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Treatment: Localised external beam radiotherapy; topical
chemotherapy (bexarotene gel/carmustine ointment); phototherapy; total skin electron beam therapy; extracorporeal
photochemotherapy. Bexarotene is a type of retinoid.
Sezary syndrome is a type of cutaneous T cell lymphoma
with skin lesions with special Sezary cells having cribriform
nucleus. It is often associated with leukaemias. It is treated
like any other cutaneous T cell lymphoma.
Tumour Lysis Syndrome (TLS)
It is due to release of intracellular components of malignant cells
due to the effect of chemotherapeutic agents or spontaneous
SRB’s Manual of Surgery
activity of the tumor burden. Released components are—
potassium, phosphate and nucleic acid. Nucleic acids are broken
into xanthine and hypoxanthine and then uric acid by xanthine
oxidase. Uric acid may precipitate in the renal collecting duct and
cause renal failure. Effects are—hyperuricaemia, hyperkalaemia,
hyperphosphataemia, secondary hypocalcaemia, metabolic
acidosis. Presentations are—nausea, vomiting, diarrhoea,
anorexia, lethargy, hematuria, heart failure, arrhythmias,
convulsions, muscle cramps, tetany, syncope and sudden death
can occur. It is commonly associated high-grade NHL and acute
lymphoblastic leukemia (ALL). Factors associated with this
are—high tumour cell proliferation rate; chemosensitivity of the
malignancy; bulky disease; WBC count >50,000/m; preexisting
reduction in renal function; oliguria and volume depletion.
Treatment of TLS are—hyperhydration with 1.5–2.0 times the
normal maintenance fluid requirement; Allopurinol, should
be started early and adequately; urate oxidase which inhibits
formation of uric acid crystals.
CHYLOUS ASCITES
It is collection of lymph in the peritoneal cavity. It is due to
obstruction of intestinal lymphatics and subsequent leak.
Causes
Most common cause is—congenital lymphatic abnormality in
children (megalymphatics with lymphoedema) and in adults
lymph node malignancy, either primary or secondary.
Filarial lymphoedema causing obstruction.
Malignancy either nodal secondaries or nodal primary causing
obstruction.
Tuberculosis causing blockage of lymph drainage and rupture
and leak into the peritoneal cavity.
Post-surgical cause.
Features
Ascites, often massive.
Severe malnutrition and protein deficiency.
Features specific to the cause.
Triglycerides >110 mg/dl in ascitic fluid is diagnostic.
Ascitic fluid aspiration is chalky white in colour and it shows
chylomicrons. It should be studied for fat globules, proteins,
AFB and malignant cells.
Laparoscopy and biopsy is necessary when lymphoma/
secondaries are suspected.
CT scan and CT guided biopsy may be needed.
Lymphangiography to find out the site of leak.
Treatment
¾
Control of infection.
¾
Antituberculous and antifilarial drugs.
¾
Fat free, protein rich diet.
¾
Nutritional support—TPN/enteral.
¾
Medium chain triglycerides can be given as it directly
gets absorbed into the blood rather into the lymphatics.
¾
Repeated tapping, peritoneovenous shunts are often
required.
¾
Surgical ligation of leaking lymphatic duct.
CHYLOTHORAX
It is accumulation of lymph in the pleural cavity.
It is common on right side because of long course of thoracic
duct towards right side.
Causes
Injury due to trauma/surgeries in neck or chest. Surgical
trauma is the most common cause— may be oesophageal
surgeries, pneumonectomy, cervical sympathectomy, neck
dissections or aortic surgeries.
Tuberculosis, lymphoma or secondaries in the mediastinum.
Carcinoma lung or oesophagus.
Features
¾
Chest pain, dyspnoea, pleural effusion.
¾
Protein loss and malnutrition
¾
Pleural tap will show chalky white fluid rich in chylomicrons. Triglycerides more than 110 mg/dl in the pleural
fluid.
¾
Chest X-ray, CT chest are needed.
Treatment
¾
ICT drainage, oral diet of medium chain triglycerides which
is absorbed directly into blood not through lymphatics;
with TPN, is the usual earlier way of management.
