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

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Index to Subjects Abductor digit! quinti (see ulnar nerve) Abductor pollicis (see ulnar nerve) Abductor pollicis brevis (see median nerve) Abductor pollicis longus (see radial nerve) Age at injury autonomic recovery, 344 frequency distribution, 40 motor recovery, 106 Agent of injury associated injuries and, 38-39 autonomic recovery and, 344 brachial plexus lesions, 390, 397 painful phenomena and, 337-338 variety of, 13 Amputation, 48-49, 355, 361-362, 406-407 Aneurysm, traumatic, 403-404, 628 Anomalous innervation, 223, 575 Ankle (see also lower extremity) nerve lesions, frequency of, 36-37 Arm (see also upper extremity) nerve lesions, frequency of, 36-37 Army Registry, 2, 6-13 Arterial injury denned, 37 distribution by nerve, 38 effect on autonomic recovery, 344 days from injury to suture, 52, 134 management, 627-629 motor recovery, 130-134, 138, 149 recovery generally, 447 sensory recovery, 284-285, 627-628 frequency of, 37-39 painful phenomena and, 337-338 Arthrodesis, 48-52, 394, 405-407 Associated injuries (see also under individual nerves, and arterial, bone and joint, infection, plastic repair, and soft tissue) case histories, 409-498 definition of, 35 646

Associated injuries—Continued effect on autonomic recovery, 344 management, 626-629 motor recovery, 123-138, 147, 149 sensory recovery, 278-285 frequency of, 36-38 other nerves, 32-34, 124-125, 278-279, 363 relation to agent of injury, 38-39 time in hospital, 63-68 use of cuff, 180 Atrophy, of muscles, 74, 228-229 Autonomic recovery (see also skin resistance and sweating) anatomic aspects of, 342 assessment of, 341-343 degree of, by nerve, 343-344, 632-637 effects of characteristics of injury, 343-345 technical factors, 345-346 Autonomous zone, 250-251, 343 Axillary nerve injury, motor examination, 576 Axonopraxis, 577 Bias from incomplete follow-up, 22-28 Bone or joint injury case histories, 409-498 defined, 35-36 effect on autonomic recovery, 344 days from injury to suture, 51-52 management of nerve injury, 51-52, 626-627 motor recovery, 125-127 ^ensory recovery, 279-281 frequency of, 37-39 painful phenomena and, 337-338 Braces, lower extremity, 361 Brachial plexus injury anatomic regeneration, 638 classification of, 389-390 diagnosis of, 570 electrical tests, 396 exploration and recovery, 404 grafts and regeneration, 390 joint fusion, 394 management, 399-407, 638 647

Brachial plexus injury—Continued patterns in functional disturbance, 389 recovery, 389-408 functional, 352, 390-400 motor, 390, 395-396 spontaneous, 389-391, 396-397, 399-400 tendon transfer, 394, 404-405 time limitation, 398, 406, 498 Brachioradialis (see radial nerve) British classification of motor recovery, BCMR, (see also motor recovery) classification rubrics, 116 influencing factors, 116-121 relation to pathologic forecast, 501-509, 559-562 relation to sensory and functional recovery, 368-374 U. S. modification, comparison, 114-115 variation, by center, 118 British classification of sensory recovery (see also sensory recovery) by nerve, 256 classification rubiics, 247 influencing factors, 271, 277, 284, 302-303 relation to motor and functional recovery, 368-374 relation to pathologic forecase, 501-509, 539 U. S. modification, comparison, 256-259 variation, by center, 248 Bulb suture, 299 effect on autonomic recovery, 345 motor recovery, 164, 166-167 painful phenomena, 339 sensory recovery, 299-300 Capsulotomy, 48-52 Case histories, 409-498, 589-623 Cathode ray oscillagraph, 215 Causalgia brachial plexus injury, 406 case reports, 328-334 diagnosis, 311-314, 316 history, 314-315 results, 318-317 sympathectomy, 316-318, 334, 406 treatment, 312-313, 315-317, 334-335 Cervical myelogram, 401 Chronaxiemetry anomalous innervation and, 223 center variation, 211, 229-232 64t

