Traumatic

peripheral nerve injury

(TPNI)

Dr. Moataz M. El Semary

Associate Professor of Physical Therapy
and Health Rehabilitation, CAMS, Jouf
Univ.
Nerve structure
Nerve structure
 Nerve structure

VESSELS

ENDONEURIUM
PERINEURIUM

EPINEURIUM
• An individual nerve fibre is enclosed in a collagen
connective tissue known as endoneurium.
•A bundle of such nerve fibres are further rebound
together by fibrous tissue to form a fasciculus. The
binding fibrous tissue is known as perineurium.
•A number of fasciculi are bound together by a fibrous
tissue sheath known as epineurium.
•An individual nerve, therefore, is a bundle of a number
of fasciculi.
 Neuropraxia
a. Describes mild nerve stretch or contusion
b. A focal conduction block exists.
c.Breakdown of the axon distal to the site of
injury (Wallerian degeneration) does not occur.
d. The myelin sheath is disrupted by temporary demyelination.
e. The epineurium, perineurium, and endoneurium
layers remain intact.
f. Prognosis is favorable, and recovery is expected
within 6 to 8 weeks.
 Axonotmesis
a.Describes a more severe but incomplete nerve injury,
regardless of the mechanism.
b.A focal conduction block exists, including loss of distal
sensory and motor nerve function.
c. Wallerian degeneration occurs
d. Axons are disrupted, but the endoneurium, perineurium,
and epineurium layers remain intact.
e. Prognosis is less favorable than neurapraxia, and
recovery is unpredictable.
f. Axon regrowth occurs at 1 to 2 mm per day.
g. Distal fibrillation potentials and sharp waves.
Rehabilitation
1- Passive movement for the joints which are
normally moved by the paralyzed muscles.
2- E.S for weak muscles followed by graduated
active exercises
3- Splints if needed.
4- Sensory reeducation
5- Advices to avoid injury to desensitized area.
 Neurotmesis

a. Describes a complete nerve injury (avulsion, transection).

b. A focal conduction block exists.
c. Wallerian degeneration occurs.
d. All layers, including the endoneurium, are disrupted.
e. The proximal nerve end forms a neuroma.
f. The distal nerve end forms a glioma.
g. Neurotmesis has the worst prognosis, and recovery is
always limited and incomplete despite the best possible
treatment.
Fate and rehabilitation

Wallerian degeneration 1 mm per day.

Nerve regeneration

As regeneration begins, the axonal stump from the proximal

segment begins to grow distally. If the endoneural tube with its
contained Schwann cells is intact, the axonal sprout may readily
pass along its primary course and reinnervate the end-organ. The
rate of recovery of axon is 1 mm per day.
Clinical Signs

Motor function,
Tinel’s sign ,
Sensory function.
Causes of nerve injury:
•direct injury – cut, laceration.
• infections – leprosy.
•mechanical injury – compression, traction, friction and
shock wave.
• cooling and freezing – ‘frost bite’.
• thermal injury.
• electrical injury – electric shock.
• Ischaemic injury–Volkmann's ischaemia.
•toxic agents – injection tetracycline resulting in radial
nerve palsy.
• radiation – for cancer treatment.
Type of injury?

•low energy injuries >> neurapraxia.

•high-energy injuries and open wounds>> axonotmesis or
neurotmesis.
•In doubtful cases, one may have to wait a few weeks to see if
signs of recovery appear, which would exclude complete nerve
division.
• Muscles supplied by the nerve should be tested repeatedly.
• With open wounds early exploration is the best policy.
Clinical findings

a) Which nerve is affected?

