Rehabilitation of Peripheral Nerve Injuries in Disasters and Conflicts: Difference between revisions
No edit summary |
No edit summary |
||
Line 7: | Line 7: | ||
== Introduction == | == Introduction == | ||
Peripheral nerves can sustain injury from numerous causes including traumatic thermal, chemical, or mechanical injury, inherited causes, infections, collagen or metabolic diseases ([[Diabetes|diabetes mellitus]] being one of the most common), exposure to endogenous or exogenous toxins; malignancies and iatrogenic causes<ref>Mayo Clinic. Peripheral Neuropathy. Available from: https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 (Last Accessed 24/03/2019)</ref>, which manifest with neurological deficits distal to the level of the lesion. In disaster and conflict situations there can be a significant increase in the number of traumatic peripheral nerve injuries, but all of these other causes of nerve injury will continue to be seen by patients in these situations. <ref name=":0" /> | Peripheral nerves can sustain injury from numerous causes including traumatic thermal, chemical, or mechanical injury, inherited causes, infections, collagen or metabolic diseases ([[Diabetes|diabetes mellitus]] being one of the most common), exposure to endogenous or exogenous toxins; malignancies and iatrogenic causes<ref>Mayo Clinic. Peripheral Neuropathy. Available from: https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 (Last Accessed 24/03/2019)</ref>, which manifest with neurological deficits distal to the level of the lesion. In disaster and conflict situations there can be a significant increase in the number of traumatic peripheral nerve injuries, but all of these other causes of nerve injury will continue to be seen by patients in these situations. <ref name=":0" /> In disaster and conflict situations patients with peripheral nerve injuries tend to present with other injuries, often complex and most frequently associated with limb fractures. In many cases these associated injuries need stabilised prior to the peripheral nerve injury being treated, which can often result in a delay in identification and treatment of the peripheral nerve injury. | ||
Disasters including earthquakes and storms can lead to large numbers of peripheral nerve injuries, as a result of complex limb trauma and crush injuries, or those which incur deep soft tissue injuries from flying debris, while in conflict situations, peripheral nerve injuries are also associated with complex injuries as a result of explosives devices, gunshot wounds, and penetrating injuries. Primary injury to the nerve is generally a result of the same trauma that injures the bone or joint, but can also occur as a result of moving the patient or stretching, or manipulation of the limb while treating the injury, rather than by the initial force. Infection, scar, callus, or vascular complications including haematoma, arteriovenous fistula, ischemia, or aneurysm can also result in secondary injury to the nerve. <ref name=":2">Lathia C, Skelton P, Clift Z. [https://hi.org/en/early-rehabilitation-in-conflicts-and-disasters Early Rehabilitation in Conflicts and Disasters]. Handicap International: London, UK. 2020.</ref> | |||
In the upper limb radial nerve injuries are most the common with 14% associated with humeral shaft fractures, 3% associated with fracture of the middle third of the humerus; 50%, with fracture of the distal third of the humerus; 7%, with supracondylar fracture of the humerus; and 7%, with dislocation of the radial head, while in shoulder dislocations it is the axillary nerve that may be injured as a result of stretch injuries, although this is rare and only occurs in about 5% of shoulder dislocations. Ulnar injuries account for 30% of patients with combined skeletal and neural injuries to the upper limb, and are generally associated with fractures of the medial humeral epicondyle, but often as a result of callus formation around the elbow. While elbow dislocations tend to result in median nerve injury in about 15% of combined skeletal and neural injuries of the upper limb, or after injury to the distal forearm of wrist. <ref name=":3">Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences; 2020 Dec 23.</ref> In the lower limb it is the peroneal nerve that is most commonly injured at the fibular neck, as a result of fracture of the tibia and fibula or dislocation of the knee, while the tibial nerve is injured more in distal fractures of the tibia or ankle. Lumbosacral plexus branches are injured in in less than 3% of pelvic fractures; and in 10% to 13% of posterior dislocations of the hip. <ref name=":3" /> | In the upper limb radial nerve injuries are most the common with 14% associated with humeral shaft fractures, 3% associated with fracture of the middle third of the humerus; 50%, with fracture of the distal third of the humerus; 7%, with supracondylar fracture of the humerus; and 7%, with dislocation of the radial head, while in shoulder dislocations it is the axillary nerve that may be injured as a result of stretch injuries, although this is rare and only occurs in about 5% of shoulder dislocations. Ulnar injuries account for 30% of patients with combined skeletal and neural injuries to the upper limb, and are generally associated with fractures of the medial humeral epicondyle, but often as a result of callus formation around the elbow. While elbow dislocations tend to result in median nerve injury in about 15% of combined skeletal and neural injuries of the upper limb, or after injury to the distal forearm of wrist. <ref name=":3">Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences; 2020 Dec 23.</ref> In the lower limb it is the peroneal nerve that is most commonly injured at the fibular neck, as a result of fracture of the tibia and fibula or dislocation of the knee, while the tibial nerve is injured more in distal fractures of the tibia or ankle. Lumbosacral plexus branches are injured in in less than 3% of pelvic fractures; and in 10% to 13% of posterior dislocations of the hip. <ref name=":3" /> | ||
