), the speed of impulse conduction is determined, the transition of impulses in the area of ​​myoneural synapses is studied, and the functional state is also studied reflex arc etc. Electromyographic recording of action potentials can provide important data not only of a diagnostic, but also of a prognostic nature, allowing one to catch the first signs of reinnervation. Radial nerve injuries (Cv-Cvm). Nerve damage in axillary area and at shoulder level cause a characteristic position - a “falling” or hanging hand. This position is caused by paralysis of the extensors of the forearm and hand: the proximal phalanges of the fingers, the abductor pollicis muscle; in addition, supination of the forearm and flexion are weakened due to the loss of active contractions of the brachioradialis muscle. Nerve injuries in more distal parts of the upper limb, i.e., after the departure of the motor branches, are manifested only by sensory disorders. The boundaries of these disorders extend within the radial part of the dorsum of the hand along the third metacarpal bone, including the radial part of the proximal phalanx and middle phalanx of the third finger, the proximal and middle phalanges of the index finger and the proximal phalanx of the first finger. Sensitivity disorders usually occur as hyposthesia. They are almost never deeper due to large quantity connections between the dorsal and external cutaneous nerves of the forearm with the dorsal branches of the median and ulnar nerves and therefore rarely serve as indications for surgical treatment.

With a combination of injuries to the median nerve and the superficial branch of the radial nerve, the prognosis is more favorable than with the fairly common combination of injuries to the median and ulnar nerves, which leads to severe consequences. If with the first option of combined nerve damage it is possible to some extent to replace the lost function with the intact ulnar nerve, then with the second option this possibility is excluded. Clinically in the latter case There is pronounced paralysis of all autochthonous muscles of the hand, and there is a claw-like deformity. Combined injury to the median and ulnar nerves has a disastrous effect on the function of the hand as a whole. A denervated, desensitized hand is unsuitable for any work.

Median nerve injuries (Cvin-Di). The main clinical sign of damage to the median nerve in the hand area is a pronounced impairment of its sensory function - stereognosis. In the early stages after nerve damage, vasomotor, secretory and trophic disorders appear; skin folds are smoothed out, the skin becomes smooth, dry, cyanotic, shiny, flaky and easily wounded. Transverse striations appear on the nails, they become dry, their growth slows down, Davydenkov’s symptom is characteristic - “suckiness” of the 1st, 2nd, and 3rd fingers; the subcutaneous tissue atrophies and the nails adhere tightly to the skin.

Degree movement disorders depends on the level and nature of nerve damage. These disorders are detected when the nerve is injured proximal to the level of origin of the motor branch to the muscles of the eminences thumb or isolated damage to this branch. In this case, flaccid paralysis of the thenar muscles occurs, and with high damage to the nerve, a violation of pronation of the forearm, palmar flexion of the hand occurs, flexion of the I, II and III fingers and extension of the middle phalanges of the II and III fingers are lost. In the intrinsic muscles of the hand, due to their small mass, atrophy quickly develops, which begins within the first month after a nerve injury, gradually progresses and leads to fibrous degeneration of the paralyzed muscles. This process continues for a year or more. After this period, reinnervation of paralyzed muscles with restoration of their function is impossible. Atrophy is evident in the smoothing of the thenar convexity. The thumb is placed in the plane of the other fingers, the so-called monkey hand is formed. The paralysis affects the abductor pollicis brevis and the oppons pollicis brevis muscles, as well as the superficial head of the flexor pollicis brevis muscle. The function of abduction and, above all, opposition of the thumb to the hand disappears, which is one of the main motor symptoms damage to the trunk of the median nerve.

Sensory impairment is the leading manifestation of damage to the median nerve and is always observed regardless of the level of damage. Skin sensitivity is absent in most cases along the palmar surface of the 1st, 2nd and 3rd fingers, as well as along the radial surface of the 4th finger of the hand; on the back of the hand, sensitivity is impaired in the area of ​​the distal (nail) phalanges of the I, II, III fingers and the radial part of the distal phalanx of the IV finger. Coming total loss stereognostic sense, i.e. the ability to “see” an object with your eyes closed by feeling it with your fingers. In this case, the victim can use the brush only under visual control. Replacement of sensitivity lost after a complete break in the main trunk of the median nerve occurs only to a certain level, mainly in the marginal zones of the area of ​​cutaneous anesthesia, due to the overlap of the branches of the median nerve in these areas by the superficial branch of the 496th radial nerve, the external cutaneous nerve of the forearm, as well as the superficial branch ulnar nerve.

Segmental damage to the trunk of the median nerve leads to loss of sensitivity in a certain area of ​​the skin of the hand, the size of which strictly corresponds to the number of nerve fibers innervating this area. Often, partial damage to the median nerve causes excruciating pain on the palmar surface of the hand (sometimes like causalgia). Secretory disorders are characterized by severe hyperhidrosis of the skin on the palm in the branching zone of the median nerve or anhidrosis and peeling of the epidermis. The intensity of disorders (sensitive, motor, autonomic) always corresponds to the depth and extent of damage to the nerve trunk.

