Damage to the nerve trunks. Nerve Injury Clinic

To date, the formation of traumatic nerve injury is a fairly common injury in which damage occurs to the peripheral nervous system. Such injuries, most often, are military and domestic, with combined injuries, traumatic damage to the nerves occurs, with the formation of bone injuries, there is a risk of damage to peripheral nerves.

Today, a fairly common method of treating traumatic damage to peripheral nerves is precisely the conduct of an immediate neurosurgical intervention, while special therapeutic measures are prescribed, thanks to which it becomes possible to restore the anatomical integrity of the nerve.

In this case, microsurgical techniques can also be used for treatment. But at the same time, the functional state of the injured nerve will not be taken into account, which plays a major role in restoring the natural motor activity limbs.

It is the moment when the damage to the nerve itself occurs that is the first stage at which the process of quite serious changes in the nerves begins. The duration of such changes can take quite a long period of time.

In the event that there is a rupture of the axial cylinder itself, the process of degeneration of the nerve trunk itself begins, while the path of travel is replaced by Schwann cells, which have undergone certain modifications. This process is called "Vallero rebirth".

In both directions, Wallerian degeneration of the most injured nerve occurs - retrograde degeneration (to the motor neuron), as well as anterograde degeneration (to the muscle). Anterograde degeneration will end in the muscle, and characteristic damage to the presynaptic region of the neuromuscular junction also occurs.

Considering how massive the lesion occurs within the endoneurium, the more pronounced the retrograde degeneration will be. In the event that a complete transection of the nerve occurs, this process will also reach the hillock of the motor neuron.

Under the condition of the axon break, if a violation of the most retrograde axonal transport from the muscle has formed, the state of the motor neuron begins to change, since it is the microscopic structure of the motor neuron that changes. As a result, the motor neuron stops producing electrical impulses. Its work is based on maintaining the viability of the entire motor unit system.

The axon is a part of the motor neuron, as a result of which the process of rebirth will also affect the body itself. In the event that it is not possible to completely cope with a rather serious and extensive damage, then the complete death of the motor neuron occurs.

This process is formed directly in the central segment. Anthrograde degeneration occurring in the peripheral segment can also reach the muscles. The process of denervation of the muscle fiber begins, which will manifest itself as the formation of fibrillation potentials.

In the event that a rather massive process develops, then a certain part of the muscle fibers themselves will die, and over time it will be replaced by a connective and fatty one. The manifestation of positive wave potentials begins, which can be fixed with the help of needle EMG, using concentric electrodes.

Taking into account the violation of the neurotrophic effects of the nervous system itself, the process of muscle degeneration will be determined. In this case, there is a violation of the natural supply of muscles not only with electrical impulses, but also with metabolic products that are formed during the process of neuromuscular transmission.

In the event that complete denervation occurs, the development of complete muscle degeneration begins within 8 or 10 months, and subsequent reinnervation of the motor part will not lead to the restoration of the natural motor function.

Therefore, in the event that a serious injury occurs, the development of a rather lengthy process begins. It is this process that is called "traumatic nerve disease." Such a process can lead not only to the complete restoration of the natural function of the nerve and the injured limb, but also to degeneration.

Symptoms

In the event that traumatic nerve damage occurs, a characteristic clinical picture is observed. Depending on which nerve was injured, the main signs are determined, which may include the formation of vasomotor, sensory, trophic, secretory, and of course, movement disorders.

At the same time, today the main symptoms that form in the case of damage to the peripheral nerves differ. Almost immediately after the injury was received, the presence of a syndrome of complete disruption of the normal conduction of the nerve will be determined.

The victim himself has a violation of the natural function of the nerve, while the development of characteristic sensory and motor disorders begins, reflexes disappear, and certain vasomotor disorders are formed. Despite all of the above signs, when receiving such an injury, pain will be completely absent. Approximately two or three weeks after the injury itself has been received, it becomes possible to detect atony and atrophy of the muscles of the neurotome, and trophic disorders also develop.

The formation of the syndrome of partial conduction disturbance directly along the injured nerve will be based on a violation of natural sensitivity, which may have a different level of manifestation (hyperpathy, anesthesia, paresthesia, hypesthesia).

After some time, after injury, there is a possibility that hypotonia and muscle hypotrophy begin. There is a risk of complete loss or reduction of deep reflexes. There is a possibility that the pain syndrome is completely absent or it will be pronounced. The main symptoms of vegetative or trophic disorders are moderately expressed.

At different stages of injury peripheral nerve the presence of irritation syndrome becomes noticeable. The most striking sign in education this syndrome is pain, which can have varying degrees of severity, trophic and autonomic disorders also appear.

Diagnostics

Perhaps the formation of open or closed damage to the peripheral nerves. Closed damage can appear if a fairly swipe with some blunt object, as well as as a result of compression of soft tissues, in the presence of a tumor, damage by bone fragments, etc. In this case, a complete rupture of the nerve rarely occurs, as a result of which the patient has a very favorable prognosis.

The formation of a dislocation of the lunate bone, as well as a fracture of the radius in a certain place, a characteristic compression injury may occur median nerve in the canal part. With a fracture of the hamate bone, it is possible that the formation of a break in the motor branch and the ulnar nerve is possible.

The appearance of an open nerve injury can occur as a result of being injured by a knife, a piece of glass, etc. Taking into account the nature of the damage received, as well as the period of exposure to the traumatic agent itself, the ongoing changes in the injured nerve will be determined.

Prevention

In order to prevent the formation of traumatic nerve injury, it is necessary to avoid various injuries, which may result in its formation.

Treatment

In the case of diagnosing the presence of traumatic nerve damage, conservative treatment can be used, but at the same time it is less effective than medication.

During the surgical intervention, there is a possibility that axons will grow directly from the central segment of the nerve to the peripheral one.