¾
Antibiotics therapy for the cause.
¾
Often pleurodesis using bleomycin, talc, tetracycline or
pleural stripping is needed.
¾
Thoracic duct ligation is beneficial in traumatic/iatrogenic
cases.
¾
Through thoracoscopic approach, ligation of the thoracic
duct is done if leak persists beyond one week. If oral
cream is given to the patient 6 hours before surgery,
leaking site will be better identified. Thoracic duct is
ligated above and below the leak either through thora-
coscopy or thoracotomy.
CHYLURIA
It is passage of milky white chylous urine, which is aggravated
after fatty meal.
It may be due to obstruction of intestinal lymphatic vessels
leading to high lymphatic pressure causing diversion of lymph
into renal lymphatics or it often may be due to rupture of
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intestinal lymphatics into renal pelvis or ureter leading into
a lymphourinary fistula.
The most common cause is filarial (2% of filarial cases):
Other causes are tumour, tuberculosis, malaria and ascariasis
infestation.
Urinary infection, protein loss is common.
It mimics bacterial/tuberculous pyuria or phosphaturia.
Clot colic due to lymph clot in urinary system may be the
presentation.
Urine study, culture, IVU, lymphangiography, U/S abdomen
is needed.
Treatment is low fat, protein rich diet, antibiotics, DEC, plenty
of oral fluid intake, ligation of dilated lymphatics through
laparotomy or sclerosing the lymph vessels.
Condition causes severe psychological and nutritional
problem.
A B
Figs. 1.459A and B: Gross feature of sarcoidosis of spleen
(Courtesy: Dr Arunkumar, M
Ch, Gastroenterologist).
257
CHAPTER 1O General Surgery: Lymphatics
SARCOIDOSIS
It is a differential diagnosis for lymph node mass. It is basically
a granulomatous condition of unknown cause with bilateral
hilar lymphadenopathy; with involvement of lungs, liver, spleen,
lymph nodes, lacrimal glands, parotid glands, CNS, hypercalciuria, acute onset of erythema nodosum in the skin. Fever and
loss of weight are not common. It shows noncaseating epithelioid granuloma with positive Kveim-Siltzbach skin test (80%);
high levels of serum angiotensin converting enzyme (SAGE).
Investigations needed are—CT chest; mediastinoscopy; nodal
biopsy; slit lamp examination of eye; often abnormal immunoglobulins in the circulation. It is treated by corticosteroids with
good response. It should be differentiated from other causes of
lymphadenopathy especially Hodgkin’s lymphoma.
Note:
For topics tuberculous lymphadenitis and lymph node secondaries please
refer chapter ‘Neck’.
Courage is fear that has said its prayers.
C hapter Outline
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P. Peripheral Nerves
·
Peripheral Nerve Injuries
·
Tinel’s Sign
·
Brachial Plexus Injuries
·
Causalgia
·
Median Nerve Injury
·
Carpal Tunnel
Syndrome
·
Ulnar Nerve Injury
·
Claw Hand
·
·
·
·
·
·
·
PERIPHERAL NERVE INJURIES
Radial Nerve Injury
Common Peroneal
Nerve Injury
Foot Drop
Medial Popliteal Nerve
Injury
Axillary Nerve Injury
Long Thoracic Nerve
Injury
Meralgia Paraesthetica
Fig. 1.461: Dermatomes.
SUNdERLANd’S CLASSIFICAtIoN
B
I: Conduction block—temporary neuronal block
II: Axonotmesis but endoneurium is preserved
III: Axonotmesis with disruption of endoneurium, but perineurium
is preserved
IV: Here disruption of endo and perineurium has occurred but
epineurium is intact
V: Neurotmesis with disruption of endo, peri and epineurium has
occurred
Fig. 1.460: Cross-section of a nerve.