Ulnar nerve injury (Cvn-CVIH). The leading clinical symptom of ulnar nerve damage is motor impairment. Branches from the trunk of the ulnar nerve begin only at the level of the forearm; therefore, the clinical syndrome of its complete lesion at the level of the shoulder to the upper third of the forearm does not change. The weakening of the palmar flexion of the hand is determined, active flexion of fingers IV and V, partially III is impossible, it is impossible to bring and spread fingers, especially IV and V, there is no adduction of the thumb on the dynamometer. A significant loss of muscle strength is detected in the fingers of the hand (10-12 times less than in the fingers of a healthy hand). After 1-2 months after the injury, atrophy of the interosseous muscles begins to appear. Retraction of the first interosseous space and the area of ​​elevation of the little finger is especially quickly detected. Atrophy of the interosseous and lumbrical muscles contributes to the sharp outline of the metacarpal bones on the back of the hand. In the long term after the injury, secondary deformation of the hand occurs, which acquires a peculiar claw shape as a result of palmar flexion of the middle and distal phalanges of the IV-V fingers (due to paralysis of the lumbrical muscles that flex the proximal phalanges and extend the middle and distal ones), as well as as a result of atrophy of the muscles of the eminence little finger (hypotenar).

When the fingers are clenched into a fist, the tips of the fourth and fifth fingers do not reach the palm, and closing and spreading the fingers is impossible. The opposition of the little finger is disrupted, and there are no scratching movements with it.

Impairments of skin sensitivity when the ulnar nerve is damaged are always observed in the zone of its innervation, however, the extent of areas of complete anesthesia is variable due to the individual characteristics of the branching of the nerve, as well as depending on the distribution of branches of the neighboring - median and radial - nerves. The disorders involve the palmar surface of the ulnar edge of the hand along the IV metacarpal bone, half of the IV finger and the entire V finger. On the back of the hand, the boundaries of sensitivity disorders run along the third interosseous space and the middle of the proximal phalanx of the third finger. However, they are highly variable. Vasomotor and secretory disorders spread along the ulnar edge of the hand, their borders are slightly larger than the borders of sensitivity disorders.

Segmental damage to the outer trunk of the ulnar nerve in the middle third of the forearm leads to loss of sensitivity on the palmar surface of the hand with minimal severity on the back; in case of injury to the inner part of the barrel, the ratios are reversed.

Damage to the sciatic nerve (Uv-v-Si-sh). High nerve damage leads to dysfunction of flexion of the tibia in the knee joint due to paralysis of the biceps, semitendinosus and semimembranosus muscles. Often, nerve injury is accompanied by severe causalgia. The symptom complex also includes paralysis of the foot and fingers, loss of the heel tendon reflex (Achilles reflex), loss of sensitivity along the back of the thigh, the entire lower leg, with the exception of its medial surface and feet, i.e. symptoms of damage to the branches of the sciatic nerve - the tibial and peroneal nerves . The nerve is large, its average diameter in diameter in the proximal part is 3 cm. Segmental lesions of the trunk are not uncommon, manifested by a corresponding clinical picture with a predominant loss of functions governing one of its branches.

Peroneal nerve injuries (Liv-v-Si). The nerve roots (Liv-v-Si) form the trunk. The nerve is mixed. Damage to the peroneal nerve leads to paralysis of the extensors of the foot and fingers, as well as the peroneal muscles, which ensure the outward rotation of the foot. Sensory disturbances spread throughout outer surface lower leg and dorsum of the foot. Due to paralysis of the corresponding muscle groups, the foot hangs down, is turned inward, and the toes are bent. The gait of a patient with a nerve injury is characteristic - “cock-like”, or peroneal: the patient raises his leg high and then lowers it onto his toe, onto the stable outer edge of the foot, and only then rests on the sole. The Achilles reflex, provided by the tibial nerve, is preserved, pain and trophic disorders are usually not expressed. Tibial nerve injuries (Liv-SHI). The mixed nerve is a branch of the sciatic nerve. Innervates the foot flexors (soleus and gastrocnemius muscles), toe flexors, as well as the tibialis posterior muscle, which rotates the foot medially.

The posterior surface of the lower leg, the plantar surface, the outer edge of the foot and the dorsal surface of the distal phalanges of the fingers are provided with sensory innervation.

When the nerve is damaged, the Achilles reflex is lost. Sensory disorders spread within the boundaries of the back surface of the lower leg, the sole and outer edge of the foot, and the dorsum of the fingers in the area of ​​the distal phalanges. Being functionally an antagonist of the peroneal nerve, it causes a typical neurogenic deformation: the foot is in extension, pronounced atrophy of the posterior group of muscles of the leg and sole, sunken intermetatarsal spaces, a deepened arch, bent position of the toes and a protruding heel. When walking, the victim relies mainly on the heel, which significantly complicates gait, no less than when the peroneal nerve is damaged. With damage to the tibial nerve, as with damage to the median nerve, a causalgic syndrome is often observed, as well as significant vasomotor-trophic disorders. Tests of movement disorders: inability to flex the foot and toes and rotate the foot medially, inability to walk on toes due to instability of the foot.

