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Peripheral Nerve Regeneration: A Follow-Up Study of 3,656 World War II Injuries (1957)

Chapter: Functional Recovery and Occupational Adjustment

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Suggested Citation:"Functional Recovery and Occupational Adjustment." 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:"Functional Recovery and Occupational Adjustment." 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 350
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 351
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 352
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 353
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 354
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 355
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 356
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 357
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 358
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 359
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 360
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 361
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 362
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 363
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 364
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 365
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 366
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 367
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 368
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 369
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 370
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 371
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 372
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 373
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 374
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 375
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 376
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 377
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 378
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 379
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 380
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 381
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 382
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 383
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 384
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 385
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 386
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 387
Suggested Citation:"Functional Recovery and Occupational Adjustment." 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 388

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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

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

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

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

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

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

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

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

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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it was desired to evaluate functional capacity with the benefit of all thera- peutic and rehabilitative procedures, not merely surgery, the stated per- formance depends to some extent upon braces. No effort was made to determine the precise contribution of the brace per se, but it is of interest to note that the numbers of limbs evaluated with braces are 54 for peroneal lesions, 2 for tibial, and 88 for sciatic, among the totals shown in table 206. Table 206.—Specific Functional Capacity of Lower Extremities With Lesions Treated by Suture Pure Functional capacity Peroneal Tibial Sciatic ' 1. Will not bear weight Percent 0 Percent 0 Percent 1.6 2. W^llcy Inn thar) nnp hlrvlr * ....*..* 0 0 2.4 20.4 11.7 21.4 4 IJnlin^tcd walkiog; c^n't run * ...... . 46.9 50.0 56.3 S. Oan run or dance 32.7 38.3 18.3 Total 100.0 100.0 100.0 Number of limbs 113 60 126 i Both sciatic branches sutured. Amputation is omitted from the scale there because none occurred in the limbs on which the table is based; a single amputation of the lower ex- tremity was seen in all the patients brought in for follow-up examination: Case 4673. A complete sciatic lesion in the upper third of the left thigh incurred in a truck accident 19 June 1943 during Z/I maneuvers. Compound fracture of femur, with extensive muscle damage. The right femur was also fractured, but without nerve injury. He had skeletal traction with Kirschner wire in the distal third of each tibia* with the limbs in Thomas splints. On 10 July 1943 the fracture of the right femur was manipulated to correct angulation, but without success. Skeletal traction of right extremity maintained until 10 October, of left until Novem- ber. On 10 November skin grafts were applied to the posterior surface of left leg, and thigh and legs replaced in suspension splints. On 4 February 1944 Keller operation was performed on right great toe because of persistent hallux rigidus. During February patient was allowed up with weight bearing on right lower ex- tremity but not on the left. Knee motion was improving in both legs, but there was no return of sciatic function in the left. On 18 April 1944 the left sciatic nerve was explored, and an extensive nerve gap visualized. Following the exploration, the patient was allowed up with weight bearing on the right leg, and ischial caliper on the left. On 7 September 1944, first stage nerve grafts of both left sciatic branches were placed. Each gap was 15 cm. in length. On 15 January 1945 the grafts were explored, found to be completely avascular, and removed. Second grafts were placed at that time. There was no evidence of regeneration prior to discharge and hopes were pinned on procedures to stabilize the knee to permit walking. Dis- charge occurred on 14 April 1945 without further surgery. No regeneration had taken place and the left knee was partially ankylosed. On 12 March 1948 amputation was performed above the knee, the indications being ulcers and osteomyelitis. 403930—57- -26 361

