Damage to the nerves of the upper limb: deformities of the hands. Traumatic nerve damage

According to the literature, the frequency of isolated injury median nerve accounts for 20 - 35% of all types of damage nerve trunks upper limb, second only to ulnar nerve injury. The median nerve is the main nerve trunk innervating the flexor muscles of the hand and fingers; it provides the gripping function, as well as the vegetative-trophic function of the upper limb. The causes of traumatic damage to the median nerve trunk can be: domestic injury(most often - careless handling of glass), criminal injury, suicide attempts (spontaneous wounds on the anterior surface of the forearm), etc. [possibly iatrogenic damage due to various surgical interventions]. Traumatic damage to the median nerve is characterized by the presence of a pronounced pain syndrome; it is noted approximately 2-3 times more often than with damage to other nerves of the upper limb; it often manifests itself in the form of a causalgic syndrome.

REFERENCE INFORMATION(to the website):

[1 ] Neurologist's Handbook: median nerve (n. medianus);

[2 ] Screening test for median nerve palsy (median nerve palsy detection);

[3 ] Express tests for diagnosing the main nerves of the upper limb (radial, ulnar, median);

[4 ] “Forbidden zone” brush;

[5 ] Innervation of the hand by the median nerve;

[6 ] Martin-Gruber anastomosis.

incl. materials from the article “Clinical and instrumental characteristics of traumatic injury to the median nerve on different levels» Georges Ibrahim Nicholas, Crimean State medical University them. S.I. Georgievsky, Simferopol (Ukrainian neurosurgical journal, No. 1, 2005)

Traumatic injury to the median nerve axillary area, as a rule, is accompanied by combined damage to other nerve trunks ( ! more often ). In some cases, injury to the median nerve is combined with massive blood loss due to damage to the axillary artery and with hemorrhagic shock.

The median nerve in the shoulder area is located in a single trunk, does not give off cutaneous and muscle branches, and if it is completely damaged at this level, the following are detected: characteristic symptoms:

■ disturbances of sensitivity in the form of anesthesia are localized on the radial half of the palmar surface of the hand, the thenar area, I, II, III and half of the IV fingers of the hand (however, in a small number of cases, disturbances of sensitivity can be localized mainly in the area of ​​the fingers);
■ movement disorders manifested by loss of function of all muscles innervated by this nerve (clinically, damage to the median nerve is manifested by impaired pronation of the forearm, lack of flexion movements of the distal phalanges of the 1st, 2nd and partially 3rd fingers, impaired opposition of the thumb;
■ pain syndrome (not in all cases), which is of the nature of causalgia;
■ vegetative-trophic disorders (delayed) in the form of muscle atrophy, thinning and dry skin, impaired nail growth, and the appearance of trophic ulcers.

Traumatic damage to the median nerve at the level of the ulnar fossa and the upper third of the forearm is the most difficult in diagnostic and therapeutic terms; in this area, the short branches of the median nerve extend to the muscles of the anterior surface of the forearm (pronator teres, flexor carpi radialis, flexor digitorum superficialis, deep flexor II and III fingers, long flexor of the first finger). In a small number of cases, isolated damage to these branches is possible with loss of function of the corresponding muscles. In this case, characteristic sensory disturbances may be absent, which complicates neurological diagnosis; this situation is regarded as damage to the flexor tendons. Damage to the median nerve at the level of the ulnar fossa and the upper third of the forearm, due to the specific nature of the injury in this area, is often combined. In more than half of the patients, injury to the median nerve in the area of ​​the ulnar fossa and the upper third of the forearm is accompanied by pain and vegetative-trophic disorders with changes in skin color and the appearance of trophic ulcers.

Damage to the median nerve in the middle and lower third of the forearm is manifested by dysfunction of the thenar muscles and lumbrical muscles of the 2nd and 3rd fingers, difficulty in opposing the 1st finger, dysfunction of the extensors of the distal phalanges of the 2nd and 3rd fingers. The hand grip function is usually not impaired. In approximately half of the cases, vegetative-trophic disorders (sometimes severe) are detected in the form of muscle atrophy, thinning and dry skin, and impaired nail growth. Most victims have pain syndrome (including, in a small number of cases, causalgic pain syndrome). A combination of traumatic injury to the median nerve and injury to the ulnar nerve is possible.