Chronaxiemetry—Continued follow-up data on, 221-234 methodology of, 209-211 principles of, 207-209 relation to muscle movement, 221, 234 usefulness of, 209, 219-220, 224, 585 Combined nerve lesions (see under nerve injury) Compensation ratings (see Veterans Administration) Cooperative clinical investigation, xxiii, 2-5, 29-30 Cuff (see tantalum cuff) Days from injury to suture distribution of nerve lesions as to, 43 effect on autonomic recovery, 345 motor recovery, 139, 142-157, 197, 625-626 painful phenomena, 338 recovery generally, 446-447, 469, 497 sensory recovery, 288-294, 626 factors involved, 51-53 pathological forecast and, 532, 535-537, 539, 544-545 relation to associated arterial injury, 134 associated injuries and complications, 51, 147, 149 character of injury, 42-43 echelon of repair, 43 fibrotic change, 539, 544-545 length of surgical gap, 150, 154, 546 other indices and measurements, 501-509 suture material used, 178 use of cuff, 180 variation in distal tubular diameter, 530-538 Definitive operation, 40-41 Disability rating (see Veterans Administration) Disposition from hospital, 62-63, 383-387, 630 Distance from lesion to end organ, 546, 587 Dysesthesia, 336 Early suture (see also days from injury to suture), 54-58 Echelon of nerve surgery (see also individual nerves and categories of recovery), 43-44 Elbow (see also upper extremity) nerve lesions, frequency of, 36-37 Electrodiagnosis (see also chronaxiemetry, galvanic tetanus ratio, stimulation of nerve, electromyography) analysis of follow-up data, 220-240 649

Electrodiagnosis—Continued relation to voluntary movement, 220-240 role in follow-up study, 203-204 usefulness of, 219-220 Electromyography methodology of, 214-218 relation to other motor indices, 233-235, 584-585 usefulness of, 218-219, 584-585 Epineurium, pathologic rating, 542 Extensor carpi radialis (see radial nerve) Extensor carpi ulnaris (see radial nerve) Extensor digitorum communis (see radial nerve) Extensor digitorum longus (see peroneal and sciatic-peroneal nerves) Extensor hallucis longus (see peroneal ad sciatic-peroneal nerves) Extensor pollicis brevis (see radial nerve) Extensor pollicis longus (see radial nerve) Fascicles, matching, 514-515, 526-527, 530, 538, 542, 567 Femoral nerve injury, 576 Fibrotic and neuromatous changes, 520, 539, 544 First dorsal interosseus (see ulnar nerve) Flexor carpi radialis (see median nerve) Flexor carpi ulnaris (see ulnar nerve) Flexor digitorum longus (see tibial and sciatic-tibial nerves) Flexor digitorum profundus 2 (see median nerve) Flexor digitorum profundus 4 and 5 (see ulnar nerve) Flexor hallucis longus (see tibial and sciatic-tibial nerve) Flexor pollicis longus (see median nerve) Follow-up bias from incomplete, 22-28 length of, xxii observations at, 16-18 procedures, 13-16 Foot (see also lower extremity) nerve lesions, frequency of, 36-37 Forearm (see also upper extremity) nerve lesions, frequency of, 36-37 Forward area surgery, 55-58, 569 Functional recovery assessment of, xxii, 349-354 case reports, 409-498 disposition from hospital, 383-387 follow-up data, by nerve, 354-368, 632-637 pathologic forecast and, 501-509, 539, 563-564

Functional recovery—Continued relation to motor and sensory recovery, 368-374 disability ratings, VA, 375-377 occupational handicap, 382 variation by center, 351, 353 Galvanic tetanus ratio average values, by muscle, 214 distribution of muscles as to, 212-214 methodology of, 211-212 usefulness of, 585-586 Gap (see surgical gap, length of) Gastrocnemius-soleus (see tibial and sciatic-tibial nerves) Graft, nerve, xxi, 40, 45, 61, 141, 390 Hand (see also upper extremity) amputation, 406—407 function, 400^01, 405-407, 497-498 nerve lesions, frequency of, 36 prosthesis, 394 usefulness, 635 Handedness, 377-378 Histology (see neuropathological forecast) Hospitalization, duration of, xvi, 63-68, 630-638 Hyperalgesia, 335 Hyperesthesia, 313 Hyperpathia, 312, 336 Hysteria or malingering, 581 Infection, chronic effect on autonomic recovery, 344 delay in repair, 52-53, 127, 130 motor recovery, 127-130, 135, 149 sensory recovery, 281-284 frequency of, 39 Injury, type of, 34, 501-509 Interossei (see tibial and sciatic-tibial nerve) Ischemia (see arterial injury) Knee (see also lower extremity) nerve lesions, frequency of, 36-37 Leg (see also lower extremity) nerve lesions, frequency of, 36-37 651

