Median nerve injury: clinical phenomenology. Peripheral nerve damage

Damage to the nerves of the extremities can be considered as peripheral nerve injuries.
Damage to large nerves often accompanies wounds and closed injuries of the extremities. In such cases, timely diagnosis and restorative treatment are necessary. Morphologically, a distinction is made between complete and incomplete anatomical interruption of the nerve, as well as intra-stem changes without damage to the epineurium (the so-called traumatic neuritis). With the latter type of injury, in the early period after the injury, severe loss of innervation may be observed with an electrophysiological picture of a complete disruption of nerve excitability. As hemorrhages resolve and the inflammatory reaction reverses, nerve conduction improves. Consequently, the initial clinical manifestations may give a picture of a complete break of the nerve while its anatomical integrity, and therefore in the next 2-3 weeks after a closed injury one cannot yet talk about its anatomical break. Features of symptoms determine the level and degree of damage to individual nerves.

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

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

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

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

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

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

Peroneal nerve injury

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

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

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

Epineural suture

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

Perineural suture

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, a circular saw, etc. The oncoming changes manifest themselves, depending on the nature and duration of exposure to the traumatic agent, as various syndromes of dysfunction.

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.

Compression of the nerve can occur for various reasons (prolonged exposure to a tourniquet, in case of injury - 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 such situations is rare.

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. The nature of the pain and the occurrence of new sensations that have appeared in the limb since the moment of injury are clarified.

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

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

Pain in the area of ​​the postoperative scar upon palpation is usually associated with the presence of a regenerative neuroma of the central end of the damaged nerve. Valuable information is provided by palpation of the area of ​​the peripheral segment of the nerve, which, with a complete anatomical break, can be painful, and in the case of projection pain, partial damage to the nerve or the presence of regeneration after neurorrhaphy (Tinel's symptom) can be assumed.

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

• 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 is based on the study of excitability - the reaction of nerves and muscles in response to irritation by faradic and direct electric current. Under normal conditions, in response to irritation, the muscle responds with a fast, live contraction, but with injury to the motor nerve and degenerative processes, worm-like flaccid contractions are recorded in the corresponding muscles. Determining the threshold of excitability on healthy and diseased limbs allows us to draw a conclusion about quantitative changes 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 recent years, electrodiagnostics in its traditional version has been gradually replaced by stimulation electromyography, which includes elements of electrodiagnostics.

Electromyography is based on recording the electrical potentials of the muscle being studied. The electrical activity of muscles is studied both at rest and during voluntary, involuntary and caused by artificial stimulation muscle contractions. The detection of spontaneous activity - fibrillations and slow positive potentials at rest - are undoubted signs of a complete break of the peripheral nerve. Electromyography (EMG) allows you to determine the degree and depth of damage to the nerve trunk. Using the method of stimulation EMG (a combination of electrical stimulation of nerves with simultaneous recording of the resulting oscillations in muscle potential), the speed of impulse conduction is determined, the transition of impulses in the zone of myoneural synapses is studied, and the functional state of the reflex arc is studied, etc. Electromyographic recording of action potentials can provide important data not only diagnostic, but also prognostic in 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, which leads to severe consequences. If with the first option of combined nerve damage it is possible to some extent to replace the lost function with the intact ulnar nerve, then with the second option this possibility is excluded. Clinically, in the latter case, paralysis of all autochthonous muscles of the hand is expressed, and there is a claw-like deformity. Combined injury to the median and ulnar nerves has a disastrous effect on the function of the hand as a whole. A denervated, desensitized hand is unsuitable for any work.

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

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

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

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 foot flexors (soleus and gastrocnemius muscles), toe flexors, as well as the tibialis posterior muscle, which rotates the foot medially.

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

When the nerve is damaged, the Achilles reflex is lost. Sensory disorders spread within the boundaries of the back surface of the lower leg, the sole and outer edge of the foot, and the dorsum of the fingers in the area of ​​the distal phalanges. Being functionally an antagonist of the peroneal nerve, it causes a typical neurogenic deformation: the foot is in extension, pronounced atrophy of the posterior group of muscles of the leg and sole, sunken intermetatarsal spaces, a deepened arch, bent position of the toes and a protruding heel. When walking, the victim relies mainly on the heel, which significantly complicates gait, no less than when the peroneal nerve is damaged.

With damage to the tibial nerve, as with damage to the median nerve, a causalgic syndrome is often observed, as well as significant vasomotor-trophic disorders.

Tests of movement disorders: inability to flex the foot and toes and rotate the foot medially, inability to walk on toes due to instability of the foot.

Treatment of Peripheral Nerve Injuries

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 in the preoperative and postoperative periods; its volume and duration depend on the degree of dysfunction of the affected nerve and associated injuries. The treatment complex should be carried out purposefully, with a selective approach in each specific case.

Therapeutic exercises are carried out throughout the entire period of treatment, and to the fullest extent - after the period of limb immobilization has expired. 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 following trauma or surgery, activates blood and lymph circulation, increases tissue metabolism of muscles and improves their contractility, prevents massive scarring, accelerates the resorption of soft tissue infiltrates in the area of ​​former injury or surgery, which undoubtedly promotes regeneration. nerves. The patient should be taught the elements of massage, which will allow it to be performed 2-3 times a day during the entire course of rehabilitation treatment.

