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Chapter VIII FUNCTIONAL RECOVERY AND OCCUPATIONAL ADJUSTMENT Gilbert W. Beebe A. INTRODUCTION In earlier chapters, which are concerned chiefly with evaluating various determinants of regeneration, methodological requirements place a pre- mium upon objectivity and reliability as characteristics of any index of regeneration. In comparison with the strength of a particular muscle, or the measured stimulus required to elicit a pain response, a clinical opinion as to the level of overall functional recovery must seem subjective and somewhat unreliable. Also, there is considerable clinical interest in the individual modalities themselves. For these reasons the earlier chapters are organized along the lines of individual modalities, or groups thereof, and contain no summary information about the overall level of functional recovery, except as it may correlate with a particular index of regeneration. And yet it is precisely here that the greatest clinical in- terest lies, and no study of regeneration would be complete if it portrayed recovery solely in terms of the individual modalities, to the neglect of practical function. The complexity of the functions ruled over by the peripheral nerves makes the assessment of overall functional recovery a difficult task, and any scheme one may propose will necessarily seem arbitrary. It was fortunate that the study group included at the start the late Dr. Frederic H. Lewey, who was quite aware of the divergent requirements which would be placed upon the observations and who had a special interest in the problem of describing practical function. Dr. Lewey was an advo- cate of the work-furlough as a rehabilitative procedure, and expressed keen interest in the occupational readjustments necessitated by peripheral nerve injuries. In addition to providing the scales used in evaluating functional recovery, Dr. Lewey advocated collection of systematic in- formation on occupation before and after injury, evaluation of the role of the peripheral nerve injury in any occupational change, and formula- tion of a clinical opinion as to the extent of any present occupational han- dicap attributable to the peripheral nerve injury. The present chapter is essentially descriptive in nature, containing sum- mary information on the final level of practical function attained by men with various peripheral nerve injuries. Although the individual nerves 349

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themselves are distinguished here, and complete sutures are differentiated from neurolyses, in general there is no effort to explain why function is superior in this group of cases and inferior in that. It was believed thp.t no such analysis could be as penetrating as those already presented earlier in the study of the individual modalities. Following this brief introduction there is first a section on the methods developed by Dr. Lewey for the assessment of functional recovery, followed by a section in which these classifications are used to describe the sample as a whole, nerve by nerve. A fourth section deals with the interrelations among motor, sensory, and overall functional recovery. There is next a section on the relation be- tween the clinical assessments of functional recovery developed by ex- aminers working in the peripheral nerve study centers on the one hand and the Veterans Administration disability ratings on the other. Con- sideration is then given to the occupational changes which have occurred, and to the opinions of examiners as to the role played by peripheral nerve injuries in bringing them about. In a final section appear the exarrir.crs' opinions as to the extent of any present occupational hr.ndiceps suffered by the examinees in their work, whether they had changed jobs or net. B. METHODS OF EVALUATING FUNCTIONAL RECOV- ERY AND OCCUPATIONAL ADJUSTMENT The variety and complexity of functional recovery make its elr^rificrtion an extrerr ely difficult matter. Such questions as—Is a sensory c'cf.cit more important than a motor? Is one movement rrore important than r.n- other?—do not always have satisfactory answers. With full realizetion of these difficulties, Dr. Lewey undertook to classify practical function in the upper extremity according to the following scheme: 0. Amputation. 1. Useless limb. 2. Of use only as a holder. 3. Can grasp larger objects. 4. Some opposition. 5. Good opposition. 6. Picks up pin with visual aid. 7. Picks up pin blindly. 8. Many skilled but awkward acts. 9. Good practical function. Each upper extremity was located at a particular point on this scale rs a rough indication of the level of its functional capacity, whether the injury involved the median, ulnar, radial, or combinations of these nerves. In addition, note was made of any orthopedic deformity or of any adverse functional overlay, except that only one of the latter could be chosen for any one injured limb. In the lower extremity the scale was more abbreviated, the categories being: 0. Amputation. 1. Will not bear weight. 350

