Severe injuries of the radial nerve treated by sural nerve grafting

Outcomes and prognostic factors for nerve grafting following high radial nerve injury

In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors.       Level of evidence: IV.

Transferring of femoral nerve motor branches for high-level sciatic nerve injury: a cadaver feasibility study

BACKGROUND

Sciatic nerve injuries cause significant disability. We propose here a novel reconstructive procedure of transferring the motor branches of the femoral nerve as donor nerves to reconstruct both the peroneal and tibial nerve function as a novel approach to treat high sciatic nerve injury.

METHODS

The autopsies of donor nerves (vastus lateralis nerve branch (VLN), vastus medialis nerve branch (VMN), saphenous nerve (SAN)) and respective recipient nerves (deep peroneal nerve branch (DPN), medial gastrocnemius nerve branch (MGN), sural nerve (SN)) were conducted in six fresh-frozen lower limbs. The distance between the origin or bifurcation points of the nerves to the head of fibula and the diameter of the end at the coaptation site were measured. The feasibility of tensionless direct suturing or grafting between the donor nerves and the recipient was evaluated. Finally, the nerve end at the coaptation site was harvested for observation with toluidine blue staining and nerve fiber count.

RESULTS

The mean diameter of the VMN, VLN, MGN, DPN, SAN, and SN nerves were 1.5 ± 0.1, 1.4 ± 0.1, 1.3 ± 0.1, 2.3 ± 0.1, 2.1 ± 0.3, and 1.3 ± 0.2 mm, respectively. Histological observation showed that the abovementioned six nerve bundles had a respective nerve fiber number of 392 ± 27, 205 ± 520, 219 ± 67, 394 ± 50, 308 ± 77, and 335 ± 49. A total of 5/6 specimens needed grafting for a length ranging from 5 to 15 cm to bridge the VMN-MGN, 6/6 needed a graft length of 10-20 cm for VLN-DPN bridging, and 2/6 needed a graft length of 0-4 cm for SAN-SN bridging.

CONCLUSION

The study demonstrated the feasibility of the transferring femoral nerve branches to sciatic nerve branches to restore the function for sciatic injury.

Sural nerve autografts for high radial nerve injury with nine centimeter or greater defects

PURPOSE

The purpose of this study is to present the outcome of sural nerve grafting that focuses on motor fascicles in 6 patients with high radial nerve injuries with defects of more than 9 cm.

METHODS

Six patients with a high radial nerve complete injury were treated with a sural nerve autograft during a 6-year interval from June 1994 to June 2000. The gap of the radial nerve, which was measured in the surgical field, was 9 cm in 1 patient, 10 cm in 4 patients, and 11 cm in 1 patient. There were 4 men and 2 women with an average age of 32 years (range, 14-49 years). The causes of the injuries were a fracture of the humerus in 4 patients and surgery-related complications in 2 patients. Two or 3 multiple interfascicular nerve autografts of the sural nerve were sutured to the areas that have motor fascicles dominantly. The average delay from the injury to surgery was 6 months (range, 0.5-12 months), and the average duration of the follow-up after surgery was 48 months.

RESULTS

The overall motor recovery was M5 in 2 patients, M4 in 3 patients, and M2 in 1 patient. The overall sensory recovery was S3+ in 2 patients, S3 in 3 patients, and S1 in 1 patient.

CONCLUSIONS

In summary, good to excellent motor recovery can be expected in 83% of patients who have a large gap of the radial nerve when sural nerve autografts are sutured to the areas that have motor fascicles dominantly. Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complete division of the radial nerve associated with a closed fracture of the humeral shaft in a child

The management of closed fractures of the humerus with an associated nerve palsy remains controversial. With very little written about this injury in children, we present the case of a three-year-old child with a closed humeral shaft fracture in whom surgical exploration and reconstruction of the radial nerve with a sural nerve graft was performed three months after injury. The child regained full function. To the best of our knowledge, this is the first such case to be reported in the English literature.

Nerve injuries about the elbow

Multiple neurovascular structures may be at risk during injuries or procedures about the elbow joint. An appreciation of the complex anatomy of the region, the appropriate evaluation procedures and processes to diagnose injury, and an understanding of treatment options are necessary for surgeons who treat elbow injuries. This article reviews the anatomy, diagnosis, and treatment options of injuries to neural structures about the elbow.

