Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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The Injury and Its Management
The Injury and Its Management
Pages 31-70
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From page 31... ...
Since the abstracting of service medical records necessarily extended to all active treatment received in military hospitals, the pattern of surgical management reveals important information on such points as the probability of reoperation and the practice of cuff removal. In the belief that they provide rough measures of the cost of peripheral nerve injuries to the Armed Forces, duration in hospital and disposition were also abstracted and the resulting data appear in this chapter.
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From page 32... ...
In tables 10, 11, and 12 the sample is described in terms of the nerve involved, the presence of associated nerve injury to the same limb, and the number of lesions in the same nerve. As has been noted in previous studies, and despite the effort made in this study to secure adequate samples of the less frequently injured nerves, upper extremity nerve injuries were twice as numerous as lower extremity injuries.
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From page 33... ...
380 37.7 100.0 Grand total 3,656 100.0 Table 11. -- Associated Nerve Lesions * on the Same Limb, by Nerve Total lesions Percentage with other nerve lesions, same limb Nerve Median 707 58.0 Radial 516 32.8 Ulnar .
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From page 34... ...
When the multiplicity of peripheral nerves injured in the same extremity was analysed in terms of various aspects of the clinical history, the following conclusions emerged: A high injury in the arm more often involved other nerves than a low injury, and the same phenomenon was present in the lower extremity; strangely enough, the more nerves injured in a limb, the less likely was concomitant bone or joint injury; there was a tendency for infection to be more common in the presence of multiple nerve injuries; associated vascular injuries were rare in the lower extremity but they were common in the upper extremity and were strongly associated with the presence of additional nerve injuries; for the radial nerve, there was a marked tendency for a major plastic surgical procedure to be associated with other nerve injuries. In table 13 appears the summary classification adopted for the type of injury to the nerve, as well as the frequency with which each type was found in the entire sample.
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From page 35... ...
The classification as to specific site is exhibited in table 14. Like those of table 10, and despite the sampling plan, these data reflect the concentration of nerve injuries in the upper extremity and demonstrate once more the higher percentage of wounds in that part of the extremity adjacent to the trunk.
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From page 36... ...
The probability was low for injuries above the elbow and in the upper two-thirds of the thigh, and high for injuries below these points. Also, if a bone or joint injury were incurred its chance of normal healing varied significantly in relation to site of injury in the upper extremity.
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From page 37... ...
Table 15. -- Percentage of Nerve Injuries With Associated Bone or Joint Injury, and Percentage of Bone or Joint Injuries in Which Normal Healing Occurred, by Site of Injury and Part of Body Site of nerve injury Percentage of nerve lesions with bone or joint injury Percentage of bone or joint injuries with normal healing Upper extremity Shoulder, arm upper third Arm, middle third Ann, lower third Forearm, upper third Forearm, middle third Forearm, lower third Elbow Wrist, hand All sites Lower extremity Thigh* upper third Thigh, middle third Thigh, lower third Leg, upper third Leg, middle third Leg, lower third Knee Ankle, foot All ?
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From page 38... ...
Among injuries in the upper extremity, plastic repair was more common in the forearm than in the arm. A parallel situation existed among injuries to the lower extremity (table 18)
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From page 39... ...
1 14.2 20 5 Elbow 14.7 All sites 8 8 Wrist, hand 14.4 All sites ... 11 8 Table 19. -- Associated Bone or Joint Injury and Infection, by Agent of Injury, All Peripheral Nerve Lesions Combined Percentage of nerve lesions with associated bone or joint injury Percentage of nerve lesions with associated infection Agent Combat gunshot wounds 41.5 9.3 Noncombat gunshot wounds 47.0 2.
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From page 40... ...
A cuff removal following a suture or graft is not classified as a definitive operation; a suture done after an unsuccessful graft is, however, classified as a definitive operation. In the analysis of the effect of number of operations upon nerve regeneration, bulb suture was not counted as a separate operation but considered to be the first stage of an anticipated definitive suture, but explorations, transpositions, and other operations following more definitive procedures were counted.
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From page 41... ...
5. Groups A and C do not differ as to special operative features.
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From page 42... ...
... 7 5 Radial 15.9 Sciatic-tibial 23 3 Ulnar 22 9 Peroneal 28.9 All 21.2 Sciatic-peroneal 22.4 For the entire series as a whole, table 23 indicates the time interval from injury to definitive operation, as this procedure has already been denned.
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From page 43... ...
Table 23. -- Interval From Injury to Definitive Operation, Total Sample * Interval, in days Nerve lesions Interval, in days Nerve lesions Number Percent Number Percent Under 10 100 44 252 381 495 488 382 313 212 188 116 150 2.9 1.3 7.4 11.2 14.5 14.3 11.2 9.2 6.2 5.5 3.4 4.4 360-419 90 60 40 41 20 9 11 8 4 11 2.6 1.8 1.2 1.2 0.6 0.3 0.3 0.2 0.1 0.3 10-29 420-479 30-59 480-539 60-89 540-599 90-119 600-659 120-149 660-719 150-179 720-779 180-209 780-839 210-239 840-899 240-269 270-299 300-359 Total 3,415 100.1 1 One case excluded for unknown date of definitive repair, others^ for lack of any definitive operation.