Localization, 245-248, 254-255, 257-259 Lower extremity (see also individual nerves) amputation, 361-362 anatomical and functional regeneration, 631-634 associated injuries and complications, 32-39, 498 case histories, 447-498 causalgia, 318, 324-327 deformity after nerve suture, 357 functional regeneration, 353, 357, 361-365, 564, 631-634 hospitalization, 63, 65, 631, 634 indication for further operation, 634 nerve lesions, frequency of, 36-37 occupational change, 379-381 ulceration after suture, 357 wound management concept, 625-626 Lysis (see neurolysis) Management of nerve injury (see also under individual aspects and nerves), xxii, 40-62, 569-629 Median nerve injury ancillary operative procedures, 49-50 associated lesions and complications arterial, 37-38 bone and joint, 125-127 infection, 127-130 other nerves, 33 plastic repair, 134-137 autonomic recovery, 342-344, 634 British summary, sensory regeneration, 254-259 British summary, motor regeneration, 113-121 case histories, 411-424, 608-610, 620-621 causalgia, 319-323, 330-334 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 effect of adverse factors, 198-200 arterial injury, 131-134, 284-285 bone and joint injury, 125-127, 279-281 bulb suture, 164, 167, 300 character of nerve ends, 168, 300 chronic infection, 128, 282-284 cuff, 181, 185-187, 304-307, 551 days from injury to definitive suture, 147-151, 289-293, 534, 551 days from injury to first suture, 151, 155, 158 echelon of repair, 158, 295-296 652

Median nerve injury—Continued effect of—Continued extensive mobilization and transposition, 162, 298 external or internal lysis, 192 length of surgical gap, 48^9, 160-161, 297 lysis, 119,261,263-264 multiple lesions, 121 number of operations, 140, 287, 339 other nerve injuries, 279, 343-344, 363, 366-368, 636 plastic repair, 136-138, 286 site of lesion, 91, 96, 116, 120, 269-275, 366-367, 550, 634 stay suture, 190, 370 suture line tension, 171, 301 suture material, 174-175, 178-179, 302-303 suture and lysis, compared, 102, 262 training of surgeon, 194, 308 type of lesion, 100, 108, 114, 267-268 type of surgery, 107, 122, 264-265 frequency of, 33 functional recovery, 352, 356-358, 363, 366-374, 386, 634-637 handedness, 377-378 hospitalization, length of, 65-68 localization, 255 management of (see also management of nerve injury), 40-62, 608-610, 620-621, 634-635 motor recovery, 77-123, 199-200, 235-240, 368-370, 372-374. 634 muscles studied, 73 neuropathologic forecasts, 499, ff. occupational change, 377-382 occupational handicap, 382-384 pain response, 251-252, 634 painful phenomena, 319-323, 330-338 sensory recovery, 251-266, 370-374, 634 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-254, 634 VA disability ratings, 376 Mobilization of nerve autonomic recovery, 345 frequency of, by nerve, 45-47 motor recovery, 159, 162-163 sensory recovery, 297-299 Motor examination, 574-576 Motor paralysis, 405-406 653

Motor recovery (see also under each nerve, and British classification of motor recovery) assessment of, 72-76, 203-220, 579-580 British classification of, 113-121 case histories, 409-498 effect of adverse factors, 198-201 age at injury, 106 associated injuries and complications, 123-138 bone resection, 166 bulb suture, 164-167 calendar date of suture, 157 cuff removal, 187-189 cuff, use of, 180-185 days from injury to suture, 139, 142-157 echelon of repair, 148-150, 157-158 fascicle opposition, 530, 538 infection, 127-128, 130, 134-135 length of surgical gap, 150, 154, 157-161 management, 101-106, 141 mobilization of nerve, 159, 162-163 multiple lesions, 119-121 nerve ends, 167-170 neurolysis, 93-94, 95, 101-105, 190, 192-193 number of operations, 138-141 plastic repair, 134-138 site of lesion, 87, 91-99, 119-120, 199-200 stay sutures, 185-186, 190 suture line tension, 170-173 suture material used, 174-179 training of surgeon, 191, 194-196 transposition, 159, 162-163 type of lesion, 95, 100-106, 148, 150 electrodiagnosis, 203-240, 581-582, 584-586 follow-up data on, 76-201, 220-240 groups of muscles, 106-122 individual muscles, 73-106 neuropathologic forecasts and, 501-509, 559-563 relation to autonomic recovery, 346 functional recovery, 368-370, 373-374 painful phenomena, 339-340 sensory recovery, 370-374 spontaneous, 397 tendon transfers and, 404—405 variation in, 77-123 654

