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Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
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Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
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Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
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Page 33
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
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Page 34
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 35
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 36
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 37
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 38
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 39
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 40
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 41
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 42
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 43
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 44
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 45
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 46
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 47
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 48
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 49
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 50
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 51
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 52
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 53
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 54
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 55
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 56
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 57
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 58
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 59
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 60
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 61
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 62
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 63
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 64
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 65
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 66
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 67
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 68
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
×
Page 69
Suggested Citation:"The Injury and Its Management." National Research Council. 1957. Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries. Washington, DC: The National Academies Press. doi: 10.17226/18485.
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Page 70

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Chapter II THE INJURY AND ITS MANAGEMENT Barnes Woodhall and Gilbert W. Beebe Before any follow-up data can be presented it is essential that the reader be familiar with the characteristics of the acute lesion which has been chosen for study here, and with its management. The selection of various aspects of the injury and its treatment was, of course, limited by /} priori concepts of the significance of individual factors in peripheral nerve re- generation and, even more important, by the quality and detail of the average military record. This chapter serves to introduce the different classifications of injury and treatment upon which the later analysis of regeneration depends. It includes definitions and discussions of the problems which were encountered in creating the many classifications and in adapting them to the individual case. At the same time, the struc- ture of the entire sample is revealed in terms of these classifications, and the implications of the sampling plan are explored. Since the abstracting of service medical records necessarily extended to all active treatment received in military hospitals, the pattern of surgical management reveals important information on such points as the proba- bility of reoperation and the practice of cuff removal. In the belief that they provide rough measures of the cost of peripheral nerve injuries to the Armed Forces, duration in hospital and disposition were also abstracted and the resulting data appear in this chapter. A. CHARACTERISTICS OF THE NERVE INJURY The information included under this general heading pertains to the origin of the case in terms of the sampling plan, identity of the injured nerve, presence of associated nerve injury, presence of other associated injuries of importance, presence of serious infection, type of nerve injury, site of injury, agent of injury, and presence of plastic repair at site of nerve injury. Information on age at injury is also included here. Omitted from this Ibt as an aspect of management is the length of any surgical defect. Each of these characteristics is discussed briefly, together with certain in- interrelations among them, especially those involving site of injury and identity of nerve injured. All 3,656 injured nerves, or the involved in- jured extremities, of 2,554 injured men are used in the tables from which these observations are drawn. In any particular table, however, a smaller total may appear because of lack of information concerning one or more of the factors involved. II

Three main groups of cases were established from the 10 rosters that were available and from scattered local cases that were added to this study. Group A consists entirely of cases from the large Army Peripheral Nerve Registry and within the geographical sampling areas defined for the five follow-up centers. It includes both sutures and lyses and is the most representative material in the sample except, of course, with respect to the ratio of sutures to lyses and, for the lyses, the presence of associated nerve lesions. Group B, on the other hand, was formed from the five lysis rosters chosen, it will be recalled, on the basis of the care with which the incomplete lesions had been assessed. Group C contains cases from the Army Peripheral Nerve Registry which fell outside the respective sampling areas, and from the other rosters of complete lesions (except roster 68) described on pages 6-7, i. e., cases of special interest because of some particular characteristic of injury or treatment. Thus, here are to be found Hoen's plasma glue sutures, Wrork's overseas sutures, the Lyons-Woodhall series with special pathological studies, and cases from the Registry allo- cated for study only because of arterial injury, normal bone resection, bulb suture, or nerve graft. Both sutures and lyses are represented in group C, but the factors of selection apply chiefly to sutures. The cases in group C, being of special interest for one reason or another, could not be accepted in advance as typical of peripheral nerve injuries or as homogeneous with the lesions in groups A and B. Accordingly, the several roster groups were compared on several major characteristics of injury. Most of the expected differences were found, although many of them are not as large as anticipated and seem of doubtful practical impor- tance despite their statistical reliability. Nevertheless, since group A contained 2,501 lesions, group B 280 lesions, and group C 875 lesions, it was decided that the descriptive analysis of each modality of recovery should be confined to group A insofar as it pertains to sutures. It was believed that the lyses should be drawn from all three groups, except that lyses from the Army Registry should also be confined to the sampling areas surrounding the five centers. In tables 10, 11, and 12 the sample is described in terms of the nerve involved, the presence of associated nerve injury to the same limb, and the number of lesions in the same nerve. As has been noted in previous studies, and despite the effort made in this study to secure adequate samples of the less frequently injured nerves, upper extremity nerve injuries were twice as numerous as lower extremity injuries. In the upper extremity, the ulnar nerve was the most frequently represented of the three major nerve segments, followed in turn by the median and the radial. In the lower extremity, thigh injuries involving some component of the sciatic nerve were more common than injuries in the foreleg. The sampling plan was geared to a study of the seven major peripheral nerves; occasionally, however, associated injuries involving other nerves were encountered. Regeneration studies were conducted upon these latter nerves where motor function was involved but no analysis has been made of the data. 33

Table 10.—Identity of Nerve Affected, Total Sample Number of lesions Percentage dis- tribution Part of body Nerve Nerves in this part of body All nerves Upper extremity 707 516 1,000 44 9 19.3 14. 1 27.4 1.2 .2 31.1 Radial 22.7 43.9 1.9 .4 Ulnar Axillary Total 2,276 62.3 100.0 Lower extremity 6 341 404 235 394 0.2 9.3 11.1 0.4 24.7 29.3 17.0 28.6 Sciatic-peroneal . . . Tibial 6.4 10.8 Sciatic-tibial Total 1*380 37.7 100.0 Grand total 3,656 100.0 Table 11.—Associated Nerve Lesions * on the Same Limb, by Nerve Total lesions Percentage with other nerve lesions, same limb Nerve Median 707 58.0 Radial 516 32.8 Ulnar . 1,000 40.2 Peroneal 341 24.9 Sciatic-peroneal 404 94.3 Tibial 235 35.7 394 97.0 1 In addition to the major nerves only the following were included in counting asso- ciated nerve lesions: musculocutaneous, axillary, and femoral. A high percentage of patients with nerve injury had an associated nerve injury, and multiple injuries tended to be concentrated in a single limb. The very high percentage of associated nerve injury indicated for the

Table 12.—Number of Lesions Per Injured Nerve, Total Sample Number of lesions per nerve Injured nerves Number Percent One 3,615 40 1 98.88 1.09 .03 Two Three Total .... 3,656 100.00 sciatic-peroneal and sciatic-tibial lesions is a consequence of regarding these two sciatic branches as individual nerves for the purpose of the regeneration studies. When the multiplicity of peripheral nerves injured in the same extremity was analysed in terms of various aspects of the clinical history, the following conclusions emerged: A high injury in the arm more often involved other nerves than a low injury, and the same phenomenon was present in the lower extremity; strangely enough, the more nerves injured in a limb, the less likely was concomitant bone or joint injury; there was a tendency for infection to be more common in the presence of multiple nerve injuries; associated vascular injuries were rare in the lower extremity but they were common in the upper extremity and were strongly associated with the presence of additional nerve injuries; for the radial nerve, there was a marked tendency for a major plastic surgical procedure to be associated with other nerve injuries. In table 13 appears the summary classification adopted for the type of injury to the nerve, as well as the frequency with which each type was found in the entire sample. The finer nuances of this classification are presented in another publication (46), but the criteria for its application Table 13.—Type of Injury to Nerve, Total Sample Type of injury Number Percent 22 0.6 386 11. 1 Complete nerve division 1,795 51.7 449 12 9 776 22.3 43 1.2 2 0. 1 Total known 3,473 99 9