Treatment of peripheral nerve injuries

Conservatively- rehabilitation treatment is no less important than surgical intervention on the nerve, especially with combined injuries. If during the operation the anatomical prerequisites are created for the growth of axons from the central segment of the nerve into the peripheral one, then the task conservative treatment- prevention of deformities and contractures of joints, prevention of massive scarring and tissue fibrosis, combating pain, as well as improving conditions and stimulating reparative processes in the nerve, improving blood circulation and trophism of soft tissues; maintaining the tone of denervated muscles. Activities aimed at achieving these goals should begin immediately after injury or surgery and be carried out comprehensively, according to a specific scheme, according to the stage of the regenerative process until the function of the injured limb is restored.

The course of treatment includes drug-stimulating therapy, orthopedic, therapeutic and gymnastic measures and physiotherapeutic methods. It is performed on all patients both in the preoperative and postoperative periods; its volume and duration depend on the degree of dysfunction of the affected nerve and associated injuries. The treatment complex should be carried out purposefully, with a selective approach in each specific case.

Therapeutic exercises are carried out throughout the entire period of treatment, and to the fullest extent - after the period of limb immobilization has expired. Focused active and passive movements in the joints of the injured limb for a duration of 20-30 minutes 4-5 times a day, as well as movements in easier conditions - physical exercise in water have a positive effect on the restoration of impaired motor function. The use of elements of occupational therapy (modelling, sewing, embroidery, etc.) promotes the development of various motor skills that become automatic, which has a beneficial effect on the restoration of professional skills.

Massage significantly improves the condition of soft tissues in power suffered trauma or surgery, activates blood and lymph circulation, increases tissue metabolism of muscles and improves their contractility, prevents massive scarring, accelerates the resorption of soft tissue infiltrates in the area of ​​former injury or surgery, which undoubtedly promotes nerve regeneration. The patient should be taught the elements of massage, which will allow it to be performed 2-3 times a day during the entire course of rehabilitation treatment.

The use of physiotherapeutic methods involves the rapid resorption of the hematoma, the prevention of postoperative swelling and the elimination of pain. For this purpose, on the 3-4th day after the operation, the patient is prescribed a UHF electric field and Bernard currents for 4-6 procedures, and subsequently, in the presence of pain, novocaine electrophoresis according to Parfenov’s method, calcium electrophoresis, etc., on the 22nd day - lidase electrophoresis (12-15 procedures), which stimulates nerve regeneration and prevents the formation rough scars. During this period, daily ozokerite-paraffin applications are also indicated, which promote the resorption of infiltrates, relieve pain, as well as soften scars, improve the trophic function of the nervous system and tissue metabolism, and reduce stiffness in the joints.

To maintain tone and prevent the development of atrophy of denervated muscles, it is rational to use electrical stimulation with a pulsed exponential current of 3-5 mA, duration 2-5 s with a rhythm of 5-10 contractions per minute for 10-15 minutes. Electrical stimulation should be carried out daily or every other day; There are 15-18 procedures per course. This method helps maintain muscle contractility and tone until reinnervation occurs.

Drug treatment aimed at creating favorable conditions for nerve regeneration, as well as to stimulate the regeneration process itself. It is advisable to carry out a course of drug therapy as follows: on the 2nd day after surgery, vitamin Bi2 injections of 200 mcg are prescribed intramuscularly, which promotes the growth of axons of the injured nerve, ensures the restoration of peripheral nerve endings and specific connections of the damaged nerve. Injections of vitamin Bi2 should be alternated every other day with the administration of 1 ml of a 6% solution of vitamin Bi (20-25 injections per course). This method of introducing B vitamins weakens the development of inhibitory processes in the central nervous system and accelerates the regeneration of nerve fibers.

For 2 weeks, dibazole with nicotinic acid in powder is prescribed, which has an antispasmodic and tonic effect on the nervous system.

After 3 weeks from the start of the course of treatment, ATP (500 1 ml of 2% solution; 25-30 injections) and pyrogenal should be administered according to an individual scheme, which have a beneficial effect on the reparative process and stimulate it.

The treatment complex should also include electrophoresis of galantamine, which helps to increase the functional activity of the neuron and improves the conduction of excitation at neuromuscular synapses due to inactivation of the cholinesterase enzyme. Galantamine is administered from the anode in the form of a 0.25% solution; Duration of the procedure is 20 minutes, 15-18 procedures per course.

The duration and volume of complex conservative and restorative treatment are determined by the number, level and degree of damage to the peripheral nerve, as well as the presence of concomitant injuries. After neurolysis surgery, as well as in cases of successful neurorhaphy in the area of ​​the distal third of the palm and at the level of the fingers, one course of conservative-restorative treatment is sufficient. After neurorrhaphy in the more proximal parts of the hand, forearm and shoulder, as well as at the level of the lower leg, thigh, taking into account the approximate period of axonal regeneration and reinnervation of the peripheral nervous apparatus, it is necessary to repeat the course of treatment after 1.5-2 months. As a rule, a course of rehabilitation treatment begun in a hospital ends on an outpatient basis under the supervision of the operating surgeon.