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

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

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

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

The duration and volume of complex conservative and restorative treatment are determined by the number, level and degree of damage to the peripheral nerve, as well as the presence of concomitant injuries. After neurolysis surgery, as well as in cases of successful neurorhaphy in the area of ​​the distal third of the palm and at the level of the fingers, one course of conservative-restorative treatment is sufficient.

After neurorrhaphy in the more proximal parts of the hand, forearm and shoulder, as well as at the level of the lower leg, thigh, taking into account the approximate period of axonal regeneration and reinnervation of the peripheral nervous apparatus, it is necessary to repeat the course of treatment after 1.5-2 months. As a rule, a course of rehabilitation treatment begun in a hospital ends on an outpatient basis under the supervision of the operating surgeon.

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

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

Surgical treatment:

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

Experience in treating patients with nerve injuries shows that the earlier the reconstructive operation is performed, the more completely the lost functions are restored. Nerve surgery is indicated in all cases of conduction disturbance along the nerve trunk. The time between injury and surgery should be reduced as much as possible.

In cases of failure of the primary nerve suture (increasing muscle atrophy, sensory and autonomic disorders), direct indications for reoperation arise.

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.

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

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

Neurolysis. An incomplete break or compression of the nerve trunk is manifested by mild trophic and sensory disturbances in the autonomous zone of innervation of the nerve concerned. In this case, a scar process develops in the epineurium, which can subsequently cause the formation of a scar stricture with conduction disturbances. After bruised lacerations or severe combined injuries of the extremities, especially parts, a diffuse scarring process develops, leading to compression of the nerve trunks. In such cases, sensitivity disorders and autonomic disorders are observed, the depth of which is directly proportional to the degree of compression. In these situations, if 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, carried out according to the correct indications, manifests itself in the immediate postoperative period: the function of the nerve concerned improves or is completely restored, pain and vegetative-trophic disorders disappear, sensitivity improves, and sweating is restored.

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

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

Dissatisfaction with the results of surgical treatment of injuries of mixed peripheral nerves prompted doctors to search for new methods and types of surgical interventions. A big step forward was the use of magnifying optics and especially special operating microscopes. Microneurosurgery is a new direction in the neurosurgery of peripheral nerves, combining general surgical techniques with the use of qualitatively new technology under microfield conditions: magnifying optics, special instruments and ultra-thin suture material. Microsurgical 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 in anticipation of a favorable final result of treatment.

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

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

• Traumatologist

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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, blows, falls or dislocations of joints, unsuccessful surgical interventions, gunshot wounds, etc. Factors of injury to the peripheral nervous system can be violent and rapid traction of the limbs. Injuries are generally divided into two categories: closed and open. Open injuries differ from closed ones in the presence of 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 in the nerves manifests itself in increased dryness of the skin, the appearance of edema, peeling and, in some cases, ulcerative formations.

First aid for nerve fiber damage

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

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

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

Doctor's actions aimed at confirming the diagnosis

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

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

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

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

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

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

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

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

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

Treatment and rehabilitation

The main objectives of treatment for nerve contusion:

Elimination or easing of pain.

Ensuring normal nutrition of axons, protecting motor neurons.

Reduction or complete elimination of adhesions and scar processes.

Prevention or reduction of muscle atrophy.

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

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

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

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

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

Peripheral nerve injury

The incidence of damage to large nerve trunks in peacetime is up to 1.5% of the total number of limb injuries. Very often these injuries are not recognized by doctors in a timely manner. And the reason for this is that often simultaneous damage to a large vessel, tendons, bones, and the severity of the victim’s general condition overshadow the signs of nerve injury. But mistakes are also common due to the basic lack of necessary knowledge.

Damage to nerve trunks can be open or closed. The latter are divided into concussion, bruise and compression. The causes of such injuries are bone fractures and blunt trauma to the extremities. The severity of closed injuries to nerve trunks also varies. It can be mild in the form of hemorrhage under the epineurium and severe - complete crushing with an anatomical break in the nerve trunk. Chronic nerve injury should be mentioned. It is caused by excessive bone calluses, especially with improperly healed bone fractures, scar narrowing of the natural canals (carpal, interscalene and others) through which the nerves pass.

A special group of closed nerve injuries consists of chemical damage resulting from accidental injections of drugs into the nerve trunk. Such iatrogenic damage is the result of gross violation of injection rules. The most common victims of such errors are the radial and sciatic nerves. This damage combines two factors: the toxic effect of the drug and the force of pressure at the time of injection. The nerve trunk is damaged over a large segment.

Open nerve injuries are much more common than closed ones. They occur in cases of stab, cut, torn, chopped and bruised wounds. These include gunshot wounds. In such cases, the nerve can be destroyed not only in the wound canal, but also beyond it. He suffers from a shock wave spreading through the soft tissues away from the wound channel. In the latter case, a concussion or bruise of the nerve occurs without external violation of its integrity. This leads to a very important practical conclusion: in case of gunshot injuries to a nerve outside the wound canal, one should not rush to operate on it. 2-3 weeks after such an injury, in the case of anatomical preservation of the nerve, regression of symptoms is possible as a result of conservative treatment.