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2. Walks less than one block. 3. Walks less than one-quarter mile. 4. Unlimited walking; can't run. 5. Can run or dance. In addition, any one of the following limitations might be noted by the examiner for each injured extremity: Limited by pain. Limited by weakness. Limited by uiceration. Orthopedic deformity. Adverse functional overlay. In some instances the lower extremity was evaluated with a brace, and when such was the case it was specifically noted. A limited exploration was made of center variation in the employment of the above classification of specific functional capacity. A sample of peroneal and ulnar sutures was chosen on the basis of the following criteria: 1. Only a single nerve was injured in the affected limb. 2. The nerve had been completely severed. 3. The operation was a complete suture. The first of these criteria effectively excluded sciatic cases, since these are almo:t always combined lesions. The second criterion was unneces- sarily restrictive and excessively reduced the number of cases available for study. There remained 238 ulnar and 62 peroneal sutures for study after these restrictions had been made. Only insignificant variation among centers was noted in the peroneal material but, of course, the test is weak. The centers do differ in their classification of ulnar cases, but only because a single center often used "good practical function" where others would have used "many skilled but awkward acts." Apart from this discrepancy, center variation did not appear impressive. In addition to the above scales of specific functional status, Dr. Lewey developed for the study group a scale of "overall functional evaluation" having 11 positions. The sensory contribution to practical function is quite variable, as is the anatomic regeneration of individual muscles. One muscle may recover well, but be of little importance in functional recovery in comparison with another which may be very weak. A move- ment of the greatest importance may be accomplished only by virtue of a tendon transplant. With such considerations in mind, Dr. Lewey under- took to specify, nerve by nerve, the relative functional deficit represented by specific findings, so that each limb affected by nerve injury might be scaled in a roughly uniform way over the range from 0 to 100 percent, at the decile values. The specific criteria which he prepared for this classifi- cation, and used by each center, are as follows: Radial Nerve 1. The partial loss of triceps seen in high radials does not impair function. 2. The brachioradialis is of little importance because of compensation by the biceps. 351

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3. This is true of supinator as well. 4. A complete wrist drop allows 40 percent function. 5. Wrist o. k. but complete finger and thumb drop allows 60 percent function. 6. If fingers can be opened around large object (ash tray 4 in. in circumference) but thumb not abducted—80 percent function. Ulnar Nerve \. The complete high ulnar with weak fourth and fifth flexors and clawing of fourth and fifth fingers has a hand in which small objects are still easily grasped between thumb and first two fingers. In grasping large objects, only the radial half of the hand grips* and the fourth and fifth fingers are in the way and liable to injury (because of anesthesia)—60 percent function. 2. The fourth and fifth fingers are still useless in gripping, but can be extended out of the way—70 percent. 3. Fourth and fifth fingers cannot only be extended out of the way but have good grip—80 percent. 4. Gradings above 80 percent depend on the extent of intrinsic muscle function in separating and adducting fingers and upon the degree of sensory recovery. Median Nerve 1. The complete high median with absent sensation, with poor flexion of thumb and index finger, weak grip, and absent opposition of the thumb, has a functional rating of 20 percent. 2. The median with good flexion of thumb and index finger—absent opponens, absent sensation—is rated between 25 percent and 40 percent depending upon the success in compensating for absent opponens with the short flexor and abductor of the thumb. 3. With good opposition so that the hand is mechanically nearly perfect, but with little sensory recovery—function is 50 percent. 4. With good return of pain and touch points and thresholds, there may still be no ability to use the hand in fine work without visual guidance—function is 60 percent. 5. Ratings above 60 percent depend on the degree of further sensory return, which permits action without visual aid. Combined Nerve Lesions From what has been said, a reasonable grading of combined lesions can be arrived at on the basis of the functions which are possible. Practical function of the arm is 0 percent, regardless of the muscles functioning, until the fingers can be used to grip lightly (10 percent). Function approaches 25 percent as all movements but opposition are regained. It is as high as 40 percent when opposition is performed, but, of course, such a figure would be reduced by weakness of flexion of elbow, of dorsiflexion of wrist, by stiff fingers, etc. It is also limited when the fingers curl on flexion because of absent lumbricals, and the finger pads do not meet the opposing thumb. Even with a mechanically good hand, function will be only 50 percent if sensation in the critical median area is poor. The recoveries from brachial plexus injuries are graded in the same manner, depending upon the actual movements which the hand can perform. 352

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Sciatic Nerve In the case of the leg, function is rated logically on the man's ability to walk, and this may vary widely in different individuals with the same degree of anatomical regeneration. It is very poorly correlated with motor strength and sensation. Thus, with a complete sciatic paralysis, the patient may have developed a stiff ankle in a position of dorsiflexion and be able to walk a mile with minimal difficulty. On the other hand, an injury of the tibial nerve at the ankle may give rise to paresthesias on weight bearing which make it difficult to walk a block. The proposed functional ratings given below are therefore arbitrary and not as logical as those which can be formulated for the hand. 1. With no movement present below the knee and a complete anesthesia of the dorsum and sole of the foot, the patient will usually walk well with brace which maintains dorsiflexion of the ankle. If he can walk a mile under these conditions, his functional rating is 60 percent. If he is clearly limited to a few blocks, it is 50 percent. If he experiences difficulty in walking 1 block, it is 40 percent. If even standing is uncomfortable, it is 30 percent or less. When a brace is unnecessary, because of operative fusion or spontaneous partial fixation of the ankle, function can be rated at 70 percent. 2. Walking is more effective when plantar flexion of the foot occurs forcefully; 10 percent can be added to the functional ratings given above. 3. If sustained dorsiflexion of the foot is possible while walking, no brace is neces- sary and an additional 10 percent is added (thus 70 percent if man can walk a mile). It does not matter whether this dorsiflexion has occurred by actual recovery of tibialis anticus function or by effective tendon transfer. 4. Ratings between 70 percent and 100 percent depend primarily upon the skills of dancing and running, climbing being possible in addition to unlimited walking. Toe movements, active inversion and eversion of the foot, and sensory disturbances are important only in the extent to which they limit walking or standing. Center variation was also explored for overall functional evaluation, and in the fashion already described for specific functional capacity. More center variation was observed here than in the classification of specific functional capacity, although only for the ulnar was the variation outside the usual bounds of chance. The median ratings for the ulnar, by center, are 60, 66, 71, 76, and 76. Undoubtedly, variation among examiners contributes heavily to the total variation seen in these ratings. Occupational adjustment was approached on the basis of the following elements of the history: 1. Previous work done, and industry in which work was performed. 2. Present work done, and industry in which work is performed. 3. Change in occupation, and role of nerve injury in this. 4. Handicap in present occupation. Although quite specific occupational facts were obtained and recorded, coding and related statistical processing have been confined to the following summary characterization, best described as a socioeconomic scale: Professional and semiprofessional. Farmers, farm managers, and farm laborers. Proprietors, managers* officials. 353

