Nerve Injuries Hand

Nerves are the "electrical wiring" system of the body that carries messages between the brain and the rest of the body.

Nerve Injuries Hand

Nerves are the "electrical wiring" system of the body that carries messages between the brain and the rest of the body. There are two types of nerves- motor and sensory nerves. Motor nerves carry messages between the brain and muscles to make the body move. Sensory nerves carry messages between the brain and different parts of the body to signal pain, touchand temperature.

The nerves can malfunction if compressed, stretchedor injured.

When the nerve is compressed or stretched, outer cover of the nerve remains intact, but the ability of the nerve to send and receive signals from various parts of the body is compromised.If this compression is unrelieved, it can cause permanent damage to the nerve.

When the nerve is cut or injured, fascicles within the nerve and its outer cover both are damaged with partial or complete loss of motor power and sensory input from the area of the distribution of nerve. If the nerve is not repaired, the growing nerve fibers may form a painful nerve scar, or neuroma at the cut ends.

Think of nerve as an electric wire And injury to nerve as a cut electric wire.The cut ends of the electric wire should be brought and glued together so that the electricity can travel through the wire uninterrupted and reach its destination like fan, tube light. Similarly, cut ends of the nerve should be brought together surgically and sutured under microscope with very fine sutures so that signals from the brain can reach to different parts of the body.

But there is a big difference!!! There is immediate flow of electricity through the repaired wire in contrast to the nerve repair which takes a much longer time. Nerve fibers typically begin to regrow about three or four weeks after surgery.The nerve grows at a constant speed of one inch per month after it is repaired. So, the results of nerve repair can take months to a year to appear. During the process of recovery, feeling of pins and needles in area of distribution of the nerve is common. While this can be uncomfortable, it usually passes and is a sign of recovering nerve.

Timing of Nerve Repair

After nerve repair, new fibers grow beneath the covering layer until it reaches a muscle or sensory receptor.The nerve fibers should reach the target muscle within 18 months of the injury otherwise the muscle receptor degenerates. For this reason, repair should be done as early as possible after injury to allow maximum time periodfor growth of the nerve.

The sensory receptor does not degenerate, therefore, sensory nerve repair can be done anytime or years after the injury also.

Management of Nerve Injury

If the nerve is compressed or stretched, removal of the offending structure or situation will help in spontaneous healing and recovery of the nerve.
If the nerve is cut and wound is clean, covering around both the cut ends of the injured nerve is sewn together. The goal in repairing the nerve is to suture the covering layer with minute sutures so that new fibers can grow forward across the injured site towards its target organ and the nerve can work again.

Nerve repair with realignment of bundles.

If a nerve is cut and wound is dirty or crushed, surgery may be delayed until the skin has healed.
If there is a space between the ends of the nerve, it may be necessary to take a piece of nerve (nerve graft) from another part of the body to repair the injured nerve.
The results of nerve repair depends on a number of factors like age of the patient, presence of other diseases and the level of injury etc.
Nerve fibers typically begin to regrow about three or four weeks after surgery. During this time, patients must wear a splint to prevent the repaired nerve from stretching apart.
Physiotherapy is must after nerve repair to keep the joints supple
Care must be taken to prevent oneself from burn or other injuries till the sensation returns back in cases of sensory nerve repair.

Nerve Injuries Hand

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Median Nerve Injuries

There are three main nerves in the arm: the median, the ulnar and the radial. Median nerve is one of the major nerves of forearm and hand. It originates from brachial plexus in the arm pit. This nerve provides sensation to the thumb, index, and middle fingers, and to half of the ring finger. The small finger (the "pinky") is typically not affected. This nerve is also responsible for the major movements of the thumb.

If median nerve is injured or cut, muscles of hand (base of thumb) atrophy.