Multiple lesions, 18, 32-33, 119, 121, 447 Multiple operations (see operation for nerve injury) Muscle (see also motor recovery and under individual nerves) atrophy, 74, 228-229 choice for study, 72-73 denervation, 231-233, 235-240 electrodiagnosis, 203-240, 581-582, 584-586 examination of, 72-76, 574-576, 579-580 number contracting, 109-112 pathologic forecasts, 501-509, 559-563 relation of one to another, 109-112 voluntary movement classification of, 73-74 psychological factors and, 220-221, 235-240 relation to results of electrodiagnosis, 220-240 strength of, 73-74, 77-113, 120-122 Musculocutaneous nerve injury, 332-333, 576 Nerve ends (see also neuropathologic forecasts) gross evaluation of, 51 relation to automatic recovery, 345 motor recovery, 167-170 sensory recovery, 300-301 Nerve injury (see also individual nerves and recovery categories) associated injuries and complications, 35-40, 626-629 classification of, 34-35 combined, 32-34 diagnosis of, 203-220, 569, 576 division, complete and partial, 2, 35 exploration of, 571-574, 576-589, 622-623 gross evaluation of nerve ends, 167-170 hospitalization for, 62-68, 630 incidence of, 5-6, 573-574 length of defect (see also surgical gap), 47 management of, 40-62, 401-404, 569-630 multiple, 32-34, 119, 121 neuroma in continuity, 35, 588-623 organization of medical care, 43-45, 623-629 pathological evaluation, 170, 499-547 sample studied, 5-13, 31-36 site of, 36 time and wound policy, 624-625

Neuroloysis (see also neuroma in continuity) brachial plexus injury, 396-397, 399-401 compared with suture, 101-106, 112-114, 118-119, 260-265, 343-344 355-357, 396-397 defined, 40 followed by suture, 54, 61 recovery following autonomic, 343-344 functional, 355-357 motor, 93-94, 101-106, 112, 118-119 sensory, 260-265 sampling considerations, 5-13 technique of, 190-193 treatment for causalgia, 328 Neuroma in continuity causalgia and, 328 denned, 35 evaluation of, 586, 622-623 frequency in sample, 34 management of, 95, 100-101, 588-622 Neuropathologic forecasts cases studied, 500-511, 513-539 correlation with follow-up data, 501-509, 547-565 composite index of nerve regeneration, 563-567 functional recovery, 563-564 motor recovery, 559-563 pain response, 548-551, 553 skin resistance, 552, 557-559 technique of, 539-541 touch response, 548, 552, 554-556 limitations of, 499-500, 538-539, 565-567 methodology of, 512-539 relation to length of surgical gap, 546-547 other indices and measurements, 501-509 temporal factors, 544-546 sampling considerations, 500 source of material, 499-500 variation in, 541-547 Neuropraxia and traumatic aneurysm, 403 Neurorrhaphy (see suture) Occupational adjustment classification, 353 functional recovery, relation to, 349-387 nerve injury, effect of, 354 636

Occupational change directional shift, 378 handedness in median nerve lesion, 377-378 lower extremity, 379-381 nerve injury, effect of, 377-382 upper extremity, 379 Occupational handicap classification, 354 nerve injury, effect of, 382-383 occupational category, by nerve, 383-384 overall functional evaluation, compared with, 382 Operation for nerve injury (see also neurolysis, suture, and categories of recovery) approximation suture, 40 bulb suture, 40 classification of, 40 cuff removal as, 40 definitive, 13, 40-41 exploration as, 40 multiple, 40, 138-141, 286-288, 345 number of, effect on motor recovery, 138-140 painful phenomena, 338-339 sensory recovery, 286-287 reoperation, 53-61 surgical policy governing, 570-622 time factor, 154, 588-622, 625-626 transposition as, 40 Opponens pollicis, recovery factors involved (see also median nerve), 635 Orthopedic measures (see also arthrodesis, capsulotomy, tendon transfer), xxii, 51-52, 125-127, 394, 571, 626-627 Overresponse, 335-340 Pain response (see aho sensory recovery, and under individual nerves) algesiometer, 243 assessment of, 243-244 autonomous zone, 242-243, 250-251 center variation in, 244, 250 effect of associated lesions, 278-286 characteristics of nerve injury, 266-278 technical aspects of management, 286-308 evidence of regeneration, 580 follow-up data on, 251-252, 260-262 neurolysis and suture compared, 260-262 neuropathologic forecast and, 501-509, 548-551 403930—57 44 657

Pain response—Continued relation to localization, 254-255 touch response, 244-245, 254-255 role in British classification of sensory recovery, 247-248, 257-259 Painful phenomena (see also causalgia), 335-340 Paralysis, 400 Paresthesia, 338 Partial suture (see suture) Peroneal nerve injury ancillary operative procedures, 50 associated lesions and complications arterial, 38 bone and joint, 126, 280 infection, 129 other nerves, 33, 343 plastic repair, 134-135, 137, 285-286 autonomic recovery, 343-344, 633 braces, 361 British summary, motor recovery, 113-121 British summary, sensory recovery, 256 case histories, 47-460, 598-599 causalgia, 324-327 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 effect of bone and joint injury, 125-127, 279-281 bulb suture, 165, 167, 300 character of nerve ends, 169, 300 chronic infection, 129, 282-284 cuff, 182-186, 189, 304-307 days from injury to definitive suture, 145-149, 290-294 days from injury to first suture, 152-153, 155 echelon of repair, 158, 295-296 extensive mobilization and transposition, 163, 298 external or internal lysis, 193 length of surgical gap, 48-49, 160-161, 297 lysis, 119, 261, 263 multiple lesions, 121 number of operations, 140, 287 plastic repair, 137-138, 286 site of lesion, 92, 94, 98, 270-271, 273, 276 stay suture, 190 training of surgeon, 195, 308 suture and lysis, compared, 103, 262 suture line tension, 172, 301 658

