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

Chapter: Case Study of the Best and Poorest Results Following Peripheral Nerve Suture

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Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 412
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 413
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 414
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 415
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 416
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 417
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 418
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 419
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 420
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 421
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 422
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 423
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 424
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 425
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 426
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 427
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 428
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 429
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 430
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 431
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 432
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 433
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 434
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 435
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 436
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 437
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 438
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 439
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 440
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 441
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 442
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 443
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 444
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 445
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 446
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 447
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 448
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 449
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 450
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 451
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 452
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 453
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 454
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 455
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 456
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 457
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 458
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 459
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 460
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 461
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 462
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 463
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 464
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 465
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 466
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 467
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 470
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 471
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 472
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 473
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 474
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 475
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 476
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 477
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 478
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 481
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 482
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 484
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 491
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 493
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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 494
Suggested Citation:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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:"Case Study of the Best and Poorest Results Following Peripheral Nerve Suture." 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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Chapter X CASE STUDY OF THE BEST AND POOREST RESULTS FOLLOWING PERIPHERAL NERVE SUTURE Barnes Woodhall A. INTRODUCTION Although the statistical analysis of the factors influencing the regenera- tion of peripheral nerve injuries may show trends of indisputable signifi- cance, it cannot illustrate the ideal case where all factors are so blended that they produce the maximum return of function of which each nerve may be capable. This method may readily portray those factors that mitigate against good regeneration; the obverse can then only be surmised by the absence of such adverse factors. Whether this is a valid assumption or not, it is a fact that the experienced observer can peruse a succession of individual case reports and form substantial opinions concerning the probable cause of adequate or poor neural regeneration. This approach has been taken with a moderately large group of case histories in which regeneration was recorded as developing to a point that might be termed maximal, and with a similar group in which little or no regeneration was noted after a period of many years. Ten examples of maximal regeneration and a like number with virtually no evidence of regeneration were selected from each of the 7 nerve groups (median, ulnar, radial, tibial, peroneal, sciatic-tibial, and sciatic-peroneal), a total of 140 cases. They were chosen primarily on the basis of the two modified British summaries, one of motor recovery and the other sensory. The specific criteria, of course, varied by nerve, and as shown in table 228. Use of these motor and sensory criteria produced more than 10 examples in each group. Autonomic recovery and overall functional evaluation, therefore, were used to make the final selection of 10 cases from among those eligible under the motor and sensory criteria for each group. Thus, an example of very poor recovery in the median nerve might have: (1) a complete absence of sensibility; (2) an elevated skin resistance in the total area of nerve supply; (3) an overall functional evaluation of 30 percent or less; and (4) either no motor recovery or at most just perceptible contrac- tion in proximal muscles. An example of very good recovery would include: (1) perception of superficial pain and touch throughout the autonomous sensory zone plus some two-point discrimination; (2) normal skin resist- 403930— 57 28 «>9

ance; (3) an overall functional evaluation of 80 percent or more; and (4) contraction against resistance on the part of all important muscles, both proximal and distal, plus capacity for some synergic and isolated movements. Table 228.—Motor and Sensory Criteria Employed in Choosing Examples of Good and Poor Recovery Following Complete Suture, by Nerve Nerve British motor British sensory Good recovery Median, ulnar, and radial Peroneal. Tibial... Sciatic-peroneal .. Sciatic-tibial. At least all important proxi- mal and distal muscles act- ing against resistance plus capacity for some synergic and isolated movements. At least all important proxi- mal and distal muscles act- ing against resistance. Same as peroneal At least proximal muscles act- ing against gravity, percep- tible contraction in intrinsics. Same as sciatic-peroneal At least return of superficial pain and touch, plus some 2-pt. dis- crimination in autonomous At least return of superficial pain and touch throughout autono- mous zone. At least return of some superficial pain and touch in autonomous zone. At least return of superficial pain and touch throughout autono- mous zone, with overreaction and inability to localize. At least return of some superficial pain and touch in autonomous zone. Poor recovery Median. Ulnar. Radial. Peroneal Tibial Sciatic-peroneal Sciatic-tibial. . . At most perceptible contrac- tion, proximal muscles only. No contraction at all Same as median Same as ulnar. . Same as median. Same as ulnar. . Same as median. At most deep cutaneous pain sensibility in autonomous zone. Same as median At most return of some superficial pain and touch, autonomous zone. Same as median. Same as median. No sensibility in autonomous zone. Same as sciatic-peroneal. The extent of neural regeneration has been charted against the major variables that are assumed to influence regeneration, in particular those that are capable of assessment, that is, location of wound in the extremity, time of definitive treatment after injury, extent of the neural defect, exist- ing neural pathology, and presence of complicating factors such as infec- 410

tion, concomitant vascular, bone, and extensive soft tissue injury, and surgical error. Much use has been made of illustrative case material and indeed it is from this that the reader may form his own opinions. The author has chosen to retain these case reports in their original form, and in consequence, tense, style, etc., are not uniform. A summary case report was not required by the protocol, and in most centers was not routine. In the Philadelphia center, however, Dr. Lewey early insisted upon their preparation and for this reason it is largely from the Philadelphia cases that the illustrative material has been drawn. Finally, an effort has been made to draw together and summarize the pertinent data of this case study. B. UPPER EXTREMITY 1. Median Nerve The salient features of 10 examples of median nerve recovery at its best are abstracted in table 229, and the details of several then follow. Asso- ciated nerve lesions are shown only if suture was required; incomplete, lysed lesions are omitted. Case Report 4452 HISTORY OF INJURY This soldier was wounded in action in Italy on April 8, 1944, by a shell explosion, receiving multiple perforating wounds of his left forearm in its lower third and also of his left face. He showed some impairment of his left median nerve with loss of flexion of the 1st, 2d, and 3d fingers, and anesthesia of the palm of the hand and superior half of the 1st, 2d, and 3d fingers. On October 2, 1944, neurorrhaphy was done on the left median nerve at Wakeman General Hospital. In the middle third of the forearm the median nerve showed a lateral neuroma adherent to the adjacent muscle tissue; after an attempt to enucleate this tumor mass without damage to the nerve, only a few shreds of nerve were left, and it showed no response to electrical stimulation. It was therefore resected to a gap of 3 cm. and sutured with silk. Seven months postoperatively the patient had 75 percent function in all median muscles, except the opponens which had 50 percent and the flexor pollicis brevis which had none. At 9 months all median muscles showed 75 percent function. This was the patient's status at discharge on August 16, 1945. INTERVAL HISTORY The patient has had no treatment since discharge, but he has noted the return of ability to adduct his index finger. There has been increased sensation in the palmar surface of the 1st, 2d, and 3d fingers, and all hand motions are stronger. His chief complaint is diminished sensation in the first three fingers, difficulty in picking up small objects, and a drawing up of his forearm in cold weather. He has pain with use and rapid fatigue 411

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only with heavy work. Before the war he was a pipefitter's helper. He changed his occupation because he was afraid of damaging his hand. He is now a trucker for the railway express and is slightly handicapped by the inability to do heavy lifting and he also takes time off sometimes because of his arm. His compensation is 30 percent, and he is satisfied with this. CENTER EXAMINATION March 3, 7950 The patient is left handed. Distance of the injury is 9% inches M and there is a "hot spot" present. The injured hand shows some atrophy of the thenar eminence and the middle phalanx of the index and middle fingers is smaller than normal. The forearm is diminished % inch in circumference. The injured hand is slightly cooler than normal but pulses are equal and full. There is no limitation of motion at the wrist or elbow but there appears to be some flexion contracture of all fingers. The patient is able to pick up a pail of water and to button his shirt, but he is unable to pick up a pin with his eyes closed and he now uses his right hand for most manipulations. In a typical median distribution the patient is able to feel 30 gm. pain and 16 gm. touch; because of calluses, the threshold for the normal part of the hand is 20 gm. pain and 3-5 gm. touch. There is no split sensation and there is good localization, but on the thumb two-point discrimination is 2.5 cm. and on the index finger 7 cm., compared with 2 cm. on other fingers. Position sense is slightly impaired in the median distribution. Deep pressure is almost absent on the index finger and impaired on the thumb and middle fingers. Skin resistance is about normal in the median area of the hand and normal to slightly increased in the ulnar area. Quantitative muscle evaluation is as follows: Flexor carpi radialis, palmar is longus, and flexor carpi ulnaris 100 percent; flexor pollicis longus 100 per- cent; flexor pollicis brevis 100 percent; flexor digitorum profundus to all fingers 100 percent; flexor digitorum sublimis to the index finger 100 percent, to the little finger 100 percent; opponens 14 percent; abductor pollicis brevis not tested. Flexor digitorum sublimis to the middle finger had a rheobase of 35, a chronaxie of 0.36; the opponens had a rheobase of 110, a chronaxie of 0.12. Functional evaluation. This patient has good practical function in his hand and arm; by testing, all muscles show almost 100 percent function, and his sensation is not greatly diminished. If it is true that this patient was left handed and therefore if it was his dominant hand that was injured, he may be slightly handicapped by loss of very fine and skilled movements and also by some lack of sensitivity. Because this was a low median nerve injury, only two muscles (abductor pollicis brevis and opponens) should have been affected, and these as well as sensory function in the hand show a fair degree of return of strength and practically a good degree of function. » Measured from the carpal crease in all cases of upper extremity injury. 414

Case Report 4366 HISTORY OF INJURY This soldier was accidentally shot by a guard in Luxembourg on October 18,1944. The rifle bullet penetrated his left upper arm in the lower third of the medial aspect, severing the brachial artery and the median nerve. There was also a fracture of the proximal phalanx of the right index finger. At debridement the same day the median nerve was seen to be severed 2% inches above the elbow, while the ulnar and medial antebrachial cutaneous nerves were intact. The brachial artery was ligated and the median nerve approximated; penicillin was placed in the wound. Six weeks later the patient had osteotomy performed on the right index finger. On March 3, 1945, neurorrhaphy was performed on the left median nerve at Kennedy General Hospital. At the site of approximation there was a 2-cm. neuroma and there was no electrical response in the nerve. The median nerve was resected 5.5 cm. to good fibrils, sutured with tantalum and wrapped in a tantalum foil. Five months postoperatively there was good function in the pronator teres, flexor carpi raclinlis, palmaris longus, and flexor pollicis longus. At discharge on December 17, 1945, the pronator teres showed 75 percent function, the flexor carpi radialis 75 percent, the flexor digitorum sublimis and flexor pollicis longus 25 percent, the flexor indicis proprius and the opponens 0; there was some sensory return with spread. INTERVAL HISTORY The patient has had no treatment since discharge but his wrist and finger movements have increased in strength. He complains primarily of inade- quate sensation and also of limitation in fine hand movements. Before the war the patient was a steam-shovel operator and he has returned to the same job since the war. He is limited because of fatigue in his injured arm to 50 percent of his previous earnings. The patient's compensation is 50 percent and he is not satisfied. CENTER EXAMINATION November 9, 1949 The patient is right handed. Distance of the injury is 14 inches. There is no marked atrophy, but the forearm is diminished 1 inch in circumference. Pulses are full and strong, and the hands equally warm and moist. Wrist extension is limited to 115 degrees, and there is a slight impairment in flexion of the 2d and 3d fingers. The patient is able to pick up a pin between his thumb and index finger, but is unable to do so with his eyes closed. He is able to pick up approximately 40 pounds weight. Throughout the entire hand the patient is able to feel 6 gm. pain and 5 gm. touch. Deep pressure and position sense are unimpaired. Skin resistance is not noticeably different from that in the normal hand. There is no split sensation. Quantitative muscle evaluation is as follows: Flexor carpi ulnaris, flexor carpi radialis, and palmaris longus 100 percent; pronator teres 100 percent; flexor pollicis longus 100 percent; flexor pollicis brevis 70 percent; flexor 415

digitorum profundus to the index finger 15 percent, to the middle finger 95 percent, to the ring and little fingers 100 percent; flexor digitorum sublimis to the index finger 60 percent, to all other fingers 100 percent; opponens 80 percent. The opponens shows a rheobase of 85, a chronaxie of 0.28. Functional evaluation. This patient has excellent motor function in his arm, and our testing shows the sensory function to be quite good. How- ever, he complains that he is unable to perform fine movements with his hand and that he is limited by his lack of sensation. We might, therefore, list him as possessing many skilled but awkward movements with some limitation through lack of sensation. Case Report 4266 HISTORY OF INJURY On September 16, 1944, this soldier was wounded in action in Germany, receiving a rifle bullet in the upper third of his left forearm with fracture of the left ulna and anterior dislocation of the left radius. There was no return of function below the pronator teres, and on February 1, 1945, neurorrhaphy was performed on the left median nerve. There was a 2-cm. neuroma in continuity 3 inches below the elbow, and there was no electrical response on stimulation. The nerve was resected 3 cm. to good tubules, sutured with tantalum, and a tantalum foil placed about the site of suture. At discharge on December 12, 1945, there was good function in the forearm muscles, no function in the median intrinsics, but some perception of light touch and deep pain. INTERVAL HISTORY The patient has had no treatment since discharge other than a brief period of physiotherapy. He has noted return of function in the long flexor of his thumb, increased strength of grip, and improved sensation in his fingers. His chief complaint is in diminished maneuverability of his hand, but he can perform all functions with the hand. He has no complaint of pain. He works as a clerk for the Government and does not feel handicapped by his injury. His compensation is 50 percent, of which 40 percent is for his hand injury. CENTER EXAMINA TION August 5, 1949 The patient is right handed. There is slight diminution in substance of the forearm but no gross deformities. There are trophic changes over the median area of the palm and in the nails of the thumb and index finger, and there is loss of pulp in these fingers. The distance of the in- jury is 10K inches from the carpal fold, and at this site the tantalum cuff is palpable. There is no "hot spot." The left ulna is % inch shorter than the right. There is no joint limitation. He has a very strong grip and is able to lift a chair with ease although this strength fades out after several minutes. He can pick up a pencil with his eyes shut, or a pin with his eyes open; he is able to pick the correct coin out of his pocket. 416

In a typical median distribution he perceives 2 gm. pain and 3 gm. touch, with a very minimal amount of hypersensitivity. There is no split sensation on the palm, and less than 1 cm. on the backs of the fingers. Deep pressure is felt with mild discomfort and referred each time to an- other digit. Two-point discrimination on the thumb is 4 mm. compared with a normal of 2, on the index finger 12 mm. compared with a normal of less than 2. Skin resistance is very slightly increased over the median distribution. Photographs were made of the hand showing opposition and also the trick movement of short abduction. Quantitative muscle evaluation gave the following results: Flexor carpi radialis, palmaris longus 100 percent; pronator teres 75 percent; flexor digitorum profundus to the second finger 35 percent, to the third finger 100 percent; flexor digitorum sublimis to the second finger 80 percent, to the third finger 100 percent; flexor pollicis longus 15 percent; flexor poll iris brevis 100 percent; opponens 35 percent, with substitution; ab- ductor pollicis brevis 28 percent, with substitution. Percutaneous stimula- tion of the median nerve at the elbow gave good response in all median muscles. The flexor pollicis longus had a rheobase of 185, a corrected chronaxie of 4.0; the opponens had a rheobase of 85, a chronaxie of 2.4. Electromyography was done on the opponens; on supermaximal stimula- tion this muscle gave spikes of 2.4 inches compared with a normal of 4.0 inches. Functional evaluation. This patient has excellent functional return, both motor and sensory. He is practically not handicapped. This is a high grade of motor and sensory return. The intrinsic actions of opposition and short abduction are present, but assisted by trick movements. The ten examples of poor recovery are summarized briefly in table 230. The cases chosen for detailed presentation follow. Case Report 4004 HISTORY OF INJURY On October 29, 1944, this patient suffered multiple shell-fragment wounds resulting in bilateral wrist drop and left ulnar and median paralysis from shoulder injuries. By December 27, 1944, the right wrist drop had cleared and only median motor and sensory paralysis persisted on the left. On June 6, 1945, the left brachial plexus was explored and the median nerve was found to be severed 3 cm. distal to the site of its formation from the lateral and medial head. In addition, there was an accessory lateral head which came from the anterolateral trunk to join the median nerve in the upper one-third of the arm; this also was severed. After resection of neuromata there was a gap of 6 cm. (accessory head not stated), the proximal end of which looked good but the distal end contained gelatinous material. The nerves were sutured with black cotton. The other nerves responded well to electrical stimulation. He was given a disability dis- charge on October 8, 1945, at which time he had not yet shown evidence of return of function in the median distribution. 417