to the military records are of interest here. The purpose of the classifica- tion was to describe the extent of the lesion as it appeared to the operator. Thus no attention was paid to the evidence of electrical testing or of microscopic pathological study, although both types of observation were included elsewhere in the abstract of the case for statistical purposes. The following notes guided the classification of individual cases: NORMAL NERVE COMPRESSED BY SCAR TISSUE. This is rarely found. Nerve is bound down in scar tissue but it is not itself scarred or neuromatous. No suture is done in these cases. COMPLETE NERVE DIVISION. This means there is or has been a complete separation of the nerve. Include here cases with only connecting strand of fibrosed tissue or few nonfunctioning fibers between two ends of the nerve—also cases where there is continuity but the operator sections the scarred area or "neuroma" and finds no fibers going through. In absence of operation report, if summary speaks of severance and suture overseas, this classification may be used. Bulb sutures indicate complete nerve division. PARTIAL NERVE DIVISION. Partial separation implies that the unsevered portion of the nerve contains functioning nerve fibers. When there is partial division and the rest is neuromatous* it should be coded as a neuroma, not a partial division. When the only continuity is scarred connective tissue, code complete rather than partial severance. There can be cases of partial division with a neuroma at one end and glioma at the other, but there must be some functioning fibers going through. NEUROMA IN CONTINUITY. Neuroma is more than external scar; there must be growth in the nerve itself. This classification is not compatible with a statement that any normal fibers are going through. If part of the cross section is neuromatous, and part normal, classify as partial division. There must be positive evidence of neuroma in continuity before it can be coded here. (See complete division.) If nerve is described as densely scarred or extensively scarred it is in most cases a neuroma in continuity. If nerve appears grossly normal, but on palpation at opera- tion nerve is described as lumpy, hard, irregular, or with fusiform thickening, or otherwise abnormal, it can be considered a neuroma in continuity. Where there is partial division and the rest neuromatous code as neuroma in continuity. STRETCH INJURY. Will also be called a traction injury. The classification as to specific site is exhibited in table 14. Like those of table 10, and despite the sampling plan, these data reflect the concen- tration of nerve injuries in the upper extremity and demonstrate once more the higher percentage of wounds in that part of the extremity adjacent to the trunk. Of greater import is the implication that the high and low nerve injuries will be adequate to permit comparisons as to nerve regenera- tion. Indeed, if indicated, good regeneration studies appear possible for injuries received in any part of either extremity. An analysis of the agent causing injury, among other matters, has been presented in an earlier statistical review of the Army Registry material (87). For the purposes of the regeneration study, it appears sufficient to note that 92 percent of the nerve injuries were sustained in combat. In large numbers of peripheral nerve injuries the extremity is involved in one or another grave concomitant injury to other tissues. As defined in this analysis, an associated injury is one that would be expected to bear a direct and significant relationship to the treatment and anatnrnical regener- 35

ation of the injured nerve. The relation between site of nerve injury and associated injury was studied separately for injuries in the upper and lower extremity. In both sets of cases there was an intimate association between the location of the nerve lesion and the probability of a bone or joint injury. Bone or joint injury was defined as a significant gunshot or other wound of such structures causing open fracture or destruction of tissue demanding specific orthopedic care. The probability was low for injuries above the elbow and in the upper two-thirds of the thigh, and high for injuries below these points. Also, if a bone or joint injury were incurred its chance of normal healing varied significantly in relation to site of injury in the upper extremity. These figures are shown in table 15. Table 14.—Specific Site of Lesion, Total Sample l Percentage distri- bution Part of body Specific site Number of lesions Lesions in this part of body All le- sions Arm middle third 32 422 402 358 216 217 224 208 136 12 0.9 11.8 11.2 10.0 6.0 6.0 6.2 5.8 3.8 0.3 1.4 18.9 18.1 16.1 9.7 9.7 10.1 9.3 6.1 0.5 Elbow Forearm, upper third .... Forearm, middle third . . . Wrist Hand Total 2,227 62.1 99.9 Lower extremity Thigh upper third 433 259 184 256 108 49 46 16 9 12.1 31.8 19.0 13.5 18.8 7.9 3.6 3.4 1.2 0.7 Thigh middle third ..... 7.2 5.1 7.1 3.0 1.4 1.3 0.4 0.3 Knee Leg middle third Leg, lower third Ankle Foot Total 1,360 37.9 99.9 Grand total 3,587 99.9 'Omitted are 49 upper and 20 lower extremity cases for which site was not specified in sufficient detail for this classification. 36

In the upper extremity, associated arterial injury varied quite significantly with site of injury, being especially common in the upper arm. An asso- ciated arterial injury was further defined as one implicating a major vessel supplying an extremity, i. e., the subclavian, axillary, brachial, radial, and ulnar in the upper extremity, and the iliac, femoral, popliteal, and tibial in the lower. Tables 16 and 17 show the variable frequency of such arterial injuries in association with the particular nerve affected and the specific site of the nerve lesion. Table 15.—Percentage of Nerve Injuries With Associated Bone or Joint Injury, and Percentage of Bone or Joint Injuries in Which Normal Healing Occurred, by Site of Injury and Part of Body Site of nerve injury Percentage of nerve lesions with bone or joint injury Percentage of bone or joint in- juries with normal healing Upper extremity Shoulder, arm upper third Arm, middle third Ann, lower third Forearm, upper third Forearm, middle third Forearm, lower third Elbow Wrist, hand All sites Lower extremity Thigh* upper third Thigh, middle third Thigh, lower third Leg, upper third Leg, middle third Leg, lower third Knee Ankle, foot All ? iteg. . 27.1 44.3 40.3 65.0 58.0 63.8 64.7 45.3 47.4 77.2 67.4 48.6 58.9 61.5 69.7 67.6 76.1 65.0 28.9 21.6 21.2 49. 1 57.1 52.2 28.1 52.0 30.1 73.6 67.9 69.2 79.2 71.4 75.0 79.2 92.3 74.6

Table 16.—Associated Arterial Injurv, by Nerve Percentage with asso- ciated arterial injury Percentage with asso- ciated arterial injury Nerve Nerve 32.0 Tibial 3.9 Ulnar 23.4 Sciatic -peroneal 3.0 Radial 15. 1 Sciatic-tibial 3.0 Peroneal 1.5 Table 17.—Associated Arterial Injury, by Site of Nerve Lesion Percentage with asso- ciated arterial Percentage with asso- ciated arterial injury Site of nerve injury Site of nerve injury injury Upper extremity Lower extremit r 42 4 2.5 27 8 Thigh middle third 3.9 16.2 Thigh, lower third . 3.3 Forearm, upper third 15.7 Knee 2.4 Forearm, middle third 15.2 Leg, upper third 0.9 26 8 6. 1 Elbow 12.3 Leg lower third 0 Wrist, hand 21.2 Ankle 6. 3 All sites 24 4 Foot 0 2. 8 The frequency of major plastic repair at the site of the nerve lesion also varied significantly by location of the nerve injury. Among injuries in the upper extremity, plastic repair was more common in the forearm than in the arm. A parallel situation existed among injuries to the lower extremity (table 18). The agent of injury was moderately related to the probability of associated bone or joint injury and also to the chance of an infection sufficient to delay nerve operation. It was entirely unrelated to the likelihood of arterial injury or plastic repair. The percentages with bone or joint injury, and the parallel percentages with infection, appear in table 19. In a series of military battle casualties one does not expect to find sufficient variation in as;e to have biological significance, but since the follow-up 38

Table 18.—Plastic Repair at Site of Nerve Injury, by Site of Nerve'Injury, and by Body Part Percentage with plastic repair Percentage with plastic repair Site of nerve injury Site of nerve injury Upper extremity Lower extremity Shoulder, arm, upper third 4. 3 3 2 Arm, middle third 7.6 Thigh, middle and lower 8.1 thirds 7.2 18.9 Knee 16.5 Forearm, middle third 21. 1 14.2 20 5 Elbow 14.7 All sites 8 8 Wrist, hand 14.4 All sites ... 11 8 Table 19.—Associated Bone or Joint Injury and Infection, by Agent of Injury, All Peripheral Nerve Lesions Combined Percentage of nerve lesions with associated bone or joint injury Percentage of nerve lesions with associated infection Agent Combat gunshot wounds 41.5 9.3 Noncombat gunshot wounds 47.0 2. 3 Cutting instruments and closed wounds 27.1 6. 4 All agents 40. 9 8 9 results pertain to a particular series of men, their age should be recorded here (table 20). In summary, the foregoing data serve to define the nerve injury in terms of distribution, associated nerve injury, type of nerve injury, the specific site of the nerve injury, the agent causing the injury, and the presence of associated injury to bone, vessel, and soft tissue. It is evident that any adequate number of individual nerve injuries is available for study at an site in the extremity. Furthermore, such injuries may be found with related nerve injury, an association that may not impair the study of anatomical regeneration but certainly may adversely implicate function of the extrem- ity. This is of even greater import when it may be noted that a single limb is involved in multiple nerve lesions in a high percentage of such instances.

