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Peripheral Nerve Examination
Published in J. Terrence Jose Jerome, Clinical Examination of the Hand, 2022
Mohammed Tahir Ansari, Santanu Kar, Devansh Goyal, Dyuti Deepta Rano, Rajesh Malhotra
HFU is especially helpful in trauma scenarios and compressive neuropathy syndromes. The nerve fascicles can be visualized, and interpretations can be made as 1) Complete transection/incomplete injury. 2) End neuroma/neuroma in continuity/fascicle disruptions due to fibrosis. 3) Intraneural hematoma/traction injury. 4) External compression by fracture end, bone fragment, screw or another hard. 5) Compressive neuropathy due to any aberrant compressive lesion, etc. [38–40]. Magnetic resonance neurography (MRN)
Resource-Limited Environment Plastic Surgery
Published in Mansoor Khan, David Nott, Fundamentals of Frontline Surgery, 2021
Johann A. Jeevaratnam, Charles Anton Fries, Dimitrios Kanakopoulos, Paul J. H. Drake, Lorraine Harry
Each tissue is variably susceptible to the mechanism of injury. Skin, the largest organ of the body, is particularly vulnerable to sheer and torsional forces, which disrupt the delicate network of vascular plexi that supply it from the underlying tissue planes. Large areas of skin can effectively be ‘degloved’ or lifted off the fascial and subfascial vasculature, struggling to survive. However, this may not be evident immediately and can take several days to evolve and declare itself as non-viable. The underlying fat is far more at risk from trauma compared to its durable cover. Fat is easily injured, often beyond the zone of skin injury. Necrosis quickly ensues once blood supply is interrupted, with the potential to form discrete nodules which undergo liquefactive necrosis. Muscle tissue can be bruised, sprained by stretch, or lacerated, with variable degrees of injury severity. It is extremely sensitive to direct trauma, where tearing and subsequent necrosis of the myofibrils creates space for haematoma formation and proliferation of inflammatory cells, as part of the repair process. Finally, nerve injury is well described and can be classified from mild bruising (neuropraxia) to complete disruption of the fascicles (neurotmesis), corresponding to cell death and loss of ability to transmit sensory or motor impulses.
Surgery of the Peripheral Nerve
Published in Timothy W R Briggs, Jonathan Miles, William Aston, Heledd Havard, Daud TS Chou, Operative Orthopaedics, 2020
Ravikiran Shenoy, Gorav Datta, Max Horowitz, Mike Fox
Earlier surgery following nerve injury permits easier identification of tissues (due to less scar tissue) and therefore any repair is easier as it is possible to visualise and match the arrangement of the cut ends of the nerve fascicles. The results of prompt repair are also markedly better due to the favourable biological environment for nerve healing. A nerve stimulator should be available. Magnification of at least three times with loupes is helpful. If nerve grafting is likely to be performed, a suitable donor graft should be identified preoperatively and the patient made aware of the need.
Chameleons, red herrings, and false localizing signs in neurocritical care
Published in British Journal of Neurosurgery, 2022
Boyi Li, Tolga Sursal, Christian Bowers, Chad Cole, Chirag Gandhi, Meic Schmidt, Stephan Mayer, Fawaz Al-Mufti
Superior divisional third nerve palsy, which presents as upper eyelid ptosis and limited supraduction without pupillary involvement, is typically associated with lesions localized to the anterior cavernous sinus and or superior orbital fissure compressing the superior division of the oculomotor nerve.17 However, other etiologies have been found to include those further from the expected sites, such as intrinsic brainstem disease, metastatic subarachnoid infiltration, and superior cerebellar–posterior cerebral artery junction and the basilar artery apex aneurysms.17–20 Despite similar clinical presentation, varying etiologies are a consequence of topographical arrangement of fascicles within the nerve, of which there can be anatomical variation.17,18 Clinicians should remain aware that superior divisional CN III may suggest a more distal intracranial lesion and perform appropriate diagnostic imaging studies.
Shoulder abduction reconstruction for C5–7 avulsion brachial plexus injury by dual nerve transfers: spinal accessory to suprascapular nerve and partial median or ulnar to axillary nerve
Published in Journal of Plastic Surgery and Hand Surgery, 2022
Gavrielle Hui-Ying Kang, Fok-Chuan Yong
The donor median or ulnar nerve and biceps branch of musculocutaneous nerve were identified via the same anterior axillary incision extended distally. (Figure 3) A partial longitudinal epineurotomy was made on the donor nerve for intra-operative nerve stimulation to identify suitable donor fascicles. For the median nerve, suitable donors include the fascicles to wrist or finger flexors (FCR or FDS), or forearm pronator (PT). The suitable donor fascicles for the ulnar nerve would be the fascicles to the FCU. The donor fascicles were identified when strong muscle contractions were observed with nerve stimulation and isolated to the expandable muscle. Fascicles that did not elicit a response to nerve stimulation were assumed to be sensory fascicles and were spared. Fascicles that elicited a motor response to any of the flexor digitorum profundus or flexor pollicis longus on stimulation were spared as well. The chosen fascicles were then isolated with a vessel loop. The nerve fascicle that elicited the stronger muscle contraction was chosen for neurotization to the nerve to the biceps muscle. If the ulnar nerve and median nerve fascicles elicited similarly strong muscle contractions, the ulnar nerve was chosen for neurotization to the nerve to the biceps muscle. The other donor nerve fascicle was then utilized for neurotization to the axillary nerve.
Maximising recovery from aphasia with central and peripheral agraphia: The benefit of sequential treatments
Published in Neuropsychological Rehabilitation, 2019
Pélagie M. Beeson, Chelsea Bayley, Christine Shultz, Kindle Rising
A high-resolution MRI brain scan revealed left temporo-parietal damage that extended dorsally to the superior parietal lobule and ventrally to parieto-temporo-occipital junction (Figure 1). Lesion analysis was implemented by hand on a slice-by-slice basis followed by a normalisation procedure using cost-function masking as described in Andersen, Rapcsak, and Beeson (2010). Damage was evident in the mid to posterior superior temporal gyrus, the supramarginal and angular gyri, as well as extensive parietal damage that included the intraparietal sulcus. There was also a small area of damage in the right superior parietal lobule that was evident on acute diffusion weighted images (Figure 1). Diffusion tensor imaging revealed white matter damage affecting the left middle longitudinal fasciculus.