Transcript Treatment

Peripheral nerve lesion
Peripheral nerves are bundles of axons conducting efferent
(motor) impulses from cells in the anterior
horn of the spinal cord to the muscles, and afferent
(sensory) impulses from peripheral receptors via cells
in the posterior root ganglia to the cord.
They also
convey sudomotor and vasomotor fibers from ganglion
cells in the sympathetic chain.
Classifications
Seddon's
classification
Neurapraxia
-- temporary paralysis of a
nerve caused by lack of blood
flow or by pressure on the
affected nerve with no loss of
structural continuity
Axonotmesis –
neural
tube
intact, but axons
are disrupted.
nerves are likely
to recover.
Neurotmesis
–
the neural tube is
severed.
Injuries are likely
permanent
without repair.
PATHOLOGY
Nerves can be
injured by
1.ischaemia.
2.Compression.
3.Traction.
4.Laceration.
5.or burning.
Transient ischaemia
Acute
nerve
compression
causes numbness and tingling
within 15 minutes,
loss of pain sensibility after 30
minutes and
muscle weakness after 45
minutes.
Relief of compression is
followed by
intense
paraesthesiae
lasting up to 5 minutes (the
familiar ‘pins and needles’
after a limb ‘goes to sleep’);
feeling is
restored within 30 seconds
and full muscle power after
about 10 minutes.
OBSTETRICAL
PLEXUS
BRACHIAL
PALSY
caused by
excessive traction on the
brachial plexus during childbirth, e.g.
by pulling the
bay’s head away from the shoulder or
by exerting traction with the baby’s
arm in abduction.
• Three patterns
• are seen: (1) upper root injury
(Erb’s palsy), typically in
• overweight babies with shoulder
dystocia at delivery;
• (2) lower
root injury
(Klumpke’s palsy), usually after
• breech delivery of smaller babies;
and
•
• (3) total
plexus injury.
Clinical features
Erb’s palsy is caused by injury of
C5, C6 and (sometimes) C7. The
abductors and external rotators of
the shoulder and the supinators are
paralysed.
The arm is held to the side,
at birth: after a difficult delivery the
baby has a floppy or flail arm.
internally rotated and
pronated.
There may also be loss of finger
extension.
Sensation cannot be tested in a
baby.
X-rays
should be obtained to exclude fractures of
the shoulder or clavicle (which are not
uncommon
and which can be mistaken for obstetrical
palsy).
Management
Over the next few weeks one of several things
may
happen.
Paralysis may recover completely.
Paralysis may be partially resolve.
Paralysis may remain especially in the presence
of a Horner’s syndrome
RADIAL NERVE
The radial nerve may be
injured at the elbow.
in the upper arm
or in the axilla.
Clinical
features
High and Low lesions are usually due
to
fractures or dislocations
at mid shaft of humerus or at the
elbow,
or to a local wound.
after operations on the proximal end
of the radius.
The patient complains of clumsiness
and, on testing,
cannot
extend
the
metacarpophalangeal joints of the
hand.
In the thumb there is also weakness
of extension.
Treatment
Open injuries should
be explored and the
nerve repaired or
grafted as soon as
possible.
Closed injuries
In patients with fractures of the humerus it is important to
examine for a radial nerve injury on admission,
before
treatment and again after manipulation or internal fixation.
If the palsy is present on admission, one can
afford to wait for 12 weeks to see if it starts to recover.
If it does not,
then EMG should be performed;
While recovery is awaited,
Physiotherapy
The wrist is splinted in
extension. ‘
To over come fixed
contractures
CARPAL TUNNEL
SYNDROME
In the normal carpal tunnel
there is barely room for all the
tendons and the median nerve;
consequently,
any swelling is likely to result in
compression and ischaemia of
the nerve.
• the syndrome is, however,
common
• at the menopause.
• in rheumatoid arthritis.
• pregnancy.
• and myxoedema.
Clinical
features
The history is most
helpful in making the
diagnosis.
Pain and paraesthesia
occur in the distribution
of the
median nerve in the
hand.
Night after night the
patient is woken
burning pain,
tingling and
numbness.
with
• Hanging the arm over
the side of the bed,
• or shaking the arm,
may
relieve
the
symptoms.
• In advanced cases
there
may
be
clumsiness
and
weakness
The condition is far more common in
women than in men.
The usual age group is 40–50 years;
younger patients it is not uncommon to find
related factors such as
pregnancy, rheumatoid disease, chronic
renal failure or gout.
Clinical sign
Sensory symptoms can
often be reproduced by
percussing
over the median nerve
(Tinel’s sign) or by
• holding the wrist fully flexed for less than 60
seconds
• (Phalen’s test).
In late cases
there is wasting of
the thenar muscles.
weakness of thumb
abduction and
sensory dulling in the
median
nerve
territory.
• Electrodiagnostic tests,
• which show slowing of nerve conduction
across the wrist
DD:
Radicular symptoms
of
cervical
spondylosis
may
confuse
the
diagnosis and
may coincide with
carpal
tunnel
syndrome.
Treatment
Light splints that
prevent
wrist
flexion can help
those
with night pain or
with
pregnancyrelated symptoms.
• Steroid injection into the
carpal
canal,
likewise,
provides temporary relief.