As would be suspected from the nature of the rosters and the origin of the wounds, this material shows a high percentage of completely severed nerves incurred in combat. Of real interest to the military surgeon is the pro- nounced incidence of concomitant tissue injury with the specific nerve lesions and, in particular, the association of bone injury. Table 20.—Age of Patient at Injury, Total Sample Age, in completed years Nerve lesions Age, in completed years Nerve lesions Number Percent Number Percent Under 20 348 661 550 497 389 258 222 10.6 20.1 16.7 15.1 11.8 7.8 6.7 32-33 162 126 4.9 3.8 1.8 0.8 20-21 34-35 22-23 36-37 ... . 58 25 24-25 26 27 28-29 Total known .... 3,296 100.1 30-31 B. MANAGEMENT OF THE NERVE INJURY Just as the preceding section is focussed upon the nerve injury, the present section has to do with its management and is designed to furnish background for the subsequent chapters rather than to provide generalizations about peripheral nerve injuries as a whole. The definitive operation is here defined as the last operation undertaken to treat the injury with an antici- pated good result, and no lysis may be called the definitive operation if it follows a suture or graft. All subsequent tables on management refer to it. A cuff removal following a suture or graft is not classified as a defini- tive operation; a suture done after an unsuccessful graft is, however, classi- fied as a definitive operation. In the analysis of the effect of number of operations upon nerve regeneration, bulb suture was not counted as a sepa- rate operation but considered to be the first stage of an anticipated defini- tive suture, but explorations, transpositions, and other operations following more definitive procedures were counted. Neurolysis, removal of a tantalum cuff thought to act as a barrier to nerve regeneration, and un- successful suture were defined as operations. An approximation suture, usually performed at the time of wound toilet, was not defined as an oper- ation. Since it is the definitive operation which appears on the follow-up card, the subsequent portions of this report revolve around it, and what- ever is learned from the tables in this section will provide useful background data. It should be noted that subsequent tables will embrace a total of 3,416 injured nerves with definitive operation rather than the total of 3,656 injured nerves used heretofore. The sequence of operations terminated by the definitive operation will be discussed in a subsequent section. 40

The features of the definitive operation which were abstracted from the military records are as follows: Number of operations. Interval from injury to operation. Calendar date of operation. Medical echelon of repair. Training of surgeon. Type of surgery performed. Special features of operation, e. g., bulb suture, mobilization. Length of surgical defect after resection. Other operative procedures prior to separation, e. g., tendon transplant, arthrodesis. Suture materials employed. Use of cuff. Placement of stay suture. Technique of neurolysis. Tension on suture-line. Results of electrical stimulation. Condition of nerve ends just prior to anastomosis. At the outset a study was made of the lesions derived from the three main roster groups as to their comparability in respect to treatment. These groups are, it may be recalled: A. Army Peripheral Nerve Registry cases within the sampling areas. B. Lysis rosters (rosters 40, 47, 90, 92 described on p. 7). C. Other rosters (rosters 39, 48, 61, 86, 88) and Registry cases outside the sam- pling areas. The rosters, of course, consist of men, so that the lesions contributed by each roster group may be both complete and incomplete. This is especially true of groups A and C. From the comparisons which were made, it seemed evident that the Registry cross section (group A) differed significantly from group C in a number of respects. These differences were not always striking but were sufficient to support the decision to limit the descriptive parts of the main chapters to sutures of the group A rosters and to lyses from any source except Registry cases outside the sampling area. A typical study table which is of interest in terms of the probability of more than one operation, regardless of type, is table 21. In summary form, the points on which the roster groups were compared and the results are as follows: 1. Registry cases within the sampling area (group A) were operated upon somewhat less often than group C cases. 2. The definitive operation on group A cases occurred somewhat sooner after injury than is true of group C cases. 3. The average calendar date of the definitive operation is 1 to 3 months earlier for group A than group C cases. 4. Group A cases were operated upon more often overseas than group C. 5. Groups A and C do not differ as to special operative features. 6. Group A sutures were less often done with tantalum than group C sutures. 7. The use of a cuff does not vary between groups A and C. 8. A stay suture was more often used in group C sutures than in group A. 403930—57 6 41

9. Group C cases were more often done by surgeons without known neurosurgical training. 10. Groups A and C do not differ as to such ancillary operative procedure! as cuff removal, tendon transplants, arthrodesis, sympathectomy for pain, etc. Table 21.—Percentage of Lesions Requiring More than One Operation, by Type of Injury, and by Roster Group Roster group Army Registry, within sampling area Lysis rosters Other (C) Type of injury (A) (B) 5.7 19.4 17.1 13.9 4.8 11.8 14.1 25.0 22.5 Other 30.4 28.2 34.5 5.6 19.7 9.1 Differences among the nerves in respect to the number of operations are not remarkable and are statistically significant at only two points: 1. Among normal nerves, the median much less often (3.3 percent) required more than one operation than other nerves (12.0 percent). 2. Among complete divisions, those on the tibial nerve were much less often oper- ated upon more than once (7.5 percent) than was true of other nerves (table 22). Table 22.—Percentage of Nerves Completely Divided at Injury Requiring More Than One Operation, by Nerve Nerve Percentage Nerve Percentage Median 22.3 Tibial . ... ... 7 5 Radial 15.9 Sciatic-tibial 23 3 Ulnar 22 9 Peroneal 28.9 All 21.2 Sciatic-peroneal 22.4 For the entire series as a whole, table 23 indicates the time interval from injury to definitive operation, as this procedure has already been denned. After the first 30 days, the number of cases available for study rises rapidly, in all probability reflecting the World War II emphasis upon "early" nerve suture (75). An adequate number of cases operated upon after 365 days is likewise available for study of regeneration after the assumed in-

terval for optimal recovery. Examination of the interval from injury to definitive operation in terms of the character of the operation and the type of injury suggests the following: 1. On the average a definitive suture was accomplished most promptly if the lesion was one of complete division and with the greatest delay if the operator was pre- sented with a neuroma in continuity; partial lesions occupy a middle ground. 2. Definitive lyses on nerves of normal appearance were accomplished more exped- itiously than definitive lyses on neuromas. 3. The definitive repair of a neuroma by means of suture was generally done well before a definitive lysis on a neuroma. Table 23.—Interval From Injury to Definitive Operation, Total Sample * Interval, in days Nerve lesions Interval, in days Nerve lesions Number Percent Number Percent Under 10 100 44 252 381 495 488 382 313 212 188 116 150 2.9 1.3 7.4 11.2 14.5 14.3 11.2 9.2 6.2 5.5 3.4 4.4 360-419 90 60 40 41 20 9 11 8 4 11 2.6 1.8 1.2 1.2 0.6 0.3 0.3 0.2 0.1 0.3 10-29 420-479 30-59 480-539 60-89 540-599 90-119 600-659 120-149 660-719 150-179 720-779 180-209 780-839 210-239 840-899 240-269 270-299 300-359 Total 3,415 100.1 1 One case excluded for unknown date of definitive repair, others^ for lack of any definitive operation. Table 24 shows that most definitive operations were performed in 1945, by which time the neurosurgical centers and acceptable methods of repair had been fully developed. Echelon of repair of an injured nerve is obviously related to the time- interval from injury to repair. Under the stimulus of the principle of "early" nerve suture, many definitive repairs of uncomplicated nerve divi- sions were made in neurosurgical centers in overseas hospitals. In this sample, 84.2 percent received their definitive operation in hospitals of the Zone of Interior. Medical echelon of repair was originally abstracted in terms of the following general classification, based on Army terminology: field hospital overseas, evacuation hospital overseas, general hospital over- seas, and general hospital in the continental United States. When the lesions with definitive operation were first distributed according to this classification, however, it was found that only 0.3 percent had been per- formed in field hospitals, 1.4 percent in evacuation hospitals, and 14.1 per-

cent in general hospitals overseas. Consequently, only the overseas-Z/I aspect of the classification was employed in later analyses. Table 24.—Calendar Period of Definitive Operation, Total Sample Nerve lesions Nerve lesions Number Percent Number Percent 1942 or earlier 1 0.0 1945* July-Sept 635 18.6 1943 38 1 1 1945 Oct-Dec . . 163 4 8 1944 Jan -Mar 41 1 2 1946 144 4 2 1 944 Apr —June . . . 70 2 0 1947 16 0.5 1944, July-Sept ... 237 6 9 1948 7 0.2 1 044. Ort -rW~r- •^»9 119 1945, Jan.-Mar 797 23. 3 Total 3,416 99.9 1945, Apr.-June 885 25.9 When the abstracting was being planned it was agreed by all members of the group that the training or experience of the surgeon should be a determining variable of importance in the end result. Opinions differed, however, as to just which features of training and/or experience might be significant. No such characteristic could be employed unless the clas- sification of any individual surgeon could be reduced to a simple task, for hundreds of different operators were involved in the series as a whole. It was finally decided, therefore, to attempt no more than the following classification of neurosurgical training: Trained neurosurgeon. General surgeon trained to do neurosurgery. Essentially untrained in neurosurgery. Training unknown. The trained neurosurgeons were most easily identified as the products of the various neurosurgical centers in the United States. The general surgeons with supplementary training in neurosurgery were identified largely on the basis of lists of graduates of the special courses instituted for the purpose at Columbia and the University of Pennsylvania. When the definitive operations were classified in this way it was of interest to observe that 44.4 percent had been done by trained neurosurgeons, 33.4 percent by general surgeons with supplementary training in neurosurgery, 0.4 percent by surgeons with essentially no training in neurosurgery and 21.8 percent by surgeons whose training was unknown. Many of the last group, of course, may have had considerable wartime experience in the surgery of peripheral nerve lesions. Also, in each neurosurgical, center a fully trained Chief of Neurosurgery was in charge of all cases. Surgeons with little background in peripheral nerve surgery were rigorously and intensively trained by the chief before they were permitted to operate.