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INTERVAL HISTORY This patient has had no treatment since discharge. A prewar turret lathe operator, he is now in college studying industrial engineering. His complaints include spontaneous pain, occasional paresthesias, coldness, ulcerations, and pain with use of the left arm. In his right arm he com- plains of numbness in the medial aspect of his right hand and arm. His compensation is 60 percent. CENTER EXAMINATION March 24, 1948 The injury is 29 inches above the distal palmar crease. Sensory examination. There is no return of sensation in the median area. Motor examination. He has no function in proximal or distal median muscles. Electrical examination. There was no reaction to direct stimulation of the median muscles. Intraneural stimulation at the wrist gave no reaction in the median intrinsics. POINTS OF SPECIAL INTEREST This is a high median injury sutured 7# months after injury in which there has been no return. Intervention was delayed after injury because of the feeling that the median was returning spontaneously. However, at exploration the nerve was seen to be completely severed, and there is no evidence of anomalous innervation. Reexploration of the suture line was recommended to the patient. Case Report 4307 HISTORY OF INJURY In 1943 this patient had an episode of what was called cerebrospinal meningitis, which by description is strongly suggestive of multiple sclerosis. On June 12, 1944, he received a penetrating wound in the left side of the neck and ruptured left ear drum. No sequelae. On July 30, 1944, the patient was wounded in the left axilla by a high explosive shell. The left brachial artery and vein were found severed and were ligated 2 hours later. The left median nerve was found to be fully severed and was approximated with black silk at the same time. A neurorrhaphy on the left median nerve was performed on December 13, 1944, 4.5 months after injury. The nerve was resected 6 cm. and sutured with black silk. CENTER EXAMINATION Examination shows very little function in the median nerve, either motor or sensory, but there is a bizarreness of functional deficits in the ulnar and radial areas as well, and these again suggest that he may have an overlay of stigmata of multiple sclerosis. He cannot open his hand very widely, and the use of the hand is limited to picking up small and quite light objects; functionally, he can do practically nothing with the arm. He has been able to continue at his previous skilled job, but as a result of his injury he can put in only half the time that he could previously and therefore his 420

wages are cut in half; despite this, he leads a very active life and is able to support both his wife and his mother. This is a typical median nerve injury with repair 4.5 months after wounding but with practically no return of function; the part played in this poor result by multiple sclerosis is debatable. Case Report 4110 HISTORY OF INJURY Patient was injured by shell fragments in France on June 22, 1944. He sustained a compound comminuted fracture of his right humerus in the middle third, and there was some damage to the right biceps muscle group and the brachial artery and plexus. Clinically, a median and ulnar nerve palsy was noted. October 8, 1944, bulb suture of the median was carried out. December 20, 1944, skin grafts were performed over the right hand to burns incurred while on furlough. April 20, 1945, the median and ulnar nerves were sutured at the Newton Baker General Hospital with anterior transplantation of the ulnar nerve. October 4, 1945, arthrodesis of the right wrist was performed with excision of the distal head of the radius and the proximal row of carpal bones. April 27, 1946, discharged for disability, with no functional return, elbow partially ankylosed, operative fixation of wrist, anesthesia in forearm and hand, and significant vascular insufficiency. CENTER EXAMINATION September 10, 1948 Patient was right handed and 23 years of age at the time of injury. The suture was carried out 16 in. from the distal palmar crease. The diameter of his arm 4 in. above the olecranon was 11 in. on the injured side and 12% in. on the normal side. Four inches below the olecranon it was 8% in. on the injured side and 11% in. on the normal side. The radial pulse is only faint at the wrist on the right side. There is definite limita- tion of joint function. He can extend the elbow to only 133 degrees and flex it to only 62 degrees. There is no movement at the wrist whatsoever secondary to the arthrodesis. There is no pronation or supination and only slight voluntary movement of no more than 15 degrees range in the fingers. All the interphalangeal joints are limited in motion and there is almost a complete flexion contracture of the fingers of the hand. The hand is definitely colder than normal, particularly from the middle of the upper arm down. There is marked tapering of all the fingers with loss of substance of the pulp. The nails of the 4th and 5th fingers are distorted and contain a horny growth. There is marked callus over the distal inter- phalangeal joint and the dorsal surface of the ring finger. All in all, this is the worst appearing hand we have seen since we began examining patients at this center. Sensory examination. Deep pressure sense is absent in all of his finger-tips. Position sense is absent in all his fingers. There is no split sensation. For all practical purposes the entire hand, with the exception of a small area 421

on the posterior surface of his hand, is anesthetic to 40 gm. of pain and 20 gm. of touch. Skin resistance is markedly increased all over the ab- normal hand. Motor examination. Clinically, he has a pronator teres, poor flexor carpi radialis, poor palmaris longus, and poor flexor indicis proprius. The remainder of the median innervated muscles are absent. He has a poor flexor carpi ulnaris and a poor flexor digitorum profundus, 4th and 5th. The remainder of the ulnar innervated muscles are absent. On percu- taneous stimulation at the wrist, it would seem that he has some abductor digiti quinti and some abductor pollicis. On percutaneous stimulation of the median nerve at the wrist, it would seem that he has some flicker of muscle fibers in the thenar eminence. POINTS OF SPECIAL INTEREST This injury is complicated by the extreme vascular insufficiency, par- tially ankylosed elbow and a wrist which was fixed. This arthrodesis was done when the forearm was shortened in order that the contracted fingers might have a more useful arc of motion. It is also of interest to note that prior to this surgical procedure an amputation was deemed the treatment of choice since it was unlikely that a favorable result could be obtained. Another factor further complicating this injury was a severe burn which necessitated skin grafting over the dorsum of the fingers. There is nothing that we can possibly offer this man in the way of treatment. Case Report 4336 HISTORY OF INJURY This soldier was wounded in action on Angaur Island in the Southwest Pacific on September 30, 1944, by shell fire, receiving multiple wounds on the lateral side of his right arm, antecubital fossa, and forearm. Four days after injury he was noted to have dry gangrene of the tip of his right 2d, 4th, and 5th fingers. On October 7, 1944, on the hospital ship U. S. S. Bountiful, when the cast was removed from his arm, it was noted that the forearm appeared gangrenous, and incision and drainage were carried out in this region, removing much necrotic muscle tissue from both the flexor and extensor surfaces; it appeared at this time that "he had a divided radial nerve trunk in the lower third of the forearm which was sutured with #40 silk." The gangrene and other wounds gradually healed under im- mobilization, hot soaks, and chemotherapy. Because of the poor circula- tion in this extremity, and because of a causalgic type of pain, sympathetic block was tried on February 6, 1945, at Percy Jones General Hospital; the results, judged by skin temperature reading and relief of pain, were satis- factory, and on February 12, 1945, a right dorsal sympathectomy was performed with very good results. At this time there had been a hyper- algesic return of sensation in the ulnar distribution with questionable re- turn in the abductor digiti quinti; there was good action in the radial nerve except for the extensors of the thumb, which digit was too stiff to function; 422

the entire median nerve was functionless. On May 16, 1945, at Percy Jones General Hospital, neurorrhaphy was performed on the right median nerve. The nerve was found to end in a dense neuroma distal to the branches to the pronator teres, but proximal to the pronator teres muscle; the nerve was transplanted anteriorly to the pronator, resected 6 cm. to healthy tubules, and sutured partly with silk and partly with tantalum. On electrical stimulation there was a very weak response in the pronator teres only. Carpectomy was performed on the right wrist on March 13, 1946, all carpal bone except the pisiform being removed and the wrist placed in 30 degrees dorsiflexion. This latter procedure resulted in in- creased abduction and short flexion of the thumb. On September 12, 1946, a contracting cicatrix of the right elbow was excised and replaced with a direct skin flap. He then had further plastic work done, apparently to the dorsum of the forearm and wrist, and plans were made for a number of further procedures to improve the function of the hand; these latter procedures were repeatedly postponed by red tape and the patient applied for his discharge. He was finally discharged on September 21, 1947, and at this time action was noted in all the radial muscles, in the flexor carpi ulnaris, flexor digitorum profundus to the 4th and 5th fingers, abductor digiti quinti, and short flexor of the thumb. INTERVAL HISTORY The patient has had no treatment since discharge and has noted little, if any, improvement in his arm. He notices no pain in the arm. Before the war he managed a service station; now he is a factory worker, despite his statement that his right arm is utterly useless. His compensation is 90 percent. CENTER EXAMINATION October 14, 1949 The patient is right handed. Distance of the injury is 16 inches. The right extremity is shortened 3 inches. The forearm is diminished 2 inches in circumference, and there is marked atrophy of the entire forearm and hypothenar eminence. The fingers of the right hand are cold, there is no abnormal sweating and no radial pulse is palpable on the right. The wrist is fixed at 30 degrees dorsiflexion; all of the fingers are clawed; the thumb is adducted and flexed over the index finger. The pulp of the fingers is markedly reduced, and the fingernails are overgrown and curved. The patient is unable to perform any functional tests with this arm. In the median zone 40 gm. pain are not felt as such, and he is anesthetic to 35 gm. touch; in the ulnar zone he is hypersensitive to 6 gm. pain, but feels 16 gm. touch normally. Deep pressure produces painful paresthesias in the ring and little fingers, and is not felt at all in the thumb, index, and middle fingers; no position sense is present in any of the five fingers. The only muscles in the entire arm that show clinical function are the biceps and triceps, which are normal, and the abductor pollicis longus which showed a trace of function, as does the extensor digitorum com- munis. Percutaneous stimulation of the radial nerve produced some 423

response in the brachioradialis, extensor carpi radialis, and extensor pollicis; percutaneous stimulation of the median nerve at the elbow pro- duced no response; percutaneous stimulation of the ulnar nerve at the elbow produced a moderate response of the flexor digitorum profundus to the 4th and 5th fingers, abductor digiti quinti, adductor pollicis, and 1st dorsal interosseus. The abductor digiti quinti had a rheobase of 130, a chronaxie of 2.8, slow; the extensor carpi radialis had a rheobase of 75, a chronaxie of 0.8, prompt; the opponens had no determinable rheobase. Functional evaluation. The arm is functionless. POINTS OF SPECIAL INTEREST This patient had a long and involved history. It was eight months be- fore operation could be performed on the median nerve, and this resulted in no return of function. Throughout this long hospital course there were excellent studies, including electrical ones, done on the arm. 2. Ulnar Nerve Table 231 contains a summary of the 10 cases representing maximal recovery in this series from which the following cases have been chosen for detailed presentation. Case Report 8704 HISTORY OF INJURY October 25, 1948. This patient had an accidental wound to the left elbow in November 1944 with division of the ulnar nerve. In May 1945 operation showed a lesion in continuity. There was a gap of 5 cm. after its removal, and the nerve was transplanted by sectioning rather than by retunneling. By October 1945, 5 months postsuture, the ulnar sensory area still showed a complete anesthesia and analgesia but there was de- finite innervation in the abductor digiti quinti and the adductor pollicis, as well as the flexor of the 5th finger. EMG showed the abductor digiti quinti at 25 percent. There was no tetanus at 20. Since discharge, the patient notes that he has improved in his ability to extend the 4th and 5th fingers and that he has obtained a much stronger grip. The 5th finger has become more sensitive but still feels very different from the other fingers. There are no major complaints, the patient is able to work out- doors without undue coldness of the hand, but he does notice some cramp- ing in the flexors of the 4th and 5th fingers after prolonged use of the hand. He has learned to be a plumber and does not believe that he is significantly disabled by his hand at the present time. CENTER EXAMINATION Examination shows an amazingly normal appearing hand with good filling out of the hypothenar and the abductor spaces. The hand has a very good strong grip and can be used for all types of small and large test objects. The 4th and 5th fingers are extended fully when the hand is placed around large objects, and there is only slight diminution in the 424

ability to lift very heavy things, such as chairs. All of the ulnar flexors and all of the intrinsic muscles work strongly and there is perfect lum- brical function. Even the abductor of the 5th finger is working. The abductor digiti quinti pulls 6 Ibs. as opposed to 7 on the normal side, and the 1st dorsal interosseus pulls 4 Ibs. as opposed to 4 Ibs. on the normal right side. Chronaxies are 0.4 msec. for the abductor digiti quinti and 2.8 msec. for the 1st dorsal interosseus. Tetanus could not be obtained. EMG shows .4 mv. from the abductor digiti quinti on the injured left side as opposed to .5 mv. on the right side. A handprint was taken to show the recovery of the hypothenar eminence. From a sensory standpoint, pain thresholds are 30 gm. over the volar surface of the hand but 6 over the dorsal surface, and the sensory loss is probably entirely due to callus. Touch is felt at 5 gm. throughout. There has been a fair recovery of two- point discrimination which can be felt at }f\ in. There is no split sensation. Pressure and position sense are normal. Sweating is slightly reduced on the 5th finger but definitely present. POINTS OF SPECIAL INTEREST (1) This is the best result from ulnar nerve suture that we have seen. Even two-point discrimination has recovered on the sensory side, and there has been a complete functional and anatomical recovery on the motor side. (2) The completeness of recovery suggests that the delay of 6 months between injury and operation was not significant. (3) This bears out our theory that lesions in continuity regrow better than complete severance lesions. (4) Regrowth of the ulnar nerve is probably better when it is not de- prived of its blood supply by rethreading a large portion of the nerve through a second canal alongside the median nerve. Here we simply sectioned the flexor carpi ulnaris muscle and lifted only a small portion of the nerve from its bed. (5) The excellent strength recorded is biased by patient's occupation (plumber). Case Report 4394 HISTORY OF INJURY This soldier was wounded in action in France on November 10, 1944, a machine gun bullet perforating his left elbow, fracturing his left radius and ulna. The patient was captured by the Germans, was given some surgical care, and contracted infectious hepatitis. He was liberated by the Ameri- can Army 5% months later, at which time he showed paralysis of his left ulnar nerve below the flexor carpi ulnaris. On July 12, 1945, this nerve was repaired at Halloran General Hospital. The nerve was found to end in a neuroma buried in dense scar in the upper third of the left forearm; on electrical stimulation proximal to the injury there was slight contraction of the flexor carpi ulnaris and the flexor digitorum profundus to the 4th and 5th fingers. The nerve was resected 4.8 cm. to good fascicles proximally 403930—57 29 425

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but only fair ones disfally with considerable fibrosis, and sutured with tantalum. Two months later the patient had an excision of the head of the radius and a separation of synostosis. Following this operation the patient showed a transient radial paralysis, but a tdischarge on January 11, 1946, there was full radial nerve function, 75 percent function in the flexor carpi ulnaris, beginning return of sensation but no other motor func- tion in the nlnar nerve. INTERVAL HISTORY Patient has had no treatment since discharge and the only improvement he has noted has been some increase in strength and sensation. His major complaint is of pain in his elbow in cold weather. He experiences no other pain, does not have rapid fatigue and otherwise is asymptomatic. The patient has continued at his prewar job as a commercial chemist and his earning capacity is approximately the same. His compensation is 50 percent, and he is satisfied. CENTER EXAMINATION December 8, 1949 Distance of the injury is 11 inches and there is no hot spot. Patient is right handed. There is some atrophy of the first dorsal interosseus, hypo- thenar eminence, and interossei spaces. The forearm is diminished yt inch in circumference. Both pulses are equal and full and the hands are of approximately the same temperature and moisture. Elbow extension is limited to 155 degrees, but wrist motion is unimpaired; there is slight flexion contracture of the short flexor of the 5th finger. Patient is able to pick up a pin, battery, and all other test objects, including heavy ones, and the only impairment in function is his lack of ability to adduct the 3d, 4th, and 5th fingers. The patient's sensory limitation is very slight. He is able to feel 6 gm. pain throughout the entire hand, and only in the little finger and a small portion of the heel of the hand is his sensation of touch restricted, being able to feel only 10 gm. touch on the heel of the hand and 5 gm. touch on the little finger, compared with a normal of 3 gm. touch. Skin resistance shows no consistent difference between the two hands. There is no split sensation. Deep pressure is unimpaired in all fingers except the little finger, where it produces a painful paresthesia. Position sense is unimpaired. Quantitative muscle evaluation is as follows. Flexor carpi ulnaris, radialis and palmaris longus 100 percent; flexor digitorum profundus to the ring finger 100 percent, to the little finger 50 percent; abductor digiti quinti 25 percent; abductor digiti quinti 0; first dorsal interosseus 35 percent. The abductor digiti quinti had a rheobase of 45, chronaxie 0.8; first dorsal interosseus rheobase 85, chronaxie 1.2 (both reactions were prompt, the abductor digiti quinti showing slight fasciculation and the first dorsal interos- seus marked fasciculation). Electromyography was done on the abductor digiti quinti. Functional evaluation. This patient has a remarkably good hand, with only slight limitation to testing and functionally no limitation as to either 4M

strength or skill. The only noticeable defect is the inability to adduct the 3d, 4th, and 5th fingers. This injury does not appear to handicap him at all in his profession. POINTS OF SPECIAL INTEREST This was a fairly typical ulnar injury at the elbow, but 8 months elapsed between injury and repair of the nerve, with the patient receiving little attention during the 5 months that he was a prisoner-of-war. It was noted at operation, at which 5 cm. of the nerve were resected, that the distal stump showed considerable fibrosis. Despite this, patient has had a practically normal return of sensation, and has good function in all intrinsic muscles except the interossei, and even his chronaxie is not too abnormal. He has a remarkably useful hand. Case Report 8788 HISTORY OF INJURY On August 17, 1945, this patient put his fist through a window and re- ceived lacerating wounds of the ventromedial surface of the left forearm at the junction of the lower and middle thirds and partial severance of the flexor carpi ulnaris, the extensor carpi ulnaris, palmaris longus, flexor digitorum profundus, and complete severance of the ulnar nerve except for two fascicles. There were also two smaller lacerations lower down on the radial side of the forearm with partial severance of the flexor pollicis longus and brachioradialis. On August 22, 1945, at the 33d General Hospital, the wounds were debrided, tendons were repaired, and anasto- mosis of the ulnar nerve was done. Nearly %8 in. had to be severed from each end of the ulnar nerve for anastomosis. On October 16, 1945, shortly after admission to Cushing General Hospital, there was no function of the abductor digiti quinti and the dorsal and palmar interossei of the left hand. There was just barely perceptible function of the abductor pollicis. There was complete anesthesia and analgesia over the ulnar distribution of the left hand. On December 14, 1945, the patient had function in the abductor pollicis and the abductor digiti quinti. Sensa- tion remained unimproved but the patient was said to be ready for disability discharge. CENTER EXAMINATION October 26, 1948 The patient complains chiefly of aching pain in the forearm with heavy lifting. He complains also of paresthesias, numbness in the ulnar area, coldness in the hand, adverse reaction to cold weather, hypersensitiviry, easy fatigability, and some loss of muscle power. The patient is assessed at 50 percent and estimates that his earning ability is limited to about that loss. He is now a laborer in the woolen industry and is unable to handle his former duties as wool spinner in the same industry. The distance of injury is 9 in. Sensory examination reveals thresholds of 30 gm. to pain and 16 gm. to touch in the ulnar autonomous zone. There is moderate split of sensation.

