Nerve Transfers to Restore Elbow Function

Understanding surgical decision-making in patients with traumatic upper extremity peripheral nerve injury: A retrospective cohort study

PURPOSE

Careful patient selection and optimal surgical timing are essential to the success of nerve transfers. It is important to understand what factors contribute to this decision-making. The purpose of this study was to describe the characteristics of patients referred to interdisciplinary peripheral nerve clinics with traumatic upper extremity injuries and compare those who went on to nerve transfer surgery with those who did not.

METHODS

Patient and injury characteristics, preoperative physical examination and electrodiagnostic findings, and patient-reported outcome measures were examined. Inclusion criteria were subjects ≥18 years of age presenting to an interdisciplinary peripheral nerve clinic with traumatic upper extremity peripheral nerve injuries. Subjects were stratified into surgical and non-surgical groups for comparison.

RESULTS

Eighty-three subjects met the inclusion criteria, and 36 subjects received nerve transfer surgery. More male subjects went on to have surgery than female subjects. The surgical group demonstrated a significantly higher ratio of weak and denervated muscle groups than the non-surgical group (p < 0.05). No other statistically significant differences were identified between operative and non-operatively managed subjects.

CONCLUSION

Subjects that received nerve transfer surgery demonstrated a significantly higher ratio of weak and denervated muscles than those managed non-surgically, and males were disproportionately represented in the surgical group. These findings suggest that anticipated motor recovery is the most important factor driving surgical decision-making and that male subjects may be more likely to proceed with surgery. Understanding which patients undergo nerve transfer surgery allows clinicians to interrogate their decision-making, address patient-related barriers to surgery, and better understand surgical outcomes.

Proximal and Distal Nerve Transfers in the Management of Brachial Plexus Injuries

Nerve transfer surgery utilizes the redundant and synergistic innervation of intact muscle groups to rehabilitate motor function. This is achieved by transferring functional nerves or fascicles to damaged nerves near the target area, thereby reducing the reinnervation distance and time. The techniques encompass both proximal and distal nerve transfers, customized according to the specific injury. Successful nerve transfer hinges on accurate diagnosis, innovative surgical approaches, and the judicious choice of donor nerves to maximize functional restoration. This study explores nerve transfer strategies and their integration with other procedures, emphasizing their importance in enhancing outcomes in brachial plexus injury management.

Functional Outcome following Phrenic Nerve Transfer in Brachial Plexus Injury

Background

Brachial plexus injuries are debilitating injuries resulting in paralyzed shoulder to global paralysis of the upper extremity. Treatment strategies have evolved over the years with nerve transfer forming the mainstay of surgical management. Phrenic nerve provides certain advantages as donor over other options but has been less preferred due to fear of pulmonary complications. In this study, we assess the functional outcomes of phrenic nerve transfer in brachial plexus injuries.

Materials and Methods

A retrospective study was performed on 18 patients operated between 2012 and 2017. The mean duration of injury to surgery was 4.56 months and mean follow-up was for 3.66 years. Phrenic nerve was used as donor to neurotize either biceps and brachialis branch of musculocutaneous nerve or suprascapular nerve. Assessment was done through Waikakul score for elbow flexion and Medical Research Council grading for shoulder abduction. Respiratory function assessment was done through questionnaire.

Results

Twelve (80%) patients recovered grade 3 and above elbow flexion with 6 patients having a positive endurance test according to Waikakul and a "very good" result. In phrenic to suprascapular transfer group (3 patients), all patients had more than grade 3 recovery of shoulder abduction. No patient complained of respiratory problems.

Conclusion

Phrenic nerve can be used as a reliable donor with suitable patient selection with good results in regaining muscle power without any anticipated effects on respiratory function.

Current perspectives on peripheral nerve repair and management of the nerve gap

From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.

Factors Associated with Poorer Outcomes from Triceps Motor Branch to Anterior Axillary Nerve Transfer: A Case-Control Study

INTRODUCTION

We sought to identify predictors of failed triceps motor branch transfer to the anterior division of the axillary nerve (AN) for shoulder abduction reconstruction after a brachial plexus injury (BPI).