Initially, signs of restoration of sensitivity in the form of paresthesia appear in the area close to the level of nerve damage; over time, sensitivity in more distal parts of the limb improves. If there are no signs of regeneration within 3-5 months after surgery with full conservative-restorative treatment, the issue of repeated surgery should be considered.

Sanatorium-resort treatment in Tskhaltubo, Evpatoria, Saki, Matsesta, Pyatigorsk, etc. is indicated 2-3 months after neurography. Therapeutic factors such as mud applications and balneotherapy are used.

Surgical treatment

Indications for surgery. The main indications for surgical intervention on damaged peripheral nerves are the presence of motor loss, impaired sensitivity and autonomic-trophic disorders in the area of ​​innervation of the nerve concerned.

Experience in treating patients with nerve injuries shows that the earlier the reconstructive operation is performed, the more completely the lost functions are restored. Nerve surgery is indicated in all cases of conduction disturbance along the nerve trunk. The time between injury and surgery should be reduced as much as possible. In cases of failure of the primary nerve suture (increasing muscle atrophy, sensory and autonomic disorders), direct indications for reoperation.

The most favorable time for intervention is considered to be up to 3 months from the date of injury and 2-3 weeks after wound healing, although more late period Surgeries on a damaged nerve are not contraindicated. For damage to the nerves of the hand optimal time to restore their integrity is no more than 3-6 months after injury. During this period, nerve functions, including motor functions, are most fully restored.

The following indicates a complete disruption of conduction along the nerve trunk: paralysis certain group muscles, anesthesia in the autonomous zone of the interested nerve with anhidrosis within the same limits, negative Tinel's symptom, absence of muscle contraction during electrodiagnostics - nerve irritation above the level of damage and gradually weakening and then disappearing muscle contractions, under the influence pulse current below the damage level.

Surgical treatment can be carried out at a later date after a nerve injury, if the intervention was not performed earlier for one reason or another. It should be noted that in this case one cannot count on a significant improvement in the motor function of the nerves. This especially applies to the muscles of the hand, where degenerative changes quickly occur due to their small size. After surgery, in almost all cases the focus of irritation is eliminated, sensitivity improves and vegetative-trophic disorders disappear. These changes have a beneficial effect on the function of the damaged organ. Restorative surgery on a damaged nerve, regardless of the time elapsed after the injury, always improves the function of the limb as a whole to a greater or lesser extent.

Neurolysis. An incomplete break or compression of the nerve trunk is manifested by mild trophic and sensory disturbances in the autonomous zone of innervation of the nerve concerned. In this case, a scar process develops in the epineurium, which can subsequently cause the formation of a scar stricture with conduction disturbances. After bruised lacerations or severe combined injuries of the extremities, especially parts, a diffuse scarring process develops, leading to compression of the nerve trunks. In such cases, sensitivity disorders and autonomic disorders are observed, the depth of which is directly proportional to the degree of compression. In these situations, if ineffective full course conservative treatment after nerve injury is indicated by neurolysis - careful excision of epineurium scars, which eliminates axonal compression, improves blood supply to the nerve and restores conductivity in this area.

The surgical approach to the nerve must be carefully thought out and carried out with great methodicalness and the most careful treatment of tissue. The nerve trunk is first exposed in the area of ​​obviously healthy tissue and gradually mobilized towards the area of ​​damage, while maintaining the integrity of the epineurium, as well as the vessels accompanying and feeding the nerve. The best results are obtained by early neurolysis, when the process of degeneration due to compression is less deep and reversible. The effectiveness of neurolysis produced by correct indications, manifests itself in the immediate postoperative period: the function of the nerve concerned improves or is completely restored, pain and vegetative-trophic disorders disappear, sensitivity improves, and sweating is restored.

Surgical tactics and methods of performing operations on peripheral nerves depend on the duration of the injury, the nature of the previous injury and previous surgical interventions, the degree of scar tissue changes, the level of nerve damage and concomitant injuries.

Epineural suture. Until now, the most common method of peripheral nerve reconstruction remains the classic direct epineural suture. This is the simplest surgical technique, although it requires a certain amount of experience in otherwise technical errors are possible. It has a number of disadvantages, especially when restoring mixed nerves, where precise alignment of homogeneous intraneural fascicles is required. Using an epineural suture, it is difficult to maintain the achieved longitudinal orientation of the bundles after surgery. The growth of motor axons of the central end of the nerve into the sensory axon of the peripheral or inverse relationships due to mutual rotation of the ends are one of the reasons for prolonged or incomplete restoration of the main functions of the nerve. The abundance of interfascicular connective tissue complicates the opposition of bundles; there is a real danger of juxtaposing a section of the central fascicle of the nerve with the interfascicular connective tissue, which complicates the maturation and germination of regenerating axons. This ultimately leads to neuroma formation and loss of function.