Pressure and position senses are normal. Two-point discrimination is markedly diminished in the ulnar zone. There is slight sweating over the 5th finger and the ulnar half of the 4th finger. Motor examination reveals 11 percent to 20 percent function in the ulnar- innervated intrinsic muscles of the hand. Chronaxies are 8.0 msec* in the abductor digit) quinti, and 10.0 msec. in the first dorsal interosseus. The patient is able to perform all hand functions except adduction of digit 5. The thumb is opposed to digit 5 with the eyes shut and there is a good grip, with all the fingers but the 5th. Joint ranges are normal. This case represents only a fair result from a midforearm ulnar nerve suture. The patient is handicapped chiefly by a lack of strength. The patient states that work furlough was more helpful to him than physiotherapy. Function is 90 percent. Case Report 8835 HISTORY OF INJURY October 23, 1948. This patient sustained a complete median and ulnar paralysis by virtue of a machine gun bullet wound just below the axilla. The brachial artery was involved. (Ed.—This is questionable on review of case.) Injury occurred 8 November 1944 and operation was carried out 25 January 1945. Both nerves were completely divided and gaps of 6 cm. and 4% cm. were overcome for the ulnar and median nerves, re- spectively. The ulnar nerve had to be transplanted by rethreading through the median tunnel. There was no tension. By December 1945 (11 months later), there was 50 percent power in the flexors of the fingers. There was some median sensory recovery but none in the ulnar. The patient was discharged at this time and unfortunately none of the surgeons was consulted regarding the possibility of a tendon transfer to give satis- factory opposition of the thumb, it being assumed that the partial op- ponens action would progress satisfactorily. INTERVAL HISTORY Since discharge, the patient believes that he has learned to pick up objects more satisfactorily and that the grip of his hand has greatly im- proved. He does notice some improvement in the sensation to the finger- tips. He complains only of clumsiness in the use of his right hand and notices no pain, but is disturbed by coldness of the hand when he is out- doors in the winter. He has, of course, had to switch over to the left hand for writing and for eating. He is continuing his education and hopes to be a salesman, in which work he will circumvent his handicap. Examination shows that in spite of the good regeneration to the opponens muscle, full opposition is not actually carried out, but instead the thumb is kept close to the hand, and opposition is against the side of the index finger in a fairly effective manner. The patient can pick up a paper dip in this way and does so with considerable facility. The thumb cannot be

opposed past the 4th finger. In other words, the function of opposition has been learned to about a 30 percent level. He shows a striking recovery in all forearm muscles and only the deep flexor to the 4th finger is definitely weak. There is certain function in the opponens and the abductor pollicis brevis muscles, although the actual movements do not result in opposition or abduction from the hand. Abduction of the 5th finger is done with good strength and the 1st dorsal interosseus and adductor pollicis have clearly recovered. There is also striking recovery of lumbrical function so that all fingers are well extended instead of retaining the clawed ap- pearance of most combined median and ulnar nerve injuries. Intraneural stimulation confirms our clinical impression about intrinsic muscle func- tion for both the median and the ulnar nerves, and opposition is par- ticularly strong. Sensory recovery is good and about equal for the median and the ulnar to threshold testing (10 gm. for pain, 5 gm. for touch). Split sensation is quite striking in the median distribution but not in the ulnar distribution. Two-point discrimination is practically absent. Pressure and position sense are normal. The 5th finger does not sweat as much as the others, and subjectively the patient feels his sensation is less good in the 5th. Electromyography shows abductor digiti quinti .16 on the right as opposed to .43 mv. on the left. Opponens is .25 on the right as opposed to .45 mv. on the left. Following are the points of interest: (1) This is the most ideal recovery from a high median and ulnar injury that we have seen from both a motor and sensory standpoint. The use- fulness of the hand is striking and the good result is largely due to the cooperation and intelligence of the patient, following early good surgery. Patient demonstrates that even with the most ideal median and ulnar regeneration, combined median and ulnar injuries should always have a tendon transfer to provide opposition of the thumb. This is definitely indicated in this patient now and is recommended. Case Report 4247 HISTORY OF INJURY This soldier was wounded in action in Germany on November 25, 1944, by a shell explosion, one fragment perforating the lower third of his right forearm on the ulnar aspect. He suffered complete right median and ulnar nerve paralysis. Plastic work was done on the large skin defect at the site of injury. It was felt that there was some slight return of function in some of the median muscles and in the median sensory distribution, but virtually nothing in the ulnar distribution. On August 3, 1945, at Nichols General Hospital, neurorrhaphy was performed on the right median and ulnar nerves. A 4-cm. neuroma was found in continuity in the ulnar nerve, was resected, and the nerve sutured with tantalum; the median nerve was found completely divided in the middle forearm, resected to a gap of 4 cm., and sutured with tantalum. It was noted that the median suture line 431

was 8 cm. distal to that of the ulnar. Three months later Tinel's sign had advanced 20 cm. in both nerves; at 6 months there was some return of sensation in both the median and ulnar distributions. With this status the patient was discharged on February 26, 1946. INTERVAL HISTORY Patient has had no treatment since discharge, but has noticed consider- able increase of strength in his hand and a return of sensation to the dorsum of the ulnar area. He suffers no real pain in the hand and his only com- plaint is of rapid fatigue and weakness. Before the war patient made $40 a week in a canning factory; he has no job at present. His compensation is 50 percent but the patient feels this is inadequate. CENTER EXAMINATION June 28, 1949 Patient is right handed. There is some atrophy of the thenar eminence; the patient holds his fingers in a flexed position. The hand is equally warm as compared to the normal hand, but much drier, and pulses are equal and full. He shows no true opposition, but he is able to pick up a pencil between his thumb and the side of his index finger. He is unable to pick up a heavy chair although he is able to pick up a stool. The patient is able to feel 20 gm. pain and 5 gm. touch in all areas, except the ball of the thumb where he is able to feel 10 gm. pain. There is considerable splitting of sensation in both the median and ulnar dis- tribution, the median averaging 3 cm. and the ulnar 2 cm. Position sense is about 50 percent of normal. Deep pressure in all five fingers produces a disagreeable sensation which spreads somewhat up the fingers. Two- point discrimination is described as being normal on the thumb but con- siderably diminished on the other fingers. Skin resistance is somewhat increased in the ulnar area, markedly increased in the median area. Quantitative muscle evaluation is as follows. Flexion of the wrist 100 per- cent, with the flexor carpi ulnaris being the weakest of the three muscles; flexor pollicis longus 100 percent; flexor pollicis brevis 40 percent; flexor digitorum sublimis to the index finger 100 percent, to the middle finger 100 percent, to the ring finger 70 percent, to the little finger 50 percent; flexor digitorum profundus to the index finger 100 percent, to the middle finger 65 percent, to the ring finger 95 percent, to the little finger 65 per- cent; opponens 15 percent (trick); abductor pollicis brevis 0; abductor digiti quinti 11 percent; adductor digiti quinti 0; 1st dorsal interosseus 16 percent (trick); adductor pollicis 11 percent. On percutaneous stimula- tion of the ulnar nerve at the elbow a good response was found in the abductor digiti quinti and in the lumbricales, a fair response in the first dorsal interosseus and adductor pollicis, no response in the adductor digiti quinti. Percutaneous stimulation of the median nerve at the wrist showed some response in both the opponens and the abductor pollicis brevis. Electromyography was done on the opponens and the abductor digiti quinri. Functional evaluation. This patient appears not to be making as good use 43*

of his hand as his muscle power warrants, and indicative of this is his dis- interest in getting a job. For grading purposes he has some skilled but awkward use of the hand. POINTS OF SPECIAL INTEREST This was a combined median-ulnar injury in the forearm, with suture of both nerves. The patient typically has no useful function in his opponens, even though electrical stimulation shows that there is some regeneration. The 10 examples of poor recovery are summarized in table 232. One case was chosen for presentation in detail: Cose Report 2218 HISTORY OF INJURY This soldier was wounded by machine gun and mortar fire on July 4, 1944, incurring injuries to the left arm and right side of the chest. In the first recorded examination, on July 14th, there was a gunshot wound perforating the left midarm, the entrance being on the anterior aspect of the arm. He had loss of function of the ulnar nerve below the wound, both motor and sensory, and this was accompanied by severe burning pain in the 4th and 5th fingers. There was also some pain in the palm of the hand in the median nerve distribution. A diagnosis of severe causalgia involving the left median nerve was established and, on July 26, 1944, a sympathectomy of the left upper extremity was carried out. On July 30th, the operative wound was reported to be healed and 1 week later the causalgic-type pain in the arm appeared to be subsiding. On August 7th, the wound in the middle and upper third of the left arm, on its medial aspect, was explored and the median nerve was found to be bound down in scar tissue but not severed. A so-called neurolysis was carried out and stimulation of the nerve ends showed fair contractions in the forearm mus- culature. The ulnar nerve was found completely severed and the state- ment was made in the operative note that there was considerable distance between the freshened nerve ends. The ulnar nerve was transplanted anteriorly at the elbow and sutured with tantalum. A tantalum sling suture was also used. Complicating factors of a chest wound and a sub- phrenic abscess kept this soldier in the hospital for a long time and he was eventually evacuated to the States on November 13, 1944. Neurological examination at that time reported some return of sensation in the ulnar nerve but no evidence of motor return. Regeneration of the median nerve had come along nicely with motor power in the intrinsic muscles of the hands supplied by the median nerve and normal median nerve sensation. On January 20, 1945, there was no return of motor or sensory power in the ulnar nerve but Tinel's sign was found at the wrist, approximately 35 cm. from the anastomosis site. Following a series of neurological studies, which in general suggested poor regeneration in the ulnar nerve, this patient received a disability discharge from the Army on January 24, 1946. 433

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INTERVAL HISTORY The patient apparently has had no treatment for either the chest or nerve injuries since discharge. He has continued to complain of aching pain in the ulnar aspect of the left hand. He has noticed no return of sensation in the 4th and 5th fingers and no return in muscles innervated by the ulnar nerve. He feels that the grip in his left hand is stronger than it was at his last examination 2 years ago. He still cannot use it for finer movements. There is some increase of the pain in cold weather. No information is available concerning his occupational disability. CENTER EXAMINATION April 16, 1948 Motor. The left upper extremity measures 3 cm. less in the forearm than does the right. There is atrophy of the left hypothenar eminence and marked atrophy of the ulnar side of the hand. There is atrophy of the dorsal interosseus spaces. There is weakness of the flexor pollicis longus. There is marked weakness of flexion of the fingers, especially of the 4th and 5th fingers. Flexion of the distal phalanx is entirely absent. There is weakness of the flexor carpi ulnaris although contraction can be felt at the wrist. There is weakness of the extensors of the fingers and of the wrist. The patient cannot make a cone with his fingers and the newspaper test is positive. Fingers are held flexed at the first interphalangeal joint and extended at the metacarpal phalangeal joint in a sort of clawhand. Abduction of the 5th finger cannot be performed. Abduction of the other fingers cannot be performed. The thumb has only a weak degree of op- position. The little finger cannot be opposed at all. There is marked atrophy in the first interosseus space. Sensory. There is complete loss of pinprick and cotton test touch sensa- tion in the ulnar disrribution, including the little finger. There is hy- pesthesia and hypalgesia in the index finger and thumb and in the fore- arm extending on the ulnar side up as high as the elbow. These areas include the lower third of the forearm. The isolated area of innervation of the radial nerve is well preserved. Electrodiagnostic studies carried out on the ulnar nerve, sutured 1,330 days previously, and upon the median nerve which had undergone neurol- ysis at the same time-period, showed the following changes: Abductor minimi digiti: Rheobase 5.3. Chronaxie less than 1 msec. Tetanus ratio over 3. Response to faradic current was present. Repeti- tive stimuli curve was descending. Supermaximal about 1.5 over the threshold for tetanus repetitive stimuli. Abductor pollicis brevis: Rheobase 1.7. Chronaxie 7 msec. Faradic current present. Tetanus ratio 3.1. Repetitive stimuli descending. Supramaximal about 1.2 over the threshold per tetanus repetitive stimuli. 3. Radial Nerve The 10 examples of good radial recovery are summarized in table 233. A single case was chosen for detailed presentation. 436

Cose Report 4281 HISTORY OF INJURY This soldier was wounded in action in France on September 3, 1944, when a rifle bullet penetrated the lower third of his left arm, fracturing the humerus; at debridement 7 hours later the radial nerve was found to be divided. He had a complete left radial paralysis below the triceps, and on February 6, 1945, at England General Hospital, a neurorrhaphy was performed on the left radial nerve. A large neuroma was found at the site of the fracture; the nerve was resected to fairly good tubules in the proximal stump, fair tubules in the distal stump, and sutured with tan- talum. Seven months later he had good function in the triceps and supi- nator and fair function in the brachioradialis, but no return in the other radial muscles. At 1% months function was noted in the extensor carpi radialis longus and brevis and a flicker in the extensor digitorum com- nuiiiis; at 9 months function was also noted in the extensor carpi ulnaris, extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus. Because a tantalum cuff had been placed about the nerve at the first operation, the site of suture was explored on January 29, 1946; the nerve was found bound down in dense scar tissue and adherent to callus of the bone; it was lysed externally and internally and the tantalum foil removed. The anastomosis was found slightly swollen, but the nerve gave good response on stimulation. The patient was discharged on March 4, 1946. INTERVAL HISTORY The patient has had no treatment since discharge and the only improve- ment that he has noticed in the arm is some increase in strength. He com- plains of spontaneous pain at the site of suture (or at the site of fracture), and also pain in damp weather and when he uses the hand. Before the war he was a helper in a machine shop, but now he works as an operator at a water plant, with a cut in earning of about 15 percent. His compen- sation is 40 percent. CENTER EXAMINATION August 29, 1949 The patient is right handed. The distance of the injury is 15$ inches. There is no noticeable atrophy of the forearm or hand and no trophic changes of the skin or nails. Pulses are equal and full and the hands are equally warm and moist. Supination is limited to midposition when the elbow is extended, and appears to be performed exclusively by the biceps. There is 20 degrees limitation of elbow extension. He has some disability in picking up a stool and can barely lift the chair; otherwise he shows excel- lent use of the hand, and has no difficulty in opening his hand wide. In a typical radial distribution on the dorsum of the hand he can feel 10 gm. pain and 16 gm. touch, compared with the normal of 5 gm. touch; there is a small area on the distal phalanx of the dorsum of the thumb in which he cannot feel 40 gm. pain. Deep pressure is slightly diminished on 437

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the thumb, normal on all the other fingers. Position sense, similarly, is slightly diminished in the thumb, normal in the other fingers. Two-point discrimination in the autonomous zone is 38 mm. compared with a normal of 19. There is no split sensation. Skin resistance is slightly diminished over the injured area. Quantitative muscle evaluation is as follows. Triceps 100 percent; extensor carpi radialis 50 percent; extensor carpi ulnaris 25 percent; extensor digitorum communis 35 percent, being very weak in the extensor of the third finger; abductor pollicis longus 25 percent; extensor pollicis longus and brevis 25 percent. The extensor carpi radialis had a rheobase of 145, a chronaxie of 0.6. EMG was done on the abductor pollicis longus; on supramaximal stimulation the injured muscles show spikes of 2.5 in. com- pared with a normal of only 2.0 in. and it was felt that this low normal value is the result of a poor contact with the muscle. Functional evaluations. This right-handed patient does not feel much handi- cap by his left radial injury, and is able to perform almost all acts with the arm except for heavy lifting. POINTS OF SPECIAL INTEREST This radial nerve was repaired 5 months after injury and shows an ex- tremely good functional return, both motor and sensory. The 10 examples of poor radial recovery are summarized in table 234. Individual case reports follow. Case Report 4065 HISTORY OF INJURY October 3, 1944, WIA Germany. Severe perforating shell fragment wound right axilla and shoulder severing axillary artery and radial nerve, and partially severing median and ulnar nerves. October 4, 1944, 203 General Hospital, radial nerve found completely severed, sutured with tantalum. Ulnar nerve 80 percent severed and a 1-inch portion missing, nerve not sectioned or repaired, but tantalum sutures left as a guide. Axillary artery ligated. March 14, 1945, O'Reilly General Hospital, neurorrhaphy of ulnar nerve. Much scarring and troublesome bleeding. Ulnar stimulation elicited no motor response. Stimulation of the median nerve elicited fair response in pronator and flexors of wrist. No lesion identified in median although a considerable portion was scarred. The ulnar nerve found severed with neuroma at proximal end and glioma at distal end. Resected to healthy funiculi, gap 3 cm. and with consider- able tension was sutured with #40 tantalum. Blood supply to both ends of nerve good, proximal posterior portion of sheath was poor. January 11, 1946, Halloran General Hospital, ulnar neurorrhaphy. Stimulation of proximal portion of previous suture gave good ulnar sensa- tion, no motor function. Suture site was resected, and resutured with .003 tantalum with a good approximation obtained. Median nerve found 440

bound down in scar and neuroloysis done. Stimulation above the scarred portion gave good motor response in median muscles. September 3, 1946, no return of proximal ulnar muscles. Tinel's sign is half way down the arm. Some return of deep median sensation, no return of ulnar sensation. November 14, 1946, discharge. INTERVAL HISTORY He has had no treatment since discharge. He uses his arm only as a holder. He has occasional spontaneous pain and complete numbness of the right hand. At present he is unemployed and the VA is looking for a job for him, as he wants to work. His compensation is 90 percent. CENTER EXAMINATION July 28, 1948 Distance of the injury is 20 in. and the patient is right handed. The right hand is definitely cold to palpation, and no radial or ulnar pulses are felt. The right forearm circumference is 1 % in. less than the left and the right arm is % in. less than the left. Sensory examination. Ulnar—he has no return of sensation. Median— he feels 40 gm. pain and 20 gm. of touch. Split sensation is present. Position sense is about 70 percent of normal. Skin resistance is con- siderably increased over the entire palm of the hand. The entire hand has a shiny, puffy appearance, and his thumb is kept in the simian position. Motor examination. He has limitation of extension and rotation at the elbow. He has a very good deltoid, trapezius, biceps, triceps, brachio- radialis, and a fair flexor carpi radialis. There are no thumb movements nor intrinsic hand motions. Stimulation of the ulnar nerve at the wrist and elbow shows complete lack of nerve function. However, in contrast to the clinical examination above, stimulation of the median at the wrist shows a good short flexor of the thumb and a questionable opponens. Stimulation of the radial at the midarm shows good extension of the wrist and nothing in the thumb. Functional evaluation. At the present time, he has an almost useless right arm, but he is not too willing to do much about it. He uses the arm only as a holder and tendon work would definitely give him some use in extension and abduction of the thumb. With the intact musculature he has around the elbow and shoulder, he could certainly make some use of his hand. The patient flatly refused surgery. SPECIAL POINTS OF INTEREST This patient had a suture of his partially severed (75 percent) median nerve and suture of completely severed radial nerve overseas 1 day after injury. The ulnar nerve was 80 percent severed, and unsuccessfully sutured 5 months later. The ulnar was subsequently resutured 14 months after injury and resulted in complete failure. He has had some return of sensa- tion in the median area, and a fair return in the radial. 408930—57 80