Patients may experience different sensations at the time of nerve damage. Some feel a sharp, short-term pain in the injured limb (sometimes shock occurs), others feel a dull blow or electric shock, and others do not report any additional pain.

GENERAL SIGNS OF NERVE DAMAGE

The main function of the nerve is conduction. It disappears when the nerve is completely interrupted (injured). Partial interruption or compression of the nerve leads to partial loss of its functions. Subsequently, over the course of weeks, even if the nerve is completely interrupted, the pattern of prolapse smooths out. Some of the lost functions are compensated by neighboring nerves. This phenomenon may give rise to an erroneous conclusion about the regeneration of the nerve, the restoration of its functions and the success of treatment.

With simultaneous damage to a vessel and a nerve, the characteristic signs of injury to the latter are accompanied by signs of an ischemic state of tissue: a decrease in skin temperature, cyanosis of the distal parts of the limb.

What are the main signs of nerve injury?

Movement disorders manifest themselves as flaccid peripheral paralysis of the muscles innervated by the affected nerve. The corresponding tendon reflexes are lost. An atrophic degenerative process occurs in the muscles, which is hardly noticeable during the first weeks. When examining the motor function of a wounded limb, two types of errors are possible. On the one hand, the absence of active movements when tendons, bones and joints are injured can be taken as a result of nerve damage. On the other hand, on the contrary, unrecognized nerve damage is possible due to erroneous interpretation of movements performed by synergists of denervated muscles. Such errors can be prevented based on a careful analysis of these movements, examination of sensitivity distal to the wound.

Sensory impairment with a complete break of the nerve, it is manifested by anesthesia in the zone of its innervation. The area of ​​loss of sensitivity is maximum immediately after injury. However, it soon contracts due to areas of overlap by neighboring nerves. It should be noted that the anesthesia zone is always smaller than the hypoesthesia zone. In the first, the anesthesia zone, sensitivity is provided only by the branches of the wounded nerve. It's called an "autonomous zone." For the radial nerve, for example, this is the area of ​​the anatomical snuffbox, and for the median nerve, this is the terminal phalanges of the II and III fingers.

It is known that in the composition of the nerve trunks, in addition to motor and sensory fibers, there are vegetative ones. Their damage is manifested by vascular, secretory and trophic disorders.

Vasomotor disorders observed within the same limits as sensitivity disorders. In the first hours and days after a nerve break, the denervated vessels in its zone dilate, which causes hyperemia and some regional swelling (pasty), an increase in local temperature - the “hot phase”. After 2-3 weeks, the skin of this area becomes bluish and cold - the “cold phase” begins.

Sweating disorder. In cases of complete rupture of the nerve, sweating immediately stops in the area of ​​its innervation - anhidrosis.

Trophic changes after nerve injury, they are most visible in the skin and muscles. A few weeks after the injury, the skin, having lost its elasticity, becomes thinner, its folds disappear, as mentioned above, it acquires a bluish tint. Nails become brittle and sometimes grow quickly.

Microtraumas that accompany us throughout our lives in the denervation zone lead to long-term non-healing wounds - ulcers. A decrease or absence of the sensitivity threshold leads to easily occurring and long-lasting burns. The reason for these phenomena is the absence of an adequate local vascular response of the body in response to damage.

Trophic disorders in muscles lead to their atrophy and stiffness. Tendons and their sheaths change in a similar way, and ligaments and articular cartilage suffer. All this leads to contractures and osteoporosis occurs in the bones.

When the nerve is partially damaged or compressed, say, by scars or callus, a slightly different picture is observed. Thus, movement disorders are not possible in all muscles innervated by a given nerve; paresis instead of paralysis. The changes in sensitivity are similar in this case. Instead of loss, there is irritation, which manifests itself either as paresthesia or hyperpathia. Instead of anhidrosis, hyperhidrosis is possible. With partial injury, trophic disorders are also less severe.

After a nerve is injured, all axons of its peripheral segment die - Wallerian secondary degeneration. Regenerating axons of the central segment must grow into the peripheral segment and thereby restore the anatomical integrity of the nerve. Numerous studies have established that axonal sprouting occurs at a rate of 1 millimeter per day. However, the normal restoration of the anatomy of the nerve trunk is hampered by interposition and diastasis between its ends and a scar. The regenerating axons of the central segment, having encountered an obstacle, lose the desired direction and spiral into a ball. This is how it is formed neuroma- false tumor. The latter can also occur with partial damage to the nerve, which externally retains its integrity - lateral neuroma, and in cases of bruise of the nerve or hemorrhage into it - intra-trunk.

Several weeks after injury, neuromas can be easily palpated. Percussion on it causes pain, sometimes very intense, in the area of ​​the sensitive branches of the affected nerve. During the period of nerve regeneration, percussion along its trunk causes similar sensations in the periphery of the wound site - the Hoffmann-Tinnel symptom.