He or she would not be able to bring out thumb in perpendicular direction to the palm when hand is placed flat on the table.
Loss of ability of thumb to touch tips of other fingers.
Loss of coarse movements of the hand with
Complete loss of sensation over the thumb, index, middle and half of ring finger.
Tinel's sign will be positive– Tapping on the site of injurywill elicit tingling and pain sensation in the thumb, index finger and middle finger
To confirm the diagnosis- Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG)of the affected hand is done.

Such condition is usually seen in injuries of the median nerve or in patients with leprosy or in long standing compression of the median nerve.

Treatment of Median Nerve Injuries

If the median nerve is damaged or cut, then surgical excision of the damaged part and nerve repair or grafting if required should be done as early as possible or within 1 year of the injuryfor best results.
If the patient has presented with sudden onset of paralysis of median nerve, then other neurological causes or leprosy should be investigated for.In many such cases, a nerve and muscle biopsy is taken to confirm the diagnosis of neurological disease or leprosy
If the patient presents with gradual paralysis of median nerve, then median nerve compression -carpal tunnel syndrome, Anterior interosseus nerve syndrome should be thought ofand managed accordingly.
If the patient has presented late beyond the timing suitable for nerve repair (after 1 year of the accident) or in cases where nerve is damaged beyond repair, then tendon transfers should be done to strengthen the weak portions of the hand along with the nerve repair and grafting (only if feasible). A strong functioning tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

During tendon transfers for median nerve palsy, one functioning tendon from the front of the hand is taken, re-routed and sutured to the tendon of the outer aspect of the thumb so that the patient can abduct (bring out thumb) and also make a meaningful pinch with the other fingers. This would enable him or her to hold objects with the thumb and fingers (OPPONENSPLASTY)

The surgery is usually done under brachial block or general anaesthesia and a splint or slab is given for immobilization in the post operative period. The patient is usually discharged second day after the surgery. Sutures are removed 14 days after surgery.

Splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred tendon is started so that it may regain its newly assigned function.

Radial Nerve Injury

The radial nerve is one of three nerves in your forearm, traveling from the side of your neck, down the back of your arm, through your forearm and into your hand. Your radial nerve is responsible for a lot of different arm movements, including forearm rotation, elbow straightening, and wrist and finger movements. It also supplies sensationto half of the back of the hand on side of the thumb.

If the patient has radial nerve injury, then it can lead to radial nerve palsy with-

Atrophy of the muscles of back of forearm.
He or she would be having permanent wrist, finger and thumb drop. Which means unable to straighten or extend the wrist, fingers and the thumb.
Loss of sensation on half of the back of hand
Tinel's sign will be positive– Tapping on the site of injurywill elicit tingling and pain sensation in the back of hand.
To confirm the diagnosis- Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG)of the affected hand is done

Such condition of wrist drop and finger, thumb drop (inability to extend the wrist, thumb and fingers) is usually seen in injuries of the radial nerve after accidents or fractures of humerus (bone of the arm) orin long standing compression of the radial nerves due to tumors or other reasons.

Treatment of Radial Nerve Injuries

If the radial nerve is found damaged or cut, then surgical excision of the damaged part and nerve repair or grafting should be done as early as possible or within 1 year of the injuryfor best results.
2. If the patient has presented with sudden onset of paralysis of radial nerve, then other neurological causes or any nerve tumor should be investigated for.
3. If the patient presents with gradual paralysis of radial nerve, then radial nerve compression -radial tunnel syndrome, Posterior interosseus nerve syndrome should be thought ofand managed accordingly.
If the patient has presented late beyond the timing suitable for nerve repair (after 1 year of accident), or in cases where nerve is damaged beyond repair, then tendon transfers should be done to strengthen the weak portions of the hand. A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

During tendon transfers for radial nerve palsy, 3 functioning tendons from the front of the forearm and hand are taken, re-routed and sutured to the tendons of the back of the forearm and hand so that the patient can extend his wrist, fingers and thumb. The surgery is usually done under brachial block or general anaesthesia and a splint or slab is given for immobilization in the post operative period. The patient is usually discharged second day after the surgery. Sutures are removed 14 days after surgery.

Splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred muscles or tendons is started so that they regain their newly assigned function.