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Cose Report 4109 HISTORY OF INJURY The patient sustained shell fragment wounds in his right arm in France on June 13, 1944. It was noted immediately that he had a partial palsy of his radial nerve. The wound was debrided on June 19, 1944. January 5, 1945, because of poor distal tubules, a modified bulb suture was per- formed.23 Operator noted that further surgery was indicated when the nerve was stretched. No further surgery was carried out. November 7, 1945, discharged, and it was noted that he had an inability to extend his fingers. CENTER EXAMINATION September 9, 1948 Patient is right handed and was 27 years of age at the time of his injury. The suture line was 18 in. from the distal palmar crease. The diameter of his arm 4 in. below the olecranon was 10% in. on the injured side and 11}£ in. on the normal side. Deep pressure was present in the tips of all of his fingers as was position sense. The pulses were equal and full bi- laterally. No trophic changes were noted in the fingers. He could flex his elbow to 42 degrees and extend it to 167 degrees. He could flex his wrist to 120 degrees and extend to 105 degrees. There was slight limita- tion of supination. The metacarpal-phalangeal and the interphalangeal joints were entirely within normal range. Over the back of the hand, slightly more medial than the usual snuffbox area, pain threshold was 30 gm, and touch greater than 50. On stimulation of the most radial portion of this zone there was some radiation up the back of the thumb. Skin resistance in the autonomous area was somewhat increased. Clinical examination. There was a trace of extension of the fingers and of the wrist. There was a trace of long extensor of the thumb and no ab- ductor of the thumb. The radial nerve was stimulated above the elbow by means of a percutaneous bipolar stimulus. No abduction of the thumb was noted and no extensor of the thumb was noted. There was definitely a trace of extensor communis and extensors to the wrist present. On performance test, the patient had no difficulty in grasping one's arm and finds the hand entirely useful for most purposes except heavy lifting. He is able to do his job as an electrical maintenance man without any difficulty. POINTS OF SPECIAL INTEREST Despite the inadequate type of operative procedure done, i. e., a (modi- fied—Ed.) bulb suture, the patient had a good return of function. There is possibly no more than 30 percent of normal to the long extensors of the wrist and fingers. However, the hand is entirely useful and because of the " From the operation report "* * * a modified type of bulb suture was performed which consisted of suturing the ends together. The distal end had good tubules, the proximal end still had considerable scar tissue. These ends were brought into opposi- tion." Since an end-to-end anastomosis was performed, and no subsequent surgery was done, the operation was coded as a complete suture. (Ed.)

unimportant area of anesthesia remaining, the patient has no difficulty. This man's hand can definitely be improved by means of tendon work. However, he showed no inclination to have this type of operation performed. Case Report 8785 HISTORY OF INJURY On May 14, 1945, this soldier sustained a shell fragment wound of the right midarm, with immediate complete paralysis of the ulnar nerve and paralysis of the radial nerve below the brachioradialis. Operation was performed on September 19, 1945, with suture and anterior transplant of both the radial and ulnar nerves. The median nerve was exposed and was found intact with all motor functions present. The radial nerve ended blindly at the fracture site (midhumeral) and the ulnar nerve was separated at this site. The radial nerve was transplanted beneath the biceps tendon, freshened to about a 11-14 cm. gap, with bleeding in proximal end only, and was sutured without tension. The ulnar nerve was sectioned to 8 cm., transplanted anteriorly, with bleeding from the distal end, and was sutured without tension. In transplanting the radial nerve, it was neces- sary to sacrifice branches to the brachioradialis. In August 1946, there was no definite evidence of radial nerve function, electrical stimulation being unsatisfactory due to transplantation; ulnar nerve stimulation gave flexor carpi ulnaris action and action in the deep flexors to digits 4 and 5; there was also some sensory recovery to the tip of the 5th finger. At that time, the question of tendon transplant for extension was being considered. He was discharged in November 1946. CENTER EXAMINATION October 21, 1948 The patient complains of almost complete inability to use the right arm and hand. There is numbness, hypersensitivity, and pain, especially in cold weather. There has been an abscess under the old scar for the past month; this is said to be a lighting up of an old osteomyelitis. In October 1948, an abscess was treated with penicillin. He is assessed at 80 percent and estimates a 60 percent loss of earning ability. Before injury he ran a service station but has recently had to give this up because of the abscess. He states that he is occasionally disturbed over the situation. Sensory examination reveals a pain threshold of 40 gm. and a touch threshold of 75 gm. in the ulnar area. In the radial area, there is no response to 40 gm. pain and 75 gm. touch. Pressure in the ulnar area gives diffuse pain. There is poor position sense in the 5th finger. There is no sweating over the 5th finger, which is atrophic. Motor examination reveals only barely perceptible motor action in affected radial innervated muscles. Proximal ulnar muscles function at about one-half strength, distal muscles at 10 to 15 percent. Ulnar percu- taneous stimulation results in no function of lumbrical, fair function of abductor digiti quinti and 1st dorsal interosseus. Ulnar chronaxies are high. Radial chronaxies were unobtainable because of high rheobases. Median function was unimpaired. 445

No radial function is possible. Elbow motion is restricted between 60 and 150 degrees. There is no supination, with pronation limited to 30 degrees. Wrist and finger joints are limited in motion and there is mild flexor tendon shortening. The patient has good flexion of the fingers for grasping objects placed therein and he opposes the thumb to either of the first two fingers with good strength. However, because of the complete absence of any extensor mechanism of wrist or fingers, he finds it totally impossible to make use of this function. This patient has had an average ulnar regeneration and the ulnar deficit does not constitute a significant part of his disability. The radial nerve was sutured over a huge gap by transplantation and extensive mobilization; as might be expected, this did not give useful functional recovery, although it is of academic interest that the wrist and finger extensors have visible but not useful function. Appro- priate tendon transplants are indicated and should have been done prior to discharge. 4. Summary A survey of these cases of upper extremity nerve injury indicates again the well-established fact that good neural regeneration tends to develop in simple, uncomplicated instances of nerve injury where the influence of known adverse factors is minimal. Inadequate neural regeneration, on the other hand, is almost invariably found in the more severe and compli- cated extremity wounds. Exceptions to this generalization may exist and the various adverse factors show varying degress of inhibition. These are discussed briefly. Location of injury Good regeneration in these 20 cases of median and ulnar nerve injury was associated with injury levels in the lower third of the arm or below with 2 exceptions, cases 8835 and 1217. Reasonably good intrinsic muscle function was attained and functional regeneration in selected cases is described in the case reports. Poor regeneration in 20 cases of median and ulnar nerve injury was generally associated with injury levels in the arm or elbow; of the 6 exceptions, 3 were at the level of the wrist. Little or no intrinsic muscle reinnervation was found in these cases. The question of level of injury does not enter into a consideration of neural regeneration in radial nerve cases since all cases were selected from injuries at the arm level. With this exception, peripheral nerve injuries at a high level tended to do more poorly than those at a low or forearm level. Time after injury On the average, in the 30 examples of good regeneration in upper ex- tremity injuries, the definitive suture was done 117 days after injury; in the 30 cases of poor regeneration the average time was 229 days. Good neural regeneration was obtained, however, in 6 cases operated upon at time periods of 210 days or more, or 7 months post-injury. Regeneration 446

failed to occur in 8 cases operated upon at time periods of 110 days or less after injury. In 4 cases of suture performed on the day of injury, 1 failed to secure neural regeneration and 3 succeeded. Within the limits of this study, time of operation after injury within the first year appeared to have some adverse effect upon the course of neural regeneration. Nerve defect and suture line tension The extent of the nerve defect and subsequent suture line tension tended to be greater in cases exhibiting poor neural regeneration than those with a favorable outcome. These factors reflect the magnitude of the inflicting force and are often associated with severely complicated wounds. Many instances of poor regeneration were found with small nerve defects where the cause of failure obviously rested elsewhere. The largest nerve gap found in the 30 favorable cases measured 9 cm. and the average was 4 cm. Suture material Since the majority of these cases were sutured with tantalum, no definite conclusions could be established. There were 5 plasma glue sutures, however, 4 of which failed and 1 succeeded. Complications Associated lesions or other complications also appeared to affect regen- eration adversely. These included fracture, arterial damage, multiple nerve injury, severe soft tissue injury including frostbite, and infection. Technical errors such as suture line separation and failure to recognize nerve-tendon anastomosis were also responsible for a number of poor results. Among the 30 cases of adequate regeneration, there were 9 with asso- ciated fractures, 4 with one other nerve injury and 4 with a major vessel ligation. On the contrary, among the 30 cases of poor or no regeneration, there were 28 examples of severe complicating injuries or technical errors. These included 10 fractures, 12 major vessel ligations, 20 multiple nerve injuries, 5 extensive soft tissue injuries, 10 with chronic infection delaying suture, 2 recognized suture line-separations, and 1 example of suture of nerve to tendon. Of extreme significance appear the adverse influences, respectively, of tissue ischemia secondary to vessel ligation and the appear- ance of multiple nerve injuries in a single extremity. In the former in- stance, peripheral nerve tissue is damaged not only by the inflicting force of nerve division but also by that of generalized tissue ischemia. In the latter instance, the effector mechanism is frequently irreparably damaged. C LOWER EXTREMITY 1. Peroneal Nerve The 10 examples of good peroneal recovery are summarized in table 235 and individual cases follow. For the peroneal and tibial nerves, associated nerve lesions are shown only if suture was required, but for the sciatic 447

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nerves both complete and incomplete (lysed) lesions are shown and are distinguished. Case Report 7701 HISTORY OF INJURY On July 7, 1944, this soldier was hit in the left knee by a rifle bullet. He noticed immediate inability to use the left foot. There was foot-drop. On August 23, 1944, at the 83d General Hospital, a neuroma in con- tinuity M was excised from the left common peroneal nerve and end-to-end anastomosis was performed. A tantalum cuff was used. By February' 1945, there was beginning return of sensory function with beginning extensor and peroneal function. On November 30, 1945, there was 50 percent to 75 percent function in the tibialis anticus and the extensors, and 75 percent to 100 percent function in the peronei. CENTER EXAMINATION October 26, 1948 The patient complains of aching of the left leg and foot, especially in cold weather, coldness, hypersensitivity of foot, pain with use and easy fatigability. He has had some physiotherapy in the past two winters. He was a truck driver but is unable to handle the work so he now works in a drug store. He feels he is handicapped 50 percent, but is assessed at 30 percent. Sensory examination shows a pain threshold of 2 grams with hyper- algesia in some parts of the autonomous zone, and a pain threshold in excess of 40 gm. in other parts. Touch threshold is 5 gm. over most of the autonomous zone. Pressure and position senses are normal. There is very slight split of sensation. Sweating is present. Motor examination shows normal function in the tibialis anticus and peroneus longus, 20 percent function of extensor digitorum longus, and perceptible function of extensor hallucis longus. EMG was done. The patient states that all foot functions are possible. Joints have normal ranges. Action of the foot is perfect—there is no foot-drop or limp. A brace is necessary only in icy weather. The patient cannot lift heavy weights or stand for many hours, but walking is relatively unlimited and he can run a short distance (90 percent function). This is an excellent result from a low peroneal suture done early overseas. Case Report 8751 HISTORY OF IN JURY On March 29, 1945, this soldier was wounded by mortar-shell fragments. He sustained a wound of the lateral aspect of the left popliteal space with the wound of exit on the mesial aspect. There were multiple retained foreign bodies, and the peroneal nerve was almost completely severed. There was foot-drop on the left. On April 3, 1945, at the 98th General Hospital in England the nerve was operated upon. An end-to-end anas- M Coded as a partial division on review of operation report (Ed.).

tomosis with tantalum wire was done. A tantalum foil cuff was then applied. On admission to Cushing General Hospital on May 30, 1945, there was inability to extend the toes and ankle or to evert the foot, and there was anesthesia of the peroneal nerve distribution. X-ray studies soon thereafter showed that the tantalum cuffs were crinkled. On June 2, 1945, in neurosurgical conference, it was suggested that the peroneal and tibial nerves be reexplored, that the cuffs be removed, and that the patient be given a foot-drop brace. Accordingly, on June 22, 1945, re- exploration was carried out. It was found that cuffs had been placed on the peroneal and tibial nerves in the popliteal space. These cuffs were badly fragmented and scar tissue had penetrated between the layers and crevices. The suture line of the peroneal nerve was smooth and looked good. Electrical stimulation produced good sensory but no motor re- sponse below this suture line. The posterior tibial nerve was in good con- dition and gave both sensory and motor response below the area where the cuff had been placed. Motor function improved steadily, and on November 30,1945, there was some function in all of the standard peroneal innervated muscles except for the extensor hallucis longus. It was stated that there was no return of sensitivity. The patient was said at that time to be ready for a disability discharge. There was never any evidence of significant tibial nerve involvement. CENTER EXAMINATION October 18, 1948 The patient complains of occasional tight feeling in the popliteal space, pins and needles feeling on the lateral aspect of the left leg and on the foot, and rapid fatigue. The patient states that he has been unable to continue in his previous occupation because the work was too heavy. He is now em- ployed as a short-order cook in a restaurant and is able to handle this work satisfactorily. The distance of injury is 17 in. M Sensory examination reveals that the pero- neal autonomous zone does not respond to 40 gm. of pain, and it does respond to 16 gm. of touch. The area of analgesia is extensive on the lateral aspect of the lower leg. Motor examination shows that the tibialis anticus functions at 60 percent, the peroneus longus at 100 percent, the extensor digitorum at 75 percent, and the extensor hallucis longus at 50 percent. The peroneus longus has a chronaxie of 6.0 msec. Chronaxies on the other muscles were not deter- mined because the rheobase was too high. Tibialis anticus EMG, 80 percent. Functionally, this patient has a good result. He can walk at least 1 mile. He has not worn a brace since June 1946. This is an excellent result, attributable probably to early suture. Patient had not reached an end-point in regeneration at discharge 8 months after suture, with 7 in. to grow. The extensor hallucis began to function thereafter and all other muscles became stronger. Measured from the medial malleolus. 451

COM Report 4214 HISTORY OF INJURY This patient incurred perforating wounds of left lower third of thigh on December 24, 1944, with subsequent complete peroneal and partial pos- terior tibial palsy. Just prior to exploration on March 29,1945, it was noted that tibial function was 20 percent of normal; the gastrocnemius was very weak and inversion was 50 percent of normal. At operation, the peroneal nerve showed a proximal neuroma connected to a distal glioma by a 2 cm. fibrous strand. This nerve was resected (7 cm. gap), and sutured with silk. The posterior tibial nerve showed a neuroma 1# cm. above point of divi- sion into its muscular branches occupying about 60 percent of its diameter. Electrical stimulation showed weak gastrocnemius and soleus contraction, but good long flexor contraction. The neuroma was "liberated" without disturbing the intact fibers, leaving a gap of 3J£ cm. which was sutured with silk. Electrical stimulation immediately after the removal of the neuroma gave better results than previously. The last progress note, November 14, 14, 1945, stated that "he has better tibial function than he had preoper- atively; there is fairly good dorsiflexion and slight extension of all toes except the large one; anesthesia remained in the peroneal distribution and in part of the sural; sensation on the plantar surface was quite adequate." He was discharged December 5, 1945. INTERVAL HISTORY No treatment since discharge. Dorsiflexion and eversion of foot and return of feeling to lateral aspect of foot improved about December 1946. Ankle joint "a good deal" more limber. Complains of occasional spon- taneous pain, paresthesia at site of injury on percussion, coldness at night in foot, and rapid fatigue. Receives 60 percent disability compensation, but feels he is being undercompensated for injury. Premilitary occupation: elevator operator, to which occupation he could return and apparently wishes to return, but does not attempt to recover his job. Also would like to raise hogs, has had some education in raising hogs, but does not wish to go to a hog-raising area. Complains all employers feel he is "too slow" for the job, such as short-order cook. CENTER EXAMINATION April 20, 1949 Patient was 19 years of age at time of injury, and right handed. Suture line 15 in. proximal to medial malleolus. No abnormal vasomotor responses. Motor examination. Clinically patient has an excellent foot. He needs no brace. He can walk about 1}£ miles without pain, but does have some fatigue. Patient has merest suggestion of a steppage gait. He can stand on his toes and squat very well. Examination of peroneal nerve reveals 70 percent muscle strength; the tibial nerve shows the same average return. Chronaxie examination of tibialis anticus is 1^ times normal, and of peroneus longus is 3 times normal. Electromyographic examination oi

tibialis anticus with coaxial needles on voluntary action revealed good spiking. Sensory examination. Analgesia over the lateral aspect of the lower leg and the lateral aspect of the dorsum of the foot, including dorsum of 4th and 5th digits. Feels only 16 gm. touch in this area. In the autonomous area of the peroneal, he feels 2 gm. of pain and 1 gm. touch. In the autonomous area of the tibia! nerve, he responds to 6 gm. of pain and 5 gm. of touch. Deep pressure is somewhat diminished but well localized. Two-point discrimination is 5 in. over analgesic area of lower leg. Position and vibration sense unimpaired. OVERALL EVALUATION Functionally, patient has practically a perfect foot. His analgesia is over an area which is not too frequently exposed to injury and, therefore, requires very little attention. Cos* Report 8832 HISTORY OF INJURY On December 1, 1944, this soldier sustained a shell fragment wound of the left thigh. Point of entrance was the left popliteal area in midline, wound of exit on the lateral aspect of the fibula. There was no fracture. Numbness of the dorsum of the foot was present from the beginning, and about 1 week after injury, the patient noticed foot-drop. Occasionally, he had feelings of needles and pins in his left leg. There was no severe pain in the foot. On March 1, 1945, on admission to Cushing General Hospital, examination revealed complete motor and sensory paralysis of the left peroneal nerve. There was no atrophy or sympathetic involve- ment. There was anesthesia of the left foot and ankle anteriorly, and of the left leg below the knee laterally and anteriorly. Posteriorly, there was numbness on the popliteal fossa down to the ankle. On March 7, 1945, at Cushing General Hospital, operation was performed. The peroneal nerve was found to be divided completely at the knee joint. Electrical stimulation proximal to the division produced no motor response. There was a gap of about 4 cm. in the nerve. The divided ends of the nerve were sectioned to normal-appearing nerve bundles. Both cut ends of the divided nerve bled slightly. The gap in the nerve after sectioning was found to be 6 cm. Anastomosis was performed with tantalum wire and there was abso- lutely no tension. On July 15, 1945, patient could just move the tibialis anticus if the leg were partially flexed. At that time there was some return of sensory function. On December 3, 1945, stimulation of the peroneal nerve at the popliteal space gave strong action in the peroneus longus and a definite contraction in the tibialis anticus. This patient had never been able to use his peroneus longus up to that time, but after he observed the movements in his foot, he was able to initiate strong eversion voluntarily. There was no voluntary function in the tibialis anticus at that time. Sensory function was continuing to improve. On February 4, 1946, there 4S3