Peroneal nerve injury—Continued effect of—Continued suture material, 177, 302 type of lesion, 101, 267-268 type of surgery, 107, 122, 264-265 frequency of, 33 functional recovery, 357-364, 370-374, 633 hospitalization, length of, 65-68 management of (see also management of nerve injury), 40-62, 598-599, 631 motor recovery, 77-123, 235-240, 372-374, 631-634 muscles studied, 73 neuropathologic forecasts, 499, flf. occupational change, 377-382 occupational handicap, 382-383 pain response, 251-252, 633 painful phenomena, 324-327 sensory recovery, 251-266, 372-374, 631-634 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-253, 633 VA disability ratings, 375-377 Peroneus longus (see peroneal, sciatic, peroneal nerves) Physiologic appraisal of nerve regeneration, 598-600 Physiotherapy, 74, 399-400 plasma glue suture (see suture material) Plastic repair case histories, 409-498 effect on autonomic recovery, 344 days from injury to nerve suture, 53 motor recovery, 134-138, 149 painful phenomena, 337 sensory recovery, 285-286 frequency of, 39 Position sense, 245-246 Procaine block, 322, 326, 335 Prosthesis, 394 Psychological block to voluntary contraction, 236 Radial nerve injury ancillary operative procedures, 50 associated lesions and complications arterial, 38 bone and joint, 126-127 659

Radial nerve injury—Continued associated lesions and complications—Continued infection, 129 other nerves, 33 autonomic recovery, 343, 637 British summary, motor recovery, 114-120 British summary, sensory recovery, 254-259 case histories, 386, 436-446 causalgia, 319-323, 333-334 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 effect of arterial injury, 133-134, 285 bone and joint injury, 126-127, 279-281 bulb suture, 165, 167, 300 character of nerve ends, 169 chronic infection, 128, 282-284 cuff, 182, 184, 186, 188, 304-307 days from injury to definitive suture, 134, 139, 144-151, 178, 289- 294 days from injury to first suture, 152, 155 echelon of repair, 158 extensive mobilization and transposition, 163, 298 external or internal lysis, 192 length of surgical gap, 48-49, 160-161, 297 lysis, 119, 261, 263 multiple lesions, 121 number of operations, 140, 178, 287 site of lesion, 97, 120, 269, 272* 275 stay suture, 190, 307 suture line tension, 172 suture material, 176, 178-179 suture or lysis, 103, 262 training of surgeon, 195 type of lesion, 113-114, 267-268 type of surgery, 107, 122, 264-265 frequency of, 33 functional recovery, 351-352, 355-359, 368-374, 637 hospitalization, length of, 65-68 localization, 254 management of (see also management of nerve injury), 40-62, 637 motor recovery, 77-123, 235-240, 368-370, 373-374, 637 muscles studied, 73 neuropathologic forecasts, 499, ff. occupational change, 377-382 occupational handicap, 382-383 660

Radial nerve injury—Continued pain response, 251-252, 637 painful phenomena, 324-327, 333-334, 338 sensory recovery, 251-266, 370-374, 637 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-254, 637 Regeneration (see also under individual nerves, and individual categories of recovery) anatomic vs. functional, xxi, xxii, 220-240, 588 case histories, 409-498 determination of, 576-586 factors influencing, 19, 31, 41, 446-447, 497-500, 540, 566-567 failure of, 60-61, 227-229, 235-240, 586-588 final level of, 576-577, 630-637 indices of, 539, 563-564, 576-586 neuropathologic forecasts of, 499 ff. spontaneous, 390, 397, 399-400, 497^98, 573, 577-578, 588, 603, 616, 622 Registry of Army cases, 2, 6-13 Rehabilitation (see also orthopedic measures, physiotherapy), 394, 406-407 Rheobase, 208 Sampling considerations allocations to follow-up centers, 10, 12 bias from incomplete follow-up, 22-28 criteria of eligibility, 11 geographical factors, 7-8 men in military service, 8-9 nerves involved, 5-6, 12-13 neurolysis, 7, 9 objectives of study, 5 size of sample, 12-13 source of cases, 5-7, 12 suture, 5-6, 9 test of Army Registry, 10-11 VA compensation study, 375-376 Sciatic nerve injury (see also sciatic-peroneal and sciatic-tibial) complete autonomic recovery, 342-344 braces, 361 case histories, 385, 473-496 defined, 124 functional recovery, 355-368 motor recovery, 124-125 Ml