The main task of holding conservative treatment is a warning possible development deformities, as well as joint contractures, an intensive fight against pain is carried out, fibrosis and massive scarring of tissues are prevented, while the blood circulation process is significantly improved, reparative processes in the nerve are stimulated, and the tone of denervated muscles is maintained.

All therapeutic measures that are aimed directly at achieving the above goals must be started almost immediately after the injury itself has been received. There is a need for surgical intervention. Only complex treatment brings benefits, until there is a complete restoration of all functions of the injured limb.

The course of treatment of traumatic nerve injuries includes special drug-stimulating therapy, as well as therapeutic gymnastic and orthopedic measures, and of course, physiotherapy techniques. The duration of the course of treatment directly depends on the degree and complexity of the injury, as well as taking into account the presence of concomitant injuries. Comprehensive treatment should be targeted, while selected in each case strictly on an individual basis.

It is strictly forbidden to attempt self-treatment, as this may result in more serious complications and severe consequences.

The radial nerve is the thickest branch of the brachial plexus, and, together with branches extending from 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 be obtained without even injuring the hand. Just enough to fall asleep on it.

This is where the expression "sleep paralysis" came from - a condition that occurs when a person accidentally fell asleep on his arm, and in the morning found that it did not work. Damage to the radial nerve occurs with prolonged use of crutches and with all types of traumatic injuries.

Signs of damage to the radial nerve

• Feeling of numbness and "crawling crawling" in the area of ​​I-III fingers of the hand;
• Inability to manage thumb injured hand;
• Pain when trying to move the forearm;
• Weakness in the hands - the brush 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 enough to stimuli;
• Movement disorders - it becomes impossible to move your hand or fingers;
• Redness or blanching of the skin of the hand, impaired sweating.

expressiveness clinical symptoms depends on the nature of the damage:

• With a concussion that is not accompanied by anatomical and morphological changes, the violations are reversible. Full recovery of nerve function usually occurs about two weeks after injury;
• When the nerve is injured, the anatomical integrity is preserved, but there are foci of hemorrhage. Manifestations are more persistent, but after a while the nerve will recover completely;
• Squeezing is more dangerous. If the nerve is compressed as a result of trauma and tumor growth, the only way to get rid of the problem is with the help of surgery;
• Rupture - damage in which spontaneous healing occurs only with a minimum size of the torn area. In other cases, in the area of ​​nerve damage, benign formations are formed - neuromas that do not allow it to grow together. The only way to restore the nerve is through surgery.

Treatment

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

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

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

The sections of the gap are stitched together. With the formation of a neuroma, its excision is carried out with the connection of the formed ends.

When the nerve is compressed, neurolysis with transposition is performed. The nerve is freed from traumatic effects, 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, specialists from the Department of Neurosurgery and Neuroreanimation of the University Clinic of the Moscow State Medical University named after A.I. Evdokimov and has all the necessary medical equipment. Therefore, our specialists successfully treat such injuries.

In our center, specialists from the Department of Neurosurgery and Neuroreanimation of the University Clinic of the Moscow State Medical University named after A.I. Evdokimova

Injuries to peripheral nerves, including their bruises, are much more common in wartime, and, sadly, armed conflicts make an invaluable contribution to their study. In comparison, during the First World War, damage to the nerves and plexuses amounted (in relation to all types of wounds) to 1-5%, and in modern wars - already 13-16%, due to mine fragmentation weapons and frequent shell shock. Of course, nerve injuries are not limited to military injuries, and in peacetime there are also natural disasters, traffic accidents and many other factors leading to injuries.

About the frequency of occurrence

In the first place in terms of frequency of occurrence are neuropathies of the radial nerve and peroneal,. Then, in second place - lesions of the sciatic nerve and ulnar nerve, and closes the "honorary three" median neuropathy and lesions of the lumbosacral plexus. With a large "lag" there are lesions of the axillary nerve, musculocutaneous, femoral nerves.

As a rule, nerve injuries are, as already mentioned, in the form of neuropathies (damage to individual nerves), and in the form of plexopathies, or lesions of the bundles and plexuses.

On the classification of nerve lesions

There are many various classifications nerve damage:

• etiological: gunshot, contusion, sports, road transport, industrial, domestic and even medical (post-injection, tourniquet) injuries;

The classification according to the mechanism of action of the traumatic factor is much richer. Yes, meet:

• incised, chopped stab open wounds of nerves;

• traction, with dislocations of the limbs;

• compression during falls and shocks;

• compression-traction (for example, in car accidents);

• compression-ischemic (for example, tourniquets, crutches when moving incorrectly on crutches), webbing when wearing improperly selected bags and backpacks, cicatricial when the nerve is compressed by scar tissue, tunnel syndromes when the nerve is compressed in the area of ​​\u200b\u200b"narrow" anatomical formations.

Due to all the richness of the impact of damaging factors, anything can happen to the nerve, from rupture to complete degeneration, the appearance of reflex-dystrophic syndromes due to neuroapraxia (its concussion).

Known law: farther from the central nervous system damaged nerve the more likely it is to recover.: that is, more distal injury contributes to better speedy recovery. Nerve conduction changes due to nerve injury, and this change occurs for several reasons:

• long segments, or sections of nerves are affected due to its stretching when the limb is displaced;

• due to compression or crushing of sections of the nervous tissue, sometimes due to blunt blows;

• sometimes the nerve can be compressed under a tourniquet, cuff, or tight bandage, including plaster. This can lead to iatrogenic, or medical injury;

• the nerve after the healing of the fracture can enter the area callus, as it grows.

In case of nerve injury, even a very short-term, but strong impact can lead to disruption of the myelin sheath and impaired conduction of impulses. Progressive distal atrophy of the nerve fiber develops, and, as a result, dysfunction of the underlying part.