Surgical management of a long segmental defect of the humerus using a cylindrical titanium mesh cage and plates: a case report

This is a case report of a patient who sustained multiple gunshots resulting in a Gustilo Anderson type IIIB mid-shaft humeral fracture associated with extensive segmental bone and soft-tissue loss. The patient was treated initially by multiple irrigations, wound debridement, and a unilateral external fixator. After the soft tissue healed without infection, the mid-shaft humeral defect of approximately 8 cm segmental bone loss was reconstructed with a cylindrical titanium mesh cage packed with a composite of cancellous allograft and demineralized bone matrix putty and stabilized with limited contact dynamic compression plates. At 13 months follow-up, plain radiographs demonstrated a healed construct with good alignment, and computed tomography images demonstrated bony in-growth through the cage. The patient had full range of motion at the shoulder and the elbow. This technique may be a reasonable alternative when treating large segmental bone defects of the humerus.

Results of interfascicular nerve grafting for radial nerve lesions

During the 10 year interval 1979-1989, 20 patients underwent nerve grafting of a radial nerve lesion, 13 high radial and 7 posterior interosseous. Average follow-up was 38 months (range 12 months-10 years). Overall 72% of patients achieved a Highet Scale rating of M3 or better function and 44% M4 or better recovery. Age of the patient and length of the nerve graft did not seem to influence outcome. Time from initial injury to nerve grafting did affect outcome, with 85% of patients grafted within 6 months obtaining M3 or better recovery. No patient grafted 12 months after injury recovered any useful function. Lesions of the posterior interosseous nerve had a consistently superior recovery. Power grip strength in the affected hand of patients averaged 60% of the unaffected hand while key pinch averaged 74%. There was good correlation between the Highet Scale rating of recovery and the ultimate power grip or key pinch strength obtained. Hand dexterity, as assessed by the turning and displacing tests of the Minnesota Rate of Manipulation Test, displayed a wide range of scores in both affected and unaffected hands. Nevertheless, a relative score derived from the results obtained in the displacing test did show correlation with the Highet Scale rating. All patients with M4 or better recovery obtained relative scores for the affected hand that were in the middle of the range of scores considered an average performance for a normal population. Patients who achieved M4 or better nerve recovery following radial nerve grafting also obtained a functional hand as evidenced by the results of grip, key pinch strength, and hand dexterity testing. Lesser degrees of recovery were accompanied by poorer strength and dexterity ratings reflecting inferior function.

The assessment and treatment of nerve dysfunction after trauma around the elbow

Nerve dysfunction after trauma around the elbow can lead to significant long-term pain and functional deficit. Fortunately, most of these injuries are neurapraxias that will recover spontaneously after conservative treatment. The necessity and time frame for surgical intervention for specific patterns of nerve dysfunction remains controversial. Often surgical exploration exacerbates rather than alleviates the presenting nerve problem. Distal humeral shaft fractures, elbow dislocations, Monteggia fracture-dislocations, supracondylar fractures in children, and proximal forearm trauma all have been associated with various types of nerve injuries with a variable degree of recovery. The early recognition of nerve dysfunction combined with appropriate treatment measures is the key to successful outcome.

Radial nerve laceration and retraction associated with a supracondylar fracture of the humerus

Supracondylar fracture of the humerus can be associated with varying degrees of radial nerve injury. Complete laceration of the nerve is rare. We report a case of radial nerve laceration after a supracondylar fracture in which the proximal segment of the nerve retracted into the axilla. Successful treatment resulted from long segmental sural nerve grafting.

Radial palsy in shaft fracture of the humerus

Fifty-nine patients with immediate and 16 with secondary radial nerve palsy complicating a fracture of the shaft of the humerus were reviewed. According to the preferences of the surgeon in charge, the palsy was treated either with early exploration of the radial nerve and internal fixation of the fracture or with initial expectance. Of the latter, 12 were later explored. No useful recovery of motor function could be seen in 13/59 patients with immediate and in 2/16 patients with secondary palsy. In patients with immediate palsy treated by early exploration, there were 8/27 nonrecoveries. Among those treated with initial expectance, there were 5/32 nonrecoveries. For secondary palsy, these figures were 2/10 and 0/6, respectively. No support emerged for routine early exploration.