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Clerical and sales people. Craftsmen and foremen. Operatives. Service (except protective) workers. Protective service workers. Students. Occupation not yet established. Laborers, except farm. Specific occupation and industry were converted to the above on the basis of 1948 census procedures (81). Change in occupation, and the examiner's estimate of the role played by the peripheral nerve injury, were classified as follows: 0. Never employed, including man still student without work history. 1. Never employed before, but has occupation now. 2. No change in preservice occupation, including man in student status now ex- pecting to resume former occupation. 3. Changed to new occupation, including training for new one, apparently not because of nerve injury. 4. Change to new occupation, including training for new one, apparently because of nerve injury, at least in considerable part. 5. No occupation now, and not in training for one, regards self as unemployable because of nerve injury. 6. Same as category 5, except that it is apparently not because of nerve injury that man regards himself as unemployable. No specific criteria were developed for the above classification, which each examiner applied in accordance with his own evaluation of the history. Occupational handicap was also rated rather subjectively by the ex- aminer on the basis of the history, modified, of course, by the objective findings as to function. A 4-point scale was used, as follows: 0. No handicap apparent. 1. Some handicap, not severe. 2. Severe handicap. 3. Man regards self as unemployable. Those without established occupations were not, of course, rated in this way. No criteria were developed to guide examiners in their use of this scale. C. VARIATION IN FUNCTIONAL REGENERATION For the reasons stated earlier it was not considered useful to extend the analysis beyond these few elementary characteristics: nature of definitive surgery, nerve involved, and relation between the two rating scales for function. In the descriptive parts of chapters III through VII, it may be recalled, care was taken to confine the selection of cases to men falling within the sampling area as defined in chapter I. Here, however, since the selective factors involved in this distinction did not appear to be of especially great importance in the analyses of chapters III through VII, 354

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the distinction was^dropped. Moreover, since it is the function of the limb which is being described, it seemed essential to limit the sampling to limbs with single nerve injuries, or to specify the associated nerve lesions. In the thigh the sampling was confined to complete sciatic lesions, i. e., those in which both sciatic trunks were sutured. Also, a special study was done of the influence of associated ulnar upon median injuries, and vice versa. There was great variation in the specific functional capacity of the upper extremities, depending on which nerve was involved and whether the lesion required suture or lysis. Within the set of lesions affecting a single nerve, variation was greatest for the median, and the most severe limitations were imposed by injuries to this nerve. Table 201 provides a summary of data on specific functional capacity of upper extremities, by nerve and by type of definitive surgery, for pure lesions only. The latter restriction greatly reduces the number of lysed lesions available for study, since many entered the larger series only in association with sutured lesions on adjacent nerves. Amputation is excluded from the scale there because no upper limb with a single nerve lesion was ampu- tated; a single patient with an amputation in the upper extremity was seen at follow-up. The relevant particulars of this case (3380) are as follows: A severe bullet wound in the region of the left elbow completely severed the bracliial artery* fractured the distal end of the humerus and the olecranon process of the ulna, and produced complete median and ulnar nerve paralyses. The brachial artery was ligated, and the median nerve sutured; at exploration the ulnar was seen to have a neuroma in continuity. A Volkmann's contracture developed, and led to an arthrodesis to the wrist about 7 months after injury, and eventually to amputation at the level of the wrist, about 17 months after injury. Despite their limited number, the superior performance of limbs with lysed lesions is plain. About half of the limbs with median lesions requiring suture were capable of "many skilled but awkward acts" or had "good practi- cal function," in contrast to about 90 percent of the radial and 85 percent of the ulnar. About a fifth of the limbs with median lesions requiring suture were classified as "can grasp larger objects" or "some opposition." Ortho- pedic deformity varied little by nerve, being noted in 17.6 percent of limbs with median sutures, 14.9 percent with radial, and 17.1 percent with ulnar. The scales for overall functional evaluation vary by nerve in the fasl.ian already described, and are not necessarily comparable. Since the con- tribution of each nerve to function is unique, the only surely common ground is found in specific functional tasks such as those just analysed. However, in preparing his scales for overall functional evaluation, Dr. Lewey had as his objective a rating which expressed the function of the limb as a percentage of the normal function of the extremity. In these terms, then, even relatively poor anatomic regeneration in the radial might be consistent with fairly good function, although this would not be true of a poor median nerve recovery. The overall functional evaluation of the 355

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Table 201.—Specific Functional Capacity of Upper Extremities With Pure Nerve Lesions by Nerve Involved and by Type of Definitive Surgery Specific functional capacity Median Radial Ulnar A. Complete sutures Percent 1.3 Percent 1.4 Percent 0.6 Useless limb . Only a holder . 3. 1 1.0 .8 Grasps larger objects . . 10.7 3.4 3.9 10 7 0 1 4 Good opposition 4.4 0 0.8 14 5 0 5 8 Picks up pin, blindly 6 3 1.9 5.8 Many skilled but awkward acts . . 25.8 41.8 44.8 Good practical function 23.3 50.0 41.2 Total 100. 1 100 0 100 1 Number of cases . .... 159 208 362 B. Neurolyses Percent 4.8 Percent 6.3 Percent 0 Useless limb ... .... Only a holder ... 0 0 0 Graps larger objects ... 0 6.3 0 Some opposition 0 0 0 Good opposition 0 0 0 Picks up pin, visual aid 14.3 0 0 Picks up pin, blindly 9. 5 o 4.9 Many skilled but awkward acts 23.8 0 29.3 Good practical function 47.6 87.5 65.9 Total 100.0 100.1 100.1 Number of cases . . . 21 16 41 upper extremity is summarized in table 202. The general picture is one of greater variability than characterizes the classification of specific func- tional capacity, but with no essential change in the interrelations among the several nerves. Also, limbs with lysed lesions again appear at a definite advantage in relation to those with sutures. The relation between the two scales, one of specific functional capacity and the other of overall functional evaluation, may be of value in inter- preting the foregoing data on the upper extremity. Tables on this rela- tionship were run as a preliminary and exploratory measure before the present chapter was planned, and were not confined to pure nerve lesions. 356

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Table 202.—Overall Functional Evaluation of Upper Extremities With Pure Nerve Lesions, by Nerve and by Type of Definitive Surgery Overall functional evaluation* percent Sutures Lyse, Median Radial Ulnar Median Radial Ulnar 0 1 3 1 5 0 3 4 8 6.3 0 10 0 0.5 0 3 0 0 0 20 2.6 0 0 8 0 0 0 30 6.4 0 5 0.6 0 0 0 40 12. 2 3.9 3.4 0 0 0 50 20 5 4 9 6 2 14 3 o 4 8 60 17 3 11 7 19 4 14 3 o 9.5 70 ... 18 6 17 1 23 0 38. 1 12.5 11.9 80 15 4 39 0 34.8 19.0 25.0 31.0 90 5 1 18 5 10.7 9.5 56.3 38.1 100 0.6 2.4 0.6 0 0 4.8 Total 100.0 100.0 100. 1 100.0 100. 1 100.1 Number of cases 156 205 356 21 16 42 Despite this limitation, arising out of the possibly unequal influence of associated nerve injuries upon the two functional classifications, these preliminary tables are of considerable value in exhibiting their interrelation- ship, nerve by nerve. Tables 203 through 205 embody these data, for complete sutures only. The correlation may be described as rather high, but no numerical measure of it would seem useful. It is apparently highest for the radial and about the same for median and ulnar. In general, there is more scatter along the scale of functional evaluation for a group of cases with a specific functional capacity than vice versa. For example, in the ulnar there are 170 cases with "good practical function," of which 18 percent were given ratings of 70 percent of normal function, 50 percent given ratings of 80 percent, and 21 percent given ratings of 90 percent. Conversely, of the 143 limbs rated at 80 percent of normal function, 36 percent were considered capable of "many skilled but awkward acts" and 59 percent considered to have "good practical function." The relationship is weakest for limbs classified as capable of many skilled but awkward acts or as having good practical function. In the lower extremity there were too few pure lesions treated by lysis to justify presentation, and, accordingly, in table 206 the summary of data on specific functional capacity is limited to complete sutures. The table does not extend to the limitations which examiners found, but pain and weakness were most commonly reported. Ulceration was seen in some sciatic cases, and deformity occasionally in all three groups. Since 357