Their performance of the essential operative steps was ordinarily super- vised in detail by the chief before they were permitted to proceed inde- pendently. It seems probable, under these circumstances, that the policies and degree of supervision exercised by the Chief of Neurosurgery in each center may have been of more importance than the formal training of the operating surgeon. The neurosurgical training of the operator exhibited some variation in relation to identity of nerve, type of injury, and type of operation. The most probable finding showed that, in completely divided nerves, there was a tendency for the better-trained operators to suture the sciatic and tibial nerves and for the less well-trained to handle the ulnar nerve more often than other nerves. The definitive operation has been defined earlier (p. 40). It will be recalled that a final lysis could be regarded as the definitive operation only if not preceded by a suture or graft. Table 25 presents the basic counts as to type of surgery performed at the definitive operation. It will be noted that there were 605 cases in which only lysis was performed. In 42 cases the initial operation was a graft, and additional grafts were done at the second operation. However, the final count of table 25 gives only 30 lesions with definitive operation graft, many grafts having been removed in favor of anastomosis of the nerve ends themselves. The 11 operations in the "other" category of table 25 represent reroutings, intrafascicular sutures, etc. Table 25.—Type of Definitive Operation, Total Sample l Nerve lesions Number Percent 213 6.2 Complete suture 2,556 74.8 605 17.7 Graft 30 0.9 Other 11 0.3 Total 3,415 99.9 1 Excluding one case in which the record was unclear as to type of definitive operation, and lesions not operated upon. Of more specific interest is table 26 where are presented the several special operative features that might be associated with the definitive suture or graft. The separate classifications are self-explanatory but note should be made of the large number of nerve-segment transpositions and mobilizations that were deemed necessary to carry out technically good nerve suture. The cases with antecedent bulb suture will also be a source 48

Toble 26.—Special Operative Features at Definitive Graft or Suture, Told Sample Special features Number Percent None 1 353 39 6 51 1.5 Transposition of nerve segment 607 17.8 Normal bone resection 21 0.6 26 0 8 2 0 1 MV>re than one lesion on this nerve repaired * . « 15 0.4 Bulb suture prior to this operation and extensive mobilization of nerve preparatory to suture or graft 50 1.5 Bulb suture and transposition of nerve segment 49 1.4 Extensive mobilizarion of nerve preparatory to suture . 567 16.6 Other, including other combinations 62 1.8 Not suture or graft 613 17.9 Total 3,416 100.0 Table 27.—Percentage of Completely Sutured Lesions in which Transposition * or Mobilization 1 Was Performed at the Definitive Suture, by Nerve and by Type of Injury Type of injury Complete division Neuroma Nerve Transpo- sition only Mobili- zation only Transpo- sition only Mobili- zation only M^Hian ..*..-*.*-.... * * 15.4 6.6 62.9 4.6 1.5 16.3 1.9 24.6 16.2 4.6 9.8 4.0 65.2 3.0 0 13.2 1.5 27.7 12.0 7.7 17.9 27.3 21.1 30.3 Radial Ulnar 25.5 42.4 35.6 43.9 Sciatic-peroneal Tibial Sciatic-tibial All nerves . . . 24.7 21.8 22.3 18.8 1 Omitted from the counts are a small number of both transpositions and mobili- zations associated with bulb suture as a first stage in the repair, addition of which does not materially affect the pattern of variation. of further review. The special operative features of transposition and extensive mobilization showed a great deal of variation among individual nerves (table 27). In general, transposition was rather common in the 46

ulnar and rare in the radial, sciatic, and peroneal nerves. Extensive mobilization was, on the other hand, common in the sciatic but rare in the ulnar nerve. The length of surgical defect, i. e., that following removal of all patho- logical tissue, was coded to the nearest cm. (centimeter), and the resulting distribution appears in table 28. In about 5 percent of the cases the ope- rator merely recorded that the gap was in excess of some stated number of cm., and these appear in the table at whatever number was so stated. An attempt was made to cope with the special problem presented by bulb sutures so that the estimates would reflect, not the gap at any particular operation, but the total length of the nerve excised or otherwise lost at injury and all subsequent operations. This assumes that, by the time a second stage suture is done, the first gap will have been made up, so that any second gap may be added to the first as an estimate of the total length of nerve lost. However, if two sutures were done the respective gaps were not added together in this way. Length of surgical defect is quite reliably associated with specific type of injury and the gross anatomical location of nerves. In general, com- plete nerve divisions were followed by longer surgical defects and, among individual nerves, injuries of the sciatic nerve gave rise to longer surgical defects (table 29). Table 28.—Length of Surgical Defect at Definitive Repair, by Complete Suture or Graft, Total Sample1 Length of defect, an. Nerve lesions Length of defect, cm. Nerve lesions Number Percent Number Percent Under 04 12 0 5 13 5-14 4 . . 27 1. 1 0. 4-1. 4 49 1 9 14 5-15 4 ... 17 0.7 1. 5-2. 4 169 6.6 15 5-16 4 7 0.3 2.5-3.4 375 14.7 16. 5-17. 4 3 0.1 3.5-4.4 387 15.1 17. 5-18. 4 4 0.2 4. 5-5 4 399 15 6 18 5-19 4 5. 5-6. 4 305 11 9 19 5-20 4 3 0.1 6. 5-7. 4 249 9.7 20 5-21 4 ... 7. 5-8. 4 218 8.5 21 5-22. 4 8. 5-9 4 113 4 4 22 5-23 4 3 0.1 9. 5-10 4 95 3 7 31 5-32 4 ... 1 0.0 m5-ll 4 48 1 0 11.5-12.4 48 1.9 Total 2,558 100.0 12 5-13 4 26 1 0 1 Excluding 213 partial sutures and 32 unknown for length of defect; also, 131 cases are classified as X cm. for which the record merely shows gap to have been at least X.

Table 29.—Mean Length of Surgical Defect in Centimeters, Sutures and Grafts, by Nerve and by Type of Injury Nerve Type of injury Complete division Partial division Neuroma All types cm. 6.3 5.3 6.1 6.4 7.7 7.2 8.2 cm. 4.1 3.5 3.4 4.2 5.6 4.3 5.3 cm. 4.1 4.2 4.2 5.5 5.6 5.2 5.9 cm. 5.4 4.9 5.5 5.8 6.9 6.2 7.1 \fpHfan . . . * * * * * * * * * * * * . Radial Ulnar Peroneal Sciatic-peroneal Tibial . . Sciatic-tibial All nerves 6.5 4.2 4.8 5.8 In a study of special operative features (bulb suture and transposition and extreme mobilization procedures) and the length of the surgical defect overcome at the definitive operation, these conclusions were reached: 1. Bulb suture is associated with a gap 2 to 3 times that observed in cases with no special operative procedures, as noted in table 30. This difference amounts to 6.43 cm. in the median nerve, 7.40 cm. in the ulnar nerve, 4.35 cm. in the radial nerve, and an overall average of 6.25 cm. for all nerves. 2. Transposition and extreme mobilization procedures are associated with smaller differences in length of gap, about 1.55 cm. for both complete and incomplete lesions on all nerves combined. Before they were separated from service many patients had ancillary surgical procedures of an orthopedic or neurosurgical variety, especially cuff removals, tendon transplants, sympathectomies for pain, and ar- throdeses. The list of procedures abstracted from the records appears in table 31 together with the total counts observed in the entire series. Table 32 shows how often each procedure was carried out in connection with lesions treated by suture (complete or partial) or graft, separately for each major nerve. It may be noted that such procedures were abstracted with the material for each nerve only as they related to the nerve in question, and tendon transplants only if they were done because of deficiencies in nerve regeneration. Cuff removals were noted without regard to the intent of the operator; in some instances removal was routine, and in others motivated by a desire to further the process of regeneration. Of all the supplementary procedures tendon transplants proved to be the most vari- able in relation to the nerve injured, as table 32 shows. Only for the median, radial, ulnar, and peroneal was this procedure at all frequent. Amputation for nerve injury was, of course, quite rare in this series of treated nerve lesions and was usually confined to digits of the upper extremities.