METHODS

A case-control study of adult AN or brachial plexus patients treated with a triceps motor branch transfer to the anterior division of the AN with a minimum 18 months of follow-up was performed. The failure group (case group) was defined as modified British Medical Research Council muscle scale (mBMRC) postoperative deltoid grade ≤2 and was compared to the successful outcome group (control group), defined as mBMRC postoperative deltoid grade ≥3. Clinical variables, injury mechanism, time from injury to surgery, root avulsion status, electrodiagnostic studies, rotator cuff injuries, scapula fracture, Disabilities of the Arm Shoulder and Hand scores, and preoperative triceps strength were analyzed. Subgroup analysis was performed for patients with isolated AN injuries and those with BPI.

RESULTS

A total of 69 patients met inclusion/exclusion criteria, of whom 23 regained ≥M3 deltoid muscle strength and 52° ± 69° of shoulder abduction (successful outcome group) and 46 regained ≤M2 deltoid muscle strength and 27° ± 30° of shoulder abduction (failure group). Preoperative triceps weakness (M ≤4) was significantly more common in the failure group (63% vs. 30%, P = 0.032); preoperative triceps muscle fibrillations were significantly more common in the failure group (61% vs. 30%, P = 0.02). Isolated AN injuries presented better preoperative motion and postoperative outcomes results compared to BPI.

CONCLUSIONS

Use of triceps motor branch associated with fibrillations or weakness resulted in statistically poorer outcomes compared to the use of a normal triceps motor branch in the restoration of anterior AN function after nerve transfer.

Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series

BACKGROUND

Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries.

OBJECTIVE

To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries.

METHODS

A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P &lt; .05.

RESULTS

Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance.

CONCLUSION

Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

Clinical Assessment of Functional Recovery Following Nerve Transfer for Traumatic Brachial Plexus Injuries

Surgical reconstruction and postoperative rehabilitation are both important for restoring function in patients with traumatic brachial plexus injuries (BPIs). The current study aimed to understand variations in recovery progression among patients with different injury levels after receiving the nerve transfer methods. A total of 26 patients with BPIs participated in a rehabilitation training program over 6 months after nerve reconstruction. The differences between the first and second evaluations and between C5-C6 and C5-C7 BPIs were compared. Results showed significant improvements in elbow flexion range (p = 0.001), British Medical Research Council's score of shoulder flexion (p = 0.046), shoulder abduction (p = 0.013), shoulder external rotation (p = 0.020), quantitative muscle strength, and grip strength at the second evaluation for both groups. C5-C6 BPIs patients showed a larger shoulder flexion range (p = 0.022) and greater strength of the shoulder rotator (p = 0.004), elbow flexor (p = 0.028), elbow extensor (p = 0.041), wrist extensor (p = 0.001), and grip force (p = 0.045) than C5-C7 BPIs patients at the second evaluation. Our results indicated different improvements among patients according to injury levels, with quantitative values assisting in establishing goals for interventions.

Considerations in the Selection of Donor Nerves for Nerve Transfer for Reanimation of Elbow and Shoulder in Traumatic Brachial Plexus Injuries

The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic).

Optimizing the timing of peripheral nerve transfers for functional re-animation in cervical spinal cord injury: a conceptual framework

Loss of upper extremity function following spinal cord injury (SCI) can have devastating consequences on quality of life. Peripheral nerve transfer surgery aims to restore motor control of upper extremities following cervical SCI and is poised to revolutionize surgical management in this population. The surgery involves dividing an expendable donor nerve above the level of the spinal lesion and coapting it to a recipient nerve arising from the lesional or infralesional segment of the injured cord. In order to maximize outcomes in this complex patient population, refinements in surgical technique need to be integrated with principles of spinal cord medicine and basic science. Deciding on the ideal timing of nerve transfer surgery is one aspect of care that is critical to maximizing recovery and has received very little attention to date in the literature. This complex topic is reviewed, with a focus on expectations for spontaneous recovery within upper motor neuron components of the injury, balanced against the need for expeditious reinnervation for lower motor neuron elements of the injury. The discussion also considers the case of a patient with C6 motor complete SCI where myotomes without electrodiagnostic evidence of denervation spontaneously improved by 6 months post-injury, thereby adjusting the surgical plan. The relevant concepts are integrated into a clinical algorithm with recommendations that consider maximal opportunity for spontaneous clinical improvement post-injury while avoiding excessive delays that may adversely affect patient outcomes.