Damage to the median nerve at the level of the lower third of the forearm and in the area of ​​the wrist joint is clinically manifested mainly by sensory disturbances in the form of hypoesthesia with symptoms of hyperpathy (including causalgic pain syndrome) and autonomic-trophic disorders with a slight decrease in motor function. Traumatic damage to the median nerve in the hand area is manifested by disturbances in motor and sensory functions in the innervation zone; in this case, vegetative-trophic disorders are, as a rule, absent. Pain syndrome is possible.

When the median nerve is damaged in the area of ​​the ulnar fossa and the upper, middle and lower third of the forearm, the most informative diagnostic methods are EMG, ENMG, determination of evoked potentials and thermography. Electromyographic studies of patients with damage to peripheral nerves in the preoperative and postoperative periods make it possible to judge the functional state of the neuromuscular system, the safety of innervation and the state of efferent systems. The stimulation ENMG method allows you to choose the right treatment tactics, evaluate the effectiveness of the operation used and predict the dynamics of the recovery process. This makes it possible to restore the patient’s ability to work in a shorter time.

Damage to the nerves of the upper and lower extremities, unfortunately, is one of the most common and severe types of injuries that can radically change the quality and lifestyle of a person, both in everyday life and in the professional environment. A significant number of diagnostic, tactical and technical errors in everyday medical clinical practice, unfortunately, lead to complete or partial disability of the patient, often force patients to change their profession, and become the cause of disability.

Causes of peripheral nerve damage

Peripheral nerve injuries are divided into closed and open.

• Closed damage: as a result of compression of the soft tissues of the arm or leg, for example, due to improper application of a tourniquet during bleeding, as a result severe bruise or impact, prolonged forced position of a limb with external pressure, as a consequence of bone fractures. As a rule, a complete break of the nerve is not observed in such cases, so the outcome is usually favorable. In some cases, for example, with dislocation of the bones of the hand, dislocation of the foot or large joint, closed fractures In the bones of the extremities with displacement of fragments, a complete break of the nerve trunk or even several nerves may occur.
• Open damage are the result of injuries from glass fragments, a knife, sheet iron, mechanical tools, etc. In this case, damage to the integrity of the nerve structure always occurs.

Unfortunately, nerve damage is often a consequence of surgical interventions.

The oncoming changes appear depending on the level of nerve damage, the nature of the injury or the duration of exposure to the traumatic agent by various syndromes of dysfunction.

Clinical picture

At closed injuries in case of bruise (concussion) or concussion of nerve changes internal structure the nerve trunk does not occur, disturbances in sensitivity and function of the limb are temporary, transient and, as a rule, completely reversible. Functional dysfunctions caused by a bruise are more profound and persistent, but after 1-2 months they are noted full recovery. However, the consequences of such injuries cannot be ignored, self-diagnosis and treatment are unacceptable, since the consequences of “self-medication” may be irreversible. It is necessary to immediately contact a traumatologist, surgeon, or neurologist. If necessary, the doctor may prescribe additional research, to clarify the degree of nerve damage - electromyography, ultrasound examination along the nerve trunk, sometimes even CT and MRI studies. Only a qualified doctor will prescribe adequate treatment for you.

Open peripheral nerve injuries. The fibers of all peripheral nerves are of a mixed type - motor, sensory and autonomic fibers; the quantitative relationships between these types of fibers are not the same in different nerves, so in some cases motor disorders are more pronounced, in others there is a decrease or complete absence of sensitivity, in others - autonomic disorders.

Movement disorders are characterized by paralysis of groups or individual muscles, accompanied by the disappearance of reflexes, as well as over time (1-2 weeks after injury) atrophy of the paralyzed muscles.

Sensitivity disturbances occur - decrease, disappearance of pain, temperature, tactile sensitivity. Pain that gets worse over time.