Another case, from Woodhall's Walter Reed Hospital series and ade- quately followed to the point of amputation, but not included in the allocation pattern for the follow-up study, may be of interest here: L. B. This patient made a parachute landing after his plane was shot down on a bombing mission, and sustained a compound comminuted fracture of the right femur in its lower one-third. The injury occurred on 4 April 1944. He was taken prisoner and treated by a civilian physician and a beef-bone intramedullary graft was placed in this extremity. This procedure was done on 15 May 1944. He arrived at the Walter Reed General Hospital on 25 October 1944, and at this time showed a complete ankylosis of the right knee joint in extension, atrophy of the quadriceps and calf muscles, a decubitus ulcer over the lateral aspect of the right lower leg and complete motor and sensory paralysis of the sciatic nerve. Clinically, the fractured femur appeared to have solid union. Physiotherapy was instituted in order to get knee flexion and, on 29 November 1944, the right sciatic was explored and a huge defect was found; a bulb suture was performed. On 29 De- cember 1944, quadricepsplasty was done on the right thigh and following this the patient developed about 90 degrees of flexion. On 29 March 1945* the bulb suture was resected and an end-to-end anastomosis carried out under considerable tension. By June 1945 it was possible to start him on physiotherapy, but thereafter he de- veloped an ulcer on the right heel. On 26 November 1945, a graft of the right heel was carried out, with the donor site being from the left thigh. Following this, he became ambulatory, with a brace for the right leg. At no time was there very good circulation in this leg and, in May 1946, a series of paravertebral blocks was carried out in order to enhance his circulation. In the latter part of 1946, there were muscle twitches seen in the gastrocnemius-soleus muscle group and the Tinel's sign had descended to the region of the ankle. While on pass, in February 1947, the patient slipped and sustained a complete simple fracture of the lower-third of the right femur below the point of original injury. He was put in traction and* although the fracture showed signs of healing* he developed progressive cyanosis of the right leg, with a large pressure ulcer over the right gastrocnemius muscle. Primarily because of this vascular complication, amputation was done on 15 April 1947. A supracondylar amputation was done and following this, he received his prosthesis and began to walk satisfactorily. The overall functional evaluation was made on somewhat more limbs than the determination of specific functional capacity, and it is of passing interest to note that the percentage ratings on limbs which examiners classified as unknown as to specific functional capacity are about the same as the ratings on limbs which were specifically classified in this way. Table 207 provides a summary of the overall ratings, which were least favorable for the complete sciatic lesions and most favorable for the pure tibial lesions. As may be seen there, sciatic lesions were generally rated at 40 to 70 percent of normal, peroneal at 50 to 90 percent, and tibial at 60 to 90 percent. The median ratings are 60 percent of normal for the sciatic, 66 for the peroneal, and 76 for the tibial, on Dr. Lewey's scale. Although the scale for specific functional capacity is rather abbreviated for the lower extremity, it lends additional meaning to both scales for the lower extremity to exhibit the correlation between them, as is done in table 208 for all peroneal, tibial, and sciatic-peroneal lesions treated by complete suture, whether or not other nerves were injured in the same limb. Men rated at 70 percent or more of normal almost always had no limita- 362

tion on their walking, and about 60 percent of the men rated at 80 percent or better were able to run or dance. There is, however, rather considerable variation in the overall percentage ratings on limbs capable of specific functional acts. For example, about one-third of the men able to run or walk are rated at 70 percent or less of normal. A small number of men classified as able to run or dance nevertheless have low overall ratings. This fact points up a deficiency in the scale, for a man may be able to dance, in his own peculiar and limited fashion, and yet be limited in his walking. Those who are classified as able to run or dance, and have low overall ratings, are quite limited in their ability to run or dance. Table 207.—Overall Functional Evaluation of Lower Extremities With Pure Lesions Treated by Suture Evaluation, percent Peroneal Tibial Sciatic ' Percenr Percenr 0 Percenr 0.7 0 0 10 o o o 20 0 o 2 8 30 1 6 o 3. 5 40 9. 3 5.0 12.6 50 14.0 3.8 17.5 60 23.3 18.8 26.6 70 20.2 18.8 27.3 80 17.8 41. 3 6.3 90 .... 13.2 12. 5 2 8 100 0.8 0 0 Total 100.2 100.2 100. 1 Number of limbs 129 80 143 1 Sciatic lesions are those with complete suture of both branches. The average man with combined nerve lesions on a single limb, has, of course, greater impairment than the man with but one of these lesions. Combined lesions are quite common in the present material, but any useful exploration of the functional deficit attributable to a second lesion must be restricted to well-defined lesions, and only the complete sutures satisfy this requirement. The effect of the second lesion will vary with the identity of the two nerves, but it would take a large sample indeed to provide adequate information on all the combinations of interest. From the present material the median and ulnar were chosen for an exploration along these lines. Pure median and pure ulnar nerve lesions treated by complete suture were isolated and the limbs compared, both as to specific functional capacity and overall functional evaluation, with limbs in which both 363