On the clinical picture of nerve damage in bruises and injuries

Like other disorders, plexopathies and neuropathies of traumatic origin can manifest themselves:

• sensitive disorders, which include, pain character, with the development of various paresthesias;

• motor disorders, which consist in muscle weakness, progressive or persistent hypotrophy of the muscles innervated by this nerve, or a decrease in skin turgor over the paretic muscle area;

• vegetative-trophic disorders: increased fragility of nails, hair loss, the appearance of a marbled skin color or its cyanosis, due to dysregulation of vascular tone, with an injury to a part of the nerve that carries vegetative-trophic fibers;

• it is important that in addition to the classic triad (sensory, motor and vegetative loss of functions), symptoms of excessive pathological production of nervous tissue may develop. These include reflex muscle contractures, the appearance of excessive hairiness, or hypertrichosis, the appearance of excessive keratinization of the skin (hyperkeratosis), or disorders such as hyperpathy and causalgia.

Hyperpathy is a condition of pathological pain that involves an older type of sensitivity called protopathic, as opposed to the newer, more precise and localized, epicritical sensitivity. At the same time, the applied irritation is felt inaccurate, vague, painful, and unpleasant, that is, an emotional coloring of sensations appears.

This kind of "perverse pain" occurs just after nerve injuries, in conditions where nerve isolation (or remyelination processes) have not gone well. The hallmark of hyperpathy is that the sensation of impact lasts longer than it actually does: there is a "deception" of the nervous system. The second variant of the appearance of hyperpathy is pathological processes in the higher, but subcortical centers of pain analysis, for example, in the visual tubercles or in the thalamus.

Causalgia is also called burning, intense pain. Most often, they occur with injuries of the sciatic nerve on the leg and median on the arm. A characteristic feature of such peripheral injury is that wetting the limb (applying a wet towel) reduces discomfort. It is even more unpleasant that this pain goes “outside the scope” of the physiological innervation of this nerve and captures neighboring areas.

These pathological types pain is often accompanied chronic insomnia, depression, and can even lead to suicide in special cases.

Some typical signs of damage to individual plexuses and nerves

With damage to the cervical plexus, first of all, the neck begins to bend and unbend poorly, sensitivity in the area of ​​the skin behind the ears, in the area of ​​the shoulders and shoulder girdle, and even to the subclavian region and zone 1 of the intercostal space often decreases.

Damage to the brachial plexus leads to vivid symptoms: Erb's upper palsy is manifested by loss of function of the scapular muscles, proximal parts, arms and shoulder, while maintaining the movements of the muscles of the hand and fingers.

The defeat of the lower beam, or Dejerine-Klumpke's paralysis, causes distal paralysis of the small muscles of the hand, with their atrophy. As a rule, the upper muscles work without change. In some cases, this may cause Horner's symptom: ptosis (drooping of the upper eyelid), miosis (narrowing of one pupil), and enophthalmos, or reduction in size eyeball with its decline.

With the pathology of the nerves of the lumbosacral plexus, the following common symptoms occur:

Roth's disease, or paresthetic meralgia. Occurs when the external cutaneous nerve of the thigh is compressed. Often this happens when wearing tight trousers, with a trouser belt. Manifested by a violation of sensitivity on the outer region of the thigh, "crawling".

In the case of a bruise and injury to the femoral nerve, such an activity as a simple climb up the stairs is disrupted, namely, it is difficult to extend and straighten the leg at the knee joint. Gradually, as a result, weight loss and atrophy of the anterior femoral muscles develop.

In the case of damage to the sciatic nerve, as the longest and thickest nerve in our body, many disorders can occur. So, with violations in the pelvic cavity, there is a violation of the rotation of the thigh, drooping of the foot and fingers, hypotrophy of the muscles of the thigh and lower leg along with the foot appears, since both the peroneal and tibial nerves that make up the sciatic nerve are affected.

With regard to the defeat of the tibial nerve, it is characterized by worsening of flexion in the ankle joint, and the patient cannot stand on his toes. There is a "claw-like" foot, and the sensitivity in the heel is disturbed.

When the common peroneal nerve is affected, the foot droops, the foot “slaps” when walking, or “cock’s gait” appears.

Of course, these examples are not limited to all the variety of nerve damage due to trauma and bruises. It's important to us ordinary people, know one thing: that the treatment of peripheral nerve damage must be fast.

So, with “garden bench paralysis”, when a person sleeps with his hand under his head, and then realizes that his hand “hangs”, you should not hesitate to consult a doctor or go to the neurology department in the morning. But here's what's typical, usually drunk people fall asleep like this, and in the morning, they prefer to get drunk, instead of starting urgent treatment. And alcohol itself is a factor that significantly worsens the course of any neuropathy and plexopathy.

Quite often, in addition to conservative treatment, an operation is required, for example, to decompress the nerve trunk or exfoliate it from the callus.

This is done by neurosurgeons who specialize in the peripheral nervous system - a rather rare medical specialty, since "ordinary" neurosurgeons work on the central nervous system - the brain and spinal cord. Sometimes the intervention of microsurgeons specializing in the hand is required, since the structure of this organ is very complex, and in case of compressive-ischemic neuropathies it is necessary to go there, when they are located near the hand.

Peripheral nerve damage

What is Peripheral Nerve Injury?

Nerve damage are one of the frequent and severe types of injuries that cause complete or partial disability, force patients to change their profession and often cause disability. In everyday clinical practice, unfortunately, a significant number of diagnostic, tactical and technical errors are made.

What provokes / Causes of Damage to peripheral nerves:

Peripheral nerve damage may be closed or open.

Closed damage arise as a result of a blow with a blunt object, compression of soft tissues, damage by bone fragments, a tumor, etc. A complete interruption of the nerve in such cases is rare, so the outcome is usually favorable. Dislocation of the lunate, a fracture of the radius in a typical location often leads to compression injuries of the median nerve in the area of ​​the carpal canal, a fracture of the hamate can cause a break in the motor branch of the ulnar nerve.