In the upper extremity cuff removal was done in about 8.9 percent of cases, in the lower extremity in about 7.5 percent. In the upper extremity, arthrodesis was done in 3.2 percent of the cases. Table 30.—Mean Length of Gap in Relation to Special Operative Features, by Nave and Type of Injury, Completely Divided Nerves Treated by Suture or Graft Special operative features Nerve None Bulb suture Transposition- mobilization Number of lesions Mean gap Number of lesions Mean gaP Number of lesions Mean gap em. 4.93 3.63 4.22 5.72 5.85 6.74 7.28 cm. 11.36 11.03 8.57 cm. 6.26 6.35 5.65 6.84 7.22 8.01 8.39 \frHian 126 28 29 28 120 337 62 45 54 88 70 Ulnar 91 124 93 33 90 67 Radial Tibial Sciatic-peroneal Sciatic-tibial Table 31.—Relevant Operative Procedures Other Than Nerve Repair Performed Prior to Separation From Service, Total Series Operative procedure Lesions associated with such procedures Number Percent None 2,991 81.9 Xendon transplant 252 6.9 16 0.4 53 1.5 103 2.8 Sympathectomy for pain 105 2.9 Removal of cuff or wrapping 259 7.1 Total kr>wi ' . * *..*.. 3,651 100.0 1 Frequencies do not add to totals shown because of multiple procedures per lesion. The abstracting of operation reports was extended to several technical features of the operative procedure itself, namely, the type of suture mate- rial, the use of a nerve suture cuff, the choice of a stay suture, and the 49

method of performing a neurolysis. Sutures were chiefly (71 percent) done with tantalum wire; in addition 5 percent were performed according to the plasma glue technique, and in 24 percent other materials, mainly silk, were used. Table 32.—Relevant Operative Procedures Other Than Nerve Repair Performed Prior to Separation From Service, Lesions Treated by Suture or Graft Only, by Nerve Nerve Total lesions Percentage of lesions associated with stated procedures Tendon trans- plant Ampu- tation Capsu- lotomy Ar- Sympa- thectomy Cuff None throd- esis removal Radial 518 395 73.4 78.7 80.9 86.4 84.1 86.7 86.6 13.7 14.7 5.9 8.4 1.5 0.6 0 0.4 0.3 0.6 0 0 0 0 3.1 0.8 2.1 0 0 1.7 0.4 5.2 1.5 2.7 3.5 1.2 0.6 1.1 2.5 1.3 1.7 1.0 3.1 5.6 3.6 8.9 6.8 10.0 3.5 11.0 5.6 8.7 Ulnar 780 287 327 180 277 Sciatic-peroneal. . . . Tibial Sciatic-tibial The various nerves were compared as to the use of a cuff at the time of definitive suture, and for neither partial divisions nor neuromas were sig- nificant variations noted. Among complete nerve divisions, however, the cuff was least often used in peroneal lesions. Among all nerves, 37.2 per- cent were treated by a suture-line cuff at the time of definitive suture. Practically all cuffs were made of tantalum foil. Stay sutures were most commonly used in complete divisions of the sciatic branches. Otherwise, the nerves appeared fairly homogeneous in this respect; 24.7 percent of all definitive sutures were accomplished with the aid of a stay suture. The so-called external lysis, a poorly defined procedure, appeared to be the method of choice in lysis cases, being done in 70 percent of such cases. In 25 percent the lysis extended to the internal injection of saline, and in 5 percent to fascicular dissection. Certain subjective observations were often recorded by the peripheral nerve surgeon, especially his opinion of the degree of tension upon the two nerve segments at the time of suture, his evaluation of the nerve ends to be approximated, and the response to electrical stimulation prior to suture. In 46 percent of the definitive sutures and grafts the operator failed to men- tion the subject of tension, but in 43 percent he explicitly stated that ten- sion was absent or, in effect, within normal limits. In 9 percent tension was noted as moderate in degree, and in only 2 percent was it called marked or severe. The nature of the material on electrical stimulation was frag- so

mentary and did not lend itself well to review; although it was initially abstracted no use is made of it in the subsequent analysis. Since the oper- ator's estimation of the pathologic changes in nerve ends may be of prac- tical significance, the available data are presented for review in table 33. The reliability of these observations, of course, is in sharp contrast with that of the neuropathological assessments analysed in chapter XI. Several associated injuries, and complications of injury, are thought to influence the normal course of neural regeneration. The most common of these are injuries to major arteries, bones, and soft tissue if severe, and chronic wound infection. Their influence is generally reflected in an in- crease in the injury-operation interval, and in other facets of management. On the other hand, the necessity of repairing an injury to an important vessel may actually shorten the interval between injury and nerve operation. Table 33.—Operator's Evaluation of Nerve Ends at Definitive Repair by Suture or Graft, Total Sample * Evaluation of nerve ends by operator Nerve lesions Number Percent 1. Both distal and proximal described as having normal 1,328 259 72.0 14.0 2. Both distal and proximal described as having some, but not considerable, scarring and some normal fascicles, or 3. Either distal or proximal described as having considerable scarring, and with some normal fascicles, or as being poor or very poor 117 6.3 2.5 5.0 47 93 Total 1,844 99.8 1 Excluding 959 for which ends were not sufficiently well described as well as those not treated by suture or graft. Associated bone and joint injury was studied in relation to two features of the definitive operation, i. e., days from injury and other operative procedures. Quite uniformly, there was a significant delay in the final operation for cases with associated bone and joint injury. For complete nerve division with suture the delay amounted to 52 days, and even for lyses the effect was a general one. Table 34 gives the supporting data. Operative procedures other than surgery upon the nerve injury itself were similarly analyzed in relation to associated bone and joint injury with particular reference to orthopedic rehabilitation measures and to sym-

pathectomy for pain. The following conclusions were suggested by this study: 1. The presence of associated bone and joint injury had little effect upon the fre- quency of other operations if the neurosurgical operation was that of lysis. Excep- tions were noted in the median nerve where capsulotomy and arthrodesis, and possibly sympathcctomy for pain, were done more frequently upon cases with bone and joint injury. 2. In complete nerve division* and also in incomplete lesions requiring complete suture, the number of tendon transfers was notably increased in radial and median nerve cases when the nerve lesion was associated with bone or joint injury. la the median nerve* the percentage of cases with arthrodesis and capsulotomy was also increased. Sympauiectomy for pain seems unrelated to associated bone and joint injury. Table 34.—-Mean Days From Injury to Definitive Suture, by Presence of Associated Bone or Joint Injury, by Nerve, and by Type of Injury, Complete Sutures Only Complete nerve divi- sions, by presence of associated bone or joint injury Neuromas in continu- ity, by presence of associated bone or joint injury Nerve sutured Absent Present Absent Present Mean days Ulnar 191 153 116 218 184 160 165 236 198 135 152 101 190 145 138 135 170 287 179 193 208 196 150 Radial 200 221 260 272 261 Peroneal Tibial Sciat ic-peroneal Sciatic-tibial All nerves 168 220 143 192 The interval from injury to operation and the need for ancillary surgical procedures were also studied in relation to chronic infection. A quite considerable delay was found to be associated with chronic infection, amounting to 3 to 4 months on the average (table 35). Chronic infection also increased the need for tendon transplants and other orthopedic procedures. The presence of an associated arterial injury was next studied in relation to the interval between injury and definitive repair, and to the need for ancillary surgical procedures. For cases of complete nerve division and suture, there was a significant difference between cases with and without arterial injury, those with an associated arterial injury being operated upon about 1 month earlier. No suggestion of this appears in the other injury-operation groups but the difference is not judged to be an artifact. 52