* 1 I 5 =3 1 365

median and ulnar nerves had been sutured. Injury to any nerve other than the median and ulnar was cause for exclusion from the comparison, the results of which appear in tables 209 and 210. A high-low distinction is maintained there because combined median and ulnar nerve lesions are much more common in the arm than in the forearm, and because of the general influence of site of lesion upon the recovery of specific mo- dalities. Although the distinction as to gross site impairs considerably the stability of any estimates one might make of the effect of the second lesion, it does not obscure the fact that the effect is real for both the median Table 209.—Effect of Associated Nerve Lesions Upon Specific Functional Capacity, Upper Extremity by Gross Site, Complete Sutures Only Pure median Pure ulnar Median and ulnar Specific functional capacity Percent Percent Percent High lesions Useless limb 4. 3 0.7 5.3 Useful only as holder 4. 3 1.4 21.1 Can grasp larger objects 6.4 2.0 17.5 Some opposition 6.4 1.4 22.8 Good opposition 2.1 0.7 0 10.6 0 7.0 14.9 7.5 5.3 Many skilled but awkward acts 34.0 46.3 15.8 Good practical function 17.0 40.1 5.3 Total 100.0 100. 1 100.1 Number of men 47 147 57 Low lesions Useless limb 0 0.5 0 Useful only as holder 2.7 0.5 24.0 12. 5 5. 1 8.0 12.5 1.4 16.0 Good opposition 5.4 0.9 4.0 Picks up pin, visual aid 16. 1 1.4 12.0 2.7 4.2 0 22.3 43.9 28.0 Good practical function 25.9 42.1 8.0 Total 100. 1 100.0 100.0 Number of men 112 214 25 366

Table 210.—Effect of Associated Nerve Lesions Upon Overall Functional Evalua- tion, Upper Extremity, by Gross Site, Complete Sutures Only Pure Pure Median median ulnar and ulnar Overall functional evaluation, percent Percent Percent Percent High lesions Useless limb . . . 4 3 0 7 10.3 10 0 0 8.6 20 4.3 0.7 15.5 30 6.4 0.7 19.0 40 12.8 3.5 13.8 50 21.3 5.6 20.7 60 .. 10.6 18.8 8.6 70 14.9 23.6 1.7 80 19. 1 36.1 1.7 90 6.4 9.0 0 100 0 1.4 0 Total 100 1 100. 1 99.9 Number of men 47 144 58 Low lesions Useless limb 0 0 4.0 10 0 0. 5 12.0 20 1.8 0.9 16.0 30 6.4 0.5 16.0 40 11.9 3.3 20.0 50 20.2 6.6 8.0 60 20.2 19.9 12.0 70 20.2 22.3 8.0 80 13.8 34. 1 4.0 90 4.6 11.8 0 100 0.9 0 0 Total 100.0 99.9 100.0 Number of men . . ... 109 211 25 and the ulnar, and generally quite large, but larger when the median is the second lesion. For example, among high lesions the percentages with no more than good opposition are 23.5 for pure median lesions and 6.2 for pure ulnar, but 66.7 for combined. For low lesions the figures are some- what similar: 33.1 percent for pure median, 8.4 for pure ulnar, and 52.0 367

