Holstein–Lewis Fracture
Raymond Anakwe, Scott Middleton in Trauma Vivas for the FRCS (Tr & Orth), 2017
There is some debate about how this fracture type should be ideally managed. The evidence shows that the vast majority of nerve injuries involve a neurapraxia and resolve over 3–6 months with non-operative treatment. Many surgeons believe that these distal fractures are difficult to manage with splints or braces although there are several reported series with good results. This fracture pattern is often considered a relative indication for surgery because of the relatively more common association with radial nerve injury and a perceived risk of non-union or elbow stiffness associated with brace or cast treatment although this is not supported by the literature.
Nerve
Manoj Ramachandran, Tom Nunn in Basic Orthopaedic Sciences, 2018
The degree of nerve injury affects the outcome. A neurapraxia comprises a transient concussion or crushing of the nerve. There is no Wallerian degeneration (see below), but instead there is a block to flow of nerve impulses, with consequent interruption of physical function. A neurapraxia has a favourable outcome, provided the source of the injury is removed. Axonotmesis and neuronotmesis have less favourable outcomes as they are degenerative lesions.
Peripheral nerve disorders
Ashley W. Blom, David Warwick, Michael R. Whitehouse in Apley and Solomon’s System of Orthopaedics and Trauma, 2017
The history is most helpful. A low-energy injury is likely to have caused a neurapraxia; the patient should be observed and recovery anticipated. A high- energy injury is more likely to have caused axonal and endoneurial disruption (Sunderland third and fourth degree) and so recovery is less predictable. An open injury, or a very high-energy closed injury, will probably have divided the nerve and early exploration is called for.
Differential diagnosis of knee pain following a surgically induced lumbosacral plexus stretch injury. A case report
Published in Physiotherapy Theory and Practice, 2019
William R. VanWye, Harvey W. Wallmann, Elizabeth S. Norris, Karen E. Furgal
Interestingly, peripheral nerve, which is uniquely complex tissue, is the only soft tissue that does not follow the classic physiological phases of healing (Bélanger, 2015). Seddon classified peripheral nerve injury into 3 degrees of injury. The least severe is neurapraxia, followed by axonotmesis, and finally, the most severe form, neurotmesis (Burnett and Zager, 2004). Neurapraxia is a functional injury meaning there is focal demyelination, which is transient in nature. Axonotmesis and neurotmesis are not only functional, but also anatomical, which entails a disruption of nerve continuity (Burnett and Zager, 2004). A neurapraxia can range from 1 day to 3 months with full recovery expected. Axonotmesis has the most variability in recovery time and prognosis. Sunderland further divides axonotmesis into three classifications (i.e. Sunderland II–IV). In Sunderland II axonotmesis, the axon is injured, but the endoneurial tube is normal. This generally results in full recovery in 1–6 months. In Sunderland III axonotmesis, the endoneurial tube is injured; in this case, the recovery is less certain with partial return expected in 12–24 months. Lastly, with the Sunderland IV axonotmesis, only the epineurium is intact (i.e. the outer layer of the nerve) and recovery requires surgical intervention. Neurotmesis is a loss of nerve continuity, requiring surgical intervention with unpredictable recovery (Goubier and Teboul, 2015). Considering the patient’s steady progress and full recovery, the stretch injury appeared to be consistent with either a neurapraxia or Sunderland II axonotmesis.
Current concepts review: peripheral neuropathies of the shoulder in the young athlete
Published in The Physician and Sportsmedicine, 2020
Tamara S. John, Felicity Fishman, Melinda S. Sharkey, Cordelia W. Carter
Peripheral neuropathies of the shoulder and upper extremity in the young athletic population – older children, adolescents and young adults – are uncommon, yet may result in significant pain and impairment. It is therefore important to understand the relevant anatomy, common injury mechanisms, characteristic clinical presentation, pertinent physical examination findings, diagnostic tools, treatment options and functional outcomes for these injuries. Furthermore, familiarity with standard terminology for nerve injuries is essential. Neuropraxia is the mildest nerve injury type, in which the nerve structure and its primary elements remain intact, but the myelin sheath is disrupted. The cause of a neurapraxia is typically a stretch mechanism and neurapraxias are often associated with complete functional recovery. Axonotmesis is a nerve injury in which the axon itself is disrupted in addition to its myelin sheath, although the endoneurial tubes and supportive tissues (perineurium, epineurium) remain intact. The mechanism of axonotmesis is typically a more severe stretch or crushing-type injury of the neural tissue. Finally, neurotmesis is the most severe form of nerve injury, in which there is complete nerve disruption. Neurotmetic injuries have the least potential for recovery. Fortunately, most sports-related peripheral neuropathies are either neurapraxic or axonotmetic in nature, rather than fully neurotmetic.
MR neurography of the brachial plexus in adult and pediatric age groups: evolution, recent advances, and future directions
Published in Expert Review of Medical Devices, 2020
Alexander T. Mazal, Ali Faramarzalian, Jonathan D. Samet, Kevin Gill, Jonathan Cheng, Avneesh Chhabra
As the most commonly encountered mechanism of injury to the brachial plexus, traumatic injuries are predictably a common indication for brachial plexus MRN. The aim of MRN in the setting of these injuries is twofold: A) to localize and survey the injury site and its extent, and B) to characterize the severity (grade) of injury. The two most widely utilized classification systems for grading of peripheral nerve injuries are those proposed by Seddon and Sunderland, respectively [45–48]. Seddon’s system was first described in 1943 and has remained popular due to its simplicity and three-tiered grading approach. Using this system, nerve injury is stratified into the following categories: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia refers to focal segmental demyelination without concomitant Wallerian degeneration distal to the injury site, implying the preservation of axonal structures. Neuropraxia generally occurs due to mild compression or traction to the nerve and leads to a decrease in conduction velocity through the injury site [49]. The clinical manifestations of neuropraxia can be variable depending on the extent of local demyelination, ranging from asymptomatic injury to muscle weakness [49]. Axonotmesis refers to a complete axonal injury with resultant distal Wallerian degeneration, but without disruption of the endoneurium or perineurium. Finally, neurotmesis refers to the most severe mechanism of injury described in this model, indicating complete transection of nerve axons and supportive connective tissue layers, resulting in complete discontinuity of proximal and distal nerve segments at the site of injury.