Classication
SEddoN’S CLASSIFICAtIoN
B
x Neuropraxia: It is temporary physiological paralysis of nerve
conduction. Here recovery is complete. There is no reaction of
degeneration.
x Axonotmesis: It is division of nerve fibres or axons with intact
nerve sheath. There is reaction of degeneration distally with
near complete recovery. Patient can present with sensory loss,
paralysis of muscles or causalgia.
x Neurotmesis: Here complete division of nerve fibres with sheath
occurs . Degeneration occurs proximally up to the first node of
Ranvier as well as distal to the injury. Recovery is incomplete even
after nerve suturing. There is complete loss of motor and sensory
functions with loss of reflexes. If the nerve is mixed type other
than pure motor or sensory recovery is still poorer.
Injuries may be incised or lacerated or crushed one.
Cut end of the nerve forms proximally neuroma and distally
glioma.
Neuromas may be:
¾
True neuroma or false neuroma.
¾
End neuroma or side neuroma.
Clinical Features
¾
Loss of sensory, motor, autonomous and reflex functions.
¾
Secondary changes in the skin and joint.
Management
¾
Associated injuries like fracture, vessel injury, injuries
in other systems should be looked for.
Investigations
relevant for associated injuries.
¾
Assessment of nerve injury is done by checking sensation, muscle power, reflexes and Nerve conduction
studies.
Exploration of the wound, Debridement of the area is done.
If injury is incised one, then nerve is sutured with 8-0 to
10-0 non absorbable interrupted sutures (polypropylene).
Primary nerve suturing is done if it is a clean incised wound.
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Secondary nerve suturing is done after 3 weeks if it is a
crushed wound.
Types of Nerve Suturing
Usually microscope or loup is used for nerve suturing.
Epineurorrhaphy: Only epineurium is sutured using inter-
i.
rupted sutures.
ii. Epi-perineurorrhaphy: Initially perineural sheath and then
epineurium is sutured.
Nerve suturing can be:
¾
Primary repair: It is done immediately after injury. Nerve
ends are minimally trimmed very close using a blade.
All fascicles of the nerve are oriented correctly. Two
stay sutures are placed to keep the orientation properly.
Usually epineural suturing is done using 8-0 polypropylene interrupted sutures. It needs magnification. 6–8
sutures are placed for large peripheral nerve like median
or ulnar nerve. For small nerve like digital nerve, only 2–3
sutures are placed.
¾
Secondary repair: It is done at a later period. It is done
in a preexisting scar tissue. Here first nerve ends, both
proximal and distal are identified, carefully dissected
adequately. Proximal neuroma and distal glioma are
trimmed for 1 cm to expose the normal fascicles of the
nerve ends. Often guide sutures of silk may be present
which were placed earlier during exploration of the
trauma. Once nerve ends are clean, it is sutured alike
primary suturing with stay sutures, with proper alignment of fascicles, followed by epineural suturing. Here
as epineurium is thicker, suturing is easier.
Note
• If nerve is lacerated, then marker stitches (using silk) are placed at the
cut end site to identify the nerve for suturing at a later period.
• If nerve suturing fails or if could not be done, then tendon transfer is
done at a later period after 4–6 months.
• Incomplete injury usually does not require any suturing.
Easier suturing is achieved by following methods:
• Relaxing incisions, Positioning of the limb.
• Transpositioning of the nerve, Shortening of the bone.
• Nerve graft—usually sural nerve is used for nerve graft.
• Initially neurolysis (release of the scar tissue adjacent to injury) is
done in case of secondary suturing.
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CHAPTER 1P General Surgery: Peripheral Nerves
Fig. 1.462: Primary nerve repair.
Fig. 1.463: Secondary nerve repair.
tINEL’S SIGN
It is the clinical sign (prognostic indicator) used to assess the
level of regeneration. It is elicited 3 weeks after the nerve injury
(Regeneration begins after the completion of nerve degeneration).
Tapping over the course of the nerve is done from distal to
proximal to elicit a sensation of “pins and needles” or hyperaesthesia.
If sensation is felt at the site as well as distally along the
distribution of the nerve, that means good recovery can be
expected. If sensation is felt only at the site of tapping, then
result is equivocal. If no sensation is felt it means no recovery.
Prognostic factors in healing of the nerve injury:
Higher the lesion worse the prognosis.
More the gap between the cut ends worse the prognosis.
Associated injuries alter the prognosis.
Children do better with nerve injury.
Type of the injury also decides the prognosis.