Dissatisfaction with the results of surgical treatment of injuries of mixed peripheral nerves prompted doctors to search for new methods and types of surgical interventions. A big step forward was the use of magnifying optics and especially special operating microscopes. Microneurosurgery is a new direction in the neurosurgery of peripheral nerves, combining general surgical techniques with the use of qualitatively new technology under microfield conditions: magnifying optics, special instruments and ultra-thin suture material. Microsurgical technique was introduced into daily practice in 1976 and is constantly used, provided with an operating microscope from the company "Opton" (Germany), appropriate microinstruments and suture material(8/0, 9/0 and 10/0). Hemostasis during surgery is carried out using a special microelectrocoagulator. Stopping intraneural bleeding and bleeding in the wound cavity is important, and sometimes decisive, for the success of treatment. The classic straight epineural suture can be applied to the level of the distal interphalangeal joint of the finger. It is most appropriate not only with conventional, but also with microneurosurgical techniques. The nerves of these regions contain homogeneous bundles of axons - either sensory or motor. Therefore, rotation of the ends of the nerve along the axis, the possibility of which is not excluded even with microtechniques, does not have of great importance. In areas of mixed structure of peripheral nerves, it is most advisable to apply perineural or interfascicular sutures connecting axon bundles of homogeneous function. This is necessary because after refreshing the ends of the nerve, the intra-trunk topography of the sections does not coincide, since the position and size of the bundles are on different levels nerves are different. In order to identify intra-trunk bundles, you can use S. Karagancheva’s scheme and electrodiagnostics on the operating table. In the process of using the epineural suture, its technique was modified: the sutures of one bundle are placed higher or lower than the other due to their resection in different planes, which greatly simplifies their suturing with two or three perineural and sutures, allows you to accurately adapt the ends of each bundle, unlike the most common the applied technique for stitching beams in one cut plane. Finally, the epineurium of both ends of the nerve is brought together with separate interrupted sutures on an overlay. Thanks to this, the line of perineural sutures turns out to be well isolated from the surrounding tissues by its own epineurium, the sutures of which are outside the zone of interfascicular sutures. The nerve bundles are not compressed, as with a conventional epineural suture.

Nerve plastic surgery. Particularly great difficulties in reconstructing a nerve arise in cases where there is a defect between its ends. Many authors abandoned the mobilization of the nerve over a long distance, as well as excessive flexion in the joints of the limb to eliminate diastasis in order to suture the nerve end to end. The blood supply to peripheral nerves is segmental, with most nerves having a longitudinal direction along the epineurium and between the fascicles. Therefore, mobilization of the nerve to eliminate diastasis is justified when separating them for no more than 6-8 cm. Increasing this limit leads to impaired circulation, which in such cases can only occur due to the ingrowth of new blood vessels from the surrounding soft tissues. There is no doubt that developing fibrosis in the nerve trunk interferes with the maturation and growth of regenerating axons, which will ultimately negatively affect treatment results. Such disorders are caused by tension along the line of sutures due to incompletely eliminated diastasis between the ends of the nerve. For these reasons, a diastasis between the ends of the main trunks of peripheral nerves of 2.5-3.0 cm, and of common digital and digital nerves - more than 1 cm, is an indication for neuroautoplasty. The external cutaneous nerve of the leg should be used as a nerve donor, since due to its anatomical and functional characteristics it is most suitable for these purposes. When plasticizing the main 504 nerve trunks, the defect is filled with several grafts, usually 4-5 depending on the diameter of the trunk, collected in the form of a bundle, without tension in the average physiological position of the limb joints. Between the nerve bundle and the graft, 3-4 stitches are applied with a 9/0-10/0 thread, and this area is additionally covered with epineurium. For plastic surgery of the common digital and digital nerves, one graft is usually required due to their similar diameter.

In most cases, damage to peripheral nerves is combined with damage to blood vessels, which is explained by their anatomical relationship. Along with suture or plasty of the nerve, it is necessary to simultaneously suture or plasty the damaged blood vessel, which will optimize the conditions for regeneration of the restored nerve in anticipation of a favorable final result of treatment.

Thus, microsurgical techniques for operations on peripheral nerves make it possible to create optimal anatomical conditions for restoring nerve function. The use of microsurgical techniques is especially important in operations on mixed nerves, where precise comparison of the ends of the nerve with subsequent suturing of its identical bundles is required.

Traumatology and orthopedics
Edited by corresponding member. RAMS
Yu. G. Shaposhnikova

The radial nerve is the thickest branch of the brachial plexus, and together with the branches extending from it, it innervates (supplies with nerves) many muscles of the arm. Therefore, its damage (neuropathy) is very dangerous.

Nerve damage is a common pathology that can occur without even injuring the hand. It's enough to just fall asleep on it.

This is where the expression “ sleep paralysis“- a condition that occurs when a person accidentally falls asleep on his hand, and in the morning he discovers that it does not work. Damage to the radial nerve occurs with prolonged use of crutches and with all types of traumatic injuries.

Signs of radial nerve damage

• Feeling of numbness and “crawling goosebumps” in the area of ​​the 1st-3rd fingers of the hand;
• Inability to control the thumb of the injured hand;
• Pain when trying to move your forearm;
• Weakness in the hands - the hand hangs like a whip. Such a hand is called a “seal”;
• Sensitivity disorders - superficial, deep, mixed - the hand does not respond or does not respond sufficiently to stimuli;
• Movement disorders – it becomes impossible to move the hand or fingers;
• Redness or paleness of the skin of the hand, impaired sweating.