Open damage in peacetime, they are most often the result of injuries from glass fragments, a knife, sheet iron, a circular saw, etc. The upcoming changes appear depending on the nature and duration of exposure to a traumatic agent various syndromes function disorders.

Pathogenesis (what happens?) during Peripheral Nerve Injuries:

Loss of sensitivity almost always observed with damage to the peripheral nerve. The prevalence of disorders does not always correspond to the anatomic zone of innervation. There are autonomous zones of innervation in which there is a loss of all types of skin sensitivity, i.e. anesthesia. This is followed by a zone of mixed innervation, in which, if one of the nerves is damaged, areas of hypesthesia alternate with areas of hyperpathy. In an additional zone where innervation is carried out neighboring nerves and only a slightly damaged nerve, it is not possible to determine the violation of sensitivity. The size of these zones is extremely variable due to the individual characteristics of their distribution. As a rule, the diffuse area of ​​anesthesia that appears immediately after a nerve injury is replaced by hypesthesia after 3-4 weeks. Yet the process of substitution has its limits; if the integrity of the damaged nerve is not restored, then the loss of sensitivity persists.

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, which makes it possible to determine the area of ​​nerve damage.

Manifested in disruption sweat glands; anhidrosis of the skin occurs, the area of ​​\u200b\u200bwhich corresponds to the boundaries of the violation pain sensitivity. Therefore, by determining the presence and size of the anhidrosis zone, one can judge the boundaries of the anesthesia area.

Vasomotor disorders are observed approximately in the same range 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 segment of the limb devoid of innervation is cold to the touch, the skin acquires a bluish tint. Often in this area, increased hydrophilicity, pastosity of soft tissues is determined.

Trophic disorders are expressed by thinning of the skin, which becomes smooth, shiny and easily injured; turgor and elasticity are markedly reduced. Clouding of the nail plate is noted, transverse striation, depressions appear on it, it fits snugly to the pointed tip of the finger. In the long term after injury, trophic changes extend to tendons, ligaments, joint capsule; joint stiffness develops; due to forced inactivity of the limb and circulatory disorders, osteoporosis of the bones appears.

The severity of nerve damage leads to various degree of disorders of its function.

With a concussion of the nerve, anatomical and morphological changes in the nerve trunk are not detected. Motor and sensory disorders are reversible, full recovery of functions is observed 1.5-2 weeks after the injury.

In the case of a bruise (contusion) of the nerve, the anatomical continuity is preserved, there are separate intra-stem hemorrhages, a violation of the integrity of the epineural membrane. Functional disorders are deeper and more persistent, but after a month their full recovery is always noted.

Nerve compression can occur from various causes (prolonged exposure to a tourniquet, with injuries - bone fragments, hematoma, etc.). Its degree and duration are directly proportional to the severity of the lesion. Accordingly, prolapse disorders may be transient or persistent and require surgical intervention.

Partial damage to the nerve is manifested by the loss of functions, respectively, to those intratrunk formations that are injured. Quite often at the same time the combination of symptoms of loss with the phenomena of irritation is observed. Spontaneous healing in such situations is rare.

A complete anatomical break is characterized by the death of all axons, the breakdown of myelin fibers along the entire perimeter of the trunk; division of the nerve into peripheral and central is noted, or they are communicated by a strand of scar tissue, the so-called "false continuity". Restoration of lost functions is impossible, trophic disorders develop very soon, atrophy of paralyzed muscles in the denervated zone increases.

Symptoms of Peripheral Nerve Injury:

Damage to the radial nerve (Cv-Cvm). Nerve injuries in the armpit and at shoulder level cause a characteristic "falling" or dangling hand position. This position is due to paralysis of the extensors of the forearm and hand: the proximal phalanges of the fingers, the muscle that removes the thumb; in addition, supination of the forearm and flexion are weakened due to the loss of active contractions of the brachioradialis muscle. Nerve injuries in the more distal sections of the upper limb, i.e., after the motor branches have left, are manifested only by sensory disorders. The boundaries of these disorders run within the radial part of the rear of the hand along the III metacarpal bone, including the radial part of the proximal phalanx and the middle phalanx of the III finger, the proximal and middle phalanxes index finger and the proximal phalanx of the first finger. Disorders of sensitivity proceed, as a rule, according to the type of hypoesthesia. 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 damage to the median nerve and the superficial branch of the radial nerve, the prognosis is more favorable than with a fairly common combination of injury to the median and ulnar nerves, leading to severe consequences. If in the first variant of combined nerve damage it is possible to a certain extent to replace the lost function due to the intact ulnar nerve, then in the second variant this possibility is excluded. Clinically, in the latter case, paralysis of all autochthonous muscles of the hand is expressed, there is a claw-like deformity. The combined injury of the median and ulnar nerves has a disastrous effect on the function of the hand as a whole. A denervated, numb hand is unsuitable for any kind of work.

Damage to the median nerve (Cvin-Di). Main clinical sign damage to the median nerve in the area of ​​the hand is a pronounced violation of its sensitive function - stereognosis. IN early dates after nerve damage, vasomotor, secretory and trophic disorders appear; skin folds are smoothed out, the skin becomes smooth, dry, cyanotic, shiny, flaky and easily injured. Transverse striation appears on the nails, they become dry, their growth slows down, Davydenkov's symptom is characteristic - "sucking" of I, II, III fingers; subcutaneous tissue atrophies and nails fit snugly against the skin.

The degree of 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 the origin of the motor branch to the muscles of the eminences of the thumb or isolated damage to this branch. In this case, flaccid paralysis of the thenar muscles occurs, and with a high nerve lesion, a violation of the pronation of the forearm, palmar flexion of the hand joins, flexion of the I, II and III fingers and extension of the middle phalanges of the II and III fingers falls out. In the own 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, the reinnervation of paralyzed muscles with the restoration of their function is impossible. Atrophy is revealed in the smoothing of the thenar convexity. The thumb is set in the plane of the other fingers, the so-called monkey hand is formed. Paralysis covers the short muscle that abducts the thumb and the muscle that opposes the thumb, as well as the superficial head of the short flexor of this finger. The function of abduction and, above all, opposition of the thumb of the hand falls out, which is one of the main motor symptoms damage to the trunk of the median nerve.