Cases with arterial injury more often had other operative procedures such as tendon transplants. In cases requiring suture, it was evident that a major soft tissue defect needing plastic surgery considerably delayed the definitive suture. The effect was quite marked, averaging about 60 days for complete divisions treated by complete suture (table 36). Tendon transplants, capsulotomies, and arthrodeses were about twice as frequent in cases with soft-tissue defects. Toble 35.—Mean Days From Injury to Definitive Operation, by Chronic Infection Deferring Definitive Operation, by Nature of Nerve Operation, and by Type of Injury Chronic infection Nature of nerve operation and type of injury to nerve Present Absent Mean days Complete suture: Complete division 281 256 270 181 161 154 Other Lysis : Normal appearing nerve Table 36.—Mean Days From Injury to Definitive Operation, by Presence of Soft Tissue Defect, Type of Operation, and Type of Injury Nature of nerve operation and type of injury to nerve Present Absent Mean days Complete future: Complete division 247 188 168 184 163 166 Other Lysis : Normal appearing nerve . . Soft tissue defect C. PROBABILITY OF REOPERATION A brief discussion must be devoted to the probability of reoperation and its relation to various characteristics of the injury and first operation itself. The analysis takes as its criterion of failure of the first operation the fact of a subsequent, and applies this criterion to those characteristics of the injury and its treatment which might be thought to influence the result. It might 53

be regarded as a miniature follow-up study, based on a fairly weak index of success or failure. Not all subsequent operations, of course, constitute equally valid evidence of failure of the initial operation, so that the pattern of reoperation must be defined with some care. An initial suture, for example, can hardly be said to have failed if at some later point in time a neurolysis or a cuff removal was performed; the only operation which would provide compelling evidence of failure would be a second suture, or a graft. The organization of the discussion depends upon the character of the first operation of definitive intent, i. e., whether it was a complete suture, a lysis, a partial suture, or a graft. There were so few cases in the last two groups that no attempt was made to relate the chance of reoperation to any characteristic of injury or operation; attention was confined to estima- tion of the probability of reoperation following each of these procedures as a first operation. Extensive analysis seemed warranted only for cases in which a complete suture or a lysis was the first operation. The lysis sample, of course, is biased for estimating the probability of reoperation itself because of the nature of the sampling plan. 1. First Operation Suture Some 13 characteristics of injury and the definitive operation, all of which have been described earlier, were selected for this phase of study. Reoperation was defined as a second suture (rarely a graft); cases in which a subsequent exploration, lysis, cuff removal or other procedure was done were not regarded as having been reoperated upon. The criterion of failure, therefore, is a conservative one, and reoperation is defined as resuture. In addition, studies were made on the reason for any subsequent operation and the reason for any later known failure. The entire analysis of first sutures may be brought together in the fol- lowing summary on the probability of reoperation following initial suture. Appropriate tables are included to illustrate findings of particular interest. a. The gross level of the injury has no apparent effect in lesions of the median and ulnar nerves. In the lower extremity, on the other hand, peroneal nerve lesions were reoperated upon twice as often as sciatic-peroncal* whereas tibial nerve in- juries showed a low percentage of reoperation. Table 37 gives the data for these comparisons. b. Type of lesion is quite strongly associated with the chance of reoperation, com- pletely severed nerves being resutured about twice as often as incompletely divided nerves (table 38). The nerves themselves also differ quite significantly as to the chance of reoperation. c. Chronic infection delaying repair has no surely significant influence on the chance of reoperation; there is some suggestion that such cases were less often resutured. The same suggestion is present in the material on associated bone and joint injury. Associated arterial injury and major plastic repair at the site of nerve injury have no influence upon the possibility of resuture. d. The interval from injury to operation is strongly associated with the chance of reoperation, earlier suture being followed by resuture much more frequently than later. This trend was quite noticeable in upper extremity injuries (fig. 7).

Table 37.—Chance of Resuture and Gross Site, Lesions With First Operation Complete Suture, by Nerve Nerve High lesions Low lesions Number cases Percentage resutured Number cases Percentage resutured 213 5.6 230 9. 1 Ulnar 382 9.1 349 8.3 Peroneal 306 9.8 232 21.1 Sciatic-tibia! 238 10.1 Tibial 154 3.9 Table 38.—Chance of Resuture and Type of Injury, Lesions With First Operation Complete Suture, by Nerve Type of injury Nerve Severance Incomplete Number cases Percentage resutured Number cases Percentage resutured 303 520 271 151 103 205 156 9.9 9.8 5.9 23.8 1.9 10.2 12.2 109 175 88 81 51 101 82 1.8 Ulnar 5.7 4.5 16.0 7.8 8.9 6.1 Radial Peroneal Tibial •Sciatic-tibia! It was also found that initial sutures performed overseas were rcoperated upon about five times as often as those done in the Zone of Interior (table 39). This finding reflects the high incidence of failure following nerve suture overseas and merits full consideration here. In 1946, a preliminary study was conducted of regeneration in 419 cases of "early" nerve suture, where a definitive nerve suture had been per- formed in an overseas installation at an average time period of 39 days after the initial injury (89). This group of cases was compared* in terms of regeneration, with 89 cases in which nerve suture had been performed on the day of injury and/or the day of initial wound debridement. The study utilized follow-ups at 12 months after injury and, since only the first phases of normal neural regeneration could be assessed at this time, the analysis was devoted in large part to obvious failures occurring in each group. Table XII of that early report is reproduced in part here

Figure 7. Percentage of Cases Resutured by Days From Injury to Operation PERCEK RESUT 100 "^ PERCENTAGE RESUTURED ^ ENTAGE TURED 100 80- MEDIAN* -80 60- 40- 1 • 60 40 ...p -j ••;.-•" - 20 PERCENTAGE PERCENTAGE RESUTURED inn RESUTURED 1 ULNAR* • 80 RADIAL • 80 " - ] v 60 60 : I 40 MRH - — 20 80- PERONEAL 80 - TIBIAL 80 60 60 - • 60 40 I*?* . pT^ - 40 . • 40 • 20 ,;s : :: - 20 - 20 100| roo ' 0 100 80J- SCIATIC PERONEAL 80 . SCIATIC TIBIAL • 80 J "~ 1 - 60 . - 60 1 40 M 1 40 1 0 _r—v— ^ . 20 0 0- 19 20. 39 40- 60- 159 160- 259 260- 999 0- 19 20- 39 40- 60- 160- ?60- 59 159 259 999 59 0- 2O- 40- 60- 160- 260. 19 39 59 159 259 999 DAVS FROM INJURY TO OPERATION •Completely divided by Injury 56

as table 40 and exhibits a much higher incidence of failure in sutures performed in advanced installations than in those done in general hospitals overseas. Neuro- pathological studies in 16 of the 20 failures in the emergency suture group suggested: (1) semantic confusion in the use of the terms "definitive suture," "coaptation" or "approximation suture," and "bulb suture;" (2) destruction of fascicles by badly placed sutures; (3) failure to recognize the longitudinal extent of injury; (4) frequent infection; (5) disruption of suture lines; and (6) badly scarred nerve suture beds. These and other studies (46) showed clearly, however* that a good coaptation suture, i. c.* simple approximation by a single suture of severed nerve ends visualized at debridement, reduced the extent of resection of pathologic tissue necessary at second- ary nerve repair. Table 39.—Chance of Resuture and Echelon of First Suture, Lesions With First Operation Complete Suture, by Nerve Nerve Overseas Zone of Interior Number cases Percentage resutured Number cases Percentage resutured \frHian . . . 66 148 77 50 57 44 25.8 27.0 18.2 32.0 22.8 25.0 379 582 282 182 249 194 4.2 4.0 2.1 18.1 6.8 6.7 TTInar ... Racial Peroneal Sciatic-pcrone.it . . Sciatic-tibia! Table 40.—Likelihood of Failure in Relation to Hospital Installation, Early Nerve Suture Overseas Overseas installation of suture Total Failures cases Number Percent General hospital * . * * * 419 89 21 20 5.0 22.4 Forward installation In the present study, 149 cases of emergency, or immediate or primary nerve suture were available for study. Again, the simplest criterion for failure was the fact of a second suture. When the percentage of cases requiring resuture'is calculated for successive intervals from injury to operation, separately for each nerve (fig. 7), an average resuture rate of 51 percent is found for the interval 0-19 days from injury to suture; obtained directly the figure is 54 percent, representing 81 resutures among 149 cases. Under the exigencies of military neurosurgery, this interval would include all emergency sutures and a scattering of sutures done at the time of second- 403930—57-

ary wound closure. In abstracting the clinical records an effort was made to ascer- tain the purpose and expectation of the surgeon prior to undertaking any subsequent operation, as well as the evidence on which his opinion was based. His purpose was categorized as follows: Reason for surgery Casts Exploration merely to see what had been done 1 Exploration, believing failure may have occurred 59 Repair obvious failure 17 Reason unknown.. * 4 Total 81 The evidence for his opinion was grouped as follows: Evidence of opinion Cases X-ray 2 Clinical evidence, no recovery 43 Clinical evidence, poor recovery 27 Palpation of neuroma 5 Unstated 4 Total 81 Further, on the basis of what the surgeon found at reoperation, an effort was made in the abstracting to indicate the probable reason, usually expressed by the surgeon, for any failure which was believed to have occurred. The 81 failures may be described in terms of this classification as follows: Reason for obvious failure Cases Tension, with separation of suture-line 24 Scar tissue or neuroma formed at site of suture-line 53 Separation of suture-line and neuroma 2 Unknown 2 Total 81 In view of the often-repeated assertion that many Z/I surgeons preferred to explore every peripheral nerve lesion, whether or not sutured overseas, and the possible implication that the overseas sutures were more often resutured in the Z/I merely because of excessive zeal on the part of Z/I surgeons, the senior author (BW) re- viewed the original records on median and high ulnar lesions with this possibility in mind. The records of 54 cases were reviewed among the 59 meeting these specifications, 5 being in use by investigators concerned with other parts of this report and temporarily unavailable. The choice of resuture, often verified by neuropathological studies, or simple exploration, appeared well-chosen in this series of hand-analyzed cases. Representative cases have not been described in detail but are available, as are all case folders, for the interested student e. Tension noted during the operation and recorded in the operation report appears to have had a significant influence since the chance of reoperation was about four times as high in the cases with at least moderate tension as in those with no tension. f. Special operative features are reliably associated with the chance of resuture for the median and ulnar but not for other nerves, the effect being that resuture is rare 58