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From page 44... ...
When the definitive operations were classified in this way it was of interest to observe that 44.4 percent had been done by trained neurosurgeons, 33.4 percent by general surgeons with supplementary training in neurosurgery, 0.4 percent by surgeons with essentially no training in neurosurgery and 21.8 percent by surgeons whose training was unknown. Many of the last group, of course, may have had considerable wartime experience in the surgery of peripheral nerve lesions.
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From page 45... ...
The 11 operations in the "other" category of table 25 represent reroutings, intrafascicular sutures, etc. Table 25. -- Type of Definitive Operation, Total Sample l Nerve lesions Number Percent 213 6.2 Complete suture 2,556 74.8 605 17.7 Graft 30 0.9 Other 11 0.3 Total 3,415 99.9 1 Excluding one case in which the record was unclear as to type of definitive operation, and lesions not operated upon.
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From page 46... ...
of further review. The special operative features of transposition and extensive mobilization showed a great deal of variation among individual nerves (table 27)
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From page 47... ...
Length of surgical defect is quite reliably associated with specific type of injury and the gross anatomical location of nerves. In general, complete nerve divisions were followed by longer surgical defects and, among individual nerves, injuries of the sciatic nerve gave rise to longer surgical defects (table 29)
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From page 48... ...
and the length of the surgical defect overcome at the definitive operation, these conclusions were reached: 1. Bulb suture is associated with a gap 2 to 3 times that observed in cases with no special operative procedures, as noted in table 30.
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From page 49... ...
Table 30. -- Mean Length of Gap in Relation to Special Operative Features, by Nave and Type of Injury, Completely Divided Nerves Treated by Suture or Graft Special operative features Nerve None Bulb suture Transpositionmobilization Number of lesions Mean gap Number of lesions Mean gaP Number of lesions Mean gap em.
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From page 50... ...
done with tantalum wire; in addition 5 percent were performed according to the plasma glue technique, and in 24 percent other materials, mainly silk, were used. Table 32. -- Relevant Operative Procedures Other Than Nerve Repair Performed Prior to Separation From Service, Lesions Treated by Suture or Graft Only, by Nerve Nerve Total lesions Percentage of lesions associated with stated procedures Tendon transplant Amputation Capsulotomy ArSympathectomy Cuff None throdesis removal Radial 518 395 73.4 78.7 80.9 86.4 84.1 86.7 86.6 13.7 14.7 5.9 8.4 1.5 0.6 0 0.4 0.3 0.6 0 0 0 0 3.1 0.8 2.1 0 0 1.7 0.4 5.2 1.5 2.7 3.5 1.2 0.6 1.1 2.5 1.3 1.7 1.0 3.1 5.6 3.6 8.9 6.8 10.0 3.5 11.0 5.6 8.7 Ulnar 780 287 327 180 277 Sciatic-peroneal.
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From page 51... ...
Associated bone and joint injury was studied in relation to two features of the definitive operation, i. e., days from injury and other operative procedures.
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From page 52... ...
Table 34. -- -Mean Days From Injury to Definitive Suture, by Presence of Associated Bone or Joint Injury, by Nerve, and by Type of Injury, Complete Sutures Only Complete nerve divisions, by presence of associated bone or joint injury Neuromas in continuity, by presence of associated bone or joint injury Nerve sutured Absent Present Absent Present Mean days Ulnar 191 153 116 218 184 160 165 236 198 135 152 101 190 145 138 135 170 287 179 193 208 196 150 Radial 200 221 260 272 261 Peroneal Tibial Sciat ic-peroneal Sciatic-tibial All nerves 168 220 143 192 The interval from injury to operation and the need for ancillary surgical procedures were also studied in relation to chronic infection. A quite considerable delay was found to be associated with chronic infection, amounting to 3 to 4 months on the average (table 35)
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From page 53... ...
Toble 35. -- Mean Days From Injury to Definitive Operation, by Chronic Infection Deferring Definitive Operation, by Nature of Nerve Operation, and by Type of Injury Chronic infection Nature of nerve operation and type of injury to nerve Present Absent Mean days Complete suture: Complete division 281 256 270 181 161 154 Other Lysis : Normal appearing nerve Table 36. -- Mean Days From Injury to Definitive Operation, by Presence of Soft Tissue Defect, Type of Operation, and Type of Injury Nature of nerve operation and type of injury to nerve Present Absent Mean days Complete future: Complete division 247 188 168 184 163 166 Other Lysis : Normal appearing nerve .
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From page 54... ...
The same suggestion is present in the material on associated bone and joint injury. Associated arterial injury and major plastic repair at the site of nerve injury have no influence upon the possibility of resuture.
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From page 55... ...
238 10.1 Tibial 154 3.9 Table 38. -- Chance of Resuture and Type of Injury, Lesions With First Operation Complete Suture, by Nerve Type of injury Nerve Severance Incomplete Number cases Percentage resutured Number cases Percentage resutured 303 520 271 151 103 205 156 9.9 9.8 5.9 23.8 1.9 10.2 12.2 109 175 88 81 51 101 82 1.8 Ulnar 5.7 4.5 16.0 7.8 8.9 6.1 Radial Peroneal Tibial •Sciatic-tibia! It was also found that initial sutures performed overseas were rcoperated upon about five times as often as those done in the Zone of Interior (table 39)
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From page 56... ...