was a definite voluntary contraction of the peroneus longus muscle, and a flicker in the extensor digitorum longus, but the patient could not volun- tarily use the tibialis anticus. There was good action in all peroneal muscles on intraneural stimulation. On May 9, 1946, the patient had adequate voluntary function in all peroneal musculature. The patient was discharged in May 1946. CENTER EXAMINATION October 20, 1948 The patient states that he has no really serious complaints. He does complain somewhat of sharp pain through the leg, of pins and needles sensation on the top of the foot and the toes, numbness in the lateral aspect of the leg and the foot, subjective coldness, hypersensitivity in the popliteal space, and fatigability on long use. The patient is assessed at 50 percent. He has been a student since discharge. Distance of injury is 20 in. Sensory examination reveals thresholds to 20 gm. of pain and 5 gm. of touch, in the peroneal autonomous zone. There are large areas in the peroneal zone over which only 16 gm. are felt. Position and pressure senses are normal. There is moderate split sensation. Motor examination reveals a function of 60 percent in the tibialis anticus, 50 percent in the extensor digitorum longus, 83 percent in the extensor hallucis longus, 80 percent in the peroneus longus. The tibialis anticus has a chronaxie of 2.4 msec. The patient can perform all foot functions. He walks 2 miles, and walks without a limp. Ankle motion is slightly limited, the range being from 100 degrees to 125 degrees. This case represents a good return of function in a peroneal nerve suture in the popliteal space. It is characteristic of peroneal recovery that it took the patient 5 months to learn to lift his foot after reinnervation had occurred. The 10 cases illustrating poor peroneal recovery are summarized in table 236. The detailed case reports follow for several. Case Report 4334 HISTORY OF INJURY On October 7, 1944, this soldier was wounded in action in France by shell fire, receiving multiple fragments in both buttocks and thighs, with fracture of his left femur and traumatic amputation of the left calcaneus. Prior to operation the only function that he showed in his sciatic nerve was strong action in the gastrocnemius muscle. On April 23, 1945, at England General Hospital, operation was performed on the left sciatic nerve. In the popliteal space the left tibial and peroneal nerves were found bound down in dense scar for a distance of about 1 inch; the tibial nerve had only epineural scarring, this was removed, and the nerve was lysed internally; there was a small neuroma in the peroneal, which was resected 3 cm. to normal tubules and sutured with tantalum. There was

considerable return of function in the tibial nerve but none in the peroneal, and on May 10, 1946, at England General Hospital, the left peroneal nerve was reexplored. It was found to be compressed at the head of the fibula; electrical stimulation produced slight sensory response, but no motor function, and below the site of compression the nerve appeared soft and pale; it was lysed internally and ballooned well except at the site of com- pression. This soldier was discharged on May 27, 1946. INTERVAL HISTORY The patient had about 1 year of weekly physiotherapy at a VA hospital following discharge; the only improvement that he has noted in the leg is some increased motion at the ankle joint. He complains of pain with use, with changes in weather, and when the leg becomes cold; additionally, the leg is subject to rapid fatigue. While he is able to walk 3 blocks with a brace and go up stairs, he cannot run or climb a ladder. Before the war he was a coal miner, but now he has no job, although he is thinking about getting trained for one. He received 100 percent compensation for all of his injuries. CENTER EXAMINATION October 12, 1949 Patient is right handed. When he walks without a brace he shows a marked steppage gait and very little pelvic tilt; he has a foot-drop. Dis- tance of the first operation (suture) is 19# in.; distance of the second oper- ation (lysis) is 15 in. There are no marked trophic changes, the feet are equally warm and moist, and the pulses are full and equal. The calf is diminished % in. in circumference. The ankle joint has 30 degrees motion. In a typical peroneal distribution 40 gm. pain is felt only as pressure; in the same area he is unable to feel 35 gm. touch. Deep pressure pro- duces some local pain in the 1st, 2d, 4th, and 5th toes; position sense is slightly diminished on the large toe, normal on the others; throughout the peroneal area there is 2 to 3 cm. split in sensation. Sensation is normal in the tibial area. Quantitative muscle evaluation is as follows. Gastrocnemei 100 percent; tibialis posticus 60 percent; tibialis anticus, extensor digitorum longus, extensor hallucis longus, and peronei 0. The intrinsic foot muscles had a rheobase of 130, a chronaxie of 6.0; no rheobase was obtainable for the tibialis anticus or peroneus longus. Intraneural stimulation of the peroneal nerve failed to produce any response whatsoever in the peroneal area. Functional evaluation. The patient is able to get around moderately well with his leg, and wearing a brace he is able to walk about 3 blocks before he is stopped by fatigue. POINTS OF SPECIAL INTEREST The peroneal nerve appears to have undergone two injuries, one being in the midthigh where it was severed, and again at the head of the fibula, where it was compressed. 455

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Case Report 4038 HISTORY OF INJURY This soldier was wounded in action April 6, 1945, in Germany, by an HE fragment penetrating the right knee, lateral aspect. At debridement next day a foreign body was removed, and the severed peroneal ends were tagged with silk threads. There was considerable tissue loss and the tagged nerve ends were easily seen 10 days later on examination. At McGuire General Hospital on July 10, 1945, he had incision and drainage of multiple abscesses in the right popliteal region. The peroneal nerve ended in much scar and no attempt at suture was done, due to infection. Bulb anastomosis was carried out at this time. On August 9, 1945, at the same hospital, neurorrhaphy was performed on the right peroneal nerve. There was a 3-in. gap, easily made up by flexing the knee. Suture with silk and fine tantalum wire, no cuff. The posterior tibial nerve was intact and merely freed from scar tissue. On January 19, 1946, examina- tion showed anesthesia over the peroneal area, and hypesthesia on the sole of the foot. A note states there was "improvement in anesthesia." The muscles of the posterior tibial group were classed as 50 percent func- tion with none in the peroneal group. Disability discharge on February 13, 1946, with paralysis right peroneal incomplete manifested by foot-drop, and sensory loss on dorsum of foot. CENTER EXAMINATION May 11, 1948 Sensory examination of the peroneal distribution requires explanation. There is complete loss of touch in all of the peroneal area. Burning and tingling is felt at many points throughout the area in response to 10 gin. pain stimulation, but never felt as a true pinprick. He does not feel 40 gm. pain or 20 gm. touch on the sole of the foot. Deep pressure and position sense are intact. Skin resistance is normal over the entire peroneal area, and presents a mixed pattern on the tibial area. Motor examination shows no function in the peroneal group of muscles, and 40 percent overall in the tibial group. There is no limitation of joint range. Intraneural stimulation of the peroneal nerve gave no response. This observation may not be entirely valid because the patient would not tolerate maximal nerve stimulation although good needle contact was obtained. Chronaxie and tetanus ratio determinations were not possible because the peroneal musculature would not respond to maximal currents. POINTS OF SPECIAL INTEREST (1) Failure of regeneration of peroneal nerve made more than likely by abscess formation in popliteal space at time of injury. (2) Partial injury to posterior tibial nerve, but the muscles are now functioning strongly enough that this would be a suitable case for tendon transplant, and has been recommended to the patient. His physician has been written regarding this question.

(3) No good data as to the original extent of tibial nerve injury, so that one cannot draw conclusions as to the actual amount of tibial nerve re- generation. In July 1945, the tibial group was rated to be absent clinically, not responding to faradic stimulation, but reacting to galvanic stimulation as did the peroneal group. In January 1946, the posterior tibial was recorded as having fair strength clinically. It is interesting that, in spite of the good recovery of all tibial innervated muscles seen at this time, there remains a complete anesthesia over the tibial sensory area on the sole of the foot. Case Report 4060 HISTORY OF INJURY October 1, 1944, WIA mortar fragments, Italy. Multiple severe pene- trating wounds at left elbow, both legs and thighs, with left peroneal paralysis. October 9, 1944. Secondary closure, wounds of left calf and left elbow. January 30, 1945. Neurorrhaphy, left peroneal, excision of neuroma (gap 6 cm.), end-to-end anastomosis (silk). March 21, 1946. Resuture. Excision of neuroma for 10 cms.; proximal end still unsatisfactory (hyaline appearance). Resutured in spite of this (tantalum wire). No improvement. August 21, 1946. Disability discharge—no return of function. The suture line is 18 in. from the internal malleolus. The circumference of the leg 4 in. below the tibial tubercle is 11 in. on the left and 12^ in. on the right. As far as joint function is concerned, the left knee extends to 160 degrees; the right to 175 degrees; the left knee flexes to 50 degrees and the right to 60 degrees. Examination shows good arterial pulsations in the foot which is warm. There are no gross trophic changes except for marked atrophy of the tibialis anticus and both peronei with a complete foot-drop. The patient wears a kickup splint, and is mortally afraid that we are not as disinterested as we claim to be, and consequently refuses to give the dollar compensation, although he says that he gets 70 percent plus the loss of his foot. Sensory examination shows a complete peroneal anesthesia with no feeling to 40 grams of pain and 20 grams of touch. Pressure and position sense are present in the toes however. There is a good zone of increased skin resistance corresponding to the touch area of hypesthesia. Clinically, all the peroneal musculature is completely nonfunctioning. On intraneural stimulation of the peroneal at the knee, there is no reaction. Chronaxie of the tibialis anticus is 2, peroneus longus 10; tetanus ratio of the tibialis anticus is no tetanus with a ratio greater than 2, and the same goes for the peroneus longus. On the whole, the examinations, with the exception of the intraneural stimulation, were of little value. Functionally, the patient gets along with a kickup splint without too much difficulty. 439

POINTS OF SPECIAL INTEREST (1) This patient has had two operations, the second one overcame the gap of 10 cm., and the operator stated that the nerve ends sutured seemed to be hyalinized and lacked good tubule formation. (2) The patient has no return whatsoever either sensory or motor. (3) The chronaxie and tetanus ratio are of little value, but the intra- neural stimulation made it evident that the man had no function in the muscles innervated by the peroneal nerve. (4) We feel that the kickup splint is as good a therapeutic prop as any- thing else. 2. Tibial Nerve The 10 examples of good tibial recovery are summarized in table 237. The individual case reports on five of these follow. Case Report 4209 BISTORT OF INJURY November 16, 1944, while in action in Germany, patient sustained a gunshot wound of the right leg in the posterior calf region—upper %. This was said to result in a right tibial paralysis with anesthesia over the heel and weakness in flexion of the toes. January 22, 1945, at the 83d General Hospital, the tibial nerve was resected to a 5-cm. gap. Tan- talum wire and a cuff were applied. He was splinted for 12 days. On August 30, 1945, he was discharged from the Ashford General Hospital with an excellent return of function in both the sensory and motor com- ponents according to the chart. INTERVAL HISTORY Patient's chief complaint at the present time is fatigue in the affected leg along with a peculiar aching feeling in the foot after prolonged walking. Approximately 12 months after discharge he noted improved ankle and toe motion. At the present time he has some numbness on the outer aspect of the foot and some coolness of the entire foot in cold weather. He feels fatigue after 3 hours of standing or walking 2 to 3 miles. He is able to walk these 2 to 3 miles without any aid whatsoever; however, he finds it more difficult to walk in cold weather. Prior to his injury, he had a job in a gas station. At the present time, he is well situated doing wood- work refinishing. He feels that his 50 percent disability is a fair adjustment. CENTER EXAMINATION April 8, 1949 The wound is \Q% in. from the internal malleolus. The circumference of the lower leg is equal bilaterally. The dorsalis pedis pulse is good and equal bilaterally; the posterior tibial is extremely poor on the right. The right foot is definitely cooler and more moist than the left. There is no impairment of joint function. Sensory examination shows pressure sensibility to be 75 percent of 460

normal in all the toes. Position sense is less definitely present to a degree of about 60 percent of normal. Clinical evaluation of muscle function shows the gastrocnemius, tibialis posticus, and the long flexor of the toes to be about normal in strength. However, the intrinsic foot muscles show only about 10 percent return. Definitive sensory examination on the sole of the foot shows that the patient is able to feel 30 gm. of pain all over and 35 gm. of touch. There is no question that he would feel more than 40 gm. were it not for the fact that the sole is extremely calloused. It is interesting at this point to note that there is absolutely no hypersensitivity of the sole. Skin resistance shows approximately the same findings in the normal and abnormal foot, with the exception of the lateral aspect of the sole where there is definitely decreased skin resistance in the injured foot. Chronaxie of 4.4 msec. was slightly higher than was expected in the gastroc- nemius. However, the figure of 12 msec. is what would have been expected in the case of the intrinsic foot muscles. Electromyography was not performed for technical reasons. FUNCTIONAL EVALUATION Except for fatigue which comes on only after standing for several hours or walking for several miles, this foot is as good as the normal one. POINTS OF SPECIAL INTEREST This good result illustrates what can be expected in the very low tibial injuries. Case Report 4133 HISTORY OF INJURY On December 20, 1944, the patient sustained multiple penetrating wounds of the middle % of the left arm and of both legs, 2-3 in. proximal to the malleolus. There was resultant complete paralysis of both posterior tibial nerves and partial paralysis of the median and ulnar. On February 25, 1945, neurorrhaphy was performed on both tibial nerves. The left was resected \% cm. and the right, 2 cm. Both were sutured with tantalum and tantalum cuffs were placed about the lines of anastomosis. Prior to operation, an incomplete sensory loss was noted on examination; no nota- tion is available on the status of the intrinsic foot muscles at that time. An external neurolysis was performed on the median and ulnar nerves on March 12, 1945; prior to this procedure a slight decrease in muscle strength and a sensory deficit were noted. At examination on April 24, 1945, all muscles were graded as 4 plus, and there was still a slight sensory deficit in the median area. CENTER EXAMINATION September 30, 1948 Hand. Sensory examination revealed normal thresholds throughout the hand; skin resistance, position sense, deep pressure and pain points were also within normal limits. There was a diminution in two-point perception over the ulnar area, but the median was normal. There was no atrophy 461

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and motor power was found to be equal on both hands. Functionally, there was no difficulty in performing any movements with the hand and there was no complaint. Feet. The patient complains of spontaneous pain, paresthesias, numb- ness, coldness, hypersensitivity and pain with use. Sensory examination reveals threshold of 6 gm. pain and 2 gm. touch in both feet. Position sense is approximately 80 percent of normal and deep pressure sense is normal. Motor examination results list the left leg as having good function in all muscles but the right showed the intrinsics to be functioning weakly. Functionally, the only limitation is by pain on extended use; the patient can walk several miles, however. POINTS OF INTEREST The injuries present no handicap in the patient's job as a bartender. The leg injuries were just proximal to the malleolus and therefore muscle involvement was confined to the foot itself. Case Report 4231 HISTORY OF INJURY On January 6, 1945, this officer was wounded in action in France, sus- taining a gunshot wound of the left ankle. Debridement same day with ligation of posterior tibial artery. Compound comminuted fracture lower left tibia, and the leg was casted. Posterior tibial nerve injury noted June 10, 1945. August 23, 1945, McCloskey General Hospital, the posterior tibial nerve was resected to a 5^ cm. gap; #120 cotton suture was used. Diameter of distal stump approximately twice that of proximal stump, with no tension. Using a closed pedicle flap, a skin graft was also performed using the right thigh as donor site. September 18, 1945, attached closed pedicle graft cut. December 1945, same hospital, excision of cicatrix from ankle, with splinting. September 26, 1947, retired, and the spring-type brace unsuccessful. Evaluation showed atrophy of intrinsic foot muscles and limitation of joint motion. INTERVAL HISTORY Walter Reed General Hospital January 1948 Keeler procedure on last 4 toes (% of proximal phalanx excised) resulting in flail toes. No improve- ment in mobility or strength but entire sole of foot except heel has become more hypersensitive. Complains of spontaneous pains in foot at times, paresthesias and hypersensitivity over ball of foot, arch, and under toes when stepping over uneven areas such as rocks; numbness in heel and rapid fatigue. Can walk about a mile without pain or undue fatigue. Patient was a Regular Army officer and therefore 100 percent disabled for his former job. He is now doing postgraduate work. CENTER EXAMINATION May 17, 1949 Patient was 22 years old at time of injury. Suture line approximately 4 in. proximal to medial malleolus. Circumference of thigh 8 in. above

tibial, tubercle is 1% in. less than the right, while the circumference of lower leg 4 in. distal to tibial tubercle is % in. less on the left. He is able to dorsiflex ankle on right to 70 degrees, on left to 90 degrees, able to extend foot on right 140 degrees, on left 125 degrees. There is good passive motion in toes of left foot and they maintain themselves in normal position. Pulses and color normal bilaterally, with no atrophic changes or abnormal vasomotor responses present. Motor examination. Clinically there is about 50 percent muscle strength present in the intrinsic foot muscles. The patient is able to walk about 1 mile, to stand on toes and heels, to squat and dance. He is able to flex, extend, invert, and evert the ankle well, as well as cup the foot and flex and extend the toes fairly well. Chronaxie examination of intrinsic foot muscles was 20 times normal. Sensory examination. Hypersensitive to pinprick with 2 gm./mm. and touch with 3 gm./mm. over entire sole of foot except heel. There is anesthesia and analgesia over the heel. He feels "sharp" with 10 gm. and touch with 16 gm./mm. over the plantar aspect of toes, and distal portion of dorsum of 4th and 5th toes. Deep pressure sensation on the little toe caused pain sensation up into the lateral aspect of the foot. Vibration and position sense are intact. OVERALL EVALUATION As would be expected from such a low injury, this patient has an excellent functioning foot. His main difficulty is the hyperesthesia on the sole of the foot which probably can be well controlled with the use of a rubber sponge and he has so been advised. He also has been advised to continue the use of the bar in his shoe just proximal to the ball of the foot in order to take the weight off the very hypersensitive ball. Case Report 4208 HISTORY OF INJURY Patient WIA, March 30, 1945, Germany. Shell wounds, perforating lateral and medial malleoli right lower leg. "Posterior tibial artery severed and posterior tibial nerve partially severed," noted on evacuation hospital chart. Chip fracture right medial malleolus of tibia and right lateral malleolus of fibula. March 31, 1945, 107 Evacuation Hospital, posterior tibial vein and artery ligated. Ends of tibial nerves approximated with tantalum wire. Boot cast applied. April 7, 1945, closure of wounds. July 19, 1945, plantar flexion limited to 100 degrees; extension to 90 degrees. Mottling and erythema of skin. Only dorsalis pedis artery pal- pable. Ankle edema. No neuroma. Anesthesia of sole of foot. "Some motor function of all muscles, flexor digitorum longus and flexor hallucis longus being weak." December 3, 1945, Halloran General Hospital, exploration of right posterior tibial nerve. Electrical stimulation distal and proximal to suture gave both sensory and motor response. Small 445

