- Laura Simionescu, MD
Laura Simionescu, MD
- Assistant Professor of Neurology
- Upstate Medical University and University Hospital
Traumatic peripheral nerve injuries may cause significant disability and have a serious impact on the patient’s life. Therefore, early diagnosis, accurate and timely management, and close follow-up are warranted. This topic discusses the classification and evaluation of traumatic nerve injury, and briefly outlines treatment considerations. The specific neurologic deficits associated with particular nerve injuries are discussed more fully elsewhere.
ANATOMY AND PHYSIOLOGY
The peripheral nerve consists of myelinated and unmyelinated nerve fibers. Unmyelinated axons are surrounded by the plasma membrane of a supporting cell called the Schwann cell. Myelinated axons are surrounded by a myelin sheath, a specialized structure of the Schwann cell that wraps around the axon and insulates it with layers of cell membrane. Gaps in myelin occur at regular intervals, called the nodes of Ranvier. The segments of axon covered by myelin between the gaps are called the internodal segments [1,2]. The myelin sheath has a low capacitance and a high resistance to electrical current, so that current flow is directed longitudinally along the axon, rather than transversely across the axon membrane. Ion channels within the axon membrane are differentially distributed at the node of Ranvier and under the myelin sheath. The differential expression of ion channels and the insulating properties of the myelin sheath result in a rapid mode of nerve transmission called saltatory conduction.
Traumatic nerve injury results from the application of kinetic energy to the nerve, with consequent compressive and tensile forces applied to the nerve. Examples include injuries from a sudden stretch of a limb; a laceration from a sharp object, and a gunshot wound with associated cavitation effect produced by the bullet moving through tissue with a high velocity .
Mononeuropathies caused by trauma produce signs and symptoms that relate to the specific location and severity of the injury. However, trauma is unique from other causes of mononeuropathy in several respects. The sudden nature of the event leads to a well-defined sequence of abnormalities on clinical neurophysiologic evaluation, and recovery is strongly related to the type and severity of injury. In addition, therapy is directed to anatomic reconstruction rather than disease modification.
Most commonly, nerve injury occurs from traction/stretch, laceration, compression, or ischemia. The nerve dysfunction results primarily from the direct mechanical forces applied to it and secondarily from the vascular compromise that follows, with consequent ischemic nerve damage.
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- ANATOMY AND PHYSIOLOGY
- Nerve laceration
- Combined injuries
- CLASSIFICATION AND PATHOPHYSIOLOGY
- Mechanisms of functional recovery
- COMMON LOCATIONS
- Median neuropathies
- Ulnar neuropathies
- Radial neuropathies
- Sciatic neuropathies
- Peroneal neuropathies
- Tibial neuropathies
- Femoral neuropathies
- - Electrodiagnostic testing
- Neurapraxic lesion
- Axonotmetic and neurotmetic lesions
- - Somatosensory evoked potentials
- - Radiography
- - Magnetic resonance imaging
- - Ultrasound
- TREATMENT OVERVIEW
- Open nerve injuries
- Closed nerve injuries
- Surgical techniques
- SUMMARY AND RECOMMENDATIONS