Sciatic nerve injury—Continued complete—Continued occupational change, 380—382 occupational handicap, 382—383 component trunks considered separately, 12-13 Sciatic-peroneal injury ancillary operative procedures, 50 associated lesions and complications arterial, 38 bone and joint, 126 infection, 129 other nerves (see sciatic nerve injury) autonomic recovery, 343-344, 632 British summary, motor recovery, 113-121 British summary, sensory recovery, 256 case histories, 487-496, 589-591 causalgia, 324-327 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 effect of bone and joint injury, 125-127, 279-381 bulb suture, 165, 167, 300 character of nerve ends, 169 chronic infection, 129, 282-284 cuff, 183-186, 189, 304-307 days from injury to definitive suture, 145, 290, 292-294 days from injury to first suture, 153, 155 echelon of repair, 158 extensive mobilization and transposition, 163, 298 external or internal lysis, 193 length of surgical gap, 48-49, 160-161, 297 lysis, 119, 261, 263-264 multiple lesions, 121 number of operations, 140 other nerve injuries, 124—125 site of lesion, 98, 273, 632 stay suture, 190 suture line tension, 173 suture material, 177 suture or lysis, 103, 262 training of surgeon, 195 type of lesion, 101, 108, 113-114, 267-268 type of surgery, 107, 122, 264-265 frequency of, 33 functional recovery (see complete sciatic nerve injury) hospitalization. length of, 65-68

Sciatic-peroneal injury—Continued management of (see also management of nerve injury), 40-62, 589-591, 631 motor recovery, 77-123, 235-240, 372-374, 632 muscles studied, 73 neuropathologic forecasts, 499 ff. occupation (see complete sciatic nerve injury) pain response, 251-252, 632 painful phenomena, 324-327 sensory recovery, 251-266, 372-374, 632 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-253, 632 Sciatic-tibial injury ancillary operative procedures, 50 associated lesions and complications arterial, 38 bone and joint, 126 infection, 129 other nerves (see sciatic nerve injury) autonomic recovery, 343-344, 632 British summary, motor recovery, 113-121 British summary, sensory recovery, 256 case histories, 473-487 causalgia, 324-327 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 effect of bone and joint injury, 125-127, 279-281 bulb suture, 165, 167, 300 character of nerve ends, 169 chronic infection, 129, 282-284 cuff, 183-184, 186, 189, 304-307 days from injury to definitive suture, 146-147, 290-294 days from injury to first suture, 153, 155 echelon of suture, 158 extensive mobilization and transposition, 163, 298 external or internal lysis, 193 length of surgical gap, 48-49, 160-161, 297 lysis, 119, 261, 263-264 number of operations, 140 other nerve injuries, 124-125 site of lesion, 98-99, 273-274, 632 stay suture, 190 663

Sciatic-tibial injury—Continued effect of—Continued suture line tension, 173 suture material, 177 suture or lysis, 103, 262 training of surgeon, 195 type of lesion, 101, 108, 113-114, 267-268 type of surgery, 107, 122, 264-265 frequency of, 33 functional recovery (see complete sciatic nerve injury) hospitalization, length of, 65-68 management of (see also management of nerve injury), 40-62, 631 motor recovery, 77-123, 235-240, 372-374, 632 muscles studied, 73 neuropathologic forecasts, 499 ff. Occupation (see complete sciatic nerve injury) pain response, 251-252, 632 painful phenomena, 324-327 sensory recovery, 251-266, 372-374, 632 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-253, 632 Sciatic-tibial and sciatic peroneal nerves, combined, 299 Sensory recovery (see also under each nerve, individual sensory modalities, and British classification of sensory recovery) assessment of, 242-250, 256-259 British classification of, 247-248, 256-259 case histories, 409-498 effect of anatomic completeness of lesion, 266-268 associated arterial injury, 284-285 associated bone or joint injury, 279, 281 associated injuries, 278-286 associated nerve injury, 278-279 bulb suture, 299-300 character of nerve ends, 300 characteristics of nerve injury, 251, 266-278 cuff, 303-306 chronic infection delaying repair, 281, 284 days from injury to definitive suture, 288-294 echelon of definitive repair, 296 extensive mobilization and transposition, 297-299 length of surgical gap, 295-297 matching of proximal and distal fascicles, 516, 526-527, 538 multiple lesions, 276-278 664