branch of posterior tibial going to heel found severed with neuroma.2* Neuroma excised and proximal end of nerve placed in subcutaneous tissues. Unable to locate distal end of nerve. March 16, 1946, disability discharge. INTERVAL HISTORY No treatment since discharge. Complains of edema of foot on standing and pain in ankle and foot on walking. Hypersensitive on medial aspect sole of foot when walking on uneven ground. Coldness over medial portion of ankle and occasionally in toes. Markedly hypersensitive to touch and "sharp" sensation over area of arch of foot. Pain in whole foot when walking more than 5 blocks. Rapid fatigue. Claims marked improvement in flexion of toes since September 1948 and slight improve- ment in inversion of foot since March 1948. Claims marked improvement in range of ankle motion. Claims hypersensitivity in arch of foot since discharge. Due to injury, unable to resume prewar job of machine hand at Bethlehem Steel. Now in college preparing for business. CENTER EXAMINATION April 4, 1949 Patient 24 years old at time of injury and left handed. Suture-line at site of medial malleolus. Circumference of ankle at right 11 in., on left 9% in. Dorsiflexion of ankle on right 89 degrees, on left 75 degrees; extension on right 155 degrees, on left 170 degrees. No autonomic abnormalities. Posterior tibial pulse on right not palpable. Marked nonpitting ankle edema on right. Motor examination. 50 percent muscle strength in the intrinsic foot muscles. Chronaxie examination 16 times normal. Functionally, patient without shoes has a slight limp due to inability to put entire weight on right ankle and foot. With shoes, patient's gait is normal. He is able to walk 6 blocks without discomfort. Sensory examination. Patient able to feel "sharp" with 10 gm. and touch with 16 gin ./mm. over the posterior tibial distribution in the sole of the foot. Marked hyperesthesia over the arch of the foot is present extending to within 1 in. of the medial malleolus. Patient hypersensitive to "sharp" with 2 gm. and touch with 3 gm./mm. in this area. Position and vibra- tion sense normal. Deep pressure on toes revealed a nondisagreeable pressure sensation at point of stimulation. Pricking or touching hyper- sensitive area "feels as if nerve was hit, but disagreeable sensation does not spread." Skin resistance is slightly decreased on the right over both the posterior tibial distribution on the sole of the foot and the long saphenous distribution. OVERALL EVALUATION This patient has a practically perfectly functioning foot. His edema probably can be controlled by the use of a thin rubber bandage applied snugly from the ball of the foot to the lower third of the tibia. He was " Coded as partial division on review of operation report (Ed.).

so advised. The hyperesthesia due to some irritation of the long saphenous nerve is not sufficiently disagreeable to the patient to warrant further investigation. In view of the fact that this patient's future lies in the business field, he has a functionally satisfactory foot. Case Report 8717 HISTORY OF INJURY This patient had a complete injury to the sciatic nerve on the right in March of 1945, and this was sutured overseas May 1945, by overcoming an 8.0 cm. gap for both peroneal and tibial components, the point of suture being 4 in. above the popliteal space. At the time of admission in July 1945, 4 months after suture, there was a Tinel's sign 3 in. below the head of the fibula. By April 1946, 13 months after suture, there was good function in the gastrocnemius and the posterior tibial on the right, as well as beginning function in the anterior tibial, peroneus, and extensor of the toes. Turning to the left leg, this also showed a wound at the same level about 3 in. above the popliteal space. The patient showed intact peroneal nerve function but a complete tibial nerve paralysis. Operation on this was delayed until July 1945, while the right leg was mobilized following operative fixation of the knee for suture of the nerve. The tibial nerve was found divided below some branches to the gastrocnemius muscle so that the good recovery of that muscle must not be attributed to the suture. The peroneal division was found intact. A gap of 8 cm. was overcome in suturing the tibial nerve in the popliteal space. Our last note on this patient is in March 1946, and at that time he still showed no function in the left tibial nerve except for the flicker in the gastrocnemius which was innervated above the suture line. In the 2 years since discharge, the patient has noticed an increase in his ability to dorsiflex the right foot. He also believes both legs have increased in strength of all muscles. He is able to walk very satisfactorily for a distance of as long as 1 % miles and the only things which he finds difficult are climbing ladders or running. He feels that he has been limited in his earning ability because he cannot be a machine operator and stand on his feet for long periods of time. He therefore changed to a job which allows him to be an inspector and sit a good portion of the day, which he does quite comfortably. CENTER EXAMINATION October 19, 1948 An examination of the right leg, which has a complete sciatic nerve suture done overseas, shows good function in all of the peroneal group of muscles and all of the tibial group of muscles, except that there is no flexion of the toes and extension of all the toes is slightly weak. Chronaxies and tetanus ratios could be done only on the intrinsic muscles and here the rheobase was 120 and the chronaxie was 12.0 msec., indicating complete denervation which was the clinical impression. There seems to be a fair recovery of sensation throughout and this had to be mapped by slight 467

differences with the pin, it being impossible in this patient to get good thresholds on either side. Examination of the left leg showed that the peroneal component had intact function as previously and there was some function in all of the tibial musculature except for the posterior tibial. Gastrocnemius was measured at 12 Ib. but plantar flexion was greatly aided and substituted for by the peroneus longus muscle. Again electrical study could be done only on the short flexor of the great toe where the rheobase was 100 and the chronaxie was 6.0 msec. Sensation seemed definitely recovered but again could not be very well mapped except to say that the tibial area had slightly dim- inished sensation as compared to the rest of the leg. From a functional standpoint, the patient walked with no foot-drop of any kind. He limped slightly with the left leg when he was barefoot, but walked with no dis- ability whatsoever when he had both shoes on. POINTS OF INTEREST The left tibial nerve had regenerated about as one might expect but the regeneration of the right leg has been singularly satisfactory. This may be attributed both to the low lesion in the popliteal space involving both tibial and peroneal nerves on the right, and it may also be partly the result of extremely early suture which was carried out 8 weeks after injury. The 10 cases representative of poor tibial recovery are summarized in table 238. Full details on four of these follow. Case Report 4442 HISTORY OF INJURY This patient was wounded in action in Germany on February 13,1945,when struck by high explosive shell. He sustained a penetrating wound of the lower third of the right leg, with compound comminuted fracture of the lower third of the right fibula. His status at the beginning of April 1945 was "inability to flex toes, anesthesia of sole, with early causalgia." On April 11, 1945, a bulb suture operation was performed on the right tibial nerve. Stumps of the nerve were found 4 to 5 cm. separated in the middle and lower third of the right leg. They were sutured side-to-side with silk, apparently under considerable tension, and wrapped in tantalum foil. On September 13, 1945, a neurorrhaphy was done (second-stage bulb suture) on the right tibial nerve. This nerve was resected 4 cm. to normal nerve tissue, and sutured with tantalum. Patient was given a disability discharge on February 18, 1946, at which time there was a TinePs sign to the medial malleolus but, as yet, no return of function. CENTER EXAMINATION February 2, 1950 This was a very low tibial nerve injury at the ankle. Suture was of the bulb type in two stages, definitive repair occurring 7 months after injury. There is slight sensory return to the sole of the foot, 40 gm. of pain being appreciated occasionally, with touch running between 50 gm. and 35 gm. From a motor standpoint the intrinsic foot muscles show no voluntary 46S

action but do show a flicker on nerve stimulation. Chronaxie for the adductor hallucis is 9.0 msec. This patient is in no way disabled except that he cannot run as well as previously, so that he has had to give up playing professional baseball. He probably would be more disabled if his nerve had grown back better. It is hard to see how these extensive procedures help the patient in any way, and it raises the question as to whether an effort should be made to overcome an extensive gap in the posterior tibial nerve. Case Report 4075 HISTORY OF INJURY This patient received a perforating wound of the left lower leg with resultant paralysis of the posterior tibial nerve and fracture of the left tibia. The level of injury was such that loss of function was limited to the intrinsic foot musculature and sensory perception in the foot. At neurorrhaphy on September 14, 1945, considerable scar formation was encountered; a defect of 10 cm. was made up by flexing the knee to 80 degrees. Fibrin foam and tantalum foil were utilized to cover the scarred nerve bed. Prior to discharge on February 8, 1946, there was definite evidence of sensory return on the sole of the foot. CENTER EXAMINATION There is complete anesthesia in the autonomous zone to 40 gm. of pain and 20 gm. of touch; the remainder of the foot shows a variable threshold. Deep pressure sense is poor in the 4th and 5th digits and position sense is present but diminished in the same area. Clinically, the intrinsic foot muscles seemed to be nonfunctioning nor could they be made to contract upon electrical stimulation. No rheobase or chronaxie was obtained. Skin resistance tests showed an area of increased resistance along the lateral edge of the foot. The patient can walk without difficulty; except for the hypersensitivity of the sole of the foot he has no real problem. POINTS OF INTEREST There was a time lapse of 1 year before suture and a distance of 10 cm. was made up at operation. Case Report 4008 HISTORY OF INJURY Patient was injured March 9, 1945, on Luzon. Multiple perforating gunshot wounds resulting in incomplete fracture of the right tibia and fracture of the neck of the right femur. He was admitted to Ashford General Hospital May 30, 1945. On July 31, 1945, a neurorrhaphy of the posterior tibial nerve of the right lower extremity was carried out. The gap closed was approximately 8 cm. An end-to-end anastomosis was carried out with interrupted cotton sutures, with moderate tension. The 469

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surgeon made a note that the neurorrhaphy was considered unsatisfactory because it was impossible to resect enough nerve tissue to obtain normal fascicles. He was discharged in November 1945 with no evidence of sensory recovery. CENTER EXAMINATION March 31, 1948 This man complains of discomfort in the sole of his foot when he is on the foot for more than 2 hours. The foot swells somewhat and occasionally he suffers a transient ulceration on the heel. He used to work in a textile stockroom and now is a gas station attendant with minor limitation. Sensory examination shows no evidence of regeneration. The sole of the foot is anesthetic to 40 gm. pain and 50 gm. touch. Motor examination indicates the only muscles affected are the intrinsics. They have no voluntary innervation and nerve stimulation at the ankle failed to produce any visible contraction. The tendon of the flexor hallucis longus was involved in the original injury, but this is not disabling to the patient. For all practical purposes the motor function is unimpaired. Functional evaluation. This patient has an entirely useful foot and does not require a brace to walk with an entirely normal gait. Because of his pain on long standing and his susceptibility to edema of the foot and occasional ulceration, his function is rated at 80 percent. Comment. There is absolutely no evidence of tibial nerve regeneration. If there were regeneration, function would be probably worse than it is now because of pain. This is another case which raises the question as to whether extensive operations to overcome defects in the distal tibial nerve are really indicated. Case Report 4002 HISTORY OF INJURY While on active duty in Europe, October 17, 1944, the patient was struck by a mortar-shell fragment, which penetrated his right arm, lower third, causing a transient ulnar nerve paresis. Simultaneously, a wound in the right leg, upper third, resulted in tibial nerve paralysis. By January 1945, the ulnar difficulty recovered to only a slight qualitative change in sensation. On January 20, 1945, it was noted that he had all movements of the foot except spreading of the toes, and that he had some numbness over the tibial sensory distribution. A resection was carried out of a neuroma February 13, 1945, and an end-to-end anastomosis with cotton sutures was made after excision of 4 cm. of a neuroma in continuity. By September 15, 1945, there was return of touch to the foot. The long toe flexors never lost their innervation but the tendons were partially involved in the scar. CENTER EXAMINATION March 23, 1948 Motor examination. The only function he did not have was flexion of the toes. He had strong inversion to 24 Ib. and strong plantar flexion to 42 Ib. Intraneural stimulation failed to achieve any flexion of the toes, 472

although the intrinsic foot muscles responded feebly, indicating slight motor recovery through the suture. Sensory examination. Patient was insensitive to pain to 40 gm. over the sole of the foot. Deep pressure felt via peroneal. No sweating over sole of the foot. Function is excellent since the patient can walk indefinitely. He notes slight pain at the end of the day. He can't run or dance (80 percent). He is learning to do auto fender work at present, giving up prewar job as laborer. POINTS OF INTEREST This man is not handicapped by his poor tibial regeneration. The nerve might just as well have been left alone. 3. Sciatic-Tibial Nerve The 10 cases illustrating good recovery in the sciatic-tibial are sum- marized in table 239. Individual case reports follow. Case Report 4406 BISTORY OF INJURY This soldier was wounded in action in the Southwest Pacific on January 22, 1944, by a shell explosion with perforating wounds of the middle third of his right thigh and also his left thigh and scrotum. He showed a total sciatic nerve paralysis on the right, but operation was repeatedly delayed because of two attacks of malaria and because of a hurricane in New Jersey. On October 31, 1944, neurorrhaphy was done on the right sciatic nerve. The nerve was found severed over a distance of 2 in. and imbed- ded in dense scar tissue just external to the sciatic notch; it was mobilized extensively, resected 9 cm. to fairly good tubules in the proximal stump (moderate bleeding, but having a grayish cast) and good tubules in the distal stump; it was sutured with tantalum under slight tension; branches which apparently led to the biceps femoris were included in the suture. Ten days postoperatively the patient had a third attack of malaria, which was suppressed with atabrine. Five months postoperatively there was return of function in the biceps femoris; 9% months in the soleus; 12 months in the gastrocnemius, with some return of peroneal sensation; 13 months in the peroneus longus, with some tibial sensation; 16 months in the tibialis posticus. At discharge on May 29, 1946, the patient had fairly good function in his thigh muscles, good function on gastrocnemius and tibialis posticus, fair in the peroneus, beginning return of the tibialis anticus, and fair return of sensation in both tibial and peroneal distributions. INTERVAL HISTORY The patient has had no treatment since discharge, and has noted no improvement in his leg. He has no complaints at present, experiences no pain whatsoever, and is able to walk 2 miles before becoming fatigued. 408980—BT 32 471

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He wears a brace while walking, finds climbing stairs somewhat difficult and requires something to hold onto, and is unable to stand on the injured leg for a protracted length of time. Before the war the patient was a mechanic with a railroad; he has returned to work with a transit com- pany as a clerk, with a decreased earning ability of about 30 percent. His compensation is 90 percent and he is satisfied with this. CENTER EXAMINATION December 27, 1949 Distance of injury is 29 in. There is no gross atrophy, but the calf is diminished 2 in. in circumference. Both feet are equally warm and dry, and pulses are equal and full. There is slight limitation of motion at the ankle. In both the tibia! and peroneal sensory areas the patient is able to feel approximately 10 gm. pain and 3 gm. touch. Deep pressure produces a painful sensation. There is no impairment of position sense. Quantative muscle evaluation is as follows. Gastrocnemius 50 percent; tibialis posticus trace; flexor digitorum longus 35 percent; flexor hallucis longus 0; tibialis anticus 7 percent; peroneus longus 4 percent; extensor digitorum longus 6 percent; extensor hallucis longus 0. Percutaneous stimulation of the tibial nerve at the knee produced flexion of the foot and slight inversion; percutaneous stimulation of the peroneal nerve at the head of the fibula produced marked eversion and extension of the foot. The tibialis anticus had a rheobase of 140, a chronaxie of 2.0; gas- trocnemius had a rheobase of 65, a chronaxie of 2.0. EMG was attempted on the tibialis anticus but there were no photographs made due to tech- nical difficulties; however, there were observed only some very low ampli- tude waves of varying frequency. Functional evaluation. The patient is able to walk 2 miles with the use of a brace, and is not limited by pain. Our tests show that he has a slight degree of function in all the major muscles of the lower leg, but the only effectively functioning muscle is the gastrocnemius. It is interesting that he has practically no sensory deficit in the foot. POINTS OF SPECIAL INTEREST This was a complete sciatic lesion just external to the sciatic notch. For various reasons repair was postponed 9 months after injury, and at that time required resection of 9 cm. There is a very nice chronological listing of the return of function to the various muscles, and of the sensory return. It is also interesting that a patient with so high a nerve lesion should shown such good function in the gastrocnemius. Case Report 4367 HISTORY OF INJURY This soldier was wounded in action in Germany on November 19, 1944, by shell fire, receiving a through-and-through wound of his left posterior thigh in the middle third. He had no function elicitable in the left sciatic nerve, and on November 30, 1944, at the 98th General Hospital, neuror- 476

rhaphy was performed on the left tibial nerve and neurolysis on the left peroneal. The lateral aspect of the tibial nerve was found to be macerated and almost completely severed; 3 cm. of this were resected and the nerve was sutured with tantalum and wrapped in a tantalum cuff; the peroneal nerve appeared bruised, and it was lysed and wrapped in a tantalum cuff; sulfanilamide was sprinkled in the wound. One month postoperatively there was noted to be return of function in all the peroneal distribution. Nine months postoperatively function was noted in the gastrocnemius. At discharge on December 7, 1945, his muscle rating was as follows. All peroneal muscles 100 percent; gastrocnemius 100 percent; tibialis posti- cus 50 percent; flexor hallucis longus 25 percent; and flexor digitorum longus 0. There was hypesthesia but perception of pain over the sole of the foot. INTERVAL HISTORY The patient has had no treatment since discharge, but he has had in- creased strength in dorsiflexion of his foot and toes, and a return of sensation to the sole of the foot. His primary complaint is of tenderness and oc- casional cramps in the leg, but he suffers no real pain in the leg what- soever, although he does have rapid fatigue and numbness of digits 3, 4, and 5. Before the war he was a student; he now refills tanks on buses, and feels that he would be able to earn more if he were not injured. His compensation is 40 percent, and he is satisfied with this. CENTER EXAMINATION November 9, 1949 Distance of the injury is 24^ in. There is no grossly apparent atrophy, and the calf is not diminished in circumference. Both feet are cool and dry, but pulses are present and equal. There is very slight limitation of the extent of ankle dorsiflexion. In the calloused areas of the sole the patient is unable to feel 40 gm. pain, but he does feel 20 gm. pain at the arch; in the peroneal distribution he is able to feet 6 gm. pain. In the tibial distribution he is able to feel 16 gm. touch, and in the peroneal distribution 5 gm. touch. Deep pressure is approximately normal in the 1st and 2d toes, but produces a painful sensation in the 3d, 4th, and 5th toes. Position sense is unimpaired in the 1st and 2d toes, absent in the 3d, 4th, and 5th. There is no split sensation. Quantitative muscle evaluation is as follows. Tibialis anticus 85 percent of normal, peroneus longus 50 percent, extensor digitorum longus 100 per- cent, extensor hallucis longus 100 percent, gastrocnemius 75 percent, flexor digitorum longus 50 percent, flexor hallucis longus 25 percent, tibialis posticus 75 percent. Functional evaluation. This patient states that he is able to walk approxi- mately 1 mile without trouble, and then is forced to stop because of fatigue; he is able to climb stairs but not a ladder. All in all, he has a rather good return of function in his leg. 477