The rate of growth of nerves after peripheral nerve suturing
is 1 mm/day.
CAUSES oF PERIPHERAL NERVE LESIoNS
B
x Traumatic: Either closed or open injury
x Inflammatory: Leprosy, herpes zoster, dipht he ria
x Compression neuropathies
x Lead and Arsenical poisoning
x Alcoholism, Diabetes mellitus, Porphyria
x Vitamin B
x Neurofibroma and other neural tumours
x Idiopathic
deficiency
1
Respond intelligently even to unintelligent people.
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SRB’s Manual of Surgery
BRACHIAL PLEXUS INJURIES
Fig. 1.464: Brachial plexus anatomy.
It can be:
Supraclavicular injury 65%
Infraclavicular injury 25%
Combined 10%
It can also be:
Upper plexus injury.
Lower plexus injury.
It can be:
Pre-ganglionic injury Post-ganglionic injury
Avulsion injury Usually less severe
More dangerous Better recovery
Extends into the spinal cord
Investigations: Nerve conduction studies; CT/MRI;
Electromyogram; X-ray cervical spine and part.
Treatment
¾
Conservative, nerve repair.
¾
Tendon transfer, physiotherapy.
¾
Osteotomy of coracoid process proximal to the attachment
of pectoralis minor, short head of biceps and coracobrachialis is done to improve abduction—Sever’s operation.
CAUSALGIA
It is severe burning pain and hyperaesthesia in the distribu-
tion of a peripheral nerve due to incomplete injury to the
nerve.
Sites: Common in upper limb; Commonly seen in median
nerve, also often in brachial plexus injuries. In the lower limb
it is seen in sciatic nerve or tibial nerve injuries.
Pathology: Incomplete nerve injury produces abnormal
impulse towards sensory nerve ending causing vasomotor
instability and pain.
Features
¾
Hyperaesthesia with severe disabling and burning pain.
¾
Skin becomes red, shiny and glossy which sweats
profusely—Weir-Mitchell’s skin.
¾
Eventually skin becomes atrophic, cyanotic, cold and
blotchy.
¾
Skin is less sensitive to heat, cold, and pin prick, but
hypersensitive to touch and tender to pressure.
¾
Nails are rigid, brittle with change in colour.
¾
Investigation: Nerve conduction studies.
¾
Treatment:
–
Anti-inflammatory drugs, steroids, physiotherapy.
–
IV guanethidine regionally.
–
If not improved, sympathectomy—cervical for upper
limb, lumbar for lower limb.
MEdIAN NERVE INJURY
Median nerve arises from lateral (C
(C
and T1) of the brachial plexus. It is initially lateral to the
8
axillary artery and becomes medial in the lower part of the
arm and in the cubital fossa. It passes through the pronator
teres, descends in relation to flexor muscles and enters the
palm through the carpal tunnel at the wrist.
It supplies pronator teres, flexor carpi radialis, palmaris
longus and flexor digitorum superficialis. Anterior interos-
seous branch of the median nerve supplies pronator teres,
lateral half of the flexor digitorum profundus, flexor pollicis
longus and pronator quadratus.
) and medial cord
5, 6, 7
Features of upper and lower plexus injuries
T
Upper plexus injury (Erb-Duchenne paralysis) Lower plexus injury (Klumpke’s paralysis)
1. It is due to depression of shoulder by trauma 1. Forcible hyperabduction of shoulder causes this injury
2. After difficult labour in newborn 2. In newborn it result due to difficult breech delivery
3. Here C
4. Muscles affected are deltoid, biceps brachioradialis and
5. Effects are: 5. Effects are:
a. Elbow will be extended, pronated and upper limb is
and C6 roots are injured 3. Here C8 and T1 are injured
5
supinator
internally rotated (Policeman receiving tip)
b. Sensory deficit over the lateral aspect of arm and
upper part of the lateral forearm
4. Intrinsic muscles of the hand are involved
a. Combined median and ulnar claw hand
b. Horner’s syndrome
c. Sensory deficit over the medial aspect of forearm, hand, and
medial 1½ finger
In the wrist, it supplies abductor pollicis brevis, flexor pollicis
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and opponens pollicis of thenar emi
nence and lateral two
lumbricals. It gives sensory supply to lateral three and half
fingers of the hand.