Sensory recovery—Continued effect of—Continued neurolysis, 260-266 number of operations, 286-288 plastic repair, 285-286 site of lesion, 268-275 stay suture, 306-307 suture line tension, 301 suture material, 301-303 training of surgeon, 308 type of lesion, 267-268 type of surgery, 251-260, 265 follow-up data on, 251-265 neuropathologic forecasts and, 501-509, 547-552 relation to autonomic recovery, 346 functional recovery, 370-374 motor recovery, 242, 370-374 painful phenomena, 340 Shoulder (see also upper extremity), 36-37 Site of lesion associated injuries and, 35-39 classification of, 35-36 distribution of nerve injuries by, 36 effect on autonomic recovery, 344 motor recovery, 87, 91-99, 112-114, 119-120 recovery generally, 446, 497 sensory recovery, 268-276 Skin resistance autonomous zone and, 343 effect of characteristics of injury, 344-345 technical aspects of management, 345-346 elevated at follow-up, 343-344 index to autonomic function, 341-342, 347 neuropathologic forecasts and, 501-509, 552-559 relation to autonomic complaints, 346-347 loss of sweating, 346 motor recovery, 346 sensory recovery, 346 Soft tissue defect (see also plastic repair), 401, 629 Splinting, continuous or intermittent, 571 SR (see skin resistance) Statistical analysis, 4, 28, 198, 512-513 665

Stay suture effect on autonomic recovery, 345 motor recovery, 190 sensory recovery, 306-307 frequency of, 50 Stimulation of nerve aid to prognosis, 401, 581-582 follow-up data on, 220-240 methodology of, 204-207 relation to chronaxie, 220-234 electromyography, 233-235 voluntary movement, 220-240 Strength of movement, affected muscles (see motor recovery and under individual nerves) Surgery (see operation for nerve injury, orthopedic measures, surgical procedures, ancillary) Surgical gap, length of associated with bulb suture, 166 cuff used, 180 days from injury to suture, 150-154, 546 neuropathologic forecast of regeneration, 539-540, 546-547 other indices and measurements, 501-509 effect on functional regeneration, 497 motor recovery, 154, 157, 159, 161, 626 recovery generally, 447, 497 sensory recovery, 295-297 factors involved, 47-49 frequency, 47 Surgical procedures, ancillary, 48-50, 587-588 Suture (see also operation for nerve injury) compared with neurolysis, 101-106, 118-122, 260-265 following graft, 61 neurolysis, 61 partial suture, 61 partial and complete compared, 105-106 reasons for failure, 55-57 recovery following autonomic, 342, 344 functional, 354-374 motor, 77-100, 106-118, 235-240, 368-370 sensory, 251-259, 370-374 666

Suture—Continued reoperation following first, 54-60 Suture line tension, 50, 170-171, 301, 447, 497 Suture material effect on motor recovery, 174-175, 197 recovery generally, 447, 497 sensory recovery, 301-303 tantalum, silk, and plasma glue, compared, 174,178,197, 301-303, 345 Sweating excessive, as complaint, 341, 346-347 loss of as complaint, 341, 346 objective, 342-344, 346, 581 Sympathectomy, 51-52, 316, 318-320, 323-325, 334 Tantalum cuff effect on autonomic recovery, 345 motor recovery, 180-184 sensory recovery, 303-307 factors influencing use, 180 frequency of, 50 removal, 48-50, 62, 180, 184, 187 Tantalum suture, silk, and plasma glue, compared, 174, 178, 197, 301-303, 345 Temperature sensitivity and autonomic recovery, 341, 346 Tendon transfer, 48-52, 391-394, 404-407 Tetanus ratio (see galvanic tetanus ratio) Thigh (see also lower extremity) nerve lesions, frequency of, 36-37 Thumb opposition, factor in functional recovery, 635 Tibial nerve injury ancillary operative procedures, 50 associated lesions and complications arterial, 38 bone and joint, 126 infection, 129 other nerves, 33 autonomic recovery, 343-344, 633 British summary, motor recovery, 113-121 British summary, sensory recovery, 256 case histories, 460-473 causalgia, 324-327 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 447

Tibial nerve injury—Continued effect of bone and joint injury, 125-126 bulb suture, 300 character of nerve ends, 169, 300 cronic infection, 129, 282-284 cuff, 183-184, 186, 189, 304-307, 551 days from injury to definitive suture, 146, 290, 292-294, 536-537, 551 days from injury to first suture, 153, 155 echelon of repair, 295-296 extensive mobilization and transposition, 163, 298 length of surgical gap, 48-49, 160, 297 lysis, 119,261, 263-264 multiple lesions, 121 number of operations, 287 plastic repair, 286 site of lesion, 91, 94, 99, 269-271, 273, 276 suture line tension, 173 suture material, 177, 302 suture or lysis, 104, 262 training of surgeon, 195, 308 type of lesion, 101, 113-114, 125, 267-268 type of surgery, 122, 264-265 frequency of, 33 functional recovery, 357, 361-365, 368-374 hospitalization, length of, 65-68 management of (see also management of nerve injury), 40-62, 631 motor recovery, 77-123, 235-240, 368-370, 372-374, 633 muscles studied, 73 neuropathologic forecasts, 499 ff. occupational change, 377-382 occupational handicap, 382-383 pain response, 251-252, 633 painful phenomena, 324-327 sensory recovery, 251-266, 370-374, 633 skin resistance, 343-344 sweating, loss of, 343-344 tetanus ratio, 214 touch response, 252-253, 633 Tibialis anticus (see pereoneal and sciatic-peroneal) Tibialis posticus (see tibial and sciatic-tibial) Time from injury to repair (see also days from injury to suture), 398-399, 625-629 Time interval after suture, 545 Time limitations, and rehabilitation, 498 668