Autonomic symptoms - in the first period after injury, the skin is hot and red, after a few weeks it becomes bluish and cold (vasomotor disorders), the appearance of edema, sweating disorders, trophic skin disorders - dryness, peeling, sometimes even ulceration, deformation of the nails.

On the upper limb

In case of injury to the upper part (third) of the shoulder and the upper third of the forearm, the radial nerve is most often affected - the hand hangs down, extension of it and the main phalanges of the fingers is impossible (“seal paw”), the fingers hang gelatinously, abduction of the thumb is impossible. Sensitive disorders are less pronounced - zone of decreased or loss of sensitivity of the posterior surface of the shoulder and forearm and the dorsal surface of the hand 2 fingers without terminal phalanges. Swelling of the hand.

If the median nerve is damaged, there is no flexion of the thumb (I), index (II) and partly middle (III) fingers, rotation of the hand, opposition and abduction of the thumb, which is in the same plane as the other fingers (“monkey’s paw”), are impossible. Reduction of all types of sensitivity (hypoesthesia) on the side of the palm (3 fingers) and the terminal phalanges of the II, III, IV (ring) fingers on the back of the palm. Pain and pronounced vegetative manifestations are characteristic.

Injury to the ulnar nerve leads to impaired flexion of the IV, V (little finger) fingers, adduction and abduction of all fingers; V, IV, partly III fingers are straightened in the main and bent in the middle phalanges (“clawed paw”). Atrophy of the interosseous muscles (“skeletal arm”) is pronounced. Sensitivity is impaired on the ulnar half of the hand, the fifth and half of the fourth finger.

When the axillary nerve is injured, shoulder abduction is impossible, there is atrophy of the deltoid muscle, and impaired sensitivity in the outer posterior surface of the shoulder. Damage to the musculocutaneous nerve precludes the possibility of simultaneous extension of the forearm and supination of the hand.

On the lower limb

In case of damage to the common trunk sciatic nerve in the upper half of the thigh, flexion and extension of the foot and fingers are lost. The foot hangs down, you cannot stand on your toes and heels. Sensory disorders are present on the foot and back of the leg. Autonomic disorders and trophic foot ulcers are typical. Damage to the tibial nerve results in loss of flexion of the foot and toes. The foot is extended, the toes are in a claw-like position. Sensitivity is disturbed on the back and non-outer surface of the leg, the sole and the outer edge of the foot. Autonomic disorders are pronounced - pain syndrome. There is a lack of sensitivity on the anteroinferior surface of the leg.

Here is a brief description of the disorders that occur with injuries to the peripheral nerves of the upper extremity. Full clinical diagnosis Nerve damage is, of course, more complex, and is performed by a doctor using additional research methods.

Treatment

For closed injuries, as a rule, conservative treatment lasting about 1-2 months is carried out, consisting of physiotherapeutic influences (massage, physical therapy, electro-gymnastics, thermal procedures, ozokerite, paraffin, diathermy, iontophoresis, etc.), the use of medications agents (dibazol, prozevin) that promote nerve regeneration and, as a result, restoration of lost functions and sensitivity. It is also necessary to use drugs that relieve pain - analgesics. It is very important to give the limb the correct position and ensure rest with the help of splints and other fixation devices.

If conservative therapy is insufficiently effective, surgical treatment is resorted to after 4-6 months from the date of injury.

Surgical treatment

Experience in treating patients with nerve injuries shows: the earlier the reconstructive operation is performed, the more promising the possibility of resuming lost functions. Nerve surgery is indicated in all cases of conduction disturbances along the nerve trunk (according to electromyography studies).

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, but also in 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. In this case, the chances of a favorable treatment outcome are high. We perform the following types of surgery: epineural suture of the damaged nerve, in some cases or if necessary, using gluing with a special fibrin-based glue produced by BAXTER "TISSUKOL". If there is a defect in the tissue of the nerve trunk, nerve plastic surgery is performed using an autograft.

An incomplete break, compression of the nerve trunk after contused lacerations or severe combined injuries of the extremities contributes to the development of a diffuse scar process, leading to the formation of a scar stricture, compressing the nerve trunk and leading to disruption of nerve conduction. In this situation, neurolysis is performed - careful excision of scar tissue and epineurium scars, which eliminates axonal compression and helps improve blood supply to the nerve and restore conductivity in this area. All surgical interventions on peripheral nerves are performed using microsurgical techniques.

