Rehabilitation of Peripheral Nerve Injuries in Disasters and Conflicts

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Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Tarina van der Stockt, Kim Jackson and Jess Bell      

Introduction

Peripheral nerves can sustain injury from numerous causes including traumatic injuries, inherited causes, infections, metabolic problems (one of the most common causes is diabetes mellitus), exposure to toxins; tumours and iatrogenic causes.

Immediate Emergency Care

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Emergency Medical Teams

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Peripheral Nerve Injury Overview

The peripheral nervous system is comprised of three types of cells: neuronal cells, glial cells, and stromal cells. Peripheral nerves convey signals between the spinal cord and the rest of the body. Nerves are comprised of various combinations of motor, sensory, and autonomic neurons. Efferent neurons (motor and autonomic) receive signals through their dendrites from neurons of the central nervous system, primarily using the neurotransmitter acetylcholine among others. Afferent (sensory) neurons receive their signals through their dendrites from specialized cell types, such as Paccinian corpuscles for fine sensation and others. These signals are sent to the CNS to provide sensory information to the brain and possibly interneurons in the spinal cord when a reflex response is necessary1.

A peripheral nerve injury can result in a minor injury or a fully severed nerve. Based on the type and amount of damage, nerve regeneration may or may not be possible. Peripheral nerve Injury treatment depends on the type of injury, symptoms and the amount of nerve injury sustained.

Classification of Peripheral Nerve Injuries

Classification systems provides a common language for medical and rehabilitation professionals to effectively discuss nerve pathophysiology. There are two commonly used classification systems in use for peripheral nerve injury; the Seddon Classification and the Sunderland Classification.

Seddon was the first to classify nerve injuries into three categories; neurapraxia, axonotmesis, and neurotmesis, based on the presence of demyelination and the extent of damage to the axons and the connective tissues of the nerve. Sunderland later expanded on this initial classification to distinguish the extent of damage in the connective tissues. A Grade VI lesion was later introduced by McKennon and Dellon to denote combinations of Grade III-V injuries along a damaged nerve, although its usage has not been widely accepted

Table.1 Peripheral Nerve Injury Classification Systems

Seddon Classification	Sunderland Classification	McKennon & Dellon	Type of Injury
Neuropraxia	Grade I		Focal segmental damage Local myelin damage usually secondary to compression
Axonotmesis	Grade II		Axon severed Endoneurium intact (optimal circumstances for regeneration)
	Grade III		Axon discontinuity, endoneurial tube discontinuity. Perineurium and fascicular arrangement preserved
	Grade IV		Loss of continuity of axons, endoneurial tubes, Perineurium and fasciculi; epineurium intact
Neurotmesis	Grade V		Complete Nerve Transection Total physiologic disruption of entire nerve trunk
		Grade VI	Mixed levels of injury along the nerve