Tinel's sign, relation to regeneration, 583 Touch response (see also sensory recovery, and under individual nerves) assessment of, 244-245 autonomous zone, 242-243, 250-251 center variation in, 244-245, 250 effect of associated lesions, 278-286 characteristics of nerve injury, 266-278 technical aspects of management, 286-308 follow-up data on, 252-254, 262-263 neurolysis and suture, compared, 262-263 neuropathologic forecast and, 548, 552, 554-556 relation to localization, 247, 254-255 pain response, 245, 254-255 role in British classification of sensory recovery, 247-248, 257-259 von Frey hairs, 244 TR (see galvanic tetanus ratio) Training of neurosurgeon effect on autonomic recovery, 345 motor recovery, 191, 194 sensory recovery, 308 Transposition of nerve autonomic recovery, 345 frequency of, by nerve, 45-47 motor recovery, 159, 162-163 sensory recovery, 297-299 Triceps (see radial nerve) Ulnar nerve injury ancillary operative procedures, 49-50 associated lesions and complications arterial, 37-38 bone and joint, 125-127 infection, 127-130 other nerves, 33 plastic repair, 134-137 autonomic recovery, 342-344, 636 British summary, motor recovery, 113-121 British summary, sensory recovery, 254-259 case histories, 387, 424-436, 591-608, 610-620 causalgia, 319-323, 330-334 diagnosis of, 570, 575 disposition to duty, 62-63, 384-387 669

Ulnar nerve injury—Continued effect of adverse factors, 198 associated arterial injury, 132-133, 285 bone and joint injury, 125-127, 279-281 bulb suture, 164, 167, 300 character of nerve ends, 168, 300 chronic infection, 128, 282-284 cuff, 181, 184-185, 188, 304-307, 551 days from injury to definitive suture, 143, 147-150, 178, 291-294, 534-535, 551 days from injury to first suture, 151-152, 155 echelon of repair, 158, 295-296 external or internal lysis, 192 extensive mobilization and transposition, 162, 298, 556 length of surgical gap, 48-49, 160-161, 297, 555 lysis, 119, 261-264 multiple lesions, 121 number of operations, 140, 287 plastic repair, 136-138, 286 site of lesion, 91-97, 119-122, 201, 269-275, 366-367, 550-556, 561, 636 stay suture, 190, 307, 555 suture line tension, 171, 301 suture material, 174-179, 302-303 suture and lysis, compared, 102, 262 training of surgeon, 194, 308 type of lesion, 100, 108, 113-114, 267-268 type of surgery, 118, 122, 264-265 frequency of, 33 functional recovery, 352, 356-357, 360, 363, 366-374, 387, 635-637 hospitalization, length of, 65-68 localization, 255 management of (see also management of nerve injury), 40-62, 591-608, 610-620, 635-636 motor recovery, 77-123, 199-200, 235-240, 368-370, 372-374, 636 muscles studied, 73 neuropathologic forecasts, 499 ff. occupational change, 377-382 occupational handicap, 382-384 pain response, 251-252, 636 painful phenomena, 319-323, 330-338 sensory recovery, 251-266, 370-374, 636 skin resistance, 343-344 sweating, loss of, 343-344 670

Ulnar nerve injury—Continued tetanus ratio, 214 touch response, 252-254, 636 Upper extremity (see also individual nerves) amputation, 48, 355 anatomical and functional regeneration, 634-638 associated injuries and complications, 32-39, 285, 366-367, 446-447 case histories, 411—446 causalgia, 318-323 combined lesions, 352, 363, 366-368 frequency of nerve lesions, 36-37 functional recovery, 354-374 occupational change, 379-381 wound management concept, 625-626 Veterans Administration ratings of disability, 27, 375-377 Voluntary movement (see also motor recovery and under individual nerves) as evidence of regeneration, 71-72, 74, 220-221 grading of, 73 psychological block to, 235-240 technique of examination, 72—74 Wound management concept, 625-629 Wrist (see also upper extremity) nerve lesions, frequency of, 36-37 U. ». GOVcRNMENt rBIKIINC OFFICE: 1117 671

595 .W6 Peripheral nerve regeneration