percent for the combined lesions. If the comparison is made at the upper end of the scale of specific functional capacity, say at the level of good practical function, then for high lesions one finds such performance in 17.0 percent of the limbs with pure median lesions, 40.1 with pure ulnar, but only 5.3 percent with combined. In low lesions the figures differ but the internal pattern is similar. If the overall functional evaluation is employed to gauge the effect of the second lesion, estimates of the same order of magnitude are obtained. In general, it seems plain that the bulk of the better-than-average results observed after sutures on pure median or pure ulnar lesions are not observed following suture of com- bined lesions, and that in their stead one finds an excess not of average or nearly average results but of very poor results. Men who, with but a single lesion, might be expected to perform at least at the level of many skilled or awkward acts, with combined lesions are found capable of no more than opposition or grasping larger objects. D. OVERALL FUNCTIONAL EVALUATION IN RELATION TO MOTOR AND SENSORY RECOVERY Dr. Lewey's criteria for the overall functional evaluation are expressed in terms of specific motor and sensory capabilities, and no further refine- ment upon them can come from the intercorrelation of the summary motor, sensory, and functional assessments, subject as they are in practice to some error of observation. However, the application of these criteria can be usefully illuminated by such correlations, and in addition the summary form of the modified British motor and sensory assessments provides a facile tool for exhibiting, perhaps more dramatically than do the criteria, the sources of functional impairment. Chief interest lies in the complete picture of motor, sensory, and func- tional recovery, but it has seemed best to approach this objective by first examining the correlations in each of the three pairs of variables: motor and functional, sensory and functional, and finally motor and sensory. Tabulations were confined to complete sutures on "pure" nerve lesions, which effectively excluded the sciatic cases, as well as men with injuries to both upper or both lower extremities. Motor recovery The relation between motor recovery and the overall functional evalua- tion is shown in table 211, by nerve. Each scale has been broadly grouped into three classes, which omits some of the detail of the relationship but not at the cost of obscuring the picture in any way. In the form in which the tests were made, the relationship is a highly significant one statistically in every nerve except the tibial where the amount of material is small and the result hardly inconsistent with the notion of an overall relationship regardless of nerve. Were the relationship not a marked one, of course, it would reflect upon the validity of one or both of the assessments. It is 368

the strength of the relationship, not its presence, which is of particular interest. The difference between the median on the one hand, and the radial and ulnar on the other, is noteworthy: in the median function depends less intimately upon motor recovery than is true in the radial and ulnar, presumably because of the greater importance of sensory recovery in median function and because the correlation between motor and sensory recovery is none too high. Table 211.—Relation Between Motor Recovery and Overall Functional Evaluation Following Complete Suture, by Nerve, Pure Lesions Only Level of motor recovery • Percentage distribution as to overall function, as per- centage of normal 0-50 60-70 80-100 Total Number of cases Median At most proximal muscles acting against CTavitv . 75.0 15.0 10. 0 100 0 20 Some action in intrinsics, without synergic or isolated movements 45.9 40.0 14. 1 100.0 85 Synergic or isolated movements possible. . . . 21.3 36.2 42.6 100.1 47 Total 42.1 35.5 22.4 100.0 152 Radial At most proximal muscles acting against 22.2 48. 9 28.9 100.0 45 Some action in intrinsics, without synergic or isolated movements 9.8 25.0 65.2 100.0 112 Synergic or isolated movements possible .... 15.6 84.4 100.0 45 Total 10.4 28.2 61.4 100.0 202 Ulnar At most proximal muscles acting against 16.7 73 3 10.0 100.0 30 Some action in intrinsics, without synergic 11.4 46. 5 42. 1 100.0 271 13.2 86.8 100.0 53 Total 10.2 43.8 46.0 100.0 354 See footnote at end of table. 369