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Table 218.—Change in Occupation, All Peripheral Nerves With Single Lesions at Follow-up Lesions of men with prior oc- cupation Change in occupation All lesions Never employed Percent 6.6 Percent 0 Employed now, but not before 7. 1 0 No change 20.5 23.8 Changed, not for nerve injury 16.0 18.5 Changed, because of nerve injury 42.2 48.9 6.0 6.9 No occupation' unemployable for other reason * 1.6 1.9 Total 100.0 100.0 Number of lesions 2 489 2, 148 1 In the man's own opinion. handedness was definitely associated with occupational change, although there was a suggestion that men with high lesions were more likely to regard themselves as unemployable if the dominant hand was affected. The directional shift of occupational change was chiefly from the ranks of operatives into clerical and sales occupations. Table 219 gives the dis- tributions by broad socioeconomic class, both before service and at follow-up, for all men and for those with established occupations before service. The categories for which losses occurred are, in addition to the operatives, farmers of all kinds, craftsmen and foremen, and nonfarm laborers; in all others gains were registered. In addition, there were many changes within these broad categories, especially from jobs requiring more to those requiring less strength or fine coordination of movement. The identity of the injured nerve seems not to affect the gross picture of occupational change. When attention is confined to pure nerve lesions treated by complete suture, as in table 220, changes attributed to nerve injuries are somewhat more common for men whose lower extremities were involved, but otherwise the particular nerve involved seems unim- portant. Table 220 is confined to the more common occupational groups prior to service, and shows, in addition to the percentage changing occupa- tion (in the narrow sense) because of nerve injury, the percentage whose changes (for any reason) placed them in an entirely different occupational category. Men with median, ulnar, or radial injuries were least likely to change their jobs if their work involved clerical or sales activities. Al- though their number is not large, nonfarm laborers more often changed jobs than men in other occupational groups, as did operatives, craftsmen, and foremen. 378

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Table 219.—Percentage Distribution by Socioeconomic Class, Before Service and at Follow-up Socioeconomic category All cases Cases with pre- viously estab- lished occupation Before service At fol- low-up Before service At fol- low-up Professional, semiprofcssional . ... 2.8 3.3 4.7 3.0 18.1 20.2 36.9 2.3 1.8 0 0 9.7 5.9 1.8 5.7 27.1 13.2 20.3 3.9 2.9 13.8 0.9 4.3 6.9 2.2 Farmers of all kinds 4.0 2.5 15.2 17.0 31.1 1.9 1.5 13.2 2.6 8.2 Proprietors, managers, officials 6.7 31.8 15.5 23.8 4.5 3.4 0 0 5.1 Clerical and sales Craftsmen and foremen Operatives Service, except protective Service, protective Students Occupation not established Laborers, nonfarm . . Total 100.0 100.0 99.8 99.9 Number of lesions . . 2,576 2,169 2,450 2,088 Since only the distinction between upper and lower extremity seems to be associated with the chance of occupational change, in table 221, giving the precise change in Socioeconomic category, the individual nerves are grouped in accordance with this distinction. Also, only the most common preservice occupational categories are shown there. For both upper and lower extremity cases, it was unlikely (12 and 7 percent) that a man would remain a craftsman or foreman; he tended to shift to the other two cate- gories. Similarly, the entrance into the category of the craftsman and the foreman was not common for men previously in clerical or sales work, or for former operatives. Men in clerical and sales work were least in- clined to leave their Socioeconomic category, and yet the numbers who did are large (60 percent for upper extremity and 42 percent for lower). Behind the summary frequencies of table 221 is a welter of detail which can at best be exemplified: A coal miner with a median lesion becomes a clerk in the VA. A machine operator with a median lesion becomes a mail carrier for the U. S. Government. A blacksmith's helper with a median lesion becomes a chauffeur. A printer's apprentice with a radial lesion becomes a postal clerk for the U. S. Government. After a radial lesion, a man who was formerly a special tool grinder, doing hand- work, changes to toolgrinding requiring no hand work. A welder in a U. S. Navy yard, with an ulnar lesion, becomes a stockkeeper at the yard. A truck driver, with an ulnar lesion, becomes a clerk in a bank. 379

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Table 220.—Change in Occupation Because of Nerve Injury (A), and Change in Socioeconomic Category for Any Reason (B), by Occupation Prior to Service, and by Nerve Injured, Pure Lesions Treated by Complete Suturt Nerve and change in status Previous occupation Clerical and sales Craftsmen and fore- men Opera- tives Nonfarm laborers Median Number of men Total i 25 28.0 16.0 30 60.0 53.3 49 55.1 38.8 15 66.7 60.0 137 50.4 40.1 Percent A Percent B Radial Number of men 30 26.7 23.3 33 54.5 54.5 54 63.0 42.6 17 52.9 35.3 155 48.4 37.4 Percent A Percent B Ulnar Number of men 56 26.8 16.1 61 62.3 52.5 118 46.6 33.1 24 54.2 50.0 297 Percent A 44.4 34.0 Percent B Peroneal 13 53.8 15.4 14 57.1 50.0 41 53.7 41.5 14 57.1 42.9 99 54.5 41.4 Percent A Percent B Tibial 15 26.7 13.3 16 21 61.9 47.6 7 85.7 85.7 63 55.6 46.0 Percent A 56.3 50.0 Percent B Sciatic ' Number of men 33 48.5 24.2 38 47.4 47.4 74 59.5 43.2 26 69.2 69.2 205 57.6 46.8 Percent A Percent B 1 Includes all other occupations not shown separately. 1 Complete sciatic lesions, i. e., both branches sutured. 380