Of the auxiliary methods, the most often used is studying electrical reaction affected nerves and muscles. Classical electrodiagnostics makes it possible to identify the depth and nature of nerve damage, monitor the dynamics of recovery and the effectiveness of treatment. For this purpose, alternating (faradic) and direct (galvanic) current are used. Normally, they both cause a good muscle response, both from direct irritation and when excited through a nerve. With degenerative muscle atrophy due to damage to the nerve (as well as the anterior horn of the spinal cord), its electrical excitability also changes. There are complete and partial reactions of degeneration. The first implies a loss of excitability to both currents, and the muscles react sluggishly and slowly only to the galvanic current. The partial reaction of degeneration leads to a weakened and perverted reaction of the muscles to both currents, both in direct contact with them and through the nerve.

It should be noted that a partial reaction of degeneration is not always a favorable sign. Inadequate treatment can result in a complete reaction of degeneration. At the same time, a complete degeneration reaction does not exclude the possibility of restoring nerve function. The phenomena of the rebirth reaction usually last a long time. Its gradual recovery is “lagging” in comparison with motor and sensory functions.

DAMAGE TO PLEXUS AND INDIVIDUAL NERVES

Brachial plexus injury More often it is closed due to a car accident, a fall from a motorcycle, a fracture of the collarbone, or scapula. It is possible for roots to be torn off from the spinal cord, plexus bundles to rupture, but in the vast majority of cases the traumatic factor is a massive hematoma, followed by a scar. Due to concomitant injury to the subclavian artery and vein, victims of gunshot or knife wounds to this area rarely survive.

Total damage to the plexus is possible, but usually either the two upper (C V -C VI) or two lower (C VIII -D I) roots are affected.

Damage to the upper primary trunk of the plexus (C V -C VI roots) gives the picture Upper Erb-Duchenne palsy. It is characterized by loss of function of the suprascapular, axillary and musculocutaneous nerves. The median and radial nerves are slightly affected. Soon atrophy of the muscles of the scapula, deltoid and anterior shoulder muscles appears. The victim's arm hangs like a whip, the rotation of the shoulder inward and outward is limited. Only with the help of the healthy arm the patient abducts, lifts and bends the arm at the elbow joint. Movements of the fingers and hand are preserved. Sensitivity is upset on the outer surface of the shoulder and forearm in the form of deep hypoesthesia with symptoms of hyperpathy. The bicipital reflex disappears. Blueness and swelling of the hand are often noted.

Injury to the lower primary trunk of the plexus (C VIII -D I) manifests itself Dejerine-Klumpke lower palsy. It is characterized by loss of function of the median and ulnar nerves and the corresponding muscles of the forearm and hand. There is atrophy of the anterior group of muscles of the forearm and small muscles of the hand. Bending of the hand is limited, bending of the fingers, opposition of the first and fifth fingers, as well as spreading and bringing together the fingers is impossible. Impaired sensitivity is expressed by the type of anesthesia on the ulnar side of the forearm and on the entire hand by the type of glove. Victims with lower paralysis may experience Horner's syndrome: ptosis, miosis, enophthalmos. This is a poor prognostic sign, as it is most often associated with intradural separation of the VIII cervical and I thoracic roots from the spinal cord.

Isolated lesions of the median primary trunk (C VII root) are rare.

Radial nerve arises from fibers mainly from C VII and C VIII roots, partly from C V - C VI. It is the largest of the brachial plexus nerves and is predominantly motor. In its function, it mainly provides extension of the forearm, hand and fingers. The radial nerve gives its first branches to the triceps muscle in the axillary fossa. Then it gradually gives branches to the common extensors of the fingers and hand, to the supinator, to the intrinsic extensors of the 1st, 2nd and 5th fingers, and to the abductor muscle of the 1st finger. With its superficial branch, the radial nerve provides sensation to the outer surface of the shoulder, on the radial side of the dorsum of the hand and fingers. Its autonomous zone is located in the anatomical snuffbox and on the dorsal surface of the main phalanx of the first finger.

The peculiarity of the course of the described nerve on the shoulder, which bends around it in the groove of the humerus of the same name, often causes injury to the nerve trunk during a fracture of the shoulder. The nerve may be subject to prolonged compression during drunken sleep: the Saturday night effect. It is possible that it is iatrogenic due to the negligence of the operating room staff, when a patient under anesthesia has a dangling arm that is pressed against the edge of the operating table for a long time.

For an approximate diagnosis of damage to the radial nerve, it is enough to make sure that the victim cannot straighten and abduct the first finger.

Signs of radial nerve damage can be summarized as follows:

inability to actively extend the forearm (high damage),

absence of the tricipital reflex in this case,

inability to supinate the forearm,

hanging brush,

inability to abduct the first finger,

sensitivity disorder on the outer surface of the shoulder, the back of the hand and the main phalanx of the back of the first finger.

with lower nerve damage, the first two signs will be absent.

Median nerve arises from the fibers of the roots, starting from C V to D I. On the shoulder, the nerve often anastomoses with the musculocutaneous nerve, on the forearm - with the ulnar nerve, and on the hand with the ulnar and radial nerves. It begins to divide on the forearm. Here the nerve innervates the pronator teres and quadratus muscles, all the muscles of the flexor (anterior) side of the forearm with the exception of the ulnar and medial part of the deep flexor muscles. On the hand, the median nerve provides the work of the abductor brevis and opponens muscles of the first finger, the radial head of the flexor brevis of the first finger and the lumbrical muscles of the I-II spaces, partially III. The sensory branch of the nerve begins in the forearm. It innervates the lateral part of the palmar surface of the hand and fingers I-II-III, partly IV, the skin of the rear of the terminal phalanges of the first three fingers.