The microsurgical technique used in operations to restore peripheral nerves makes it possible to create optimal anatomical conditions (precise comparison of the ends of the nerve with subsequent suturing) for the full restoration of nerve function.

Make an appointment with a surgeon

Be sure to consult a qualified specialist in the field of hand surgery at the Semeynaya clinic.

The content of the article

In peacetime damage to individual nerve trunks most often associated with their compression in bone and osteo-fibrous canals, as well as under contractually tense muscles. Inflammatory lesion individual nerve trunks (true neuritis, plexitis or radiculitis) is extremely rare. It is possible when the inflammatory process spreads to the nerve in the area of ​​abscess, phlegmon, osteomyelitis, epiduritis, etc. Traumatic injuries - closed and open - to nerve trunks, plexuses and roots are more common: concussion of the nerve, bruise, compression, sprain or injury.
Closed injuries are relatively common in the brachial plexus region. This is due to a number of topographic-anatomical relationships and a large volume of possible movements in the shoulder joint.
Stretching and rupture of the trunks - plexuses are observed with birth injuries in newborns. In the case of “anesthesia paralysis,” when the arm is suddenly thrown back, the loss of plexus function is associated not only with mechanical effects, but also with a corresponding disruption of the blood supply to the nerve trunks. More severe traumatic sprains are observed in car accidents - avulsion of the proximal plexus or avulsion of roots from the spinal cord. Such a severe localization of the rupture is indicated by paralysis of the serratus and rhomboid muscles, as well as Horner's syndrome on the affected side and the burning nature of the pain in the arm. The same plexus can also be injured due to compression (bone paralysis). A compression component also occurs in anesthesia paralysis: the plexus is compressed between the clavicle and the first rib, or it is stretched over the head of the humerus (about damage to the plexus in scalenus syndrome and in the case of a cervical rib. Due to the mechanism of compression, the peroneal nerve is sometimes affected when a fixed bandage is poorly applied. Paralysis from a tourniquet is also known. Sometimes traumatic injuries occur due to compression of the sacral plexus before and during labor by the fetal head. The plexus can also be affected by fractures of the pelvic bones.
In military settings, peripheral nerve injuries, mostly open, account for 5-8% of all injuries. When diagnosing them, the main difficulty is to establish the nature of the damage - complete or incomplete break. Clarification of this issue allows us to determine the choice of treatment, in particular surgical treatment. Nerve rupture is possible due to crushing, compression. bleeding into it. Under these conditions, signs of a supposedly complete break are possible even if the nerve is anatomically intact. Complete loss of nerve function in the first 2-3 weeks after injury is not evidence of its anatomical interruption.

Complete nerve break

Incomplete nerve break

Peripheral nerve syndromes

Radial nerve

Ulnar nerve

Median nerve

Musculocutaneous nerve

Peroneal nerve

Tibial nerve

Sciatic nerve

Treatment of traumatic injuries to peripheral nerves

Nerve bruise

All organs operate under the control of the brain and spinal cord using peripheral nerves. These fibers can 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

Damage to this nerve is 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, impacts, falls or dislocations of joints, unsuccessful surgical interventions, gunshot wounds, etc. Factors of peripheral injuries nervous system There may be violent and rapid stretching of the limbs. Injuries are generally divided into two categories: closed and open. Open damage is different from closed by the presence wounds (lacerations, punctures, cuts, etc.) and a greater likelihood 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 injuries 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 edema, peeling and, in some cases, ulcerative formations.

First aid in case of injury nerve fibers

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 pinched nerves, which destroys the fibers even more and painful sensations are only getting stronger. 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. For the purpose of setting 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 opportunity full 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 not shown. 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.

Peripheral nerve injuries 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. A dislocation of the lunate bone or a fracture of the radius in a typical location often lead to compression injuries of the median nerve in the carpal canal area; 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 the innervation is carried out by neighboring nerves and only to a small extent by the damaged nerve, it is not possible to determine the impairment of sensitivity. 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 an important diagnostic sign that makes 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 damage to the 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. Making the correct diagnosis of nerve injury depends on the consistency and systematicity of the studies.