Sensitivity disorder - leading manifestation damage to the median nerve and is always observed regardless of the level of its damage. Skin sensitivity is absent in most cases on the palmar surface of the I, II and III fingers, as well as on the radial surface of the IV finger of the hand; on the back of the hand, sensitivity is disturbed in the region of the distal (nail) phalanges of fingers I, II, III and the radial part of the distal phalanx of the fourth finger. There comes a complete loss of stereognostic feeling, i.e., the ability to "see" an object with closed eyes by feeling it with your fingers. In this case, the victim can use the brush only under visual control. The replacement of sensitivity, which has fallen out after a complete interruption of the main trunk of the median nerve, occurs only to a certain level, mainly in the marginal zones of the area of ​​skin anesthesia, due to the overlap of the branches of the median nerve in these areas with the superficial branch of the radial nerve, the external cutaneous nerve of the forearm, and also the superficial branch of the ulnar nerve. nerve.

Segmental damage to the trunk of the median nerve leads to a 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 that innervate 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 a sharp hyperhidrosis of the skin on the palm in the zone of branching of the median nerve or anhidrosis and peeling of the epidermis. The intensity of disorders (sensory, motor, vegetative) always corresponds to the depth and extent of damage to the nerve trunk.

Ulnar nerve injury (Cvn-CVIH). The leading clinical symptom of damage to the ulnar nerve is movement disorders. Branches from the trunk of the ulnar nerve begin only at the level of the forearm, in connection with this, the clinical syndrome of its complete defeat at the level of the shoulder up to the upper third of the forearm does not change. The weakening of the palmar flexion of the hand is determined, active flexion of the IV and V, partially III fingers is impossible, it is impossible to reduce and spread the fingers, especially IV and V, there is no adduction of the thumb according to the dynamometer. A significant loss of muscle strength in the fingers of the hand is revealed (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. The retraction of the first interosseous gap and the area of ​​​​the elevation of the little finger are detected especially quickly. Atrophy of the interosseous and worm-like muscles contributes to a sharp outlining of the contours of the metacarpal bones on the back of the hand. In the long term after the injury, a secondary deformity of the hand occurs, which acquires a peculiar form of a claw as a result of palmar flexion of the middle and distal phalanges of the IV-V fingers (due to paralysis of the worm-like 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 IV, V fingers do not reach the palm, it is impossible to bring the fingers together and apart. The opposition of the little finger is violated, there are no scratching movements to it.

Disturbances in skin sensitivity in case of damage to the ulnar nerve are always observed in the zone of its innervation, however, the length of the 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. Violations capture the palmar surface of the ulnar edge of the hand along the IV metacarpal bone, half of the IV finger and completely the 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 boundaries are somewhat larger than the boundaries of sensitivity disorders.

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

Damage to the sciatic nerve (Uv-v-Si-sh). High nerve damage leads to a violation of the function of flexion of the lower leg 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 calcaneal 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 - tibial and peroneal nerves. The nerve is large average diameter in diameter in the proximal section 3 cm. Segmental lesions of the trunk are not uncommon, manifested by the corresponding clinical picture with a predominant loss of functions that are in charge of one of its branches.

Peroneal nerve injuries (Liv-v-Si). Form the trunk of the nerve roots (Liv-v-Si). Mixed nerve. Damage to the peroneal nerve leads to paralysis of the extensors of the foot and fingers, as well as the peroneal muscles that provide 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, turned inward, the fingers are bent. A typical gait of a patient with a nerve injury is “cock-like”, or peroneal: the patient raises his leg high and then lowers it on the toe, on the stable outer edge of the foot, and only then leans on the sole. The Achilles reflex, which is provided by the tibial nerve, is preserved, pain and trophic disorders are usually not expressed.

Tibial nerve injury (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 tibial muscle, which rotates the foot inwards.

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

When the nerve is damaged, the Achilles reflex falls out. Sensory disturbances spread within the boundaries of the back surface of the leg, sole and outer edge of the foot, the back surface of the fingers in the area of ​​the distal phalanges. Being functionally an antagonist of the peroneal nerve, it causes a typical neurogenic deformity: the foot is in the extension position, severe atrophy of the posterior muscle group of the lower leg and sole, sunken intertarsal spaces, deep arch, bent position of the fingers and protruding heel. While walking, the victim rests mainly on the heel, which makes walking much more difficult, no less than with damage to the peroneal nerve.

With lesions of the tibial nerve, as with lesions of the median, a causalgic syndrome is often observed, and vasomotor-trophic disorders are also significant.

Movement disorder tests: inability to flex the foot and toes and turn the foot inwards, inability to walk on toes due to instability of the foot.

Diagnosis of Peripheral Nerve Injuries:

staging correct diagnosis nerve injury depends on the sequence and systematic nature of the studies.

• Survey

Establish the time, circumstances and mechanism of injury. According to the guiding documents and from the words of the patient, the duration and volume of the first medical care. Clarify the nature of pain and the emergence of new sensations that appeared in the limb from the moment of injury.

• Inspection

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

• Palpation

Get information about the temperature of the skin of the hand or foot, its turgor and elasticity, moisture content of the skin.

Pain in the area of ​​the postoperative scar during 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 region of the peripheral segment of the nerve, which, with a complete anatomical break, is painful, and in the event of projection pain, partial damage to the nerve or the presence of regeneration after neurorhaphy (Tinel's symptom) can be assumed.

Sensitivity study. When conducting a study, it is desirable to exclude factors that distract the patient's attention. He is offered to close his eyes in order to concentrate and not control the doctor's actions with his eyesight. It is necessary to compare sensations from similar irritations in symmetrical obviously healthy areas.