Nerve function:

flexion of I-II-III fingers,

opposition of the first finger,

pronation of the forearm.

Muscle atrophy when the median nerve is injured is most clearly expressed in the tenor area. The resulting flattening of the palm and adduction of the first finger makes the hand look like a “monkey’s paw.” For an approximate diagnosis of damage to the median nerve, it is enough to identify anesthesia of the terminal phalanges of the II and III fingers.

Basic tests for nerve damage:

I-II and partially III fingers do not clench into a fist,

it is impossible to touch the tips of the fourth and fifth fingers with the flesh of the first finger (opposition),

impossibility of scratching movement with the second finger if the palm is on the table,

impossibility of rotating the first finger around another with clasped hands - “mill” test,

anesthesia of the lateral edge of the palm, the palmar surface of the I, II, III and lateral half of the IV fingers, as well as the skin of the middle and terminal phalanges of the II and III fingers on the back side, which are the autonomous zone of the nerve.

In addition to motor and sensory nerves, the median nerve contains a large number of autonomic fibers. In this regard, its damage, more often than with injury to other nerves in the arm, leads to distinct vasomotor, secretory and trophic disorders. With a partial, usually gunshot wound of the nerve, severe burning pain is possible - causalgia.

Ulnar nerve arises from fibers C VII -C VIII -D I roots. In the upper part of the forearm, branches extend from it to the flexor carpi ulnaris and to the medial heads of the flexor digitorum profundus. The nerve divides into terminal branches at the level of the pisiform bone. They supply all three muscles of the eminence of the little finger, all the interosseous muscles and two lumbrical muscles. The superficial branch of the nerve innervates the skin of the ulnar side of the palm, the palmar surface of the fifth and partially fourth fingers, sometimes also the third.

To quickly identify damage to the ulnar nerve, one can note the lack of sensitivity when compressing the terminal phalanx of the little finger.

Damage to the ulnar nerve is detected by the following methods:

with the hand lying on the table, scratching movements with the little finger are impossible,

it is impossible to move the fingers together and apart,

The IV and V fingers are only partially bent into a fist,

anesthesia of the ulnar edge of the hand, fifth and half of the fourth fingers,

ulnar abduction of the hand is impossible,

the wounded person cannot stretch a strip of paper clamped between the straightened 1st and 2nd fingers of both hands. It does not stay on the side of the affected nerve.

Later, in the contracture stage, when the ulnar nerve is damaged, the hand will acquire a characteristic appearance. The fifth, fourth and partially third fingers are extended at the metacarpophalangeal joints and bent at the interphalangeal joints, causing the hand to acquire a claw-like position. Subsequently, due to atrophy of the small muscles of the hand, especially the interosseous muscles, the interosseous spaces sharply collapse, causing the hand to take on the appearance of a “skeletal hand.”

Among the nerves of the lower extremity, the peroneal, sciatic and tibial nerves are most often affected.

Sciatic nerve formed from fibers L IV -L V and S I -S III roots. This is the thickest and longest nerve in humans. Coming out of the pelvic cavity through the greater sciatic foramen, it gives off branches to the muscles that externally rotate the femur (obturator internus and quadrate). A little lower, even in the gluteal region, branches extend from it to the muscles that extend the leg at the hip and flex it at the knee joint (semitendinosus, semimembranosus and biceps). In the popliteal fossa, and often above, the sciatic nerve is divided into two branches: the tibial and peroneal nerves.

Rarely, there is an injury to the sciatic nerve above the origin of its first branches. In this case, all the muscles of the leg are paralyzed, except for the anterior group of the thigh (quadriceps and sartorius). Sensitivity is impaired on almost the entire lower leg, with the exception of the anterior inner side of the lower leg and foot. The victims cannot lean on their legs due to paralysis of the posterior group of muscles of the thigh, lower leg and foot. They move only with the help of crutches.

If the nerve is wounded below the origin of the first branches, but above its final division, only the muscles of the leg and foot will be paralyzed. Such a patient walks without crutches, but the drooping foot forces him to lift it high when walking, making his gait “cock-like.” Of course, in both cases there is no Achilles and plantar reflex.

Vascular and trophic disorders are often pronounced. Therefore, ulcers often develop in the area of ​​​​sensitivity impairment (heel, sole). As they deepen, they can reach the bone, causing osteomyelitis. Partial injury to the sciatic nerve, especially its tibial portion, can lead to severe pain – causalgia. Burning unbearable pain is circular in nature, intensifying with physical and emotional stress. Patients strive for privacy. The slightest touch to the leg with a dry hand or clothing increases the pain. The latter subsides somewhat when the limb is wrapped in a wet rag.