• Open surgical
division of
the
transverse
carpal
ligament usually provides a
quick and simple cure.
Endoscopic
release.
carpal
tunnel
SCIATIC NERVE
• Division of the main sciatic nerve
is rare except.
• in
• gunshot wounds.
• Traction lesions may occur with
• traumatic hip dislocations
• and with pelvic fractures.
• Intraneural
haemorrhage
in
patients receiving anticoagulants
Clinical features
• In a complete lesion the hamstrings
and all muscles
• below the knee are paralysed;
• the ankle jerk is absent.
Sensation is lost
below the knee,
except
on
the
medial
side of the leg which
is supplied by the
saphenous
branch
of
the
femoral nerve.
• The patient walks with
a
• drop foot and
• a high-stepping gait to
avoid dragging the
insensitive foot on the
ground
Treatment
• suture
• or nerve grafting should be
attempted ,more than a
year for leg muscles to be
re-innervated.
• While recovery is awaited,
• a below-knee drop-foot
splint is fitted.
Spine injuries
Cervical classifications
• wedge compression
fracture of vertebral
body
burst
fracture of
vertebral
body
extension
subluxation
flexion
subluxation
fracture of the atlas
fracturedislocation of the
atlanto-axial joint
intraspinal displacement of soft
tissue
soft-tissue strain
('whiplash injury')
MECHANISM OF INJURY
Flexion
Flexion-rotation
Extension
Vertical
compression.
injuries of the cervical spine are usually caused
by indirect violence,
Such as falls on to the head or
other violent movements transmitted from the
skull. i.e in any direction.
flexion,
tension, lateral flexion or
rotationor a vertical compression force acting on
a straight spine.
Flexion and flexion-rotation
injuries
are common:
flexion alone tends to a wedge
compression fracture .
whereas combined flexion and
rotation cause subluxation ,
dislocation or fracture-disIocation.
A flexion or flexionrotation force may also
cause
massive
displacement of an
intervertebral
disc,
without bone injury
A hyperextension
force may fracture the neural arch,
especially of the atlas
Or fracture the dens (odontoid process) of the axis.
hyperextension
may
rupture
the
anterior
longitudinal ligament and
the
anulus fibrosus, forcing the
vertebral
bodies
apart
anteriorly (extension
subluxation) .
DIAGNOSIS
X RAY
Anterio posterior X ray radiograph.
lateral radiographs with the head in flexion and extension may
reveal
instability that is not shown in the routine lateral film.
oblique views
at 45° are especially
helpful
a
special
projection
through the open
mouth.
Computed tomography
(CT)
and magnetic resonance imaging (
MRI).
Treatment
It is unnecessary to attempt
reduction, and all that is
required is to support the
neck for 2 months to relieve
pain. This may be achieved
by a rigid plastic Collar.
In addition to N S A I
SOFT-TISSUE STRAIN OF THE CERVICAL
SPINE
Mechanism of injury and pathology
At the moment of impact, the head
is first
suddenly jolted forwards followed
by rebound flexion of the spine.
And a second by extension of the
neck.
Clinical features
At impact, the patient may
feel jolting or 'wrenching' of
the neck or
painful one of the shoulder,
neck pain is usually accompanied
by severe headache, which
Examination shows restriction of the range of
movement of the cervical spine, usually in all directions
Treatment
In general, the
principle to provide support and rest for
the neck at
First, in the form of a protective cervical
collar.
But after
1or 2 weeks there
should be on the restoration of mobility
by exercises within the limits
imposed by pain, preferably under the
supervision of a physiotherapist.
Dorsal and lumbar spine
Wedge compression
fracture of a vertebral
body.
Burst
fracture of a
vertebral
body.
Distraction
fracture of a
vertebral body.
Dislocation and
fracturedislocation
Minor fractures of the spinal
column
Fractures of transverse
processes .
Fracture of the sacrum
Fracture of the coccyx
Fractures of the thoracic cage.
Fractures of the ribs
Fractures of the sternum
MECHANISM OF INJURY
by vertical force acting
through the long axis of
the spinal column.
This force.
may act from above, as
when a coal miner is
buried by a fall of roof.
or from
Below, as by a heavy fall on the feet or
buttocks, in high speed motor vehicle
collisions
The thoracolumbar junction
one or more of the vertebral bodies
collapses
anteriorly and becomes wedge-shaped,
giving rise to a localized kyphosis.
WEDGE COMPRESSION
FRACTURE
Diagnosis .
obvious symptoms and
signs pointing
In cases of major fracture
there
will
be
only
between the T11 and L2
Treatment
It has been shown that
persistent wedging of a vertebral
body is compatible. With virtually
normal function.
so correction of the deformity is
not essential.
The
standard
method
of
treatment may, therefore, be
said to be conservative.
BURST FRACTURE OF A
VERTEBRAL BODY
the compression force thus
acts vertically in the line of the
vertebral bodies.
The intervertebral disc is
forced
In the affected vertebral body,
causing
a
comminuted
bursting fracture in which
fragments are driven outwards
in all directions.
Treatment
If there is no neurological
impairment, it is permissible to
employ
Conservative treatment as for
wedge compression fracture, but a
rather longer period of recumbency
is advisable.
Some surgeon
fixations.
advise
surgical
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