• Tactile sensitivity is examined by touching with a ball of cotton wool or a brush.
• The feeling of pain is determined by a prick with the tip of a pin. It is recommended to alternate painful stimuli with tactile ones. The subject is given the task to define the injection with the word "Acute", the touch - with the word "Stupidly".
• Temperature sensitivity is examined using two test tubes - with cold and hot water; areas of the skin with normal innervation are distinguished by a temperature change of 1-2°C.
• Feeling of localization of irritation: the subject indicates the place of skin injection with a pin (the injection is applied with eyes closed).
• The feeling of discrimination of two one-dimensional stimuli is determined by a compass (Weber's method). Behind normal value discrimination accept the result of the study on a symmetrical area of ​​a healthy limb.
• Feeling of two-dimensional irritations: letters or figures are written on the skin of the area under study, which should be called by the patient without visual control.
• Joint-muscular feeling is determined by giving the joints of the limbs various 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 versatile sensations (mass, shape, temperature, etc.). The definition of stereognosis is especially important in median nerve injuries. According to the results obtained, a functional assessment is given: if the stereognosis is preserved, the human hand is suitable for performing any work.

• Electrophysiological research methods

Clinical tests to assess the state of the functions of the peripheral nerve should be combined with the results of electrodiagnostics and electromyography, which allow determining the state of the neuromuscular apparatus 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 constant electric shock. Under normal conditions, in response to irritation, the muscle responds with a quick live contraction, and in case of injury to the motor nerve and degenerative processes, worm-like flaccid contractions are recorded in the corresponding muscles. Determination of the threshold of excitability on healthy and diseased limbs allows us to draw a conclusion about quantitative changes electrical excitability. One of the essential signs of nerve damage is an increase in the nerve conduction threshold: an increase in the strength of current impulses in the affected area compared to the healthy one in order to obtain a muscle contraction response. Long-term results on the use of this method have shown that the data obtained are not sufficiently reliable. Therefore, in recent years, electrodiagnostics in its traditional form has been gradually replaced by stimulation electromyography, which includes elements of electrodiagnostics.

Electromyography is based on the registration of electrical potentials of the muscle under study. 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 interruption of the peripheral nerve. Electromyography (EMG) allows you to determine the degree and depth of damage to the nerve trunk. The method of stimulation EMG (a combination of electrical stimulation of the nerves with simultaneous recording of the resulting muscle potential fluctuations) determines the speed of impulse conduction, studies the transition of impulses in the zone of myoneural synapses, and also examines the functional state of the reflex arc, etc. Electromyographic registration of action potentials can provide important data not only diagnostic, but also prognostic, allowing you to catch the first signs of reinnervation.

Treatment of Peripheral Nerve Injuries:

• Conservative treatment

Conservative and restorative treatment is no less important than surgery on the nerve, especially in case of associated injuries. If during the operation anatomical prerequisites are created for the germination of axons from the central segment of the nerve to the peripheral one, then the task of conservative treatment is the prevention of deformities and contractures of the joints, the prevention of massive scarring and fibrosis of tissues, the fight against pain, as well as the improvement of conditions and stimulation of reparative processes in the nerve , improvement of blood circulation and trophism of soft tissues; maintaining the tone of denervated muscles. Measures aimed at achieving these goals should be started immediately after an injury or surgery and carried out in a complex, according to a certain scheme, according to the stage regenerative process up to the restoration of the function of damage to the limb.

The course of treatment includes drug-stimulating therapy, orthopedic, therapeutic and gymnastic measures and physiotherapeutic methods. It is carried out for 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 complex of treatment should be carried out purposefully, with a selective approach in each case.

Therapeutic exercises are carried out during the entire period of treatment, and in the most complete way - after the expiration of the period of immobilization of the limb. Purposeful active and passive movements in the joints of the injured limb lasting 20-30 minutes 4-5 times a day, as well as movements in light conditions - physical exercise in water have a positive effect on the restoration of impaired motor function. The use of elements of occupational therapy (sculpting, sewing, embroidery, etc.) contributes to the development of various motor skills that acquire an automatic character, which has a positive effect on the restoration of professional skills.

Massage significantly improves the condition of soft tissues in power 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 injury or surgery, which undoubtedly contributes to the regeneration of nerves. The patient should be taught the elements of massage, which will allow it to be carried out 2-3 times a day during the entire course of rehabilitation treatment.

The use of physiotherapeutic methods involves the fastest resorption of the hematoma, the prevention of postoperative edema and the elimination of pain. For this purpose, on the 3rd-4th day after the operation, the patient is prescribed an UHF electric field and Bernard currents for 4-6 procedures, and later, in the presence of pain, novocaine electrophoresis according to the Parfyonov method, calcium electrophoresis, etc., on the 22nd day - lidase electrophoresis (12-15 procedures), which stimulates the regeneration of the nerve and prevents the formation rough scars. In 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 with a rhythm of 5-10 contractions per minute for 10-15 minutes. Electrical stimulation should be carried out daily or every other day; for a course of 15-18 procedures. This method helps to preserve the contractility of the muscles and their tone until the onset of reinnervation.

Medical treatment aims to create favorable conditions for nerve regeneration, as well as to stimulate the regeneration process itself. Well drug therapy it is advisable to carry out as follows: on the 2nd day after the operation, vitamin B 12 injections of 200 mcg intramuscularly are prescribed, 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 B 12 should be alternated every other day with the introduction of 1 ml of a 6% solution of vitamin B 1 (20-25 injections per course). This method of introducing B vitamins weakens the development of inhibitory processes in the central nervous system, accelerates the regeneration of nerve fibers.

Dibazol with nicotinic acid in powder is prescribed for 2 weeks, 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 a 2% solution; 25-30 injections) and pyrogenal should be administered according to an individual scheme, which have a beneficial effect on the reparative process, stimulate it.