Tibial nerve arises from fibers L IV -L V and S I -S III roots. Already within the popliteal fossa, it gives branches to the heads of the triceps muscle. A little lower - to three deep flexors: to the posterior tibial muscle, to the long flexor of the fingers, to the long flexor of the first finger. At the level of the medial malleolus, the nerve divides into two terminal plantar branches. They innervate the adductor and abductor muscles of the first finger, the short flexor of the fingers, the short flexor of the first finger, the lumbrical muscles, the quadratus plantae muscle, the abductor muscle of the fifth finger and its flexor. When the nerve is damaged, plantar flexion of the foot and fingers is lost, which, due to paralysis of the interosseous muscles, occupy the so-called claw-like position, i.e. extended at the metatarsophalangeal joints and flexed at the interphalangeal joints. The extended position of the foot gives it a heel position.

The cutaneous branches of the nerve innervate the posterior and posterior outer surface of the leg, the plantar surface of the foot and toes, and the outer edge of the foot. For quick orientation of the tibial nerve lesion, sensitivity on the plantar surface of the foot is examined.

The main signs of damage to the tibial nerve:

inability to plantar flex the foot and toes,

inability to walk on toes,

inability to raise your heels in a sitting position, resting on your toes,

inability to adduct the foot,

lack of Achilles reflex,

disorder of skin sensitivity on the plantar surface of the foot and toes.

As mentioned above, the tibial nerve contains a large number of autonomic fibers; therefore, its wound is often accompanied by severe trophic disorders in the form of ulcers after injuries in the anesthesia zone. Partial damage to the nerve often causes extremely intense pain, similar to causalgia.

Peroneal nerve formed from fibers L IV, L V, S I and partially S II roots. Coming from the lateral sections of the popliteal fossa, it bends around the head of the fibula and, heading towards the anterior surface of the tibia, almost immediately crumbles into branches. The peroneal nerve innervates: the peroneus longus and brevis, the tibialis anterior, the extensor digitorum longus and brevis, and similar extensors of the first finger.

The zone of sensitivity impairment occupies the anterior outer surface of the lower third of the leg on the back of the foot and fingers. They are quite changeable. To quickly identify lesions of the peroneal nerve, sensitivity is examined on the back of the foot and fingers, especially in the first interdigital space.

The main signs of damage to the peroneal nerve:

in a supine or sitting position, the victim cannot straighten the foot (dorsiflexion),

abduct and lift the outer edge of the foot,

stand on your heels

walk on your heels

sensitivity disorder on the outer anterior surface of the leg, dorsum of the foot and fingers.

Treatment of victims with damage to peripheral nerves is most rational in the neurosurgical department. These benefits are based on:

accurate diagnostics, including hardware diagnostics (electrodiagnostics),

performing reconstructive operations on nerves using microsurgical techniques (instruments, operating optics),

rational restorative treatment both before and after nerve surgery.

It is obvious that a neurosurgeon, having experience in treating nerve injuries, will perform this operation more successfully than a district surgeon or traumatologist, who only rarely encounters such pathology and do not have the necessary diagnostic and operating equipment and microsurgical equipment.

First aid in case of nerve injury, it is limited to the application of an aseptic dressing and immobilization of the limb. Approximate diagnosis (see above) before surgical treatment of the wound allows you to identify or suspect nerve damage.

Primary surgical treatment of the wound in the nearest surgical department where the patient will be taken, consists of its revision, removal of foreign bodies, stopping bleeding, repositioning fragments of broken bones, sutures of muscles and tendons, and so on. It is better to leave the ends of the damaged nerve, even if they were found, unsutured, since its suture is successful only using microsurgical techniques. An attempt to suture the nerve during primary surgical treatment in a district hospital is most often unsuccessful. Moreover, the nerve is often mistakenly sutured to the tendon or the suture is rough and incompetent (lack of surgical optics). The trouble is that the final results of such an operation can only be assessed after weeks and months; it is clear that the time lost in such cases only aggravates the surgeon’s mistake. In such a situation, it is much more rational to leave the nerve unsutured and inform the patient about this. Immediately after the wound has healed, he should be referred to an appointment with a neurosurgeon, who, in a neurosurgical operating room, will apply a delayed suture to the nerve. Summarizing the extensive experience of nerve suture errors during primary surgical treatment of a wound, the IV Congress of Neurosurgeons of the country (1988) recommended the widespread practice of delayed nerve sutures.

So, delayed nerve sutures may be early, if they are done in the first 3-4 weeks after injury or late– 3-4 months after injury. Rarely do they resort to later suture of the nerve, but this is done according to individual indications. Let’s say that the patient has been persistently treated for more than 4 months, including massage of the affected (denervated) muscles and they have not yet died. In this case, an attempt to suture the nerve is possible.

Operation - nerve suture consists of isolating its central and peripheral ends from scars. Then it is carried out electrodiagnostics on the operating table. Stimulation of the peripheral end of the nerve causes corresponding movements. Electrical stimulation of the central segment does not cause muscle contractions. This is followed by economical excision of the central neuroma and refreshment of the peripheral ends. Then 3-4 epineural sutures are applied. The edges of the nerve should be in slight contact. But this is not always easy to do. To facilitate the convergence of the ends of the nerve, it is often necessary to bend (or straighten) the limb at the joints and certainly fix it in this position for 2-3 weeks. A successful operation is possible only with the use of surgical optics. The latter led to the wide spread, at one time, of perineural sutures of individual nerve bundles instead of epineural ones. But such an operation is complex, time-consuming, and not without its drawbacks. The accumulated clinical experience has made it possible to verify that the perineural suture has no obvious advantages over the epineural suture, if the latter is carefully performed using the same operating optics.