-80 60401 • 60 40 ...p -j ••;.-•" - 20 PERCENTAGE PERCENTAGE RESUTURED inn RESUTURED 1 ULNAR*
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From page 57... ...
Table 39. -- Chance of Resuture and Echelon of First Suture, Lesions With First Operation Complete Suture, by Nerve Nerve Overseas Zone of Interior Number cases Percentage resutured Number cases Percentage resutured \frHian .
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From page 58... ...
The 81 failures may be described in terms of this classification as follows: Reason for obvious failure Cases Tension, with separation of suture-line 24 Scar tissue or neuroma formed at site of suture-line 53 Separation of suture-line and neuroma 2 Unknown 2 Total 81 In view of the often-repeated assertion that many Z/I surgeons preferred to explore every peripheral nerve lesion, whether or not sutured overseas, and the possible implication that the overseas sutures were more often resutured in the Z/I merely because of excessive zeal on the part of Z/I surgeons, the senior author (BW) reviewed the original records on median and high ulnar lesions with this possibility in mind.
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From page 59... ...
Among all the nerves there were 142 cases of bulb suture followed by definitive suture, with only 12 resutures or 8.5 percent. For a set of cases matched as to nerve, but having no special operative features of any kind*
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From page 60... ...
In the lower extremity there was frequently Xray or clinical evidence of no recovery. In the upper extremity X-ray evidence was rare; resuture was more often undertaken because recovery seemed poor.
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From page 61... ...
These studies show, for the sample of initial lyses used here, that a subsequent suture was done in 6.2 percent and a subsequent lysis, exploration, or cuff removal in 11.8 percent. The sampling plan for the present study, with its major emphasis upon definitive suture, and secondary emphasis upon definitive lysis, is a poor basis for estimating the chance that an initial lysis might suffice and be followed by additional surgery of one kind or another.
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From page 62... ...
c. Associated bone and joint injury.
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From page 63... ...
Analysis of the resulting observations has been directed chiefly at establishing any important differentials among the major nerves and assessing the relative influence of associated injuries of various kinds upon the time spent in hospital. On the average the men in this series, largely one of sutured nerve lesions, spent 523 days in service hospitals in contrast to about 54 days for Army wounded generally in World War II (4)
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From page 65... ...
Table 44. -- Median Days in Military Hospital, Men With Complete Sutures in the Representative Sample, by Nerve Nerve Median Nerve Median days days 541 Tibial 471 Ulnar 504 620 Radial 498 615 Peroneal . 558 All nerves 533 Associated nerve injuries were also studied for their possible effect upon duration of stay in hospital, but only in the median was significant evidence seen.
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From page 66... ...
Table 45. -- Duration of Hospitalization and Associated Injuries, Pure Nerve Lesions of the Upper Extremity Treated by Complete Suture Percentage distribution by days in hospital Type of associated injury Number of cases Less than 400 400-599 600 or more Total Median None .• 47.6 37.8 14.6 100.0 82 Bone only, with normal healing 36.5 44.4 19.0 99.9 63 41.7 54.2 4.2 100.1 24 Other l 15.3 32.2 52.5 100.0 59 Total 35.5 39.9 24.6 100.0 228 Ulnar None 27.7 50.5 21.7 99.9 184 30.3 48.7 21.1 100.1 152 53.1 37.5 9.4 100.0 32 Other * 26.5 49.0 24.5 100.0 102 Total 30.0 48.7 21.3 100.0 470 Radial 42.5 40.2 17.2 99.9 87 Bone only, with normal healing 23.9 54.9 21.2 100.0 113 Arterial only 100.0 0 0 100.0 2 Other1 12.9 45.9 41.2 100.0 85 Total 26.8 47.4 25.8 100.0 287 1 Bone with abnormal healing, or chronic infection, or plastic repair at site of nerve injury, or combinations of any of these with bone injuries healing normally or with arterial injury.
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From page 67... ...
1 17.7 Total 100.0 100.1 Number of cases 82 62 1 Involving ulnar, radial, axillary, or inusculocutancons. Table 47. -- Days in Hospital for Men With Uncomplicated Nerve Lesions 1 Treated by Complete Suture, Nerves of the Upper Extremity Days in hospital Median Ulnar Radial Total Less than 300 Percent 6.9 Percent 4.6 Percent 12.5 Percent 6.8 300-399 28 5 19 2 28.
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From page 68... ...
B 8 9 it f)
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From page 69... ...
The definitions and relationships presented here are, however, fundamental to an understanding of the subsequent chapters on regeneration, in which they figure prominently in the search for the determinants of end results. One might wish that additional information had been available, in reliable form, on the injury and its management, for peripheral nerve regeneration is an extraordinarily complicated matter, and even the array of factors presented in this chapter will not suffice to refine the surgeon's prognosis to the accuracy he might like.
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