MEdIAN NERVE IS AFFECtEd IN
B
x Injuries
– Supracondylar fracture of the elbow
– Fracture—dislocation of the elbow
– Direct cut injuries
x Leprosy
x Carpal tunnel syndrome
x As a part of brachial plexus injury
Features of Median Nerve Palsy
In high median nerve palsy
Wasting of the thenar eminence. Loss of sensation on lateral
three and half fingers.
Ochsner’s clasping test shows pointing index because of the
inactivity of lateral two divisions of the profundus.
“Ape or Simian thumb deformity” is due to overaction of the
adductor pollicis which is supplied by the deep branch of
ulnar nerve. As all other thenar muscles are paralysed, thumb
comes in the same plane of the metacarpals.
“Pen test”: In median nerve injury, pen held in front of
the hand cannot be touched by thumb as abduction is not
possible due to paralysis of the abductor pollicis brevis.
In low median nerve palsy profundus is not paralysed and
so pointing index is not seen.
Investigations:
Nerve conduction studies; X-ray of the part
in case of fracture; Electromyogram.
Treatment: Nerve suturing or nerve graft; Tendon transfer;
Treat the cause like carpal tunnel syndrome.
CARPAL tUNNEL SYNdRoME
It is the compression neuropathy of median nerve in the
carpus, deep to flexor retinaculum.
Flexor retinaculum (transverse carpal ligament) maintains
the concavity of wrist and extends laterally from trapezium
and scaphoid to pisiform and hook of the hamate medially.
Carpal tunnel is formed by carpal bones behind and flexor
retinaculum in front. It contains median nerve and long flexor
tendons of fingers and thumb. Ulnar nerve lies superficially,
not in the carpal tunnel.
Median nerve gets compressed if space of the carpal tunnel
gets reduced.
Causes: Lunate dislocation, malunited Colle’s fracture; Radio-
carpal arthritis, flexor tendon tenosynovitis; Myxoedema,
acromegaly, pregnancy.
Features
¾
Common in females.
¾
Tingling, numbness, paraesthesia and burning sensation
in the lateral three and half fingers supplied by median
nerve. Burning sensation gets aggravated at night.
¾
Ape thumb deformity, wasting of thenar muscles, weakness of opponens pollicis and abductor pollicis brevis,
i.e. features of low median nerve palsy.
¾
When BP cuff is inflated patient feels the typical pain in
the fingers.
¾
Tapping the median nerve at the distal end of forearm
with the wrist held in extension aggravates the symptoms.
¾
Condition is often bilateral.
¾
Phalen’s Test (Wrist Flexion Test): Flexion of the wrist
causes exacerbation of the symptoms within 1 minute and
the symptoms will disappear as the wrist is straightened.
Differential Diagnosis:
Cervical spondylosis; Cervical rib
syndrome.
Investigation: Nerve conduction studies; X-ray/MRI neck.
Treatment
Carpal tunnel release is cutting the both layers of the flexor
retinaculum/transverse carpal ligament adequately to relieve the
compression of the median nerve and so treating the neuropathy.
Open or endoscopic minimally access surgery or using needle
and thread can be used to release.
Open carpal tunnel release surgery (OCTR):Tourniquet is
applied. It is done under LA or Bier’s block or brachial block.
GA is occasionally used. Incision is along the web space bet
the mid and ring fingers—3rd web space or inner border of
middle finger; distal end of incision ends at Kaplan’s line. This
line is - line drawn on the medial surface of the abducted thumb
joining up to the hook of the hamate (from the apex of the skin
fold between thumb and index finger to the hook of the hamate).