The severity of clinical symptoms depends on the nature of the damage:

• With a concussion not accompanied by anatomical and morphological changes, the disorders are reversible. Full recovery of nerve function usually occurs approximately two weeks after injury;
• When a nerve is contused, the anatomical integrity is preserved, but there are areas of hemorrhage. The manifestations are more persistent, but after some time the nerve will recover completely;
• Compression is more dangerous. If the nerve is compressed as a result of injury and tumor growth, the only way to get rid of the problem is through surgery;
• A rupture is an injury in which spontaneous healing occurs only with a minimum size of the torn area. In other cases, benign formations – neuromas – form in the area of ​​nerve damage, preventing it from healing. The nerve can only be restored through surgery.

Treatment

Treatment at the Open Clinic will depend on the type of damage, duration of exposure, and degree of lost functions.

Conservative therapy is aimed at eliminating pain, stimulating recovery processes, normalizing blood circulation in the damaged area, and maintaining muscle tone. Patients are prescribed physiotherapy, massage, exercise therapy, electrotherapy, applications, electrophoresis.

Partial or complete transection of the nerve is an indication for surgical treatment. The earlier reconstructive surgery is performed, the higher its effectiveness.

The areas of the gap are sewn together. When a neuroma forms, it is excised and the resulting ends are joined.

When a nerve is compressed, neurolysis with transposition is performed. The nerve is freed from traumatic influence and, if necessary, transferred to a new location to prevent re-compression.

Operations to restore the radial nerve are considered “jewelry”. They require special equipment and trained personnel.

In our center, treatment is provided by specialists from the Department of Neurosurgery and Neuroresuscitation of the University Clinic of the Moscow State Medical University named after. Evdokimov and has all the necessary medical equipment. Therefore, our specialists successfully treat such injuries.

In our center, treatment is provided by specialists from the Department of Neurosurgery and Neuroresuscitation of the University Clinic of the Moscow State Medical University named after. Evdokimova

Damage to the nerves of the extremities can be considered as peripheral nerve injuries.
Damage to large nerves often accompanies wounds and closed injuries of the extremities. In such cases it is necessary timely diagnosis and restorative treatment. Morphologically, a distinction is made between complete and incomplete anatomical interruption of the nerve, as well as intra-stem changes without damage to the epineurium (the so-called traumatic neuritis). For the last type of damage in early period After injury, severe loss of innervation may occur with an electrophysiological picture of a complete disruption of nerve excitability. As hemorrhages resolve and the inflammatory reaction reverses, nerve conduction improves. Therefore, the initial clinical manifestations can give a picture of a complete break of the nerve while its anatomical integrity, and therefore in the next 2-3 weeks after a closed injury it is still impossible to talk about its anatomical break. Features of symptoms determine the level and degree of damage to individual nerves.

Brachial plexus in most cases it is damaged as a result of injuries to the supraclavicular and subclavian areas. Clinical symptoms vary from severe muscle weakness the entire arm to isolated paraplegia of the shoulder and forearm. Sensory disorders are expressed throughout the arm or only in the innervation zones of the median or ulnar nerve. Depending on the nature of the damage, in the next 1/2 - 1 year, complete or partial restoration of the conductive function of the nerve plexus may occur without treatment.

Radial nerve especially often damaged by fractures humerus in the lower third. The hand hangs down due to loss of function of the forearm extensor muscles. Active extension of the hand, the main phalanges of the fingers and abduction of the first finger of the hand are impossible; supination movements are also impaired. Sensitivity is absent on the back of the forearm, the radial half of the back of the hand and in the second interdigital space; sensory disorders are not permanent. If the radial nerve is damaged in the forearm, the patient cannot abduct and extend the first finger.

If damaged median nerve on the shoulder, the function of flexion of the II and III fingers, as well as the opposition of the I and II fingers, is impaired. The anesthesia zone covers 2/3 of the palmar surface of the hand and half the circumference of the II and III fingers.

Damage ulnar nerve at all levels it disrupts the function of abduction and adduction of the fingers. When examining the patient, it is stated that it is impossible to flex all fingers of the hand and adduct the first finger. Characteristic is a claw-like position of the fingers with hyperextension in the interphalangeal and metacarpophalangeal joints. There is no sensitivity on the volar surface of the ulnar side and on the IV-V fingers of the hand. Severe claw-shaped deformation of the hand is especially characteristic of simultaneous damage to the median and ulnar nerves.

If damaged femoral nerve the extension of the lower leg in the knee joint is impaired; hip flexion is weakened; atrophy of the quadriceps femoris muscle develops with loss of the knee reflex. The anesthesia zone extends to the anterior surface of the thigh and the anterior inner surface of the leg.

If damaged peroneal nerve the foot droops and its outer edge is drooped. The extensors of the foot and the main phalanges of the fingers are paralyzed, as well as the peroneal muscle, the abductor of the foot, and the anterior tibialis muscle, adducting the foot. Sensitivity is disturbed along the anterior outer surface of the lower third of the leg and on the dorsum of the foot, excluding its outer and inner edges.