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. Determine the color of the skin, the configuration of muscle groups in the affected area of ​​the limb 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.

• Tactile sensitivity is examined by touching with a ball of cotton wool or a brush.
• 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”.
• 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.
• Sense of localization of irritation: the subject indicates the location of the skin prick with a pin (the prick is applied with the eyes closed).
• 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.
• 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.
• Articular-muscular feeling is determined by giving the joints of the limbs different positions that the subject must recognize.

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 based on the study of excitability - the reaction of nerves and muscles in response to faradic and constant irritation electric shock. 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 in 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. Electrical activity muscles are studied both at rest and during voluntary, involuntary and 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 zone of myoneural synapses is studied, and also the functional state 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 damage(Cv-Cvm). Nerve damage in the axillary region and at shoulder level causes 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 the large number of 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 quite common combination of injuries to the median and ulnar nerves, leading 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 smooth 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.

The degree of movement disorders depends on the level and nature of the nerve damage. These disorders are detected when there is injury to the nerve proximal to the level of the origin of the motor branch to the muscles of the eminence of the 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- the leading manifestation of damage to the median nerve and is always observed regardless of the level of its 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 radial nerve, the external cutaneous nerve of the forearm, as well as the superficial branch of the ulnar nerve. 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 dimensions of which strictly correspond 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 damage(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, and therefore clinical syndrome his complete defeat at shoulder level 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. Revealed significant loss muscle strength 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.

Skin sensitivity disorders when the ulnar nerve is damaged, they are always observed in the zone of its innervation, however, the length 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 the 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.

Sciatic nerve injuries. 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 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 in charge of 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 along the outer surface of the lower leg and the 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 flexors of the foot (soleus and calf muscle), flexors of the toes, as well as the posterior tibialis muscle, rotating the foot inwards.

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

Conservative treatment

Conservative and restorative 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 to the peripheral, then the task of conservative treatment is to prevent deformities and contractures of the joints, prevent massive scarring and tissue fibrosis, combat pain, as well as improve conditions and stimulate 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 preoperatively and during postoperative period, its volume and duration depend on the degree of dysfunction of the affected nerve and associated damage. 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. Purposeful active and passive movements in the joints of the injured limb for 20-30 minutes 4-5 times a day, as well as movements in easier conditions - physical exercises 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 former trauma 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 throughout the course rehabilitation treatment.

The use of physiotherapeutic methods involves the fastest 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 22- day 1 - 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, a duration of 2-5 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 is 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.

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

After 3 weeks from the start of the course of treatment, ATP (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 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. They use these healing factors, such as mud applications, balneotherapy.

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 atrophy of muscles, sensory and autonomic disorders) there are 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 the wound has healed, although in a later period, operations on the damaged nerve are not contraindicated. In case of damage to the nerves of the hand, the optimal period for restoring their integrity is no more than 3-6 months after the 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 symptom Tinel, 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 in more late dates 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 they quickly attack degenerative changes in connection with small in size their. 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 similar cases sensitivity disorders and autonomic disorders are observed, the depth of which is directly proportional to the degree of compression. In these situations, if the full course of conservative treatment after a nerve injury is ineffective, neurolysis is indicated - careful excision of epineurial scars, which eliminates axonal compression, improves the 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 techniques for performing operations on peripheral nerves depend on the duration of the injury, the nature former damage and previous surgical interventions, the degree of scar tissue changes, the level of nerve damage and associated 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 fascicles; there is a real danger of comparing the section of the central fascicle of the nerve with the interfascicular connective tissue, which impedes 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 technology was introduced into everyday practice in 1976 and is used constantly, provided with an operating microscope from 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, is not 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 at different levels of the nerve 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 donor nerve, since due to its anatomical and functional characteristics it is most suitable for these purposes. When plasticizing the main 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, counting on 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.

Which doctors should you contact if you have Damage to Peripheral Nerves?

• Traumatologist

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