Damage to the nerves of the extremities: causes, symptoms, diagnosis, treatment

ICD-10 code

• S44. Injury of nerves at the level of the shoulder girdle and shoulder.
• S54. Injury of nerves at the level of the forearm.
• S64. Injury of nerves at wrist and hand level.
• S74. Injury of nerves at the level of the hip and thigh.
• S84. Injury of nerves at the level of the shin.
• S94. Injury of nerves at ankle and foot level.

What causes damage to the nerves of the extremities?

Damage to the peripheral nerves of the limbs occurs in 20-30% of those injured in road accidents, in occupational injuries and during sports activities. Most authors agree that the most and forearms, by the paresis of the fibers of the median nerve, go to the flexor of the fingers. Paralyzed all the small muscles of the brush, perhaps, and the long flexors of the fingers of the hand. Skin sensitivity is broken along the ulnar side of the shoulder, forearm and hand (in the zones of the ulnar and median nerves). With the loss of the functions of the cervical sympathetic nerve, Horner's syndrome (ptosis, miosis and enophthalmia) is revealed.

Damage to individual trunks of the brachial plexus, as well as total damage to it, can also occur with closed injuries.

In cases of complete paresis of the brachial plexus, the upper limb hangs along the trunk, is moderately edematous, cyanotic, without signs of muscle functioning. Sensitivity is absent to the level of the shoulder joint.

Damage to the long thoracic nerve (C ₅ -C ₇ )

Occurs when pulling on the hands, as a result of the pressure of a heavy backpack among climbers, etc. A consequence is the paresis of the anterior dentate muscle. When you try to raise your hands forward, the medial edge of the scapula (pterygoid scapula) extends from the patient. There are no sensory abnormalities.

[1], [2], [3], [4], [5], [6]

Damage to the axillary nerve (C ₅ -C ₆ )

The cause of the injury is shoulder dislocations, less often fractures of the surgical neck of the shoulder. It is characterized by the paresis of the deltoid and small round muscles, as a result of which the outflow and external rotation of the shoulder are violated. The sensitivity falls on the outer surface of the proximal part of the shoulder (the width of the palm).

[7], [8], [9]

Damage to the nasal cavity (C ₄ -C ₆ )

The causes of the appearance and disturbances of the functions are the same as in the lesions of the axillary nerve. The result is paresis of the supraspinatus and subacute muscles. Sensitivity does not suffer.

[10], [11], [12], [13]

Damage to the skin-muscular nerve (C ₅ -C ₇ )

Isolated lesions are rare, more often the skin-muscular nerve is injured with other plexus nerves. Paralysis of the biceps brachii muscle, and with higher lesions - the beak-brachial and brachial muscles, which causes weakness in flexion and supination of the forearm and a slight decrease in sensitivity along the radial side of the forearm.

[14]

Damage to the radial nerve (C ₅ -C ₈ )

Damage to the radial nerve is the most common type of damage to the nerves of the upper limb, resulting from gunshot wounds and closed shoulder fractures. The clinical picture depends on the level of injury.

• If the nerve is damaged at the level of the upper third of the shoulder, paralysis of the triceps muscle of the shoulder is revealed (there is no extension of the forearm) and the reflex disappears from its tendon. The sensitivity falls on the back of the shoulder.
• If the nerve is damaged at the level of the middle third of the shoulder, the most known clinical picture arises, characterized by the paresis of the extensors of the hand (the "hanging brush"), it becomes impossible to unbend the hand, the main phalanx of fingers, the removal of the first finger, the supination is broken. Skin sensitivity is upset at the rear of the forearm and radial half of the rear of the hand (not always with clear boundaries), more often in the zone of the main phalanges I, II and half of the 3rd finger.

[15], [16]

Damage to the median nerve

The cause is gunshot wounds to the shoulder, cut wounds of the distal part of the palmar surface of the forearm and wrist wrinkle.

If the nerve is damaged at the level of the shoulder, it becomes impossible to flex the wrist and fingers, compress the hand into a fist, contrast the first finger, and pronate the wrist. Rapidly developing atrophy of thenar gives the brush an original look ("monkey's paw"). The sensitivity is disturbed by the radial half of the palmar surface of the hand and the first three and a half fingers on the rear - the middle and terminal phalanges of the 2nd and 3rd fingers. There are pronounced vegetative disorders: vascular reaction of the skin, changes in sweating (often increased), keratoses, increased nail growth, causalgia with a positive symptom of a "wet rag": wetting the brush reduces burning pain.

If the nerve is damaged below the branches that extend to the pronators, the clinical picture changes. It manifests itself only by a violation of the opposition of the first finger, but the sensitive disorders are the same as with damage at the shoulder level.

[17], [18], [19], [20], [21], [22], [23], [24]

Injuries of the ulnar nerve

Meet with fractures of the condyle of the shoulder, cut wounds of the forearm and wounds at the level of the wrist joint. The ulnar nerve basically innervates the small muscles of the hand, so when it is damaged, the I and V fingers are removed, the fingers are moved and spread, the nail phalanges are extended, especially the IV and V fingers, and the finger is opposed. Developed atrophy of the hypothenar gives the brush a characteristic appearance ("clawed brush"). The sensitivity falls on the ulner half of the hand, as well as on one and a half fingers of the palm and two and a half fingers of the back side.