Five Reliable Nerve Transfers for the Treatment of Isolated Upper Extremity Nerve Injuries

LEARNING OBJECTIVES

After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers.

SUMMARY

Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered.

Nerve transfers to restore femoral nerve function following oncologic nerve resection

INTRODUCTION

Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection.

METHODS

Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale.

RESULTS

Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use.

CONCLUSION

Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.

Restoration of elbow flexion in adult traumatic brachial plexus injury - a quantitative analysis of results of single versus double nerve transfer

BACKGROUND

Restoration of elbow flexion is one of the key components of adult brachial plexus surgery. Nerve transfers are routinely used to attain elbow flexion.

PURPOSE

This study aims to quantify the recovery of elbow flexion power and to compare the outcome following single nerve transfer and double nerve transfer to branches of the musculocutaneous nerve in adult traumatic brachial plexus injury.

METHOD

We conducted a retrospective cohort study of patients with traumatic upper brachial plexus injury who underwent nerve transfer of the musculocutaneous nerve with either Ulnar nerve fascicles (SN) or both Ulnar and Median nerve fascicles (DN) for restoring elbow flexion. Patients with a minimum follow up of 18 months after surgery were included in this study. Elbow flexion strength was quantified using a force transducer and software module and the results were compared between the two groups.

RESULT

The median strength of elbow flexion was 14.3 Newton meter. In the SN group, the mean strength of elbow flexion was 5.4 ± 5 Nm, and for DN group it was 20.4 ± 9.9 Nm. Elbow flexion strength following DN procedure was significantly better when compared with SN.

CONCLUSION

The additional nerve transfer of median nerve fascicles with musculocutaneous nerve branch to the brachialis muscle does not add clinically obvious morbidity to the patient but has definite benefit as observed in this study. We advocate double fascicular nerve transfer for elbow flexion in upper brachial plexus injuries if the median and ulnar nerve functions are normal.

Nerve transfers in the upper extremity: A review

Injury of the brachial plexus and peripheral nerve often result in significant upper extremity dysfunction and disability. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries. These transfers require an intimate knowledge of nerve topography, a technically demanding Intraneural dissection and require extensive physical therapy for retraining. In this review, we present a summary of the most widely accepted nerve transfers in the upper extremity described in the current literature.

Surgical reconstructions for adult brachial plexus injuries. Part I: Treatments for combined C5 and C6 injuries, with or without C7 injuries

Brachial plexus injuries will cause a significantly decreased quality of life. Patients with upper arm type brachial plexus injuries, which means C5 and C6 roots injury, will lose their shoulder elevation/abduction/external rotation, and elbow flexion function. Additional elbow, wrist, and hand extension function deficit will occur in patients with C7 root injury. With the advances of reconstructive procedures, the upper arm brachial plexus injuries can be successfully restored through nerve repair, nerve grafting, nerve transfer, muscle / tendon transfer and free functioning muscle transfer. In this review article, we summarized the various reconstructive procedures to restore the function of shoulder and elbow. Nowadays, the upper arm type BPI can be treat with satisfied outcomes (80-90% successful rate).