POINTS OF SPECIAL INTEREST This is an unusually early suture (11 days) of a fairly high sciatic nerve injury (24% in.)- The tibial nerve was sutured; the peroneal was only lysed. The patient shows an unusually good return of function in both nerve distributions. Case Report 4329 HISTORY OF INJURY This soldier was wounded in action in France by a shell explosion on September 18, 1944, receiving a penetrating wound of the left lateral popliteal area. During debridement 7 hours later the peroneal and tibial nerves were noted to be lacerated. Because the patient continued to show a total motor and sensory paralysis of both his peroneal and tibial nerves, neurorrhaphy was performed on the left sciatic nerve at Percy Jones General Hospital on January 15, 1945. The sciatic nerve was found buried in dense scar tissue and severed, and gave no electrical response. It was resected leaving a 6 cm. gap, with the nerves combined into a single stump proximally, but with separate peroneal and tibial stumps distally; these were sutured with black silk. The pathological report is of interest in that it notes that the sections from the tibial nerve showed "atrophy and fibrosis of the epineurium and perineurium, but with normal appearing fibers traversing it" Three months postoperatively the patient showed 50 percent function in his gastrocnemius, with the peroneal Tinel sign in the lower third of the lower leg, and the tibial Tinel to the middle third of the calf. There was a good function in the tibialis anticus and a flicker in the peroneus at 4 months. Six months postoperatively the patient showed 75 percent function in the gastrocnemius, tibialis posticus 50 percent, tibialis anticus 50 percent, peroneus longus 25 percent, and a flicker in the extensor digitorum longus. At 7 months there was a return of pinprick sensation in the peroneal area. At 9 months, when the patient was dis- charged on December 19, 1945, there was 50 percent to 75 percent func- tion in all the leg muscles except an absence of function* in the flexors of the toes, and there was returning sensation in both components. INTERVAL HISTORY Since discharge the only treatment the patient has been receiving is physiotherapy at a VA hospital. The only improvement he has noted is increased strength and flexibility at the ankle and some further return of sensation. His primary complaints are weakness in the leg, pain with use, spontaneous pain, and he is also bothered by hypersensitivity of the sole. Before the war he worked as a machine operator; he is now a clerk and his earning ability is approximately the same. His compensation is 50 percent and he feels that this is not quite adequate. CENTER EXAMINATION October 7, 1949 Distance of the injury is 18% in. There is no marked atrophy, except that the left thigh is diminished 1% in. in circumference, and the left calf 478

is diminished X in. in circumference. Pulses are equal and full bilaterally, and both feet are warm and dry. There is only slight limitation of motion at the ankle. The patient states he is able to walk approximately a half mile, but he is unable to stand for more than about 15 minutes. He is able to roller skate about 5 minutes at one time. In a typical peroneal area the patient is able to distinguish 25 gm. touch and 30 gm. pain, but he is able to perceive lesser stimuli as pares- thesiae. In the tibial area on the sole of the foot the patient is hyper- sensitive to 10 gm. pain and 25 gm touch. The patient is slightly hyper- sensitive to deep pressure; position sense is somewhat impaired, particularly in the 2d and 5th digits. Quantitative muscle evaluation is as follows. Gastrocnemius 75 percent of normal; tibialis posticus 100 percent; flexor digitorum longus 100 percent; flexor hallucis longus 55 percent; tibialis anticus 95 percent; peroneus longus 70 percent; extensor digitorum longus 65 percent; extensor hallucis longus 0. Functional evaluation. This patient is apparently able to walk without a foot-drop brace a distance of approximately one-half mile, being limited by fatigue. His other difficulty occurs in the hypersensitivity of the sole of his foot, but this apparently does not affect him much when he is wearing shoes as he is able to roller skate. POINTS OF SPECIAL INTEREST This was a combined peroneal and tibial injury at the level of the knee, with a 6-cm. gap, and there being a single sciatic stump proximally, but a separate peroneal and tibial stump distally. The nerve was repaired 4 months after injury. The pathological note regarding the tibial nerve sections is of interest. The patient has a well-documented history of the return of motor function which, as noted above, was exceedingly rapid and surprisingly full. Ten examples of poor sciatic-tibial recovery are summarized in table 240. The individual case reports follow. Case Report 4198 HISTORY OF INJURY June 5, 1944, this patient sustained a perforating wound of right thigh while in action in Rome. The sciatic nerve was recognized as being injured. June 17, secondary closure was carried out. It was not until August 22 at Walter Reed General Hospital that both components of the sciatic were resected. There was a 7 cm. gap. Tantalum wire with foil was used. No tension. Leg was flexed to 90 degrees and was placed in a cast for 6 weeks. Patient had 5 lumbar sympathetic blocks because there was swelling of the right leg and foot. There was no appreciable improvement in his condition. These were carried out in June and July of 1946. On October 24,1946, at Halloran General Hospital, the tantalum cuff was removed. The suture site was excellent. Stimulation distal to 479

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the suture resulted in good motor and sensory response. November 1946, he was discharged and a note was made that there was some motor and sensory return of the tibial with no peroneal return. The patient had a chronic ulcer on his foot which prolonged his hospitalization. INTERVAL HISTORY Chief complaint of the patient is his great difficulty in walking. There has been no change in his muscle or sensory status since discharge. At the present time, he has definite difficulty with coldness of his foot, and with changes in weather hypersensitivity is marked in the sole of the foot and the toes. He also has ulcerations in the region of the heel and some pain and rapid fatigue with use. He walks approximately 1 block with a brace. He finds it impossible to perform extended walking or standing for any length of time. The only treatment he has had since discharge has been for trophic ulcers at a VA hospital. He receives 100 percent compensation which of course he feels is adequate. Prior to his injury he was a route man for a laundry but now is unable to work. CENTER EXAMINATION March 15, 1949 Reveals a patient who for all practical purposes has no use of his right leg whatsoever. It is markedly thin and atrophic throughout compared to the left, and on clinical examination he showed no function at all in the peroneal musculature and no function in any of the tibial muscles except about 10 percent strength in the gastrocnemius. Position and pressure sense in the toes are entirely absent, and although pulses are equal and full bilaterally, there are numerous old pigmented areas of previous ulcerations on the sole of the foot, and the foot is definitely cooler and drier than on the left side. There is no real joint dysfunction, but there is marked shortening of the Achilles tendon on the involved side so that dorsiflexion is limited to 134 degrees. The ankle is definitely swollen on the involved side as well. It was noted that there was marked fibrosis of the muscles generally. Sensory examination revealed that he was unable to feel 40 gm. of pain and 35 gm. of touch anywhere below the knee. Special electrical exami- nations were of interest because intraneural stimulation of the peroneal at the knee showed a moderately good response in the tibialis anticus and the peronei and the extensor of the toes. Stimulation of the tibial at the ankle, however, failed to reveal any function in the intrinsic foot muscles. Chronaxie measurements of the tibialis anticus could not be made because the rheobase was 275. The rheobase was 90 in the gastrocnemius and the chronaxie was 2.0 msec; in the intrinsic foot muscles, once again the rheobase was 275 plus. The patient is barely able to support himself on his withered and atro- phied foot without his brace. He is unable to walk barefooted and prac- tically falls on his face. For all practical purposes, at the present time he has a useless extremity. The muscle fibrosis is so marked that even though there is good or fairly good response to the peroneal nerve on stimulation, 482

it is unlikely that he can ever get a really good functioning extremity unless he puts in an exceptional amount of work and effort. POINTS OF SPECIAL INTEREST This is a high sciatic lesion which was well treated and which resulted in better function neurologically than is present clinically. Case Report 8767 HISTORY OF INJURY On December 9, 1944, this soldier sustained shell-fragment wounds, perforating, of the upper third of the left thigh. There was immediate sciatic paralysis, and there was a fracture of the upper third of the femoral shaft. On admission to Cushing General Hospital, August 20, 1945, there had been no improvement in the left sciatic nerve; there was complete sensory and motor paralysis of the left sciatic nerve in the upper third of the left thigh; there was a positive Tinel's sign in the upper third of the left leg, along both peroneal and tibial nerves. On September 24, 1945, needling of both nerves at the popliteal space showed evidence of some intact sensory fibers in each nerve, but no motor response. On Septem- ber 26, 1945, the left sciatic nerve was sutured. The nerve was dissected free from the gluteal fold down to the upper portion of the popliteal space; there was moderate scarring in the midthigh. There were a few bundles going through the lesion, carrying sensation to the sole of the foot and to the lateral side of the foot on stimulation. This functioning portion represented less than one-fourth of the nerve. The involved portion was resected to a 7 cm. gap and normal bundles. End-to-end suture was per- formed, using tantalum wire; there was no tension on the suture line. On May 4, 1946, there was a Tinel's sign for both nerves in the lower third of the calf. Gastrocnemius function began in July (10 in. in 10 months) and patient was given a disability discharge August 1946. CENTER EXAMINATION October 21, 1948 The patient complains chiefly of difficulty in walking, and of occasional drainage from the wound. He complains also of numbness of the lower leg and foot, pain with use, loss of motor power and rapid fatigue. The patient has noticed an increase in strength of plantar flexion, but no other motor recovery or return of sensation. His disability is assessed at 100 percent and he feels that this is fair because he can not resume his ma- chinist's duties, due to inability to stand or use the leg for any length of time. Patient is now a college student. Sensory examination reveals no response to 40 gm. pain and 75 gm. touch in either nerve's autonomous zone. Motor examination reveals 20 percent of normal strength in the gastroc- nemius and no clinical function in any of the other standard posterior tibial and common peroneal muscles. There is a 3-plus contraction in the biceps. It was not possible to determine chronaxies by direct muscle

stimulation. Stimulation of the peroneal at the knee gave a barely visible contraction in the peroneus longus muscle. The patient can walk one-fourth mile (using a brace) at the most. He is unable to walk to any extent without a brace and walks with a marked limp even with a brace. This represents an almost complete failure of sciatic nerve suture in the upper third of the thigh about 9^ months after injury—average result for this level with this delay. Delay was due to fracture plus need for securing knee flexion after fracture immobilization. The functional disability (pain on walking) is more the result of the fracture than of the nerve injury. Case Report 4153 HISTORY OF INJURY This soldier received a gunshot wound March 12,1944, perforating through the soft tissue posterior to the bone in the lower one-third right thigh, 4 in. above knee, (partly—Ed.) severing the sciatic nerve and some tendons. Wound debrided 3 hours later when nerve repaired with i black silk suture in nerve and 4 in the sheath and leg splinted in partial flexion. A skin graft to wound of exit March 25, 1944. Neurorrhaphy performed May 24, 1944, at Walter Reed General Hospital. Previous anastomosis found pulled apart with black silk buried in middle of neuroma. Both nerves resected to good tubules, gap 5 cm. each with distal stumps larger than proximal. Sutured with .003 tantalum without sling stitch and tibial nerve only wrapped in tantalum. After no improvement postoperatively, neurorrhaphy again performed November 16, 1944. Suture found pulled apart in both nerves, gap 2.2 cm. A dirty brown fluid found in the tan- talum cuff. Both nerves resected 5.3 cm. Tubules still edematous but a larger gap was not permitted. Peroneal stump again larger distally than proximally. Tibial sutured with interrupted .003 tantalum and peroneal with three interrupted sutures and a continuous running suture because of the difference in size of the two stumps. Individual cuffs were put on. January 1945, patient developed fibrinous pleurisy and partial occlusion of right femoral artery, probably from scar tissue, which improved on medi- cal treatment. October 26, 1945, cuffs removed at England General Hospital. Anastomosis larger than rest of nerve but smooth, and tubules appeared large and fragile. Stimulation showed some function in both peroneal components. External lysis only performed. At discharge on June 13, 1946, pinch perceived throughout except on sole; no pinprick. Gastrocnemius 40 percent; tibialis posticus 25 percent; peronei 25 percent. Tibialis anticus o; flexor digitorum longus and flexor hullucis longus o. Tinel's sign in lower leg for both nerves. INTERVAL HISTORY Was a poultryman before the war and now that he is going to commercial college, he feels his earning ability will not be limited even though his right

leg is useless. Receives 87 percent compensation. Main complaints are pain in the sole, and callous, and scar, some paresthesias, hypersensitivity, numbness, coldness, pain with use, and rapid fatigue. Has recovered no more sensation or motor power and has even lost his gastrocnemius function present for about 6 months after discharge. With brace, walks about 5-6 blocks before fatigue. Without brace, walks a block. Without brace or shoes, he cannot walk at all. CENTER EXAMINATION November 24, 1948 Right leg shows severe atrophy below knee. Both feet are warm. Dorsalis pedis equal bilaterally but posterior tibial decreased on right. Distance of injury 21 in. Absent position and pressure sense and complete anesthesia and analgesia throughout peroneal and tibial area. Skin resis- tance decreased in tibial area. Motor function. Biceps femoris 3 plus; tibial is anticus o, chronaxie 10 msec., contraction slow; peronei trace, chronaxie 20 msec., contraction slow; extensor digitorum longus o; extensor hallucis longus o; gastrocnemius o, chronaxie, 2.0 msec.; tibialis posticus o, flexor digitorum profundus o; flexor hallucis longus o; intrinsic foot muscles o, chronaxie 8.0 msec. Percutaneous stimulation of nerves at knee gives a 3-plus response in gas- trocnemius and i -plus response in tibialis posticus, none in peroneal muscles. POINTS OF SPECIAL INTEREST Illustrates clearly the great importance of good mobilization of the nerves, freedom from excess scarring and positive splinting in flexion to secure good union after suture in this location. Case Report 4301 HISTORY OF INJURY On March 8, 1945, in Germany, this soldier was wounded in action, a rifle bullet perforating the middle third of his right thigh with fracture of the femur. In August of 1945 he received several lumbar blocks for swelling and cyanosis of the foot (at this time the posterior tibial pulse was good, the dorsalis pedis absent). There was no function in either component of the sciatic nerve, and on September 21, 1945, at England General Hospital, neurorrhaphy was performed on the right sciatic nerve. The nerve seemed to end in a massive scar at the level of the gluteal fold. The nerve was resected 9 cm. to normal tubules and, following extensive mobilization, was sutured with tantalum. The blueness, coldness, and pain continued in this soldier's foot, and in October 1946 lumbar sympathetic block was tried prognostically, producing nothing except a fleeting warmth; however, on January 7, 1947, at Walter Reed General Hospital, a right lumbodorsal sympathectomy was performed, removing the sympathetic chain from above D-n to below L-2. At discharge on April 27, 1947, there had been no record made of function in the leg or of the outcome of the sympathectomy.

INTERVAL HISTORY The patient has had no treatment since discharge and has noted no improvement in the foot. He complains of spontaneous pain, paresthesiae, numbness, pain in cold weather, hypersensitivity, pain and rapid fatigue with use, and ulcerations overthe Achilles tendon. He cannot walk without a foot-drop brace, and with it he is limited by pain to 3 or 4 blocks. He had a sixth-grade education, then received training in welding, and before the war worked both as a welder and as a crane operator; he has not worked since the war. He receives 100 percent compensation. CENTER EXAMINATION September 15, 1949 The patient is right handed. There is a soft tissue defect on the posterior aspect of the right thigh with considerable diminution of muscle substance on the posterior thigh and of the entire lower leg. Distance of the injury is 29 in. The thigh is diminished 3% in. in circumference, the calf iK in. There are moderate trophic changes of the skin of the foot. Dorsalis pedis pulses are equal and full, but the right posterior tibial pulse is not palpable; on oscillornetry, the right leg shows an excursion of 1.5 mms., the left 6.0 mm. When he walks barefooted his gait is steppish, with a pelvic tilt and a foot-drop. After exertion there are fibrillations and clonic-like reactions. The entire foot, the lateral and posterior aspects of the leg, and the lateral aspect of the lower two-thirds of the thigh are insensitive to 40 gm. pain, 35 gm. touch. Deep pressure and position sense are 0. Skin resistance on the leg is markedly increased in an area well demarcated and corresponding to the sensory area. There is a trace of function in the gastrocnemius, but unmeasurable; the biceps femoris has a moderate amount of strength; all other peroneal and tibial muscles show no clinical function. The peroneus longus has a rheo- base of 120, a chronaxie of 8.0 msec. The gastrocnemius has a rheobase of 140, a chronaxie of 10.0, prompt; the tibial intrinsics have a rheobase of 180, a chronaxie of 16.0; the til nulls anticus has no rheobase obtainable at 275 volts. Electromyography was done on the tibialis anticus, but no recording was made because there were no definite voluntary action cur- rents. On stimulation there were marked polyphasic spikes, and on supra- maximal stimulation the tibialis anticus had maximum spikes of 2.0 inches, compared with a normal of 6.0. Functional evaluation. Without a foot-drop brace this leg is practically use- less; even with the brace he is limited to 3 to 4 blocks walking by pain and fatigue. POINTS OF SPECIAL INTEREST This was a high injury (gluteal fold), a long gap of 10 cm., and operation a little more than 6 months after injury; there has been practically no return in the leg. Sympathectomy had been done to improve circulation in this leg with no clear-cut result. 486