Ulnar Nerve Injuries

The ulnar nerve goes from neck down to your arm, forearm and to your hand. Ulnar nerve provides sensation to the small finger and half of the ring finger and control fine movements of the fingers. This is a very important nerve of the hand as it is responsible for hand grip strength and stability.

If the patient has ulnar nerve injury

Small muscles of hand are paralysed
He or she would not be able to bring the fingers together or separate them
He or she would be having permanent curling of little and ring finger (inability to extend or straighten fingers at the middle and distal finger joints)-ULNAR CLAW HAND.
Flat appearance of the palm
Hollowed out appearance of the palm and back of hand
Loss of fine movements of the hand
Complete loss of sensation over the little and the ring finger.
Tinel's sign will be positive– Tapping on the site of injury will elicit tingling and pain sensation in the little and ring finger.
To confirm the diagnosis- Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG) of the affected hand is done

Such condition is usually seen in injuries of the ulnar nerve or in patients with leprosy or with long standing compression of the ulnar nerve.

Treatment of Ulnar nerve Injures

If the ulnar nerve is damaged or cut, then surgical excision of the damaged part and nerve repair/grafting should be done As early as possible or within 1 year of the injury for best results.
If the patient has presented with sudden onset of paralysis of ulnar nerve, then other neurological causes or leprosy should be investigated for. In many of such cases, release of cubital tunnel with anterior transposition of the nerve is done and a biopsy of the nerve fascicle and muscle is taken to confirm the diagnosis of neurological disease or leprosy.
If the patient presents with gradual paralysis of ulnar nerve, then ulnar nerve compression -cubital tunnel syndrome, Guyon's tunnel compression syndrome should be thought of and managed accordingly.
If the patient has presented late beyond the timing suitable for nerve repair (after 1 year of the accident) or in cases where nerve is damaged beyond repair, then tendon transfers should be done to strengthen the weak portions of the hand along with the nerve repair and grafting (only if feasible). A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

During tendon transfers for ulnar nerve palsy, 2 functioning tendons from the front of the forearm and hand are taken, re-routed and sutured to the tendons of the side of the fingers so that the patient can extend his or her fingers at their finger joints. This tendon transfer also enables a meaningful side pinch of the thumb.

Splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred muscles or tendons is started so that they regain their newly assigned function.

Digital Nerve Injury

Digital nerves are nerves of the fingers that travel from the palm to the tips of the fingers and thumb. Each finger and thumb has 2 digital nerves running on the sides of the finger. They are responsible to provide sensation of pain, touch, temperature and pressure of their respective sides of the finger.

They can be commonly damaged by accidental injuries and less commonly by pressure or stretching. Injury to digital nerve stops the transmission of signals to and from the brain resulting in loss of sensation in the fingers.

Digital nerve injuries can be partial or complete. Repair is routinely recommended for complete injuries (completely cut nerve fibers). Injuries that only bruise the nerve or are partial, typically heal on their own in few weeks.

Because it is sometimes difficult to determine the extent of the injury, it's important to consult a qualified hand surgeon for assessment and treatment. Nerve repair after digital nerve injuries is important. If repair is not done, the sensory loss can leave the finger more prone to injuries and burns.

Treatment of Digital nerve Injuries

Since the sensory receptor does not degenerate, therefore, sensory nerve repair can be done anytime or years after the injury also. Digital nerve repair is a microsurgical procedure to reconnect the severed ends of a digital nerve in the finger or hand under the microscope. In few cases where end to end repair is not possible, a suitable nerve graft is harvested from the back of the wrist or from the leg and nerve is repaired with nerve grafting.

Nerve fibers typically begin to regrow about three or four weeks after surgery. During this time, patients must wear a splint to prevent the repaired nerve from stretching apart. Patients usually feel pins and needles in the fingertips, which is a sign that the nerve is healing. Nerve growth is gradual, and it can take as long as few months before sensation returns to the fingertips.

Nerve Injuries Hand

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Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.

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