Proximal extension of the incision is up to wrist crease or
variable but ideally should not cross the wrist crease. Incision
is just medial to the curved crease and straight, longitudinal
ideally; even though many advocate slight curved incision with
convexity towards ulnar side parallel to the crease line. Palmar
cutaneous nerve of the median nerve should be safeguarded;
so incision should be medial (towards ulnar side); this nerve
arises 4 cm proximal to wrist crease travels along the flexor
carpi radialis (FCR) tendon and hence skin incision has to be
medial. Double hook retractor or mastoid retractor is used to
retract cut skin edges. Deep fascia–palmar aponeurosis is cut
longitudinally; Deep dissection once is done, transverse carpal
ligament (flexor retinaculum) is identified; origin of thenar
muscles are identified to confirm the structure as transverse
carpal ligament. After making a small incision in transverse
carpal ligament, McDonald retractor is placed underneath
to protect the just underlying median nerve which is whitish
shiny stout longitudinal structure. Ligament is cut distally up to
visibility of the fat; fat visibility marks the end of the transverse
carpal ligament release. Entire ligament should be cut completely
to avoid recurrence. Proximally deep fascia of the forearm
is cut up to 3 cm from the wrist line subcutaneously without
extending the skin incision proximally; tourniquet is released.
Haemostasis maintained using bipolar cautery or fine ligatures.
261
CHAPTER 1P General Surgery: Peripheral Nerves
It’s how you deal with failure determines how you achieve success.
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SRB’s Manual of Surgery
A B
Figs. 1.465A and B: Anatomy of the carpal tunnel and flexor retinaculum.
Skin is used using 3 zero polypropylene sutures using curved
cutting needle; dressing is placed; 4” crepe bandage is applied
for few days; sutures removed in 7–10 days. Postoperative
exercise is required during recovery period. Cutaneous nerve
or median nerve injury; incomplete release; bleeding by injuring
arches of the palm; scar and contracture development; wound
infection; persistent wrist pain—are complications of surgery.
Fig. 1.466: Incision for carpal tunnel syndrome.
tissue and deep fascia is not cut; it is minimally invasive method
with fast recovery and is also done under LA. But chances of
recurrence are slightly higher compared to open transverse
carpal ligament release. Chow two portal device or 3 M Agee
single portal devices are available for endoscopic release.
Newer method called thread carpal tunnel release (TCTR) is
being advocated. Under LA, under sonological guidance spinal
needle is passed underneath the transverse carpal ligament from
distal (hand) to proximal (wrist); fine thread is passed through
this needle from proximal to distal; needle is removed and
reinserted again from distal to proximal but this time in front of
the transverse carpal ligament under the skin and subcutaneous
tissue; proximal end of the remaining thread is passed through
the needle to reach distally so that both ends of the thread will be
distal encircling the transverse carpal ligament. Frictional effect
of the thread (sawing like) is utilised here to cut the carpal ligament by repetitive sawing motion of the ends of thread.
Balloon carpal tunnelplasty is under experimental stage wherein
through a small incision distal to wrist crease under endoscopic
guidance a balloon is passed under the transverse carpal ligament and is inflated to widen the space.
Adequate postoperative physiotherapy is required.
Fig. 1.467: Open method carpal tunnel release.
In endoscopic carpal tunnel release (ECTR), two ports are
placed in the distal forearm one for telescope another for cutting
the transverse carpal ligament under vision. Here subcutaneous
ULNAR NERVE INJURY
After arising from the medial cord of the brachial plexus (C
), it runs on the medial aspect of the axillary artery up to
and T
1
middle of the arm. Then it enters the posterior compartment
in relation to triceps muscle. After passing behind the medial
epicondyle and through two heads of flexor carpi ulnaris, it
runs in front of the flexor digitorum profundus (FDP) in the
forearm. It reaches the hand in front of the flexor retinaculum
through “Guyon’s canal”. Here it divides into superficial and
deep branches.
Ulnar nerve supplies flexor carpi ulnaris, medial half of flexor
digitorum profundus, all muscles of the hypothenar eminence
(palmaris brevis, abductor digiti minimi, opponens digiti
8
minimi, flexor digiti minimi), adductor pollicis of the thenar
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eminence and all interossei of the hand. It also gives sensory
supply to medial part of the hand, medial one and half fingers.
ULNAR NERVE IS AFFECtEd IN
B
x Supracondylar fracture
x Injury to the medial epicon-
dyle
x Tardy ulnar palsy
x Leprosy
x Cubitus valgus deformity
Features
Claw hand deformity.