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Table 221.—Change in Socioeconomic Category for Any Reason, Men With Pure Lesions Treated by Complete Suture in Most Common Preservice Occupational Categories Occupational category at follow-up Preservice occupation Clerical, sales Craftsmen, foremen Operatives Nonfarm laborers Upper extremity 4 0 4 5 1 8 6 7 Farmers of all kinds 0.0 0.0 0.0 0 0 Proprietors, managers, officials 12.0 7.6 6.4 6.7 40.0 34.8 24.8 16.7 8.0 12.1 18.3 6.7 Operatives 24.0 27.3 32.1 30.0 Service except protective 0.0 7.6 11 0 16.7 Service, protective 8.0 4.5 1.8 0 0 4.0 1.5 3.7 16.7 Total 100.0 99.9 99.9 100.2 Number of cases 25 66 109 30 Lower extremity Professional, scmiprofessional 3.8 3.6 4.8 3.3 Farmers of all kinds 0.0 7. 1 1.6 3. 3 11.5 3.6 12.7 0.0 57.7 42.9 30.2 36.7 Craftsmen and foremen ... 7.7 7. 1 11. 1 16.7 19.2 32.1 31.7 33.3 Service, except protective 0.0 0.0 3.2 0.0 0.0 3.6 0.0 0.0 0.0 0.0 4.8 6.7 Total 99 9 100.0 100 1 100.0 26 28 63 30 Since the occupational changes which men made, although frequent, ap- pear not to have been quite specific to the identity of the injured nerve, it is not surprising to find, at follow-up, no important differences in the dis- tributions by broad socioeconomic category. Table 222 provides the data for these comparisons, and is confined to pure lesions and complete sciatic lesions. 381

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Table 222.—Percentage Distribution of Cases by Socioeconomic Category at Follow-up, by Nerve, for Pure Lesions Treated by Complete Suture Socioeconomic category Nerve Total Me- dian Ra- dial Ulnar Pero- neal Tibial Sci- atic ' Professional, scmiprofessional Farmers of all kinds 5. 1 1.3 5.8 26.3 12.2 22.4 5.8 3.2 14.1 .6 3.2 6.0 2.0 10.5 24.5 10.5 20.0 4.5 2.5 13.0 .5 6.0 5.8 1.2 3.8 25.1 16.2 26.6 2.9 3.2 11.6 .6 3.2 3.3 2.5 4.9 23.8 12.3 28.7 1.6 2.5 13.9 .8 5.7 2.6 0.0 6.6 26.3 19.7 27.6 1.3 0.0 13.2 1.3 1.3 5.4 2.3 5.2 1.6 6.6 25.5 13.3 23.9 2.8 2.4 14.2 .9 3.6 Proprietors, managers, officials. . . Clerical and sales 8.5 26.9 10.8 20.8 .8 1.5 19.2 1.5 2.3 Craftsmen and foremen Operatives Service, protective Student Occupation not established . . Laborers, nonfarm Total 100.0 100.0 100.2 100.0 99.9 100.0 100.0 Number of cases 156 200 346 122 76 260 1,160 1 Complete lesions; both trunks sutured. G. OCCUPATIONAL HANDICAPS Even after changing their occupations because of nerve injuries a majority of the men continued to have at least some handicap in their new work. For the sample as a whole at follow-up, examiners considered only 29 percent to have no apparent handicap; they regarded 57 percent as having less than a severe handicap, and 8 percent a severe handicap, in addition to the 7 percent who regarded themselves as unemployable. Table 223 presents the basic data on occupational handicap by nerve, for pure lesions treated by complete suture. Men with median or complete sciatic lesions were considered by examiners to be the most handicapped, and men with ulnar or tibial the least. When the examiners' assessments as to occupa- tional handicap were studied in relation to overall functional evaluation, some correlation, by no means close, was found. In the main, those with the greatest handicaps had the poorest functional recovery, but this was by no means uniformly true. An occupational handicap is a two-sided matter, depending at least as much upon the requirements of the work as upon the capabilities of the man. After all the occupational changes which men were able and willing to make, there remained a few with fairly good practical function, by average standards, who nevertheless seemed to examiners to be severely handicapped in their work. Although it is not possible here to display the detail required to show the