among those with special operative features generally. The study of particular features was confined to bulb suture and transposition. Among all the nerves there were 142 cases of bulb suture followed by definitive suture, with only 12 resutures or 8.5 percent. For a set of cases matched as to nerve, but having no special operative features of any kind* the percentage reoperated upon was 13.6, which does not differ significantly from 8.5 percent. In complete lesions of the ulnar nerve there were 314 cases with transposition but no other special operative feature, and in only 12 or 3.8 percent was resuture attempted, in contrast to 26.3 found in cases with no special operative features. The latter difference is large and quite significant statistically. These differences represent a reluctance on the part of the operator to attack again surgical problems that have already had the benefit of extreme efforts to overcome nerve gap. g. Suture material appeared to be a factor in the chance of reoperation, cases with tantalum suture being less often resutured. h. On the average, cases with stay suture were resutured with 1.9 times the fre- quency observed for cases in which stay suture was not used. i. No effect was found associated with the length of surgical defect. j. Sutures performed by essentially untrained surgeons were repeated about five times as often as those done by trained neurosurgeons and general surgeons with neurosurgical training. This may represent an influence of echelon of repair. k. The operator's evaluation of nerve ends correlates somewhat with the chance of reoperation, and in the expected direction. If a resuture were necessary, surgical intervention usually started either as an exploration of a possible failure or a frank effort to repair an obvious failure but there were large differences among the nerves in the relative importance of the two purposes (table 41). Failure was more often ob- vious in the leg nerves generally, and rarely obvious in the ulnar and median. Table 41.—Reason JOT Resuture, Lesions With First Operation Complete Suture, by Nerve Exploration in belief of possible failure Repair of obvious failure Nerve Total cases 28 4 32 Ulnar 53 7 60 Radial 14 4 18 Peroneal 36 13 49 Sciatic-peroneal 18 12 30 Tibial 3 3 6 Sciatic-tibial 14 8 22 Total known 166 51 212

Table 42.—Evidence for Decision To Resuture, Lesions With First Operation Complete Suture, by Nerve Clinical evidence of no re- covery Clinical evidence of poor re- covery Palpa- tion of neuroma Nerve X-ray Total cases Median 1 13 14 4 32 Ulnar 1 26 28 6 61 Radial 2 9 7 0 18 Peroneal 12 21 15 1 49 Sciatic -peroneal 13 14 2 0 29 Tibial . 2 2 2 o 6 Sciatic-tibial 7 10 4 o 21 38 95 72 11 216 Table 43.—Reason for Obvious Failure of First Suture, Lesions With First Operation Complete Suture, by Nerve Tension caus- ing separation of suture line Scar tissue or neuroma Total cases Nerve Other Median 8 22 47 12 11 5 2 5 3 3 1 4 1 2 0 33 63 20 49 30 6 24 Ulnar 13 7 34 24 2 19 Radial Peroneal Sciatic-peroneal Tibial Sciatic-tibial Total known 107 104 14 225 Evidence for the decision to reoperate was also made the subject of a comparison of nerves; highly significant differences were found (table 42). The variation exhibited in table 42 parallels that seen in connection with the reason for surgery. In the lower extremity there was frequently X- ray or clinical evidence of no recovery. In the upper extremity X-ray evidence was rare; resuture was more often undertaken because recovery seemed poor. The reason for obvious failure of the first suture was also studied for variation among nerves, and quite significant differences were found (table 43). The chief reasons were tension, with separation of the suture-line, and scar tissue or neuroma formed at the suture-line. In the lower ex- 60

tremity failure is more often (72 percent) attributed to tension with separa- tion of the suture-line and, in the upper extremity, to the formation of scar tissue or neuroma at the suture-line (70 percent). 2. First Operation Lysis A much more limited study was done on lesions first treated by lysis, using only the following characteristics: a. Interval from injury to operation. b. Type of lysis. c. Training of surgeon. These studies show, for the sample of initial lyses used here, that a subse- quent suture was done in 6.2 percent and a subsequent lysis, exploration, or cuff removal in 11.8 percent. The sampling plan for the present study, with its major emphasis upon definitive suture, and secondary emphasis upon definitive lysis, is a poor basis for estimating the chance that an initial lysis might suffice and be followed by additional surgery of one kind or another. However, the sample is not obviously biased in regard to the effect which various characteristics of injury and treatment might have upon the rate of reoperation, whatever the true average level may be. Differences among nerves are of little importance except that subsequent suture was rare in the tibial. In the upper extremity, gross height of lesion is of some importance; in median and ulnar injuries the chance of subsequent suture is 2.1 percent in high and 15.6 percent in low lesions first treated by lysis. Interval from injury to operation has considerable influence upon the chance of reoperation, early lyses being repeated or replaced by sutures more often than late. Training of surgeon bears no evident relation to the chance of reoperation. The type of lysis originally performed also has no relation to the chance of reoperation. 3. First Operation Partial Suture No detailed analysis was made of the probability of reoperation following partial suture. Among the 216 partial sutures done at first operation 44 cases were reoperated upon as follows: Complete suture 12 Partial suture 4 Lysis, cuff removal, etc 28 Total 44 The differences among nerves are not statistically significant. 4. First Operation Graft Reoperation following an initial graft was studied in the 42 cases available in the entire series. Of these, 12 were never reoperated upon, in 10 any reoperation was confined to exploration, cuff removal, or lysis, and in 20 an end-to-end anastomosis was eventually done. 61

D. CUFF REMOVAL This brief analysis has to do with the matter of cuff removal in relation to selected characteristics of the nerve injury and its definitive treatment. The placing of some form of protective cuff about a peripheral nerve anastomosis has engaged the interest of surgeons since the beginning of nerve surgery. In World War II, and thus in the sample under study, the suture-line cuffs were formed from tantalum, either held in a cylindrical form by absorbable sutures or annealed in the desired circular form. In the present investigation first operations with sutures were chosen for all 7 major nerves and those with cuffs were subdivided as follows: 1. Cuff placed and not removed—755 cases, or 76.7 percent. 2. Significant cuff removal—94 cases, or 9.6 percent. A significant cuff removal was defined as an operative procedure designed to remove an assumed barrier to the normal course of nerve regeneration. 3. Routine cuff removal—135 cases, or 13.7 percent. Here the cuff was removed simply in the course of operative study of the suture line or because the therapeutic role of the cuff was regarded as temporary. The proportions falling into these three groups were then studied in relation to the following characteristics of the nerve injury without finding any significant variation: a. Site of injury. b. Type of lesion. c. Associated bone and joint injury. d. Medical echelon and tension. e. Special operative techniques. The significant cuff removals were done on the basis of factors outside the scope of the present analysis, namely, those having to do with the course of regeneration following suture. E. DISPOSITION FROM MILITARY HOSPITALS In abstracting the details of the injury and its management note was made of disposition in the expectation that useful information might be obtained on variation in the percentage of men returned to duty. How- ever, when the material on disposition was tabulated for the representative sample of sutures it was found that the percentage of men returned to duty was so small as to render fruitless any extended study of variation. For all 1,890 sutures in the representative sample (Registry cases within the sampling area) the percentage returned to duty is only 2.3, and the variation among the seven major nerves is confined within the range of 0.6 to 4.2 percent, as follows: Median 2. 9 Ulnar 1.7 Radial 3. 3 Peroneal 4.2 Tibial 3.2 «X

