Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Case Study of the Best and Poorest Results Following Peripheral Nerve Suture
Case Study of the Best and Poorest Results Following Peripheral Nerve Suture
Pages 409-498
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From page 409... ...
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)
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From page 410... ...
At least return of some superficial pain and touch in autonomous zone. Poor recovery Median.
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From page 411... ...
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.
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From page 413... ...
-• s si •$ I s !
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From page 414... ...
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 percent; 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.
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From page 415... ...
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.
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From page 416... ...
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.
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From page 417... ...
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; abductor pollicis brevis 28 percent, with substitution.
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From page 418... ...
a I C4 15 ber o d .
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From page 419... ...
Is c o e 1 ot tested..
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From page 420... ...
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.
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From page 421... ...
Deep pressure sense is absent in all of his finger-tips. Position sense is absent in all his fingers.
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From page 422... ...
Because of the poor circulation 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 satisfactory, and on February 12, 1945, a right dorsal sympathectomy was performed with very good results. At this time there had been a hyperalgesic return of sensation in the ulnar distribution with questionable return 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
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From page 423... ...
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.
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From page 424... ...
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 definite innervation in the abductor digiti quinti and the adductor pollicis, as well as the flexor of the 5th finger.
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From page 425... ...
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.
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From page 428... ...
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 interosseus marked fasciculation)
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From page 429... ...
Case Report 8788 HISTORY OF INJURY On August 17, 1945, this patient put his fist through a window and received 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.
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From page 430... ...
and 4% cm. were overcome for the ulnar and median nerves, respectively.
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From page 431... ...
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.
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From page 432... ...
On percutaneous stimulation 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.
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From page 433... ...
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.
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From page 435... ...
\S' ', - • •< H S roe If?
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From page 436... ...
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 neurolysis at the same time-period, showed the following changes: Abductor minimi digiti: Rheobase 5.3.
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From page 437... ...
At 1% months function was noted in the extensor carpi radialis longus and brevis and a flicker in the extensor digitorum comnuiiiis; 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.
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From page 440... ...
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.
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From page 441... ...
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.
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From page 443... ...
Skin resistance... cent.
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From page 444... ...
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.
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From page 445... ...
Proximal ulnar muscles function at about one-half strength, distal muscles at 10 to 15 percent. Ulnar percutaneous stimulation results in no function of lumbrical, fair function of abductor digiti quinti and 1st dorsal interosseus.
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From page 446... ...
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.
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From page 447... ...
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.
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From page 448... ...
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From page 449... ...
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From page 450... ...
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.
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From page 451... ...
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.
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From page 452... ...
Chronaxie examination of tibialis anticus is 1^ times normal, and of peroneus longus is 3 times normal. Electromyographic examination oi
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From page 453... ...
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.
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From page 454... ...
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.
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From page 455... ...
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.
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From page 456... ...
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From page 458... ...
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.
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From page 459... ...
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.
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From page 460... ...
CENTER EXAMINATION April 8, 1949 The wound is \Q% in. from the internal malleolus.
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From page 461... ...
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.
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From page 462... ...
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From page 464... ...
Compound comminuted fracture lower left tibia, and the leg was casted. Posterior tibial nerve injury noted June 10, 1945.
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From page 465... ...
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.
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From page 466... ...
CENTER EXAMINATION April 4, 1949 Patient 24 years old at time of injury and left handed. Suture-line at site of medial malleolus.
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From page 467... ...
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.
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From page 468... ...
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.
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From page 469... ...
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.
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From page 470... ...
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From page 472... ...
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.
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From page 473... ...
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.
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From page 474... ...
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From page 475... ...
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From page 476... ...
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.
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From page 477... ...
Quantitative muscle evaluation is as follows. Tibialis anticus 85 percent of normal, peroneus longus 50 percent, extensor digitorum longus 100 percent, extensor hallucis longus 100 percent, gastrocnemius 75 percent, flexor digitorum longus 50 percent, flexor hallucis longus 25 percent, tibialis posticus 75 percent.
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From page 478... ...
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.
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From page 479... ...
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.
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From page 480... ...
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From page 481... ...
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From page 482... ...
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.
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From page 483... ...
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.
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From page 484... ...
Tibialis anticus o; flexor digitorum longus and flexor hullucis longus o. Tinel's sign in lower leg for both nerves.
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From page 485... ...
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 gastrocnemius and i -plus response in tibialis posticus, none in peroneal muscles.
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From page 486... ...
touch. Deep pressure and position sense are 0.
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From page 487... ...
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.
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From page 490... ...
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.
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From page 491... ...
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.
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From page 494... ...
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.
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From page 495... ...
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.
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From page 496... ...
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.
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From page 497... ...
Case 4406, a complete 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.
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From page 498... ...
In the poor cases, by comparison, 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.
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