Table 211.—Relation Between Motor Recovery and Overall Functional Evaluation Following Complete Suture, by Nerve, Pure Lesions Only—Continued Level of motor recovery ' Percentage distribution as to overall function, as per- centage of normal 0-50 60-70 80-100 Total Number of cases Peroneal At most perceptible contraction in proximal muscles 37. 5 48.2 14.3 100.0 56 Proximal muscles acting against gravity, at most perceptible contraction in intrinsics . . All important muscles, at least acting against resistance . . 22. 6 5. 1 25.8 51.6 41.0 100.0 99.9 31 39 53 8 Total 23.8 44.4 31.7 99.9 126 Tibial At most perceptible contraction in proximal muscles 15.8 42. 1 42. 1 100.0 19 Proximal muscles acting against gravity, at most perceptible contraction in intrinsics. . All important muscles, at least acting against resistance 12.1 33.3 30.4 54.5 69.6 99.9 100.0 33 23 Total 9.3 34.7 56.0 100.0 75 1 The three groupings correspond to the following rubrics in the classification on p. 75: Upper extremity—(0+1 + 2) v. (3 + 4) v. (5 + 6); lower extremity—(0+1) v. (2+3) v. (4 + 5 + 6). Sensory recovery As may be seen from table 212, which is arranged in the same fashion as the motor table, the correlation between sensory recovery and the overall functional evaluation is much poorer than motor and functional. One would not want to insist upon a correlation between sensory and functional as a condition of the validity of the individual assessments, but the suggestion is that at least a weak correlation is probably characteristic of each nerve. Only for the median and ulnar nerves, however, is the association of table 212 a significant one statistically (P<.01 in each case). For the median the association is somewhat closer than for the ulnar. In the median, the chance of a poor functional classification (0 to 50 percent of normal) ranges from 74 to 16 percent, depending on level of sensory recovery; in the ulnar the range is from 13 to 3.5; the chance of a good functional classification (80 percent or more of normal) ranges from 14 to 32 in the median, and from 29 to 62 in the ulnar. The variation is thus large at the low end of the functional scale for the median, and at the high end for the ulnar. 370

Table 212.—Relation Between Sensory Recovery and Overall Functional Evaluation Following Complete Suture, by Nerve, Pure Lesions Only Level of sensory recovery ' Percentage distribution as to overall function, as percent- age of normal Number of cases Median 0-50 60-70 80-100 Total Not more than superficial pain 73.8 11.9 38.3 52.0 14.3 20.0 32.0 100.0 100.0 100.0 42 60 50 Some touch, overresponse still present 41.7 16.0 Overresponse has disappeared Total 42. 1 35.5 22.4 100.0 152 Radial Not more than superficial pain 17.0 10.5 19.1 31.6 30.6 63.8 57.9 62.2 99.9 100.0 99.9 47 57 98 Some touch, overresponse still present Overresponse has disappeared 7.1 Total 10.4 28.2 61.4 100.0 202 Ulnar Not more than superficial pain 13.2 13.4 3.5 57.9 39.4 34.5 28.9 47.2 61.9 100.0 100.0 99.9 114 127 113 Some touch, overresponse still present Overresponse has disappeared Total 10.2 43.8 46.0 100.0 354 Peroneal Not more than superficial pain 28.0 19.5 22.9 54.0 41.5 34.3 18.0 39.0 42.9 100.0 100.0 100.1 50 41 35 Some touch, overresponse still present Over response has disappeared Total 23.8 44.4 31.7 99.9 126 Tibial Not more than superficial pain 8.8 9.7 10.0 44.1 32.3 10.0 47.1 58.1 80.0 100.0 100.1 100.0 34 31 10 Overresponse has disappeared Total 9.3 34.7 56.0 100.0 75 1 The three groupings correspond to rubrics (0+1 +2) v. (3 + 4) v. (5 + 6+7) in the classification on page 247. 371

Table 213.—Relation Between Motor and Sensory Recovery Following Complete Suture, by Nerve, Pure Lesions Only Motor recovery l Percentage distribution by sensory recovery * Number of cases Median A B C Total A 30 29 23 50 41 32 20 29 100 99 100 20 85 47 B C 45 Total 28 39 33 100 152 Radial A 33 23 13 22 33 22 44 44 64 99 100 99 45 112 45 B C Total 23 28 49 100 202 Ulnar A 63 31 21 27 40 21 10 29 100 100 100 30 271 53 B C 58 Total 32 36 32 100 354 Peroneal A 54 42 18 25 39 38 21 19 100 100 100 56 31 B C 44 39 Total 40 33 28 101 126 Tibial A 58 21 58 35 21 9 13 100 100 100 19 33 23 B 33 52 C Total 45 41 13 99 75 1 The A, B, and C groupings are precisely those of tables 211 and 212. 372