Nerve damage (neuropathy) is an injury to the nerve trunk caused by compression, stretching, or complete interruption. Cells of nerve tissue damaged by fiber trauma regenerate very poorly, and in the case of a complete or partial break in the distal (terminal) part of the nerve, a process called Wallerian degeneration develops, in which the nerve tissue is replaced with scar connective tissue.

In this regard, it is quite difficult to predict the outcome of treatment, even if the therapy is carried out by an experienced, qualified doctor. Unfortunately, in practice, mistakes are often made when diagnosing, choosing treatment tactics or techniques for restoring the nerve trunk.

Reasons for the development of pathology

Damage to single nerves and nerve plexuses can be caused by various injuries, which may be caused by:

• natural disaster;
• accident during sports, at home or at work;
• hostilities.

In most cases, they occur in young and middle-aged people. Nerve damage often causes long-term disability and may require a change in occupation and cause disability.

Damage to several peripheral nerves at the same time is caused mainly by diseases, including:

• diabetes;
• chronic kidney disease;
• long-term vitamin deficiencies;
• dysfunction of the immune system;
• lack of certain microelements.

Classification of nerve trunk injuries

There are several types of neuropathies depending on the severity of damage to the nerve trunk:

1. Neuropraxia (according to Doynikov's classification, nerve concussion) is a temporary loss of nerve fiber conductivity as a result of its slight damage. In this case, changes occur only within the myelin sheath; they cause impairment of motor functions and a slight loss of sensitivity in the area innervated by the damaged fiber. All functions are restored within 10-14 days.
2. Contusion or bruise of a nerve is a more serious injury in which the continuity of the nerve is preserved, but there may be small tears in the epineural sheath and minor hemorrhages in its tissue. With adequate therapy, functional features are restored within 30-40 days.
3. Axonotmesis - develops as a result of prolonged compression or stretching of the nerve trunk. Its continuity is maintained, but signs of Wallerian degeneration appear below the site of damage. Clinical manifestations and treatment tactics depend on the duration and severity of the effect on the nerve.
4. Partial damage (incomplete rupture) is manifested by loss of certain functions and impaired sensitivity. It does not go away spontaneously; such damage often requires surgical intervention.
5. Neurotmesis (complete interruption of the nerve trunk) requires surgical intervention. In most cases, even with adequate therapy started on time, the middle section of the nerve (the site of damage) is replaced by scar tissue, which causes persistent dysfunction and disability of the person.

Depending on the number of damaged nerve trunks, mononeuropathy (damage to one nerve) and polyneuropathy (multiple damage) are distinguished.

In addition to the classifications described above, all nerve injuries can be divided into:

1. Closed - without damaging the integrity of the skin, the reason for their development is compression of soft tissues by a foreign body, neoplasm, bone fragments during fractures or its end during dislocations; and trauma with a blunt object. Most often, closed injuries are incomplete.
2. Open - occur as a result of cut, stab and gunshot wounds. Often this is a complete break in the nerve.

Symptoms of the disease

The clinical manifestations of the disease depend on how much time has passed since the injury. With partial or complete damage to the nerve, and sometimes with its compression, the process of Wallerian degeneration occurs, which has its own characteristics of the course.

In essence, Wallerian degeneration is a process of decomposition of nerve tissue that begins immediately after injury; it cannot be avoided even with urgent surgical intervention. Regeneration begins 3-5 weeks after surgery, provided that the bundles of nerve fibers are accurately aligned.

Acute period of the disease

Lasts from the moment of injury to 3 weeks after it; during this period, first of all, it is necessary to pay attention to post-traumatic shock, the amount of blood loss, and possible secondary infection of the wound. Clinically, in the acute period, nerve damage is manifested by impaired sensitivity and motor function.

For open injuries that require surgical intervention, it is advisable to perform the operation 1-2 days after the injury, so that the best results of subsequent recovery can be achieved. In this case, it is necessary to have trained personnel, materials for surgical treatment, and the patient’s condition must be stable without complications from the wound and general well-being.

Remote period

The long-term period begins from the fourth week after the injury and can last more than a year. It is more expedient to divide it into early long-term (up to 4 months from the moment of injury), intermediate (up to a year) and late (over 12 months). Carrying out reconstructive treatment in the late long-term period is impractical, since it is characterized by the development of irreversible changes.