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

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 and restorative treatment is sufficient.

After neurorhaphy 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 axon 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, the course of rehabilitation treatment started in the 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 adjacent to the level of nerve damage; over time, the sensitivity in the more distal parts of the limb improves. If there are no signs of regeneration within 3-5 months after the operation, with full conservative and restorative treatment, the issue of repeated surgical intervention should be considered.

Sanatorium-and-spa treatment in Tskhaltubo, Evpatoria, Saki, Matsesta, Pyatigorsk, etc. is indicated 2-3 months after neurography. Use such healing factors, as mud applications, balneotherapy.

• Surgical treatment

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

Experience in the treatment of patients with nerve injuries shows that the earlier a reconstructive operation is performed, the more fully the lost functions are restored. Nerve surgery is indicated in all cases of impaired conduction along the nerve trunk. The time between injury and surgery should be as short as possible.

In cases of failure of the primary suture of the nerve (increasing muscle atrophy, sensory and vegetative 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 wound healing, although more late period surgery on the damaged nerve is not contraindicated. With damage to the nerves of the hand optimal time to restore 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 complete impairment of conduction along the nerve trunk is evidenced by the following: paralysis of a certain muscle group, anesthesia in the autonomic zone of the nerve concerned with anhidrosis within the same limits, negative Tinel's symptom, absence of muscle contraction during electrodiagnosis - nerve irritation above the level of damage and gradually weakening, and then disappearing muscle contraction, under the influence of a pulsed current below the level of damage.

Surgical treatment can be carried out in more late dates after a nerve injury, if the intervention for one reason or another has not been performed earlier. It should be noted that in this case one cannot count on a significant improvement in the motor function of the nerves. This is especially true for the muscles of the hand, where degenerative changes quickly occur due to their small size. After the operation, 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. Recovery operation on the damaged nerve, regardless of the time elapsed after the injury, it 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 unsharp trophic and sensory disturbances in the autonomic zone of innervation of the nerve concerned. At the same time, a cicatricial process develops in the epineurium, which subsequently can cause the formation of a cicatricial stricture with impaired conduction. After bruised-lacerated wounds or severe combined injuries of the extremities, especially a part, a diffuse cicatricial process develops, leading to compression of the nerve trunks. IN similar cases sensitivity disorders and vegetative disturbances are observed, the depth of which is directly proportional to the degree of compression. In these situations, with the ineffectiveness of the full course of conservative treatment after a nerve injury, neurolysis is indicated - gentle excision of epineurium scars, which eliminates axonal compression, improves blood supply to the nerve and restores conduction in this area.

An operative approach to the nerve must be carefully thought out and carried out with great methodicalness and the utmost care for the tissues. The nerve trunk is first exposed in the area of ​​obviously healthy tissues 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 is reversible. The effectiveness of neurolysis produced by correct testimony, manifests itself as soon as possible after the operation: the function of the nerve concerned improves or is completely restored, pain and vegetative-trophic disorders disappear, sensitivity improves, sweating is restored.

Surgical tactics and technique for performing operations on peripheral nerves depend on the duration of the injury, the nature of the former injury and previous surgical interventions, the degree of cicatricial tissue changes, the level of nerve damage and associated damage.

Epineural suture. Until now, the classic direct epineural suture remains the most common method of peripheral nerve reconstruction. This is the simplest operational technique, although it requires some experience, in otherwise technical errors are possible. It has a number of disadvantages, especially in mixed nerve repair, where precise matching of homogeneous intraneural bundles is required. With the help of an epineural suture, it is difficult to maintain the achieved longitudinal orientation of the bundles after the operation. Sprouting of the motor axons of the central end of the nerve into the sensory axon of the peripheral or inverse ratios due to mutual rotation of the ends is one of the reasons for the prolonged or incomplete recovery of the main functions of the nerve. The abundance of interfascicular connective tissue complicates the opposition of the bundles, there is a real danger of comparing the cut of the central bundle of the nerve with the interfascicular connective tissue, which makes it difficult for the maturation and germination of regenerating axons. This eventually leads to neuroma formation and loss of function.

Dissatisfaction with results surgical treatment injuries of mixed peripheral nerves prompted physicians 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 neurosurgery of peripheral nerves that combines general surgical techniques with the use of a qualitatively new technique in a microfield: magnifying optics, special instruments and ultra-thin suture material. Hemostasis during the operation 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.

A classic straight epineural suture can be placed up to the level of the distal interphalangeal joint of the finger. It is the most appropriate not only for conventional, but also for microneurosurgical techniques. The nerves of these areas contain homogeneous bundles of axons - either sensory or motor. Therefore, the rotation of the ends of the nerve along the axis, the probability of which is not excluded even with microtechnology, is of little importance.

In areas of mixed structure of peripheral nerves, it is most expedient to apply perineural or interfascicular sutures that connect axon bundles that are homogeneous in function. This is necessary because after refreshing the ends of the nerve, the intratrunk topography of the sections does not match, since the position and size of the bundles on different levels nerve are different. In order to identify intratruncal beams, you can use the Karagancheva 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 above or below 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, in contrast to the most common the applied technique of stitching beams in one plane of the cut. In conclusion, the epineurium of both ends of the nerve is brought together with separate interrupted sutures in the overlay. Due to this, the line of perineural sutures is 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 plasty. Particularly great difficulties in the reconstruction of the nerve arise in cases where there is a defect between its ends. Many authors refused to mobilize the nerve over a long distance, as well as excessive flexion in the joints of the limb to eliminate diastasis in order to sew the nerve end to end. The blood supply to the peripheral nerves is carried out according to the segmental type, with most of the nerves having a longitudinal direction along the epineurium and between the bundles. Therefore, mobilization of the nerve to eliminate diastasis is justified when separating them for no more than 6-8 cm. An increase in this limit leads to impaired blood circulation, which in such cases can only be carried out due to the ingrowth of new blood vessels from the surrounding soft tissues. There is no doubt that the developing fibrosis in the nerve trunk prevents the maturation and growth of regenerating axons, which ultimately will adversely affect the results of treatment. Tension along the line of sutures due to incompletely eliminated diastasis between the ends of the nerve leads to such violations. For these reasons, diastasis between the ends of the main trunks of peripheral nerves of 2.5-3.0 cm, and between the ends of the general digital and digital nerves proper - more than 1 cm is an indication for neuroautoplasty. The external nerve should be used as the donor nerve. cutaneous nerve lower leg, since in terms of its anatomical and functional characteristics it is most suitable for these purposes. During the plastic surgery of 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. Plasty of the common digital and digital nerves usually requires one graft due to their identical diameter.