b) At what level is the nerve affected?
c) What is the cause?
d)What type of nerve injury (neurapraxia etc.) is it likely
to be?
e) In case of an old injury, is the nerve recovering?
Peripheral nerve injury
Dermotome : is an area of skin supplied by a single spinal
root.
Myotome : Represents a muscle unit supplied by a single
spinal root.
Simple screening tests
Ulnar nerve injury :
Loss of pain at tip of the little finger.
Medial nerve injury :
Loss of pain at tip of index finger.
Radial nerve injury :
Inability to extend thumb.
Nerve by site and mechanism
Attitudes & deformities
• Wrist drop >> radial nerve
• Foot drop >> common peroneal
• Winging of scapula >> long thoracic nerve
• Claw hand >> ulnar nerve
• Ape thump >> median nerve
• Pointing index >> median (prox. to elbow)
• erb’s >> upper brachial plexus (C5,6)
• Klumpke’s >> C8-T1.
Muscle atrophy
start : post-injury 1 month
peak : 3rd - 4th month
Muscle wasting
Clinical examples
Carpal Tunnel Syndrome

PAIN & PARASTHESIA

DISTRIBUSION
PREGNANCY TYPE WRITING
SUPRA-CONDYLAR FRACTURE
anterior displacement
Median nerve injury
RADIAL NERVE INJURY
Fracture of shaft of humrus
RADIAL NERVE INJURY
WRIST DROP
Claw Hand Deformities
Ulnar nerve lesion
GUYON’S CANNAL SYNDROME
Ulnar Nerve
CUBITAL TUNNEL SYNDROME
Ulnar Nerve
FROMENT’S SIGN Flexior pollicus longus (median nerve) compensates for a weak
addcutor pollicis (ulnar nerve ).
 Sciatic nerve injury

Posterior dislocation of the hip.

deep I.M injections.
# shaft femur.
Penetrating injury and gunshot injury.
COMMON PERONEAL
Fracture of the head of fibula
PERONEAL NERVE INJURY SYMPTOMS
Decreased sensation, Slapping gait, foot drop, toes drag.
Principles of management
Closed injury:-
low energy >> conservative.
high energy >> explore.
Open injury >> explore.
Neurotmesis >> nerve repair.
Large segment >> nerve graft (sural).
No recovery within 18-24 mnths, >> consider tendon transfer
(e.g. radial nerve).
 Conservative treatment
Indications
Short history, mild-moderate, intermittent, reversible causes
(pregnancy, oral contraceptive, endocrine abnormalities, type-
writer)
Method
Non-steroidal anti-inflammatory drugs, splint.
• Preserve mobility of the joints.
• Care of the skin and nails.
• Relief of pain.
Signs of recovery
•Tinel's sign: On gently tapping over the nerve along its
course, from distal to proximal, a pins and needle sensation is
felt in the area of the skin supplied by the nerve. A distal
progression of the level at which this occurs, suggests
regeneration.
•Motor examination: The muscles begin to contract from
proximal to distal as they are reinnervated one after another
(motor march).
•Electrodiagnostic test: This can help in predicting nerve
recovery even before it is apparent clinically.
Principles of management
Closed injury:-
low energy >> conservative
high energy >> explore
Open injury >> explore
Neurotmesis >> nerve repair
Large segment >> nerve graft (sural)
No recovery within 18-24 months, >> consider tendon transfer
(e.g. radial nerve).
 Treatment

Time of operation
Open injury Closed injury
Early intervention Delayed intervention
Delayed intervention
 Surgical Indications

• Failed conservative treatment.

• Severe injury (sensory loss, muscle atrophy,
motor weakness).
 Nerve repair

Epineural suture

Perineural suture

Epi-perineural suture

Nerve grafting
(sural nerve commonly)
The following are time estimations for rehabilitation
after nerve repair:
° zero to three weeks to protect repair in plaster and or splint.
Education undertaken.
° Three weeks to three months to prevent secondary deformity
with joint mobilization and splintage at nightime.
° Three months to 12 months to look for signs of early
protective sensory return and to start sensory re-education.
° Three months to six months to look for signs of motor return
and work at muscle strengthening.
Rehabilitation
Pain control.
Splint (Avoid pressure sores).
Nerve and muscle stimulation.
Nearby joints range of motion.
Months ----- years.
Pain management
Pain is one of the most common and annoying consequences of
nerve damage.
This pain management is an interdisciplinary approach centered
by pharmacological treatments. New treatment strategies for
neuropathic pain are mainly invented considering the changes in
central nervous system. Anticonvulsants and tri-cyclic anti
depressants are the most popular drugs for neuropathic pain.
Complete relief is very difficult and only 40-60% of patients
achieves partial relief. Other modalities which have some role in
neuropathic pain management are yoga, massage, meditation,
cognitive exercise, acupuncture and Transcutaneous electrical
nerve stimulation (TENS).
Topical agents such as lidocaine patches and
capsaicin may be useful.