In conflict situations nerve injuries are generally distributed evenly between the upper and lower limbs, with explosions (63%) the main cause of peripheral nerve injury with 82% nerve injuries associated with open injuries, and a portion of patients presenting with injury to two or more nerves. Neurapraxia (45%) is the most common type of injury to the nerve, followed by axonotmesis (35%) and neurotmesis (20%). The ulnar, common peroneal and tibial nerves were most commonly injured, and in a large portion of these injuries was associated with a vascular injury, fracture, or both at the level of the nerve lesion, which is a small number of situation s result in amputation secondary to major tissue loss and the level of nerve damage. | |||
In disaster and conflict situations peripheral nerve injuries can be missed when medical or surgical team prioritise working to save limb or life, and rehabilitation professionals are often the first member of the team to identify possible nerve complications during their assessment and treatment. As such rehabilitation professionals should always ensure that every patient who has injured a limb or limb girdle should be evaluated and monitored for any possible peripheral nerve damage, in particular post surgery, manipulation, casting, and recovery from skeletal injury to detect any possible secondary neural injury. Early rehabilitation plays a key role in the management of peripheral nerve injuries, with education key to minimise possible complications and maximise independent function. <ref name=":2" /> | In disaster and conflict situations peripheral nerve injuries can be missed when medical or surgical team prioritise working to save limb or life, and rehabilitation professionals are often the first member of the team to identify possible nerve complications during their assessment and treatment. As such rehabilitation professionals should always ensure that every patient who has injured a limb or limb girdle should be evaluated and monitored for any possible peripheral nerve damage, in particular post surgery, manipulation, casting, and recovery from skeletal injury to detect any possible secondary neural injury. Early rehabilitation plays a key role in the management of peripheral nerve injuries, with education key to minimise possible complications and maximise independent function. <ref name=":2" /> |
Revision as of 11:47, 24 April 2022
Original Editors - Naomi O'Reilly
Top Contributors - Naomi O'Reilly, Tarina van der Stockt, Kim Jackson and Jess Bell
Introduction[edit | edit source]
Peripheral nerves can sustain injury from numerous causes including traumatic thermal, chemical, or mechanical injury, inherited causes, infections, collagen or metabolic diseases (diabetes mellitus being one of the most common), exposure to endogenous or exogenous toxins; malignancies and iatrogenic causes[1], which manifest with neurological deficits distal to the level of the lesion. In disaster and conflict situations there can be a significant increase in the number of traumatic peripheral nerve injuries, but all of these other causes of nerve injury will continue to be seen by patients in these situations. [2] In disaster and conflict situations patients with peripheral nerve injuries tend to present with other injuries, often complex and most frequently associated with limb fractures. In many cases these associated injuries need stabilised prior to the peripheral nerve injury being treated, which can often result in a delay in identification and treatment of the peripheral nerve injury.
Disasters including earthquakes and storms can lead to large numbers of peripheral nerve injuries, as a result of complex limb trauma and crush injuries, or those which incur deep soft tissue injuries from flying debris, while in conflict situations, peripheral nerve injuries are also associated with complex injuries as a result of explosives devices, gunshot wounds, and penetrating injuries. Primary injury to the nerve is generally a result of the same trauma that injures the bone or joint, but can also occur as a result of moving the patient or stretching, or manipulation of the limb while treating the injury, rather than by the initial force. Infection, scar, callus, or vascular complications including haematoma, arteriovenous fistula, ischemia, or aneurysm can also result in secondary injury to the nerve. [3]
In the upper limb radial nerve injuries are most the common with 14% associated with humeral shaft fractures, 3% associated with fracture of the middle third of the humerus; 50%, with fracture of the distal third of the humerus; 7%, with supracondylar fracture of the humerus; and 7%, with dislocation of the radial head, while in shoulder dislocations it is the axillary nerve that may be injured as a result of stretch injuries, although this is rare and only occurs in about 5% of shoulder dislocations. Ulnar injuries account for 30% of patients with combined skeletal and neural injuries to the upper limb, and are generally associated with fractures of the medial humeral epicondyle, but often as a result of callus formation around the elbow. While elbow dislocations tend to result in median nerve injury in about 15% of combined skeletal and neural injuries of the upper limb, or after injury to the distal forearm of wrist. [4] In the lower limb it is the peroneal nerve that is most commonly injured at the fibular neck, as a result of fracture of the tibia and fibula or dislocation of the knee, while the tibial nerve is injured more in distal fractures of the tibia or ankle. Lumbosacral plexus branches are injured in in less than 3% of pelvic fractures; and in 10% to 13% of posterior dislocations of the hip. [4]
In conflict situations nerve injuries are generally distributed evenly between the upper and lower limbs, with explosions (63%) the main cause of peripheral nerve injury with 82% nerve injuries associated with open injuries, and a portion of patients presenting with injury to two or more nerves. Neurapraxia (45%) is the most common type of injury to the nerve, followed by axonotmesis (35%) and neurotmesis (20%). The ulnar, common peroneal and tibial nerves were most commonly injured, and in a large portion of these injuries was associated with a vascular injury, fracture, or both at the level of the nerve lesion, which is a small number of situation s result in amputation secondary to major tissue loss and the level of nerve damage.