In most cases, peripheral nerve damage is combined with vascular damage, which is explained by their anatomical relationship. Along with the suture or plasty of the nerve, it is necessary to simultaneously suture or plasty the damaged blood vessel, which will allow optimizing the conditions for regeneration of the restored nerve, counting on a favorable end result of treatment.

Thus, microsurgical technique for operations on peripheral nerves allows creating optimal anatomical conditions for restoring nerve function. The use of microsurgical techniques is especially important in operations on mixed nerves, where precise matching of the ends of the nerve with subsequent suturing of its identical bundles is required.

Which doctors should you contact if you have Peripheral Nerve Injury:

• Traumatologist
• Surgeon

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Other diseases from the group Injuries, poisoning and some other consequences of external causes:

Damage to the nerves of the extremities can be considered as peripheral nerve injury.
Damage to large nerves often accompanies wounds and closed injuries of the extremities. In such cases, it is necessary timely diagnosis and rehabilitation treatment. Morphologically, a complete and incomplete anatomical rupture of the nerve is distinguished, as well as intratrunk changes without damage to the epineurium (the so-called traumatic neuritis). With the last type of damage in early period after an injury, there may be a severe loss of innervation with an electrophysiological picture of a complete violation of the excitability of the nerve. As the resorption of hemorrhages and the reverse development of the inflammatory reaction, there is an improvement in nerve conduction. Therefore, the initial clinical manifestations can give a picture of a complete break of the nerve with its anatomical integrity, and therefore, in the next 2-3 weeks after closed injury one cannot yet speak of its anatomical interruption. 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 of the supraclavicular and subclavian region. Clinical symptoms range from severe muscle weakness of the entire arm to isolated paraplegia of the shoulder and forearm. Sensory disorders are expressed on the entire arm or only in the areas of innervation of the median or ulnar nerve. Depending on the nature of the damage, in the next 1 / 2 - 1 year and without treatment, complete and partial restoration conductive function of the nerve plexus.

radial nerve especially often damaged by fractures of the humerus in the lower third. The hand dangles due to the loss of function of the muscles - the extensors of the forearm. Active extension of the hand, 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 II interdigital space; sensory disturbances are intermittent. With damage to the radial nerve on the forearm, the patient cannot abduct and extend the first finger.

When damaged median nerve on the shoulder, the function of flexion of the II and III fingers is disturbed, as well as the opposition of the I and II fingers. The area of ​​anesthesia captures 2/3 of the palmar surface of the hand and half of the circumference on the II and III fingers.

Damage ulnar nerve at all levels violates the function of abduction and adduction of fingers. When examining the patient, it is stated that it is impossible to bend all the fingers of the hand and adduct the first finger. The claw-like position of the fingers with hyperextension in the interphalangeal and metacarpophalangeal joints is characteristic. Sensitivity is absent on the volar surface of the ulnar side and on the IV-V fingers of the hand. Pronounced claw-like deformity of the hand is especially characteristic of simultaneous damage to the median and ulnar nerves.

When damaged femoral nerve the extension of the lower leg in the knee joint is disturbed; weakened hip flexion; develops atrophy of the quadriceps femoris muscle with a loss of the knee reflex. The area of ​​anesthesia extends to the anterior surface of the thigh and the anterointernal surface of the lower leg.

When damaged peroneal nerve the foot sags, and its outer edge is lowered. The extensors of the foot and the main phalanges of the fingers are paralyzed, as well as the peroneal muscle, which abducts the foot, and the anterior tibialis muscle adducting the foot. Sensitivity is upset along the anteroexternal surface of the lower third of the leg and on the back of the foot, excluding its outer and inner edges.

Peroneal nerve injury

When 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 disturbed along the back of the lower leg, as well as the outer and plantar surfaces of the foot and toes. Trophic ulcers develop in the zone of sensitivity disorders; there are projection pains in the foot and toes. The clinical picture of the lesion sciatic nerve consists of the described symptoms of lesions of the peroneal and tibial nerves.

The integrity of the large nerve of the limb, if it is damaged, should be restored immediately after the injury (primary suture) or in the next 3–4 weeks (delayed suture). Primary seam nerve damage is subject to incised and stab-cut wounds, accompanied by a minimum 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 regenerate along with tendons.

The technique of suturing the nerves involves preliminary refreshing of its ends (strictly transverse crossing 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. Fixation of the limb (gypsum) in a bent position facilitates the convergence of the nerve segments with their subsequent retention for 3–4 weeks.

Epineural suture

The results of suturing an injured nerve are greatly improved when modern microsurgical (precision) techniques are used. When it is used, the frequency and severity of the local inflammatory reaction significantly decrease, nerve regeneration improves and, as a result, peripheral innervation in the area of ​​the restored nerve conductor. Surgical intervention 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. Through the perineurium of each bundle, 1–2 sutures are applied (monophilic thread No. 10-0) and an exact comparison of individual funicular groups is carried out. Finally, the epineurium is sutured without tension with numerous individual sutures (monofilament thread No. 9-0 or 8-0).

Perineural suture