Free Gracilis Muscle Transfers Compared with Nonfree Muscle Flaps for Reanimation of Elbow Flexion: A Meta-Analysis

Objectives  Elbow flexion loss is a debilitating upper extremity injury. Surgical treatment options include nonfree muscle transfers (tendon transfers, nerve transfers, Steindler procedure, Oberlin transfers, and pedicled muscle transfers) or free muscle transfers. We sought to determine if free muscle transfers and nonfree muscle transfers have similar outcomes for elbow flexion reanimation. Materials and Methods  A literature search for studies evaluating free and nonfree muscle transfers for elbow flexion reanimation was performed. Included studies reported on transfer failure (strength Collapse

Key Words

• brachial plexus
• elbow
• elbow flexion reanimation
• free muscle transfer
• gracilis
• meta-analysis
• nerve transfer
• range of motion

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Affiliation(s)

Joseph P. Scollan Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
Jared M. Newman Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
Neil V. Shah Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States
Erika Kuehn Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States Department of Orthopedics, University of Massachusetts, Worcester, Massachusetts, United States
Steven M. Koehler Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York SUNY Downstate Medical Center, Brooklyn, New York, United States

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Factors associated with failed ulnar nerve fascicle to biceps motor branch transfer: a case control study

We sought to identify predictors of failed ulnar nerve fascicle (to flexor carpi ulnaris) to biceps motor branch transfer. A retrospective review of adult brachial plexus patients treated with flexor carpi ulnaris to biceps transfer with a minimum 1-year follow-up was performed. Failure, defined as modified British Medical Research Council grade <3 elbow flexion was compared with randomly selected controls (M ≥ 4-). Ninety-one patients, of which 80% regained >M3 flexion met criteria. Eighteen failures and 18 controls, with similar follow-up (20 vs 23 months) were evaluated. Preoperative flexor carpi ulnaris weakness (M < 5) was significantly more common in failures (78% vs 33%). The rate of flexor carpi ulnaris recovery after operation was significantly higher in controls (86% vs 7%). Increased failure risk can be expected with impaired preoperative flexor carpi ulnaris function. The challenge is how to identify which patients will regain near normal flexor carpi ulnaris strength as excellent outcomes can be obtained. Level of evidence: III.

Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study

INTRODUCTION

Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury.

METHODS

PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed.

RESULTS

In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022).

CONCLUSIONS

Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.

LEVEL OF EVIDENCE

Level II.

The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction

Therapeutic management of brachial plexus injuries remains complex. The impact of brachial plexus injuries on everyday human functioning should not be underestimated. Early active-assisted range of motion following such injuries may prevent myostatic contractures, minimize muscle atrophy, facilitate muscle fiber recruitment, and enable a faster return to baseline strength levels. The dynamic assist elbow flexion orthosis proposed is designed to provide patients with a graded system for muscle reeducation and function. No clinical data are currently available on the use of this orthosis design; however, this article presents a treatment option based on sound clinical reasoning to facilitate rehabilitation following this devastating injury.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury

BACKGROUND

To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps.

METHODS

Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months.

RESULTS

For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery.

CONCLUSIONS

The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Surgical strategy in extensive proximal brachial plexus palsies

PURPOSE

To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI).

METHODS

Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension.

RESULTS

Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%).

CONCLUSIONS

A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury.

LEVEL OF EVIDENCE

IV.

Nerve injuries of the upper extremity and hand

A nerve injury has a profound impact on the patient’s daily life due to the impaired sensory and motor function, impaired dexterity, sensitivity to cold as well as eventual pain problems.

To perform an appropriate treatment of nerve injuries, a correct diagnosis must be made, where the injury is properly classified, leading to an optimal surgical approach and technique, where timing of surgery is also important for the outcome.

Knowledge about the nerve regeneration process, where delicate processes occur in neurons, non-neuronal cells (i.e. Schwann cells) and other cells in the peripheral as well as the central nervous systems, is crucial for the treating surgeon.

The surgical decision to perform nerve repair and/or reconstruction depends on the type of injury, the condition of the wound as well as the vascularity of the wound.

To reconnect injured nerve ends, various techniques can be used, which include both epineurial and fascicular nerve repair, and if a nerve defect is caused by the injury, a nerve reconstruction procedure has to be performed, including bridging the defect using nerve-grafts or nerve transfer techniques.

The patients must be evaluated properly and regularly after the surgical procedure and appropriate rehabilitation programmes are useful to improve the final outcome.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160071. Originally published online at www.efortopenreviews.org