Motor and sensory The correlation between motor and sensory recovery is not remarkable, as may be seen from table 213. Whatever the forces of regeneration may be, they do not appear to act uniformly upon motor and sensory fibers. The primary importance of motor recovery dictates the form of the final tables in this set. For a given level of motor recovery, the influence of sensory recovery is shown upon the overall functional evaluation, for each nerve individually. Two tables were prepared, one showing the percentage of poor functional results (50 percent or less of normal), the other showing the percentage of good functional results (80 percent or more). The tibia! has been omitted from these tables because of small numbers; among the denominators for the 9 cells only 4 exceed 10 cases, and none exceeds 20. Otherwise, the only attempt to cope with the irregu- larity induced by small numbers has been to place an asterisk (*) beside any percentage based on less than 10 cases. In the first (table 214) it is Table 214.—Percentage of Cases With Poor Functional Assessments, by Levels of Motor and Sensory Recovery Level of sensory recovery ' Percentage with poor func- tion, by level of motor recovery ' Median A *100 76 54 B 80 37 27 C *25 28 0 Ulnar A 16 14 0 B *25 14 0 C *0 5 0 Radial A 33 12 *0 B 10 14 0 C 20 6 0 Peroneal A 33 31 *0 B 29 17 13 C 58 *17 0 1 The A, B, and C groupings are precisely those of tables 211 and 212; a poor functional evaluation is one in the range of 0 to 50 percent of normal. •Based on less than 10 cases. 373

easily seen that poor function in the median depends almost equally upon motor and sensory recovery. For none of the other nerves does sensory recovery play a major role independently of motor recovery. On an over- all basis for all nerves combined, it does appear that, for fixed motor recovery, poorer sensory recovery is associated with a poorer functional assessment, however. The influence of variable sensory recovery (motor fixed) upon the chance of having a good functional assessment (80 percent or more of normal) is evident from table 215. Motor and sensory contribute about equally to median function, but for the other nerves the influence of sensory recovery seems slight indeed. Table 215.—Percentage of Cases With Good Functional Assessments, by Levels of Motor and Sensory Recovery Level of sensory recovery ' Percentage with good func- tion, by level of motor recovery ' Median A *0 8 36 B 10 14 40 C *25 20 48 Ulnar A 16 25 82 B *0 47 82 C *0 53 90 Radial A 47 73 *67 B 0 65 90 C. . . 30 61 86 Peroneal A 7 39 *29 B 36 50 33 C 8 *83 53 1 The A, B, and C groupings are precisely those of tables 211 and 212; a good functional assessment is one in the range of 80 to 100 percent of normal. *Based on less than 10 cases. 374

E. RELATION BETWEEN FUNCTIONAL RECOVERY AND COMPENSATION RATINGS BY VETERANS ADMIN- ISTRATION Systematic information on VA compensation ratings was not sought, but in connection with the study of follow-up bias it was planned to use the VA rating as a means of comparing examined and not examined men. In this study the VA ratings were obtained for matched groups of 84 each (examined and not examined) from the New York allocation, the matching being done on the particular nerve injured, type of injury, type of operation, site of injury, and presence of associated injuries. It was thus possible to study the VA ratings in relation to the study examiners' ratings of overall disability for 84 men, with the result shown in table 216. Although the effective sample size is not large, it covers all major nerves and all operative procedures except graft; 52 were men with injuries to the upper extremity and 32 men with injuries to the lower. No significant association (P=.08) was found between the two classifications on the basis of the data in table 216. It was at first thought that the lack of correlation might result from the concentration of cases in the region of 60 to 80 percent on Dr. Lewey's scale, and a second sampling was undertaken to investigate this possibility. Table 216.—VA Disability Ratings and Follow-up Examiners' Overall Func- tional Evaluations, New York Sample Representing All Major Nerves VA disability rating, percent Overall functional evaluation 100 0 10 20 30 40 50 60 70 80 90 100 Un- known Total 90 1 1 80 1 1 1 1 1 1 2 3 2 5 4 3 1 2 2 3 2 3 9 70 1 1 1 1 7 1 9 18 14 19 9 3 60 9 2 5 1 1 50 ... 1 2 3 3 40 30 1 3 20 10 . . 0 No. claims filed . Total 2 2 1 1 1 5 11 20 21 9 15 84 Mean rating. . . in o SO 0 w n 60 0 40 1 s? 5 SS ? 4? ? 56.2 52.6 375