Peroneal nerve injury

If damaged tibial nerve and flexion of the foot and toes becomes impossible due to paralysis of the muscles on the back of the leg and small muscles of the foot. The sensitivity of the skin is impaired along the back surface of the lower leg, as well as the outer and plantar surface of the foot and fingers. Trophic ulcers develop in the area of ​​sensitivity disorders; Projection pain occurs in the foot and toes. Clinical picture of the lesion sciatic nerve consists of the described symptoms of damage to the peroneal and tibial nerves.

When damaged, the integrity of a large nerve of a limb should be restored immediately after the injury (primary suture) or in the next 3 to 4 weeks (delayed suture). The primary suture is subject to nerve damage during cutting and stab wounds, accompanied by a minimal zone of destruction and contamination of surrounding tissues. In gunshot, severely crushed and contaminated wounds, it is possible to restore the integrity of a large nerve only after complete cleansing and wound healing (after 3 - 4 - 6 weeks); nerves are restored along with tendons.

The technique of applying a suture to the nerves involves preliminary refreshing of its ends (strictly transverse intersection with a razor blade). Then, with an atraumatic needle passed through outer shell(epineurium) of the central and peripheral ends, at least 4 sutures are applied, which the surgeon and assistant simultaneously tighten and tie. Fixing the limb (plaster) in a bent position facilitates the approximation of the nerve segments with their subsequent retention for 3 - 4 weeks.

Epineural suture

The results of suturing a damaged nerve are significantly improved when modern microsurgical (precision) techniques are used. Its use significantly reduces the frequency and severity of the local inflammatory reaction, improves nerve regeneration and, as a result, peripheral innervation in the area of ​​the restored nerve conductor. Surgery is performed under an operating microscope; the epineurium of the proximal and distal ends of the nerves is excised very sparingly; Using microsurgical techniques, each of the nerve bundles, consisting of axons, together with the surrounding perineurium, is separated. 1 - 2 sutures (monofilament thread No. 10-0) are placed through the perineurium of each bundle and an exact comparison of individual funicular groups is carried out. Finally, numerous separate sutures (no. 9-0 or 8-0 monofilament suture) are placed on the epineurium without tension.

Perineural suture

Nerve bruise

Under the control of the head and spinal cord all organs work with the help of peripheral nerves. These fibers may be damaged due to various circumstances. Deviations from the normal functioning of nerve endings are called neuritis. When a nerve trunk is bruised, hemorrhage or tears occur. Neuromas form within the fascicle or trunk. With bruises, the nerve trunk thickens, and the surface becomes less smooth and dense. Nerve fibers can be divided into two groups: the first - those responsible for movement, the second - for sensitivity. As a result, nerves can be divided into two types: sensory and motor. It should be noted that the most common types are combined.

Symptoms of nerve contusion

Nerve damage can be recognized by the following signs: cessation of muscle contraction and decreased (or complete absence) of sensitivity in the area where organs and tissues are supplied by nerves. After some time, the muscles undergo atrophy and are replaced by connective tissues; trophic changes also occur on the skin.

Ulnar nerve

Causing harm this nerve accompanied by a complete lack of movement of the small muscles of the bone. This means that the fingers can assume a position similar to the claws of birds. The flexion of the fourth and fifth fingers is impaired. Paralysis of the interosseous muscles occurs. Stretching the thumb is impossible (adductor paralysis). Disorders associated with the sensitivity of the surface of the hand and palm appear.

Median nerve

This type of injury is characterized by paralysis of the flexor carpi radialis as well as the longus palmaris muscle. In such cases, the hand bends and deviates towards the elbow. There is a violation of pronation and flexion of the first, second and third fingers. The radial side of the hand, as well as the back of the first three fingers, lose sensation.

Femoral nerve

Injury to the femoral nerve is accompanied by problems with leg extension in the knee joint, hip flexion is weakened, atrophy of the quadriceps femoris muscle, and the death of the knee reflex are observed. Loss of sensation in the front of the thigh.

Peroneal nerve

The consequence of the damage is the foot sagging downward or inward, the toe clinging to the ground while moving, and the inability to step on the heel. Anesthesia occurs on the outer surface of the lower leg and the back of the foot.

Tibial nerve

A bruise of the tibial nerve is accompanied by paralysis of the muscles that are responsible for flexing the foot (and fingers) and turning it inward. The Achilles reflex is destroyed. Anesthesia of the back of the leg, foot and fingers. Atrophy develops on the posterior group of leg muscles and the muscles of the sole. The foot takes on the appearance of a claw due to paralysis of the interosseous muscles. As a result of such injuries, it becomes impossible to walk on the toes.

Sciatic nerve

Injury to the sciatic nerve is accompanied by complete paralysis of the surface of the foot and fingers.

Types of nerve damage

The causes of damage are fractures, blows, falls or dislocations of joints, unsuccessful surgical interventions, gunshot wounds, etc. Factors of injury to the peripheral nervous system can be violent and rapid traction of the limbs. Injuries are generally divided into two categories: closed and open. Open injuries differ from closed ones by the presence of wounds (lacerations, punctures, cuts, etc.) and more likely introduction of infection. With closed injuries, recognition of damage to the trunk is more difficult, especially in cases of gunshot wounds, when a large scale of tissue is affected.