Common Peripheral Nerve Injuries

Upper Limb

Nerve	Related Injuries	Muscle Affected	Motor Function	Sensation	Test
Spinal Accessory Nerve	Fracture Atlas or Hyoid Neck Trauma	Trapezius	Elevates Pectoral Girdle Retracts Scapula Depresses Shoulder Ipsilateral side flexion of neck		Posture Scapular Winging at Rest Assess Abduction Test Hand behind back and lift hand away from back
Long Thoracic Nerve	Sudden Scapular Depression Axillary Crutch Use	Serratus Anterior	Scapula Protraction Upward Scapular Rotation		Scapular Winging with Movement
Axillary Nerve	Most common peripheral nerve injury to affect the shoulder. Fracture Shoulder Dislocation Shoulder	Deltoid Teres Minor	Abduction from 15° Shoulder Extension Shoulder Flexion External Rotation Atrophy Deltoid - Flat Shoulder	Regimental Patch	Unable to Abduct Arm to 90 degrees Unable to maintain resisted abduction at 90 degrees
Suprascapular Nerve	Shoulder Fracture Clavicular Fracture Proximal Humeral Fracture	Infraspinatus Supraspinatus	Initial 15° Abduction External Rotation Atrophy Supraspinatus and/or Infraspinatus		Infraspinatus Test Suprascapular Nerve Stretch Test
Musculocutaneous Nerve	Isolated injury to the Musculocutaneous Nerve is rare Knife wound to Axilla	Biceps Brachii Brachialis Coracobrachialis	Elbow Flexion Supination Weak or Absent Biceps Tendon Reflex Atrophy Anterior Compartment Arm	Lateral and Volar Aspect of  the Forearm	Unable to Flex Elbow
Ulnar Nerve	At risk of Injury at Medial Epicondyle, in Cubital Tunnel, or at the Wrist; Fracture Elbow Dislocation Elbow Laceration at Wrist	Forearm: Flexor Carpi Ulnaris Flexor Digitorum Profundus	High Lesion - Ulnar Paradox; Hyperextension 4th & 5th Finger at MCP Joint Paralysis 4th & 5th Finger at IP Joint; Straighter Fingers Loss Ulnar Deviation Loss of FCU Tendon on Ulna Flexion Loss Interossei Function Loss Thumb Adduction Wasting Hypothenar Eminence Wasting Interossei	Palmar Surface of 5th & ½ 4th Digit Dorsal Surface of 5th & ½ 4th Digit	Inability to cross second and third finger Poor Grasp and Release
		Hand Hypothenar Eminence; Abductor Digiti Minimi Flexor Digiti Minimi Opponens Digiti Minimi Thenar Eminence; Adductor Pollicis Short Muscles; Lumbrical 3 & 4 Dorsal Interossei Palmar Interossei Palmaris Brevis	Low Lesion - Partial Claw Hand; Hyperextension 4th & 5th Finger at MCP Joint Flexion 4th & 5th Finger at IP Joint Loss Interossei Function Loss Thumb Adduction Wasting Hypothenar Eminence Wasting Interossei		Inability to cross second and third finger Poor Grasp and Release Partial Claw Hand
Radial Nerve	Humeral Fracture Elbow Fractures Elbow Wounds	Arm Triceps Brachii Anconeus             Extensor Indicis	High Lesion; Loss Elbow Extension Loss Wrist Extension Loss Hand Extension Loss Radial Deviation Atrophy Forearm	No Sensory Involvement if Posterior Interosseous Branch is Damaged Alone 1st Webspace; Dorsum Aspect Hand from 1st to ½ 4th Digit	Wrist Drop Present
		Forearm; Brachioradialis Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Supinator Extensor Digitorum Extensor Digiti Minimi Extensor Carpi Ulnaris Abductor Pollicis Longus Extensor Pollicis Longus Extensor Pollicis Brevis	Middle & Low Lesion; Loss Wrist Extension Loss Hand Extension Loss Radial Deviation Loss Thumb Extension Atrophy Forearm
Median Nerve	Supracondylar Humeral Fractures	Forearm; Pronator Teres Flexor Carpi Radialis Palmaris Longus Flexor Digitorum Superficialis Flexor Digitorum Profundus Flexor Pollicis Longus Pronator Quadratus	High Lesion; Loss Wrist Flexion Loss of Opponens Loss of Ulnar Deviation Wasting of Thenar Eminence	Palmar Aspect 1st - ½ 4th Ring Finger	Ok Test Pinch Test
			Low Lesion; Long Flexors Unaffected Loss of Opponens Thenar Muscle Wasting
		Hand; LOAF Lumbricals 1 & 2 Opponens Pollicis Abductor Pollicis Flexor Pollicis	Carpal Tunnel; Wasting of Thenar Eminence; Weakness Abductor Pollicis Brevis Loss of Opponens

Lower Limb

Nerve	Related Injuries	Muscle Affected	Motor Function	Sensation	Test
Gluteal Nerve		Gluteus Medius	Hip Abduction		Trendelenburg Sign
Femoral Nerve	Fracture Hip Fracture Pelvis Acetabular Fracture Stab Wounds Gunshot Wounds	Quadriceps	Flexion Hip Extension Knee	Anterior Thigh Medial Thigh Medial Leg to Hallux (Great Toe)	Difficulty straightening knee
Tibial Nerve	Dislocation Knee Fracture Tibia Fracture Fibula Laceration Injury	Popliteus Gastrocnemius Soleus Plantaris Flexor Digitorum Longus Flexor Hallucis Longus			Unable to walk on toes
Peroneal Nerve	Dislocation Knee Fracture Fibular Head	Biceps Femoris Tibialis Anterior			Unable to walk on heels

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion