Nerve Repair and Grafting in the Upper Extremity

S. Houston Payne, Jr., MD

J South Orthop Assoc. 2001;10(2)

Introduction

The diagnosis and treatment of injury to the peripheral nervous system is one of the greatest challenges in orthopaedic surgery. These common injuries with potentially devastating results provide ongoing stimulus for researchers striving for improved understanding of peripheral nerve biology and its application to nerve repair. A basic understanding of peripheral nerve biology, particularly as it relates to the process of nerve degeneration and regeneration, is critical to patient care. This knowledge, coupled with a thorough understanding of clinical anatomy, provides the clinician with the necessary tools for initial evaluation of the nerve-injured patient. To construct an appropriate plan of management, the physician must understand the operative and nonoperative treatment alternatives for specific nerve injuries. A reconstructive plan can then be formulated with realistic expectations based on reported clinical results.

For more detailed information on nerve repair and grafting, the reader is referred to Orthopaedic Care: Medical and Surgical Management of Musculoskeletal Disorders (www.orthotextbook.net), which is available online from the Southern Orthopaedic Association, Clinical Orthopaedic Society, and affiliated organizations.

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Table 1. Nerve Injury Classification ^[23]
Seddon	Sunderland	Pathophysiologic Basis
Neuropraxia	I	Local myelin damage. Axons preserved. No degeneration.
Axonotmesis	II	Endoneural tube preserved. Axon degeneration.
	III	Loss of endoneural tube continuity. Perineurium intact. Axon degeneration.
	IV	Endoneural tube and perineurium disrupted. Epineurium intact. Axon degeneration.
Neurotmesis	V	Complete loss of neural continuity.

Table 2. Selected Muscle Evaluation for Diagnosis of Motor Nerve Injury ^[35]
I.	Median nerve: intrinsic
	A. Thumb-palmar abduction (abductor pollicis brevis)
II.	Median nerve: extrinsic
	A. All flexor digitorum sublimi
	B. Flexor profundus digitorum to index
	C. Flexor pollicis longus
	D. Flexor carpi radialis
III.	Ulnar nerve: intrinsic
	A. First dorsal interosseous muscle
	B. Muscles of the hypothenar eminence
IV.	Ulnar nerve: extrinsic
	A. Flexor digitorum profundus, small finger
	B. Flexor carpi ulnaris
V.	Radial nerve: extrinsic
	A. Wrist extension (extensor carpi radialis brevis and longus, extensor carpi ulnaris)
	B. Extension of fingers at metacarpophalangeal joint (extensor digitorum communis, extensor indicis proprius, extensor digiti minimi)

Table 3. Sensory Evaluation for Specific Peripheral Nerve Injury ^[35]
I.	Median nerve -- Pulp of thumb and index finger
II.	Palmar cutaneous branch of median nerve -- Proximal palm over thenar eminence
III.	Ulnar nerve -- Pulp of small finger
IV.	Dorsal cutaneous branch of ulnar nerve -- Dorsal ulnar surface of hand
V.	Radial nerve -- Dorsal radial hand over first web space
VI.	Digital nerve -- Area of the distal phalangeal joint flexion crease

Table 4. Evaluation of Motor Recovery After Peripheral Nerve Injury
M0	No contraction
M1	Return of contraction in the proximal muscles
M2	Return of contraction in both proximal and distal muscles
M3	Return of function in both proximal and distal muscles of such a degree that all important muscles are sufficiently powerful to act against gravity
M4	Return of function as in M3; in addition, all synergistic and independent movements are possible
M5	Complete recovery

Table 5. Evaluation of Sensory Recovery After Peripheral Nerve Injury ^[40,54]
S0	Absence of sensibility in the autonomous area
S1	Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve
S2	Return of some degree of superficial cutaneous pain and tactile sensibility within the autonomous area of the nerve
S3	Return of superficial cutaneous pain and tactile sensibility throughout the autonomous area, with disappearance of any previous overresponse
S3+	Return of sensibility as in S3; in addition, there is some recovery of 2-point discrimination within the autonomous area (7-15 mm)
S4	Complete recovery (2-point discrimination, 2-6 mm)

Table 6. Vascularized Nerve Grafts: Donor Nerves and Associated Vessels
Nerve	Vascular Supply
Superficial radial	Radial artery
Ulnar	Superior ulnar collateral artery
Sural	Superficial sural artery
Anterior tibial	Anterior tibial artery
Superficial peroneal	Superficial peroneal artery
Saphenous	Saphenous artery

Adapted from Breidenbach and Terzis. ^[70]

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Nerve Repair and Grafting in the Upper Extremity

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