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relation between specific occupation and handicap in its performance, some of the information which is useful may be obtained from an analysis by broad occupational category, as in table 224, which is confined to the three most common occupational groupings. Severe handicaps were rare for men who were able to work at occupations in these three categories, but some handicap was usual, and especially so for men with median, radial, or ulnar lesions working as craftsmen, foremen, and operatives as contrasted with clerks and salespeople. The occupational category has no such influence upon the handicap of men whose injuries involved the lower extremities. Table 223.—Percentage Distribution of Cases by Occupational Handicap at Follow-up, by Nerve, Pure Lesions Treated by Complete Suture Nerve Occupational handicap Present Number of men None apparent Not severe Severe Unem- ployable1 Total Median 26.7 31.2 32.6 34.5 44.9 24.2 56.2 59.7 61.5 54.0 47.8 58.4 8.9 4.8 3.4 5.3 5.8 6.1 8.2 100.0 100.0 100.0 100.0 99.9 100.0 146 186 322 113 69 231 Radial 4.3 2.5 6.2 1.4 11.3 Ulnar Peroneal Tibial Sciatic * 1 In the man's opinion. 1 Complete lesions; i. c., both branches sutured. H. FUNCTIONAL CAPACITY OF MEN WHO REMAINED IN SERVICE From the some 3,000 cases originally considered for allocation, 22 men were found to be back on duty with the Armed Forces. Letters were written to their commanding officers, or theater surgeons, requesting that they be examined and that some statement be made concerning their fitness for duty. Fourteen replies were received. Although this group is a small one, and their examinations not comparable in completeness to those carried out in the study centers, a brief description of the post-injury course of these individuals seems indicated. There were 4 officers, all of whom had been members of the Regular Army at the time of their initial injury, 9 noncommissioned officers, and 1 enlisted man, all of whom had continued in service following hospitaliza- tion for their peripheral nerve wounds. It was evident that these officers 383

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Table 224.—Occupational Handicap and Socioeconomic Grouping at Follow-up, by Nerve, for Pure Lesions Treated by Complete Suture, Employable Men Only Percentage distribution by occupa- tional handicap Number of men Nerve and socioeconomic grouping Not severe None Severe Total Median 50.0 47.4 85.7 69.7 2.6 7.1 6.1 100.0 99.9 100.0 38 14 33 7.1 24.2 Radial 43.5 31.6 23.5 54.3 57.9 76.5 2.2 10.5 0 100.0 100.0 100.0 46 19 34 Craftsmen, foremen Operatives Ulnar 45.9 20.0 20.7 51.8 72.7 75.9 2.4 7.3 3.4 100. 1 100.0 100.0 85 55 Operatives 87 Peroneal 32.0 42.9 38.7 68.0 57.1 54.8 0 0 6.5 100.0 100.0 100.0 25 14 31 Tibial Clerical, sales 50.0 33.3 45.0 45.0 58.3 45.0 5.0 8.3 10.0 100.0 99.9 100.0 20 12 Craftsmen, foremen Operatives 20 Sciatic ' Clerical, sales 31.7 38.5 22.7 61.9 61.5 77.3 6.3 0 0 99.9 100.0 100.0 63 26 Operatives 44 1 Complete lesions; both branches sutured. and men were compelled by personal motives having to do with furthering and continuing their careers in the Armed Forces. The peripheral nerve injuries included 2 of the sciatic nerve, 3 of the common peroneal nerve, 3 of the radial nerve, (1 combined with a median nerve division), 3 of the ulnar nerve and 3 of the median nerve. All nerve injuries were initially selected as instances of complete nerve division and 384

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were treated by nerve suture in neurosurgical centers in England or in the Zone of Interior at time intervals ranging from 1 to 11 months. They were hospitalized until, in the opinion of their physicians, maximal hospital benefit had been achieved. Except in terms of motivation, there was no obvious dissimilarity between this small sample and the major group. The neurological review of the two patients with sciatic nerve division suggested a marked difference in anatomical reinnervation. Letters from these patients or their superior officers describe excellent or at least adequate functional rehabilitation. The first patient was injured by shell fragments on 14 January 1944, with evidence of complete sciatic nerve division in the upper third of the thigh. Nerve suture was done in April of 1945 and subsequent roentgen- ography of the suture site disclosed displacement of the tantalum sutures. He was reoperated upon in November of 1945, suture line disruption was proved, and it was necessary to remove 15 cm. of the proximal and distal nerve segments to attain reasonably good nerve ends. Examination in 1951 disclosed complete foot drop, weak plantar flexion, and hypalgesia over the sensory domain of the sciatic nerve. In spite of this evidence of poor anatomical regeneration, and the adverse factors responsible for it, the following note was received. "I would like to say that in spite of the rather severe nature of my nerve injury, I was retained on active service in the Army and have been able to perform my regular duties without the loss of even a day's duty due to any trouble with my wound. I would estimate that I have gotten about 60 percent return of function of my sciatic nerve." The man was then serving with the 7th Infantry Division in Korea. The second patient sustained a shell fragment wound of the upper third of the thigh on 10 April 1945. He was operated upon in November 1945, a 9-cm. gap was recorded as a result of resection of pathologic nerve ends and sciatic nerve suture was performed. In 1951 there was "partial" foot drop, normal plantar flexion, and slight hypesthesia over the lateral aspect of the foot. The evidence for fairly adequate anatomical regeneration seems to be present. His examining physician writes: "This officer states that there is no limitation placed upon him as a result of his old injury for usual activities. He states that he has taken prolonged marches with soldiers without difficulty. However, his left leg will not 'react as fasf as the right leg. (The patient) is well pleased with the results that he has had. It also seems to me that he has had a splendid result and has probably reached maximum benefit from surgery." In the group of 3 patients with injury to the common peroneal nerve, close scrutiny of the hospital records of 1 case shows that complete nerve division was not present and that but one fascicle was sutured. This patient returned to full duty with evidence of good anatomical and func- tional regeneration. The second patient with complete nerve division and subsequent suture of the common peroneal nerve still showed complete foot drop and sensory changes in 1951. He was on duty in the United 385