Clinical manifestations of damage to various nerves

The symptoms of the pathology depend on which nerve trunk is damaged:

1. The long thoracic nerve can be damaged by pulling or pressure on the shoulders from the straps of a heavy backpack (bag). Sensitivity is not impaired; when raising the arms forward, the edge of the scapula rises.
2. The axillary and subscapular nerves are injured when the shoulder joint is dislocated or the surgical neck of the humerus is fractured. Damage to the axillary nerve is manifested by impaired sensitivity of the upper shoulder and dysfunction (impossibility of abduction and rotation of the arm). With a subscapularis injury, sensitivity is not impaired, but paresis of the infraspinatus and supraspinatus muscles develops.
3. Damage to the radial nerve most often develops with closed fractures and gunshot wounds of the shoulder. With an injury in the area of ​​the upper third of the shoulder, there is a loss of sensitivity on the back surface of the shoulder, there is no extension of the forearm and a tendon reflex. With injuries in the area of ​​the lower two-thirds, loss of sensitivity in the back of the forearm and half of the hand may develop, as well as impaired extension and adduction of the hand and fingers.
4. Damage to the median nerve can be caused by injuries to the wrist and forearm, as well as compression of the nerve in the carpal tunnel. With compression, carpal tunnel syndrome develops, manifested by the appearance of swelling and sharp pain in this area; after cutting the transverse carpal ligament, functional features are restored. With injuries, the clinical picture depends on the location of the injury and can range from a violation of the opposition of the thumb to the “monkey's paw” syndrome with severe burning pain.
5. Damage to the ulnar nerve leads to the development of disturbances in the motor activity of the fingers and the disappearance of sensitivity in the skin of the hand.
6. When the pelvis or femur is fractured, injury to the femoral nerve may occur, which is manifested by the inability to straighten the leg, the disappearance of the knee reflex and skin sensitivity in the area of ​​the anterior surface of the leg and thigh.
7. Clinical manifestations of damage to the sciatic nerve combine the symptoms of damage to the small and tibial nerves.
8. Injury to the peroneal nerve is manifested by sagging of the foot, the inability to turn and flex, and lack of skin sensitivity in the area of ​​the anterior surface of the leg and the dorsum of the foot.
9. Damage to the tibial nerve is characterized by a lack of flexion and adduction of the foot and toes, loss of sensation on the sole and back of the leg.

Symptoms of polyneuropathies

Clinical manifestations of polyneuropathies depend on the severity and number of damaged nerve fibers. They can be mild and go away on their own or be complex and require surgery.

Guillain-Barré syndrome or acute polyradiculitis

The disease is caused by a disorder of the functioning of the immune system, in which the body produces antibodies that destroy the myelin sheath of its own nerve fibers. This disease manifests itself as an ascending weakening of the muscles, which can lead to the inability to eat and breathe. The development of such a pathology requires immediate hospitalization of the patient.

Methods for diagnosing nerve damage

In the diagnosis of neuropathies, specialists use questioning, examination, palpation, sensitivity testing and electrophysiological methods.

Questioning, inspection and palpation

During the interview, the time, mechanism and circumstances of the injury are clarified, and it is determined whether first aid was provided and to what extent. The patient’s subjective sensations are determined (presence of pain, unusual sensations, discomfort). During the examination, the doctor determines the objective picture of the disease. Palpation allows you to determine the temperature and firmness of the skin, their elasticity and moisture.

Sensitivity testing methods

When conducting research, the patient needs to close his eyes and distract himself from external stimuli. To assess changes in sensitivity, the doctor performs tests on symmetrical surfaces. Such tests include:

• studying tactile sensitivity by touching a brush or cotton wool;
• pain sensitivity is determined by pricking with a needle;
• temperature - by touching test tubes with hot and cold liquid;
• when examining the feeling of the location of the irritation, the patient must accurately indicate the site of the needle injection;
• the sense of one-dimensional images is determined using Weber’s method using a compass;
• when determining the sense of two-dimensional images, the patient must name which letter or figure the doctor depicted on his skin;
• to determine the joint-muscular feeling, the limb is bent at the joint, the patient must name the pose of the limb without visual control;
• stereognosis - the patient must determine with his eyes closed what object the doctor has placed in his palm.

Electrophysiological diagnostic techniques

There are two electrophysiological techniques:

1. Classical electrodiagnostics is the study of the reaction of a damaged nerve to exposure to direct and alternating electric current. The excitability threshold is determined on the diseased and healthy limbs.
2. Electromyography is a study of the electrical potentials of muscle fibers at rest and during voluntary and involuntary movements that are caused by artificial stimulation.

Basic methods of treating pathology

Treatment of neuropathies is carried out by a traumatologist, neurosurgeon and neurologist; it must be comprehensive and may include surgical and conservative methods, depending on the chosen tactics. After the necessary surgical intervention, conservative treatment is prescribed.

Conservative treatment of the disease

In any case, treatment of the pathology begins with immobilization of the injured limb. In case of arm injuries, it prevents it from sagging and the development of overstretched muscles, blood vessels and nerves. In case of lower limb injuries, it fixes them in the most advantageous position.

Drug therapy

Consists in prescribing the following drugs:

• vitamin B2;
• dibazole;
• a nicotinic acid;
• galantamine.

Additional treatments

In addition to drug therapy, the following are used:

• physiotherapeutic methods of treatment - electrical stimulation of muscles, electrophoresis of novocaine, calcium and lidase, UHF, ozokerite and paraffin applications;
• massage;
• a set of therapeutic gymnastics exercises;
• Spa treatment.

Surgical methods of treatment

Indications for surgical intervention are the presence of movement disorders, loss of sensitivity and the development of trophic disorders in the area of ​​innervation of the damaged nerve.