Femoral nerve damage

Damage to the femoral nerve occurs with fractures of the pelvis and hip. Damage to the femoral nerve causes paralysis of the quadriceps and sartorius muscles; extension of the shin becomes impossible. The knee jerk disappears. Sensitivity is broken along the front surface of the thigh (anterior cutaneous femoral nerve) and the anterior surface of the lower leg (subcutaneous nerve).

[25], [26]

Sciatic nerve damage (L ₄ -S ₃ )

Damage to this largest nerve trunk is possible with a variety of injuries at the level of the pelvis and hip. These are gunshot wounds, punctured wounds, fractures, dislocations, sprains and compression. The clinical picture of the lesion consists of the symptoms of affection of the tibial and peroneal nerves, and the defeat of the latter has more vivid manifestations and always comes to the fore. Identification of signs of abnormalities of the pain of the sciatic nerve at the same time indicates trauma to the sciatic nerve.

Damage to the peroneal nerve (L ₄ -S ₂ )

The most common cause of isolated damage to the peroneal nerve is a trauma in the area of the head of the fibula, where it is closest to the bone. The main signs are: hanging of the foot and its outer edge ("horse foot"); active rear flexion and pronation of the foot are impossible due to the paresis of the peroneal muscles. Skin sensitivity is absent in the anterior anterior surface of the lower third of the tibia and at the rear of the foot.

[27], [28], [29], [30], [31]

Damage to the tibial nerve

Meet with fractures of the tibia and other mechanical injuries in the area of passage of the nerve. Turning off of innervation leads to loss of function of flexion of foot and fingers, its supination. Walking on socks becomes impossible. The Achilles reflex disappears. Sensitivity is disturbed on the posterior-external surface of the shin, the outer edge and the entire plantar surface of the foot and fingers.

[32], [33], [34]

General principles of treatment of nerve damage of the extremities

Treatment of damage to the nerves of the limbs should be complex, it should be started from the moment of diagnosis. Distinguish conservative and operative treatment. This division is conditional, since after an operative intervention they use the entire arsenal of conservative agents that help restore innervation.

Conservative treatment of nerve injury of the extremities

Begin with the immobilization of the limb in a functionally advantageous position with the greatest possible exception of the effect of gravity on the damaged if the damage to the nerve trunk is located in the proximal limb (shoulder, shoulder, thigh). Immobilization serves as a means of preventing contractures in a vicious situation. Its use is mandatory, because with closed injuries, the prognosis and timing of treatment is extremely difficult to predict. Immobilization in the form of gypsum and soft tissue (bandage-snake or kosynochnaya) bandages prevents and limb hanging. The upper limb left without fixation as a result of the action of gravity hangs downwards, overstretches paralyzed muscles, vessels and nerves, causing secondary changes in them. From excessive traction, neuritis of previously unaffected nerves may occur.

Assign medicamental stimulation of the neuromuscular apparatus according to the following scheme:

• injections monofostiamine 1 ml subcutaneously and bendazole 0,008 inside 2 times a day for 10 days;
• then within 10 days the patient receives injections of 0.06% solution of neostigmine methylsulfate 1 ml by intramuscular injection;
• then again repeat a 10-day course of monofostiamine and microdoses of benda-ash.

In parallel, physiotherapy is prescribed. Begin it with UHF on the area of trauma, then apply anesthetic physioprocedures (electrophoresis procaine, DDT, "Ray", laser). Subsequently, they switch to treatment aimed at the prevention and resolution of the cicatrical-adhesive process: electrophoresis of potassium iodide, phonophoresis of hyaluronidase, paraffin, ozocerite, mud. Very useful are longitudinal galvanization of nerve trunks and electrostimulation of muscles in a paresis state. These procedures prevent the degeneration of nerves and muscles, contractures, reduce edema. It is mandatory to use active and passive medical gymnastics, massage, water procedures, hyperbaric oxygenation.

It is known that the regeneration of the nerve and its growth does not exceed 1 mm per day, so the treatment process stretches for months and requires the perseverance and patience of both the patient and the doctor. If there are no clinical and electrophysiological signs of improvement within 4-6 months of treatment, then surgical treatment should be switched on. If conservative treatment does not give results within 12-18, a maximum of 24 months, there is no hope for restoring the functions of the damaged nerve. It is necessary to switch to orthopedic methods of treatment: muscle grafting, arthrodesis in a functionally advantageous position, arthritis, etc.

Operative treatment of nerve injury of extremities

Surgical treatment of damage to the nerves of the limbs is indicated in the following cases.

• With open lesions, allowing to perform the primary nerve stitch.
• In the absence of the effect of conservative treatment, conducted for 4-6 months.
• With the development of paralysis 3-4 weeks after the fracture.

With open limb injuries, the primary nerve suture can be performed in cases where, after initial surgical treatment, the suturing of the wound is tightly tightened. Otherwise, surgical treatment should be delayed up to 3 weeks or up to 3 months or more. In the first case we are talking about an early delayed intervention, in the second - about the late. If damage to bones and vessels is detected, then first it is necessary to perform osteosynthesis, then stitching the vessels, and then neuroraphy.

Primary nerve seam is produced after its mobilization, truncation of the damaged ends with a razor, preparation of the bed, rapprochement and contact of "refreshed" surfaces. Atraumatic needles with thin threads (No. 00) impose 4-6 nodular sutures for the epineurium, trying to avoid compression of the nerve and its twisting along the axis. After suturing the wound, a plaster immobilization (longet) is applied in a position that facilitates the approach of the ends of the nerve for 3 weeks. The patient undergoes the entire complex of conservative treatment of damage to the nerves of the extremities.