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States and no detailed comment about his fitness is available. The third patient, on limited duty at present in Japan, was wounded in June 1944 and operated upon in July 1944. From the neurological examination, anatomical regeneration was grossly inadequate. The following comment was appended to the examination report: "From a functional standpoint, this man has had a good recovery from a serious injury in that he can walk with minimal objective evidence of disability and minimal subjective discomfort from pain." Two of the 3 patients with radial nerve division did well and the third patient had a double nerve injury. The first patient was wounded by a shell fragment in July 1944 and was operated upon in September 1944. A 3-cm. defect was found and a relatively easy peripheral nerve suture was accomplished. Anatomical regeneration was good with full return of extension of wrist and fingers with the exception of the extensor hallucis longus. The extent of his regeneration is attested to by an accompanying letter. "Subjectively (the patient) suffers little disability. He is able to play the piano* shoot a pistol and to use the typewriter efficiently. His only adverse sensation-; connected with use of the limb occur when he plays the piano for any length of time. He then feels that his lateral forearm muscle group becomes unduly and rather easily fatigued. In addition, he reports that a mild blow over the wound produces a 'shooting, tingling sensation' down the course of the radial nerve in the forearm. He is able, however, to perform all of his duries without disability." The officer was then on duty with the 3d Infantry Division in Korea. The second patient is on duty in Hawaii and his examiner described "fair" return in muscles innervated by the radial nerve and "good" func- tional return. No further information is available. The third patient received a shell fragment wound of the elbow in November 1944 and nerve divisions of the radial and median nerve were sutured in February 1945. Anatomical and functional return in the radial musculature was described but residual paralysis of intrinsic muscles of the hand innervated by the median nerve was reported, together with the return of diffuse pain appreciation in the distal half of the index finger. The examining physi- cian writes from a station in Europe: "Patient's overall functional usefulness of his right arm is limited about 50 percent. He can do crude, unskilled light work involving the right hand, but is unable to do heavy work, skilled work or fire a gun. Patient works as a motor pool supply ser- geant, and can do all that is required in his job, except for heavy lifting." Upon review, one median nerve injury proved to be a partial nerve suture. The patient was reported on full duty as a member of the military police in Europe. The neurological examination in the other two in- stances of median nerve injury were incomplete but suggested no return of intrinsic muscle power and only return of pain appreciation in the sensory domain. Both patients were on full duty, 1 overseas and 1 in the United States. Excerpts from the accompanying letters state "can do full duties" and "grossly appears normal."

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The ability of patients with ulnar nerve division to carry on military duties in spite of inadequate anatomical regeneration is further noted in the three patients in this group. The first patient sustained ulnar nerve division above the wrist in September 1944, and was sutured in February 1945 following a 4-cm. resection of pathologic nerve ends. In 1951, there was complete loss of all sensory modalities over the autonomous zone of this nerve and atrophy and paralysis of all intrinsic muscles innervated by the ulnar nerve. His examining physician in Europe writes: "He is at present assigned to an Engineer's Service Bn. He has successfully com- pleted a course of training at Equipment Operators School and serves now as an equipment operator. This work requires considerable manual dexterity in manipula- tion of machine controls. His commanding officer registered surprise when told of the nature of the man's wound because there has never been a question of (the patient's) efficiency or usefulness. His service is unlimited." The second and third patients showed evidence of anatomical regeneration only in some return of the appreciation of pain in the autonomous zone. There was no motor return following injuries in the lower forearm. Letters from their examiners follow: "In my opinion this officer is fit to perform his duties, but would be handicapped in combat requiring active use of the right arm. His immediate superior officer feels that this officer is fully qualified in his present job." He was with the 3d Air Division in Europe. "(The patient) is able to perform all his duties properly, including fine move- ments required in maintenance of material." In summary the reports upon the physical status of these men are ad- mittedly inadequate. They serve to demonstrate the fact that resolute individuals, with proper motivation, can resume useful military duties in spite of any type of common peripheral nerve injury. 387

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