Sciatic-peroneal 0. 9 Sciat ic-t i bial 0. 6 Total 2. 3 F. TIME IN MILITARY HOSPITALS Duration of hospitalization provides a rough measure of the medical cost of an illness or injury, and since there are rather good comparative military data on such broad categories as disease generally, nonbattle injury, and wounded-in-action plus battle injury, the opportunity was taken, in abstracting data from the service medical records, to note the total time from injury to final discharge from military hospital, usually at the same time as separation from service on a certificate of disability. Analysis of the resulting observations has been directed chiefly at estab- lishing any important differentials among the major nerves and assessing the relative influence of associated injuries of various kinds upon the time spent in hospital. On the average the men in this series, largely one of sutured nerve lesions, spent 523 days in service hospitals in contrast to about 54 days for Army wounded generally in World War II (4). The complete dis- tribution appears in figure 8 in comparison with the estimate for the Army wounded of World War II; the data are plotted in the form of the number remaining in hospital on successive days after admission. It will be seen that the number discharged from hospital prior to day 200 is negligible, and that the great bulk of the men were in hospital between 1 and 2 years. The actual duration of hospitalization was in many cases far less than that indicated, since many patients spent much of their time on furlough or leave from hospital. In general, men were hospitalized near their homes and, when specialized physical therapy was not important, they spent a great deal of time with their families. Men whose lesions fall into the representative sample of complete sutures do not vary greatly by nerve injured, although, of course, duration is longer for men with sciatic lesions. In table 44 the major nerves are compared as to median duration of hospitalization. The effects of associated lesions were sought by nerve, the nerves of the upper extremity being studied in the greatest detail. Table 45 exhibits some of the variation attributable to associated bone, arterial, and soft- tissue defects or chronic infection in pure lesions managed by complete suture. The variation seen in the median is quite significant statistically. Uncomplicated bone and arterial injuries do not appear to prolong hos- pitalization, but other complications or combinations of these associated injuries do greatly delay hospitalization; about 50 percent of the latter group remained in hospital beyond day 600, and only 15 percent were discharged before day 400. In the ulnar lesions, on the other hand, the variation seen in table 45 lies well within chance limits. In the radial, 63

men with uncomplicated bone injuries were retained in hospital longer than men with none of the complications considered here, and men with two or more complications, infection, or plastic repair were delayed even further. In men with pure peroneal or tibial nerve lesions the various complications were considerably less frequent and exerted less effect upon duration. Table 44.—Median Days in Military Hospital, Men With Complete Sutures in the Representative Sample, by Nerve Nerve Median Nerve Median days days 541 Tibial 471 Ulnar 504 620 Radial 498 615 Peroneal . 558 All nerves 533 Associated nerve injuries were also studied for their possible effect upon duration of stay in hospital, but only in the median was significant evi- dence seen. In table 46 these data are presented for complete sutures on the median nerve with no complications involving bone, artery, or soft- tissue. In the ulnar and peroneal lesions associated nerve injury appeared to have no significant effect upon duration of stay. In the smaller tibial sample a suggestive difference was found between men with and men without associated nerve lesions, and of the type seen in table 46 for the median. In view of the variable influence of associated nerve and other lesions upon the duration of hospitalization for men with a given nerve lesion, the major nerves were compared on the basis of pure lesions devoid of all the complications which have been enumerated. No roster restrictions were placed upon the selection of cases, however. Table 47 provides these data for the three major nerves of the upper extremity, from which the advan- tage of uncomplicated radial injuries is immediately apparent. In addi- tion, men with ulnar lesions evidently were required to stay longer than men with median injuries. Tibial and peroneal lesions were similarly com- pared and found to differ significantly; 38 percent of the men with peroneal lesions were in hospital on day 600, in contrast to 17 percent of the men with tibial lesions. Finally, for all median sutures in the representative sample a rough di- vision was made into those with poor, fair, and good motor recovery on the basis of the modified British scale 9 and length of stay tabulated sepa- ' This scale is presented on p. 75 and discussed on pp. 113-117. The three recovery groups were selected as 0-2, 3-4, and 5-6 on the scale appearing on p. 75.

rately for each group. Figure 9 presents the results of this comparison, which shows remaining on day 600 about 22 percent of the good results, 36 percent of the fair, and 58 percent of the poor. Table 45.—Duration of Hospitalization and Associated Injuries, Pure Nerve Lesions of the Upper Extremity Treated by Complete Suture Percentage distribution by days in hospital Type of associated injury Number of cases Less than 400 400-599 600 or more Total Median None .• 47.6 37.8 14.6 100.0 82 Bone only, with normal healing 36.5 44.4 19.0 99.9 63 41.7 54.2 4.2 100.1 24 Other l 15.3 32.2 52.5 100.0 59 Total 35.5 39.9 24.6 100.0 228 Ulnar None 27.7 50.5 21.7 99.9 184 30.3 48.7 21.1 100.1 152 53.1 37.5 9.4 100.0 32 Other * 26.5 49.0 24.5 100.0 102 Total 30.0 48.7 21.3 100.0 470 Radial 42.5 40.2 17.2 99.9 87 Bone only, with normal healing 23.9 54.9 21.2 100.0 113 Arterial only 100.0 0 0 100.0 2 Other1 12.9 45.9 41.2 100.0 85 Total 26.8 47.4 25.8 100.0 287 1 Bone with abnormal healing, or chronic infection, or plastic repair at site of nerve injury, or combinations of any of these with bone injuries healing normally or with arterial injury. 66

Table 46.—Days in Hospital and Presence of Associated Nerve Injury, Complete Sutures on the Median Nerve, in Men With No Other Associated Injury Associated n erve injury * Days in hospital None Any Percent 47.6 Percent 19.4 Less than 400 400-499 12 2 22.6 500-599 25.6 21.0 600-799 8.5 19.4 800 or more 6. 1 17.7 Total 100.0 100.1 Number of cases 82 62 1 Involving ulnar, radial, axillary, or inusculocutancons. Table 47.—Days in Hospital for Men With Uncomplicated Nerve Lesions 1 Treated by Complete Suture, Nerves of the Upper Extremity Days in hospital Median Ulnar Radial Total Less than 300 Percent 6.9 Percent 4.6 Percent 12.5 Percent 6.8 300-399 28 5 19 2 28. 1 23.6 400-499 16.7 30.3 32.3 26.7 500-599 23.6 21.1 9.4 19.6 600-699 9.7 9.6 7.3 9.2 700 or more 14.6 15. 3 10.4 14.2 Total 100.0 100.1 100.0 100.1 Number of lesions 144 261 96 501 i No associated injuries of any kind. Length of hospitalization is a major factor in the medical logistics of peripheral nerve injuries. It is seriously questioned whether military hos- pitals should be asked to assume the entire burden of such care, and also whether such duration of hospitalization as is exhibited here should not now be regarded as excessive. This problem was attacked in World War II through the close association of convalescent hospitals with general hospitals to which men returned for reevaluation at regular intervals. 67

B 8 9 it f) 68

G. SUMMARY No attempt will be made here to summarize the considerable detail of background material presented here on the acute injury, its surgical man- agement, and the other points of special interest. The definitions and re- lationships presented here are, however, fundamental to an understanding of the subsequent chapters on regeneration, in which they figure promi- nently in the search for the determinants of end results. One might wish that additional information had been available, in reliable form, on the injury and its management, for peripheral nerve regeneration is an extraor- dinarily complicated matter, and even the array of factors presented in this chapter will not suffice to refine the surgeon's prognosis to the accuracy he might like. It remains unfortunately true that some factors with im- portant influences upon regeneration are not subject to measurement, or even observation, in a clinical series. 69

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Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries Get This Book
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In peacetime, the busiest civilian clinics do not see enough peripheral nerve injuries to permit authoritative conclusions to be drawn about their management. In World War I, large numbers of these injuries were skillfully cared for by a small group of pioneer neurosurgeons, but there was no comprehensive follow-up and the opportunity to use the experience to the fullest possible extent was lost.

The publication of Peripheral Nerve Regeneration: a Follow-Up Study marks the end of a huge clinical research program that began in 1943, in the course of World War II. The program was participated in by more than a hundred of the neurosurgeons who served in the Medical Corps, as well as by many neurologists, neuroanatomists, neurophysiologists, neuropathologists, physical therapists, statisticians, and representatives of the administrative personnel of every echelon of command in the Army Medical Corps. Later the program was also participated in by representatives of the Veterans Administration and the National Research Council.

The primary purpose of this study was to evaluate the suites of peripheral nerve injuries sustained in World War II, with the hope of standardizing such treatment for future wars and, where possible, for similar injuries of civilian life. The secondary purpose of this study was to discover nerve injuries among veterans of all services that still required remedial measures. Peripheral Nerve Regeneration: a Follow-Up Study describes the final level of regeneration in representative cases of complete suture, neurolysis, and nerve graft, examines the apparent influence of gross characteristics or the legion, and or associated injuries, upon final result, and evaluates predictions of final recovery based on gross and histologic study of tissue removed at operation. The report of this study of postwar nerve regeneration provides for the surgeons of the future a body of information upon which they may guide repair of injured peripheral nerves and initiate needed orthopedic rehabilitation.

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