TENS method (20 min)

-Mild electrical impulses are transmitted through the skin
-Cause body to release endorphins, the body’s own pain-
relieving hormones.
-These 'positive signals' to the brain block the slower-
moving pain messages.

Continuous Ultrasound : for proximal affection.(5 min)

Deep cold laser (Infra red laser)(3min)

Interferntial current.
Sensation deficit and relearning

Body image, objects’ shape and texture recognition and avoiding

hazardous objects are the principles roles of an intact sensation.
Sensory stimuli also send a feedback to motor system for proper
adjustment in function. Contra-lateral somatosensory cortex play
as a central processing unit for almost all of these functions.
Following a peripheral nerve injury one or all of above
mentioned functions may be impaired based on the severity of
insult. Complete injury of a major nerve or its sensory part turns
off related contra-lateral somatosensory cortex until reinnervation
or repair is occurred.
Sensation deficit and relearning

In this scene all of principle sensory functions are being impaired.

If reinnervation occurs in a disorganized pattern the sensory
cortex faced a new pattern of input which is usually unknown.
This is the basis of sensory rehabilitation or re-familiarization even
with a successful surgical nerve repair.
Shape and texture relearning with open eye and stimulating deep
receptor by rough objects are helpful methods of proper
reorganization.
Sensation deficit and relearning
Sensation deficit and relearning

Large nerves injury such as sciatic in lower

extremities’ nerve and also more widespread nerve lesions
such as neuropathies have a profound effect on all sensation
and motor related functions but proprioception is one of
the most important one.
- Standing on a balance board is often used to retrain or
increase proprioception abilities, particularly as physical
therapy for ankle, knee and its nerve injuries.
Sensation deficit and relearning

- Advanced balance abilities which are used usually for

athletes following nerve repair could be achieved by Yoga,
and Tai-chi .
- There are even specific devices designed for
proprioception training, such as the exercise ball.
Sensory re education :
A- Protection of desensitized area to avoid burn &
injuries.
B-Brushing skin with different materials as :cotton
–silk ….
C- Occluded vision : ask to recognize different
objects ( sharp – smooth ).
D- Occluded vision : ask to recognize nature of
material by touch.
Muscle weakness

Several methods are proposed for functional recovery and prevent

muscle wasting.
One of them is electrical stimulation which has a great
controversy regarding beneficial effects in nerve regrowth or
diminish the speed and accuracy of reinnervation.

Overall, there is very little supportive data in humans to support

the widespread use of electrical stimulation of denervated
muscles. The patient must become actively involved in the
treatment program.
Another modality, is low level laser therapy or phototherapy
which has promising effects in nerve re-growth.
Splints

Static and detachable splints are useful mechanical devices to

give rest to the paralyzed muscles and joints, preventing
overstretching and shortening and to allow exercises and other
therapeutic methods to be given regularly for preventing
complications of continued immobilization.
Joint stiffness
The insensitive joints and ligaments and other surrounding
tissues which are affected by the injury to all or some supplying
nerves are at the risk of stiffness, shortening and finally
contracture.
Regular daily passive motion in full range at least one time per
day and protective detachable static splints could prevent these
complications. In case of joint stiffness dynamic splints and
physical modalities such as ultrasound and laser will help to
regain the softening and range of motion.
 Summary of treatment

1- Pain management
2- Motor relearning
3- Sensory reeducation
4- Limb protection
THANK YOU