In the second study of the relationship between VA ratings and follow-up examiners' ratings, pure median and pure peroneal lesions were chosen from the allocations of all five centers and with no residuals of any as- sociated injuries, and a deliberate effort was made to give adequate repre- sentation to the entire scale. Although the latter objective was not com- pletely realized, the resulting sample was a marked improvement over the first sample in this respect. Table 217 provides a summary of the resulting observations, which also provides no real evidence of an association between the two classifications. Table 217.—VA Disability Ratings and Follow-up Examiners' Overall Functional Evaluations, Pure Median and Pure Peroneal Lesions Overall functional evaluation VA disability rating* percent 0 to 50 60 to 70 80 to 100 Total Median 100, 90 80, 70 3 5 1 9 60, 50 4 4 5 13 40, 30 14 7 11 32 20, 10 2 2 0 1 1 Total 21 18 18 57 43.8 46.7 38.9 43.2 Peroneal 100* 90 80, 70 60, 50 7 3 9 19 40, 30 6 10 5 21 20 10 2 2 5 9 0 Total 15 15 19 49 44.7 37.3 38.4 40.0 The foregoing studies were made as statistical operations after the follow-up examiners had completed their work, and no attempt has been made to review the cases individually to uncover the source of the dis- crepancy. However, certain other observations, made during the course of this and other studies participated in by the NRC Follow-up Agency, have 376

some bearing on the probable reasons why the two ratings fail to agree. In some related work on men with peripheral nerve injuries it was noted that VA ratings were appreciably higher for men with combined nerve lesions than for men with pure lesions. In another study (15) on peripheral vascular injuries, a high correlation was found between VA ratings and the number of different sources of disability (vascular, nerve, bone, soft tissue, etc.) noted by follow-up examiners. Finally, in connection with the bias studies described earlier (pp. 22-27) the chairman of the present study group used Dr. Lewey's scale to rate both examined and not examined men with pure ulnar lesions, vising only the appropriate reports of VA examinations undertaken for rating purposes. For the 26 men seen by the follow-up examiners of the New York center the chairman was kept in ignorance of the center's overall functional ratings based on its own examinations. Nevertheless, statistical analysis showed a high cor- relation between the two ratings of overall function, one by the New York examiner who saw the patient, the other by the study group chairman who saw only the last VA rating examination made before the research examination in New York. In 9 of the 26 cases the ratings were the same, and in 24 they were within 10 percent (one step on the scale); the overall correlation was +.8. This suggests not only that the New York ratings were reasonable and reproducible, but also that the VA examination contained the bulk of the information required to satisfy Dr. Lewey's classification. One can only conclude, from these various facts, that the VA percentage rating does not closely reflect the recorded findings of the rating examination in the same way that Dr. Lewey's classification does. At the same time, it would appear that VA percentage ratings do closely reflect the various components of disability insofar as these may be traced to the different structures involved in the original injury. This is consistent with the view that the percentage rating is a compound of actual disability found at examination and of the characteristics of the injury as noted in the original records underlying the claim. F. OCCUPATIONAL CHANGES As explained earlier, occupational changes were approached by asking the examiner to obtain specific occupation (job and industry) before service and at follow-up, and to determine whether any change seemed attributable to the nerve injury. The gross data on the latter point are exhibited in table 218 for all lesions with follow-up except the few with more than one lesion on a single nerve. For the sample as a whole, change in occupation was the rule for men with previously established occupations, and the great majority of the changes appeared to examiners to have resulted, at least partly, from the nerve injuries. A control group would be necessary to delineate the precise role of the nerve injury, but the clinical opinion is quite clear: The peripheral nerve injury contributed to a change in occupation in 49 percent of the cases, and to an apparent inability to work in another 7 percent. An investigation on the median failed to show that 40398ft—67 26 377

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

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

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

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

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

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

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

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

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."

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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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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