In disaster and conflict situations peripheral nerve injuries can be missed when medical or surgical team prioritise working to save limb or life, and rehabilitation professionals are often the first member of the team to identify possible nerve complications during their assessment and treatment. As such rehabilitation professionals should always ensure that every patient who has injured a limb or limb girdle should be evaluated and monitored for any possible peripheral nerve damage, in particular post surgery, manipulation, casting, and recovery from skeletal injury to detect any possible secondary neural injury. Early rehabilitation plays a key role in the management of peripheral nerve injuries, with education key to minimise possible complications and maximise independent function. [3]
Peripheral Nerve Injury Overview[edit | edit source]
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[edit | edit source]
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. [2][5] 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. McKennon and Dellon introduced a further classification to denote combinations of Grade III-V injuries along the route of the damaged nerve, although it is not as widely accepted in use.[6]
Seddon Classification | Sunderland Classification | McKennon & Dellon | Type of Injury | Potential for Recovery |
---|---|---|---|---|
Neuropraxia | Grade I |
|
High likelihood for full recovery | |
Axonotmesis | Grade II |
|
Good likelihood of full recovery | |
Grade III |
|
Potential for recovery, but will likely be slow, with less than 100% recovery. Surgery may be required | ||
Grade IV |
|
Requires surgical intervention | ||
Neurotmesis | Grade V |
|
The chances of recovery are very poor without surgical repair. | |
Grade VI | Mixed levels of injury along the nerve |
Common Peripheral Nerve Injuries[edit | edit source]
Upper Limb[edit | edit source]
Nerve | Related Injuries | Muscle Affected | Motor Function | Sensation | Test |
---|---|---|---|---|---|
Spinal Accessory Nerve |
|
|
Posture
Test
| ||
Long Thoracic Nerve |
|
|
| ||
Axillary Nerve | Most common peripheral nerve injury to affect the shoulder.
|
|
|
| |
Suprascapular Nerve |
|
|
| ||
Musculocutaneous Nerve | Isolated injury to the Musculocutaneous Nerve is rare
|
|
|
| |
Ulnar Nerve | At risk of Injury at Medial Epicondyle, in Cubital Tunnel, or at the Wrist;
|
Forearm: | High Lesion - Ulnar Paradox;
|
|
|
Hand
Hypothenar Eminence; Thenar Eminence; Short Muscles; |
Low Lesion - Partial Claw Hand;
|
| |||
Radial Nerve |
|
Arm | High Lesion;
|
No Sensory Involvement if Posterior Interosseous Branch is Damaged Alone
|
|
Forearm; | Middle & Low Lesion;
| ||||
Median Nerve | Forearm; | High Lesion;
|
|
| |
Low Lesion;
| |||||
Hand; LOAF | Carpal Tunnel;
|
Lower Limb[edit | edit source]
Nerve | Related Injuries | Muscle Affected | Motor Function | Sensation | Test |
---|---|---|---|---|---|
Gluteal Nerve |
|
|
|||
Femoral Nerve |
|
|
|
| |
Tibial Nerve |
|
|
| ||
Peroneal Nerve |
|
|
Resources[edit | edit source]
Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion
Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion
References [edit | edit source]
- ↑ Mayo Clinic. Peripheral Neuropathy. Available from: https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 (Last Accessed 24/03/2019)
- ↑ 2.0 2.1 2.2 Campbell WW. Evaluation and Management of Peripheral Nerve Injury. Clinical Neurophysiology. 2008 Sep 30;119(9):1951-65.
- ↑ 3.0 3.1 Lathia C, Skelton P, Clift Z. Early Rehabilitation in Conflicts and Disasters. Handicap International: London, UK. 2020.
- ↑ 4.0 4.1 Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences; 2020 Dec 23.
- ↑ Lee SK, Wolfe SW. Peripheral Nerve Injury and Repair. Journal of the American Academy of Orthopaedic Surgeons. 2000 Jul 1;8(4):243-52.
- ↑ 6.0 6.1 Menorca RM, Fussell TS, Elfar JC. Peripheral Nerve Trauma: Mechanisms of Injury and Recovery. Hand Clinics. 2013 Aug;29(3):317.