Before making a diagnosis: concussion, bruise or compression of nerves, the patient must undergo a whole range of observations. Nerve damage are divided into complete fiber damage, and partial - only a fragment of the nerve trunk fiber is damaged.

The fact that the anatomical break of the nerve destroyed the fiber is evidenced by the paralysis of all muscles and anesthesia in the area of ​​action of the affected nerve. This means that the body does not react to injections or sharp irritations with a needle or other sharp objects. As a result, blue skin appears in the injured areas, a decrease in temperature, and disturbances in the sweating process. Damage to autonomic fibers within nerves manifests itself in increased dryness skin, the appearance of swelling, peeling and, in some cases, ulcerative formations.

First aid for nerve fiber damage

First aid depends on the location of the damaged nerve, but regardless of whether the injury is closed or open, there are several rules that must be followed before a medical examination.

The first thing to do is to provide calm to the damaged area of ​​the body. It is advisable to apply a cooling compress, as cold helps reduce pain. Often patients try to stretch the pinched nerves, but the fibers are destroyed even more and the pain only intensifies. Therefore, making unnecessary movements is strictly prohibited. If you cannot support the damaged part of the body yourself, you can secure it with a bandage. Especially in cases where the wound is open and it is necessary to stop the bleeding, bandages become indispensable, the main thing is to apply them correctly (not too loosely, but not too tightly). If the injuries sustained are on the spine, then the patient must be admitted and transported to the hospital. Under no circumstances should you sit the victim down, stretch your legs or arms, or perform any other similar actions. To reduce sensitivity to touch, you can take painkillers (bromine, luminal, injections of analgin 50%-2 ml, or amidopyrine 4%-6 ml intramuscularly). The drugs should not be used if there is suspicion of damage to internal organs.

After a week, if the course is favorable, you can use gentle massages, passive and active gymnastics. If the functionality of the nerve is not restored, it is necessary to seek help from medical institutions.

Doctor's actions aimed at confirming the diagnosis

During the study period, it is necessary to completely isolate the patient, freeing him from unnecessary distractions. The first thing the doctor pays attention to is the position of the fingers, hand, and foot. Deviations from the standard position indicate the nature and extent of nerve injury. In addition, the color of the skin of the examined area is compared with a healthy surface, changes in the structure of the nails are noted, the degree of vasomotor disorders, and if there are wounds or scars, their condition is compared with the location of the neurovascular bundle.

After a thorough examination, the doctor begins to obtain information about the skin temperature of the damaged area, tissue swelling, elasticity, and moisture. To make a diagnosis, it is necessary to compare sensations in the injured area and symmetrical healthy areas. In order to make a correct diagnosis, the patient must undergo an examination consisting of several stages:

Testing tactile sensitivity is carried out by touching a brush, cotton wool or other light objects.

The perception of pain is tested by pricking with a sharp object (needle, pin, etc.). It is recommended to check tactile and pain stimuli in turn.

Sensitivity to temperature changes is varied using test tubes containing cold and hot water.

To determine the location of the irritation, the patient must indicate the injection site (during the injection, the patient's eyes are closed).

The feeling of two-dimensional irritation is determined by writing letters or figures on the damaged areas, and the patient must determine what exactly was indicated on the surface of the skin.

To determine the state of muscle sensation, the joints of the limbs are given different positions, which the patient must recognize without visual control.

Stereognosis determines the ability of the subject to recognize an object based on his versatile sensations.

Treatment and rehabilitation

The main objectives of treatment for nerve contusion:

Elimination or easing of pain.

Ensuring normal nutrition of axons, protecting motor neurons.

Reduction or complete elimination of adhesions and scar processes.

Prevention or reduction of muscle atrophy.

Ensuring normal functional load of the nervous system as a whole.

Closed injuries usually require conservative treatment for a period of 1 to 2 months. Recovery consists of physiotherapy (massage, physical exercise, thermal procedures, diathermy, etc.), taking medications to promote nerve regeneration, restoration of sensitivity and impaired functions. It is mandatory to take analgesics - drugs that relieve pain. It is important to adhere to the correct position of the damaged areas; for this, splints or other fixing devices are used.

In cases where conservative therapy did not bring the expected results, 3-8 months after the injury they resort to surgical treatment. As the practice of treating patients with nerve bruises shows, the earlier reconstructive operations are performed, the more promising the possibility of a complete recovery and restoration of lost system functions. The period of nerve recovery depends on the degree of damage, location and timely treatment. To eliminate the consequences, for example, damage to the hand, the optimal rehabilitation period is 3-6 months after the injury.

For serious damage to nerve trunks Patients will be hospitalized in neurosurgical hospitals. The timing of treatment for nerve contusion is determined after a decision on the clinical prognosis. In the absence of an anatomical break, surgical treatment is not indicated. If nerve regeneration has begun, the recovery period is 3 to 4 months. Considering the rate of restoration of nerve function, the patient can return to work, be sent for examination to obtain a certificate of disability, or continue treatment.

After surgery and complete healing of the consequences, patients are recommended physical therapy: thermal baths, paraffin or ozokerite. Then massage, therapeutic exercises, and mud therapy are prescribed under the supervision of specialists.