4. Sciatic-Peroneal Nerve Ten examples of good sciatic-peroneal recovery are abstracted in table 241. Detailed case reports follow. Case Report 4068 HISTORY OF INJURY On August 1, 1944, patient was struck by an 88-mm. shell fragment in left thigh at junction of the lower and middle thirds. He suffered a chip fracture of the femur, a complete peroneal palsy, and an incomplete tibial palsy. He had paralysis of tibial anticus, long toe extensors, peronei, and "hypesthesia" over dorsum of foot and outer aspect of leg. Weak plantar flexion was present. Operation was performed October 20, 1944. Pero- neal nerve did not respond to galvanic or faradic stimulation. Stimulation of posterior tibial nerve gave a slight contraction of tibialis posticus muscle. A neuroma in continuity involving both portions of the nerve was found and was resected to a gap of 4 cm. to good tubules. Tantalum wire and cuff were used for suture without tension. On discharge February 2, 1946, all movements were possible except flexion and extension of the toes; the anesthetic zone was very small. CENTER EXAMINATIONS August 3, 1948, and again on March 78, 1949 The patient complains only of numbness in the foot and hypersensitivity of the sole. He is able to perform all movements to some extent; toe motion is limited. He does not need a brace and can walk barefooted with scarcely any limp. The toe of the shoe on the involved side shows but slightly more wear than the normal. He has the same job as he had prewar, and is not handicapped. Sensory examination reveals perception of 2 gm. pain and touch throughout except for calloused areas. Pressure sense is good throughout, position sense fair to excellent. All muscles function against resistance. Toe flexion and extension, however, are weak. Tibialis anticus had a chronaxie of 0.4 msec., peroneus longus 1 msec., both fast. Intrinsics had slow response at 0.8 msec. Myog- raphy revealed a 60 percent spike on voluntary motion of injured side in tibialis anticus. There was insignificant change in the second examination as compared with the first. For that reason prognosis for further improvement must be guarded. However, this is one of the best sciatic sutures we have seen and we have nothing to offer the patient. Case Report 415 7 HISTORY OF INJURY November 3, 1944, while in action in Germany, the patient stepped on a land mine sustaining multiple wounds to both feet and legs as well as the thighs. Both the tibia and fibula were fractured in the left leg, and the fibula was fractured in the right. The right ankle was fractured as 487

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well. Debridement was carried out and cast applied. Injury to the nerves was not noticed at this time. On July 6, 1945, at McCloskey General Hospital, the sciatic nerve was sutured. The gap was 5 cm. and no cuff was applied. A cast was applied with the knee flexed to 90 degrees. On February 8, 1946, the patient was discharged and a notation was made that there was some return of sensation and muscle function. CENTER EXAMINATION December 6, 1948 The suture line is 11^ in. from the medial malleolus. The suture-line is palpable with a fusiform swelling but no radiating pain can be released on pressure. The circumference of the leg, 6 in. below the tibial tubercle, is 9 in. on the left and 12 in. on the right. It is of interest that the left leg is 1 in. shorter than the right, and that there is severe atrophy of the calf. The left foot is definitely cooler although there are no gross ulcerations or trophic changes present in the skin. The pulses are somewhat diminished on the left side but still quite full. The knee joint is perfectly free and mobile as are the toes. The ankle, however, is somewhat stiff and can be only dorsiflexed to 105 degrees as compared to 90 degrees on the normal side. This is simply a function of the minimal work that the patient has put into limbering this joint. On performance tests, he claims that he can walk with or without his brace for about the same distance, a mile. However, without his brace he is very fatigued and complains of a great deal of pain in the foot at the end of this distance. He is unable to walk barefooted because of pain. At the present time his brace is broken and he is making an attempt to get it fixed. Pressure sensation is present in all the toes but is not normal pressure sense, but is rather a painful tingling which shoots backward up the leg. Position sense is about 50 percent of normal in all the toes. Clinical examination of muscle function shows an excellent biceps femoris; the peroneus longus can just be made out, tibialis anticus is 2-plus, the extensor digitorum longus and the extensor hallucis longus show a trace. The gastrocnemius is strong, the tibialis posticus and the flexor digitorum profundus show only a trace, as does the flexor hallucis longus. The intrinsic foot muscles are definitely present, but weak. Chronaxie examination of the tibialis anticus shows a rheobase of 120 and a chronaxie of 1.2 msec., which is excellent. The extensor digitorum longus shows 75 rheobase and a 4.8 msec. chronaxie. The intrinsic foot muscles show a 90 rheobase and a 12 msec. chronaxie. This more or less confirms the clinical impression of the amount of regeneration present in these muscles. Stimulation of the nerve was said not to be necessary be- cause of the patient's good clinical result. Sensory examination showed a good return of sensation over the entire foot. There was some slight hypersensitivity of the sole to nocuous stimuli.

Functionally, we felt that this patient, despite the shortening of the leg and the marked atrophy of the calf, had an unusually good result, con- sidering that this was a complete sciatic suture. He has good dorsiflexion at the ankle, and provided he loosens up the joint, will have even better function. He should wear a thick sponge rubber insert sole and a some- what larger shoe. However, the patient did not seem interested in our sending a letter to him to that effect, and possibly he will go over to the VA to see whether or not they can arrange for the new shoes. Ten cases illustrating poor recovery in the sciatic-peroneal are summarized in table 242. Detailed case reports follow. Case Report 4042 HISTORY OF INJURY This soldier was wounded in the buttocks September 16, 1944, suffering a complete right sciatic nerve paralysis. Neurorrhaphy was performed December 13,1944. The nerve was found to be involved in a large neuroma just below the sciatic notch; after resection there was a 12 cm. defect. It was necessary to sacrifice some of the branches to the hamstrings. End- to-end suture with tantalum wire was performed without undue tension and the ends wrapped in tantalum foil. Before discharge in May 1946, he was noted to have feeble plantar flexion, no return of sensation, and a Tinel's sign in peroneal nerve to within 3 inches of ankle. INTERVAL HISTORY This patient worked in a distillery prior to his service, and is presently employed as a file clerk at lower salary. His compensation is 70 percent. He complains of spontaneous pain in the ankle and toes, paresthesias, complete sensory loss in the affected area, painful response to extreme cold, severe ulcerations on the sole of the foot, pain with use, and marked fatigability at end of day's work. He wears a brace and can walk 1 mile before he is required to rest. Despite these complaints he is apparently not markedly handicapped in his present position. CENTER EXAMINATION May 14, 1948 On the sensory side, there was a complete analgesia and anesthesia throughout the peroneal and tibial distributions. Skin resistance was sharply increased over this same area. Position sense seemed normal for both the ankle and large toe, absent in the other toes. On voluntary motor examination, only the gastrocnemius functioned (70 percent). There was stiffness in the ankle and toe joints. Percutaneous stimulation of the peroneal nerve at the knee gave only perceptible contractions in tibial anticus, peronei and toe extensors. There was no response to posterior tibial stimulation at the knee and ankle. Neither chronaxie nor tetanus ratio could be determined because of the high rheobase of all musculature. Functionally, the patient walks without a limp with his brace. He shows a complete foot-drop when he attempts to walk without the brace. 4*1

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POINTS OF SPECIAL INTEREST (1) Unsatisfactory recovery from a high sciatic lesion. The nerve was sutured in the region of the sciatic notch after overcoming a gap of 12 cm. This procedure was carried out 3 months after injury under apparently ideal situations. (2) The patchy nature of the recovery. Although the gastrocnemius has received a good innervation, all of the remaining posterior tibial muscles are without innervation. The peroneal muscles have regained slight inner- vation but this is insufficient to be of any practical use to the patient. A complete anesthesia with trophic disturbances persists. (3) From the standpoint of treatment, only an ankle fusion would be feasible and this is not desirable as it would result in the loss of the stepping off function which is provided by the well-functioning gastrocnemius. Case Report 4027 HISTORY OF INJURY This soldier suffered a penetrating wound from a shell fragment in the upper third of the right thigh on April 23, 1943, in Tunisia. By the next day, it was apparent that there was a severe cellulitis present in the wounded area; this healed fairly well in 2 weeks. He was noted to have paralysis of the sciatic nerve, right, common peroneal portion, with inability to dorsi- flex foot and anesthesia over the dorsum of foot. On August 26, 1943, the nerve was explored. There were dense adhesions, but the "peroneal" (actually the tibial—Ed.) nerve was found to be in fairly good continuity with a small injury to the nerve itself. A neuroma in continuity was removed along with a small amount of scar tissue in the nerve. Neurorrhaphy was deemed unnecessary because of the limited involvement; therefore, internal neurolysis was performed, the nerve was wrapped in tantalum foil and the wound closed. Postoperatively an advancing Tinel's was noted down to the ankle, but despite this the only return was a slight amount of sensation. Accordingly, he was reoperated upon February 8,1945. Electrical stimula- tion showed hamstrings and tibial nerves functioning normally but no peroneal function. It was discovered that the tibial nerve had been lysed and cuffed in the previous operation. The peroneal segment was bound in dense scar tissue; it was sectioned to good tubules proximally, but the distal end appeared degenerated even after a defect of 8^ cm. was fashioned. The nerve was sutured with tantalum; no cuff used. At discharge on January 25, 1946, there were "fairly definite peroneal muscle contractions" and patient could evert his foot. There was no tibialis anticus function or toe extensor function. CENTER EXAMINATION April 19, 1948 The patient complains chiefly of numbness in the peroneal area and adverse reaction to cold. He must wear a foot-drop brace continuously, but he is able to walk over a mile and can be on his feet from 1 to 2 hours, before pain forces him to rest. He has had some trouble with his braces, 494

having broken several. He is a gardener as he was prewar; evidently he handles the job without too much difficulty or handicap. He has abso- lutely no function ascertainable sensory-wise or motor-wise. His peroneal muscles show chronaxies distinctly above the normal range. Tetanus ratio was not possible to determine. There is little to be offered this man in the way of treatment other than a satisfactory brace. He does have a painful callus on the lateral surface of the sole—padding should help. Possibly tendon work would help him if he were interested. POINTS OF INTEREST The case is very interesting from several standpoints. First of all, there has been no return of function, doubtless because of the long interval before suture—when sutured, the distal segment of the nerve appeared quite degenerated. Secondly, the original operation in August 1943 was unsuccessful, due to the fact that electrical stimulation was not performed. Because it was not, the chance for definitive repair of the peroneal segment was missed. The tibial component was lysed with the thought that it was the peroneal. Thirdly, following lysis of the tibial component, the peroneal component was repeatedly observed to have an advancing Tinel's sign. Either Tinel's didn't mean much here or the observers were overenthusiastic. Case Report 4243 HISTORY OF INJURY This soldier was wounded in action in France on January 3, 1945, by a shell explosion, one fragment of which penetrated the medial third of his left thigh, resulting in a paralysis of his left sciatic nerve. He showed an inability to dorsiflex or plantar flex his left foot, although the extensors and flexors of the knee were functioning, and he had a complete sensory loss in the peroneal area with dimished sensation in the tibial area as well. However, the ankle jerk was active, and the knee jerk hyperactive. On March 29,1945, at Lawson General Hospital, neurorrhaphy was performed on the peroneal component of the left sciatic nerve, and neurolysis on the tibial component. While there was scarring over a distance of 10 to 12 inches in the middle of the thigh, the tibial component was found to be grossly continuous and neurolysis was considered sufficient; there was a 5-cm. gap in the peroneal component, which was resected and sutured with tantalum; sulfanilamide was dusted freely throughout the wound. At discharge on June 20, 1946, there was weakness but no atrophy of the muslces of the lower leg. Two bands of hypesthesia were present, one on the posterior aspect of the thigh, the other on the posterior aspect of the leg. There was some return of function in the tibial component, but none in the peroneal. INTERVAL HISTORY In June 1948 the patient was at a VA hospital for physiotherapy for his leg, but he has received no other treatment and has noted no improvement in the leg except some return of sensation to the sole of the foot. He has 495

no complaint of pain in the leg under any circumstances, nor of rapid fatigue; his only complaint is the inability to dorsiflex his foot. Before the war he installed oil burners; now he is a farm laborer, receiving room and board. His compensation is 90 percent for his leg and an additional 10 percent for his shoulder, which he considers fair. CENTER EXAMINATION June 16, 1949 Distance of the injury is 30 inches. Circumference of the left calf is diminished K inch. Dorsiflexion of the ankle is limited to 10 degrees passively. Pulses are equal and full bilaterally, and there is equal warmth and moisture. There is some atrophy of the intrinsic foot muscles and of the peroneal muscles of the leg. The patient does not use the foot-drop brace, and he walks well on flat surfaces as long as he wears his shoes; he is able to walk a mile without difficulty, and has no trouble climbing stairs unless he is carrying weight. In both the peroneal and tibial distributions the patient is unable to feel 40 gm. pain even as pressure, or 35 gm. touch. Skin resistance is decreased in the peroneal area, with a line of demarcation following the anterior border of the tibia. Deep pressure of the toes is referred to the peroneal cutaneous area of the calf as an ache; there is about 25 percent position sense. Quantitative muscle evaluation is as follows. Gastrocnemius 75 percent of normal; tibialis posticus 25 percent; flexors of all the toes, intrinsic foot muscles, tibialis anticus, peroneus longus, and extensors of all toes, 0. The gastrocnemius had a rheobase of 165, chronaxie 16.0 (at 280 volts), fast; the intrinsic foot muscles had a rheobase of 175, chronaxie 16.0 (280 volts), slow; tibialis anticus had a rheobase of 150, chronaxie of 16.0 (280 volts), slow; the peroneus longus showed only a flicker at 280 volts. Electromyography was done on the tibialis anticus. Functional evaluation. Despite the fact that this patient has function only in the gastrocnemius and tibialis posticus, he is able to do without a foot- drop brace and is able to walk at least a mile, and otherwise shows very little handicap as a result of his injury. POINTS OF SPECIAL INTEREST This was a fairly high sciatic nerve injury (30 inches); however, the main injury was only to the peroneal component, with some scarring of the tibial component. Ten weeks after injury, neurorrhaphy was performed on the peroneal nerve and neurolysis on the tibial nerve; despite this there was return of function only in the gastrocnemius and tibialis posticus, and no sensory return in either component. In the face of this meager return, the patient has made a very satisfactory adjustment, and suffers very little handicap. 5. Summary The normal functions of the lower extremity have to do with the main- tenance of an erect station and adequate ambulation aided by the appro- 496

priate appreciation of touch, pain, and proprioceptive sensory modalities. In the examples of good regeneration in the lower extremity, sensory return was not complicated by incapacitating painful sensation; in the poor cases, there was usually complete lack of sensory return, a relatively minor handi- cap in the foot as compared to a similar failure of sensory return in the hand. The apparent influence of the factors involved in regeneration in the lower extremity was as follows: Location of injury There were 35 cases of complete sciatic nerve injury among 40 sciatic- peroneal and sciatic-tibial injuries, and in only 7 of the good results was the injury at or above the upper third of the thigh. Thirteen of the poor results, on the other hand, were situated at this level. Case 4406, a com- plete sciatic nerve injury just external to the sciatic notch, showed good and painless sensory return to the foot and motor power return adequate for ambulation, suggesting that high sciatic sutures can be followed by adequate neural regeneration. This analysis only suggests that high lesions do less well than low injuries. Certainly the evidence is not as striking as that found concerning the influence of this factor in the upper extremity. Time after injury In cases exhibiting good regeneration the average nerve suture was performed 121 days after injury; in the poor cases, the average definitive suture was done 241 days postinjury. This latter figure probably represents merely the association of a more complicated leg injury since satisfacory regeneration was found in case 2,166, sutured 290 days after injury, and in cases 2,151 and 4,157, both sutured 240 days after injury. By comparison, very poor neural regeneration was obtained in 20 cases that were defini- tively sutured 30 to 160 days postinjury. Six secondary sutures, performed because an obvious failure was demonstrated after the initial suture, all failed at time intervals from 250 to 810 days postinjury. When suture was done under an 8-month period, no unequivocal influence of delay could be demonstrated in this small series. Nerve defect and tension In general, long nerve defects and suture line tension were more often found in instances of poor nerve regeneration, particularly in the more severe and complicated nerve injuries. Some striking exceptions were seen, as noted in case 2,151, where good tibial nerve regeneration was found in the presence of a 12-cm. defect, and in case 3,455 where good sciatic nerve regeneration was found after repair of an 11-cm. nerve defect. Suture material No positive influence of the type of suture material could be demonstrated except in the X-ray diagnosis of suture line disruption in the tantalum sutures, which represented a common cause for failure. 497

Complications Except for suture-line separations and neuromas, there was no striking difference between the cases of good and poor nerve regeneration with respect to frequency of complications in the lower extremity. In the good cases, there were 23 instances of a second nerve injury in the same extremity, 14 fractures, 3 major soft tissue injuries, 3 wound infections of significance, and 3 vessel ligations low in the extremity. In the poor cases, by compari- son, there were 21 concomitant nerve injuries, 17 fractures, 6 major soft tissue wounds, 1 arterial ligation, 5 wound infections, and 11 suture line separations or neuromas. The very high incidence of proved suture line separations in nerve operations in the lower extremities suggests a probable cause for the many instances of poor regeneration for which an adequate reason has not been otherwise demonstrated. D. CONCLUSION A careful scrutiny of 140 records of good and bad instances of peripheral nerve regeneration has failed to demonstrate any single factor that favor- ably influences regeneration and reveals only the general impression that simple uncomplicated injuries do better than their counterparts. It is easy, on the other hand, to show that high injuries, particularly in the upper extremity, do less well than low injuries, that combined nerve- artery injuries in the upper extremity do poorly and that in the lower ex- tremity technical errors or excessive suture-line tension, followed by suture line separation, play a very significant role in the failure of regen- eration. Although the average time of suture after injury is appreciably lower in cases of good regeneration than in those of poor regeneration, many injuries sutured at 8 to 9 months after injury showed good sensory and motor return. No really good results were found in sutures performed after the 1-year period and, in particular, late secondary sutures in this series always showed failure of regeneration. The most helpful aspect of this review of records supports a host of personal observations by military neurosurgeons that adequate motor and sensory return can be obtained in uncomplicated or pure nerve lesions, when the necessary surgical experience is applied to the problem at hand, when the effector mechanism has not been destroyed by undue delay of suture after injury and when the same mechanism is kept in order while reinnervation is proceeding. Unfortunately, the realities of war injury permit all these circumstances to combine in few cases. The potential gain of nerve suture must be viewed objectively and equal if not greater emphasis must be placed upon other means of rehabilitation, especially for those nerve injuries in which suture must inevitably fail. 498

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

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

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

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