Weakness of all the muscles supplied by the ulnar nerve.
“Card test”: A card is placed between the two fingers of the
patient to grasp. As the palmar interossei are weak, patient
cannot grasp [palmar interossei are adductors of the fingers
(PAD)].
Abduction of fingers are checked [dorsal interos sei are
abductors (DAB)].
Froment’s sign: A book is placed to grasp between fingers and
thumb of the patient. Normally thumb will be straight because
of the action of adductor pollicis muscle. As it is paralysed in
ulnar palsy, grasp is achieved by the action of flexor pollicis
longus and there will be flexed thumb.
Loss of sensation over medial one and half fingers and hand.
Investigations: Nerve conduction studies; Electromyogram.
Treatment: Nerve suturing or nerve grafting; Tendon transfer.
Note:
• Intrinsic minus deformity: It is due to loss of intrinsic muscle power,
i.e claw hand.
• Intrinsic plus deformity: It is due to muscle contracture and fibrosis.
• Ulnar paradox: In ulnar palsy, higher the lesion, lesser the deformity,
lower the lesion more the deformity. In higher lesion, FDP is also paralysed. In lower lesion FDP is intact and so FDP causes more flexion
(over action) and so aggravates the claw hand.
A
B
Figs. 1.468A and B: Ulnar claw hand with hyperextension of
metacarpophalangeal joints and flexion of proximal and distal inter
phalangeal joints in medial two fingers due to ulnar nerve palsy.
A
263
CHAPTER 1P General Surgery: Peripheral Nerves
-
CLAW HANd
It is the hyperextension of the metacarpopha langeal joint with
flexion of the interphalangeal joints of the hand.
Extension of MCP joint is due to unopposed action of extensor
digitorum.
Flexion of MCP joint and extension of interpha langeal joints
are by extensor hood of interossei and lumbricals. So
extensor hood is functioning mainly by ulnar nerve and also
by median nerve. In ulnar or median nerve palsies, these
actions are paralysed and so patient develops claw hand.
It is actually intrinsic minus deformity.
Causes: Leprosy; Trauma; Entrapment neuropathies; Tardy
ulnar palsy; Klumpke’s palsy.
Features
¾
Typical claw hand.
¾
Loss of sensation along the distribution of the nerve.
¾
Inability to grasp card between the fingers.
¾
While holding the book between the thumb and fingers,
thumb will be flexed in ulnar claw hand (positive
Froment’s test).
Defeat is not nal when you fall down; it is nal only when you fail/refuse to get up.—Gosta Norlen
B
Figs. 1.469A and B: Combined claw hand involving all fingers due
to both ulnar and median nerve injuries.
Types
¾
Ulnar claw hand: Only medial two fingers are involved.
–
Low ulnar palsy: Here lesion is in the wrist (at Guyon’s
canal). Here deformity is more because of the over
action of the FDP.
–
High ulnar palsy: Here FDP is also paralysed and
over action is not there. So lesser deformity occurs.
-
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Ulnar paradox: Higher the lesion lesser the deformity,
lower the lesion more the deformity.
¾
Median claw hand: Only lateral two fingers are involved.
It is less common.
¾
Combined median and ulnar claw hand: Here all four
fingers of the hand are involved.
Investigations: Electromyogram; Nerve conduction studies.
Treatment:
¾
Paul Brand’s operation: Extensor carpi radialis longus or
brevis (ERCB) is transferred with a graft to the extensor
hood through the lumbrical canal. Graft is taken from
palmaris longus or plantaris muscle.
¾
SRB’s Manual of Surgery
Stye-Bunnell’s operation: Flexor digitorum super ficialis
of index finger is used (only in ulnar claw hand) to transfer
to extensor hood.
¾
Fowler’s operation: Extensor digitorum is used to transfer
to extensor hood.
¾
Riordan operation: Flexor carpi radialis is used for tendon
transfer.
¾
Anterior transpositioning of the ulnar nerve in case of
tardy ulnar palsy.
RAdIAL NERVE INJURY
Deep branch also called as posterior interosseous nerve
winds round the radius supplying supinator and extensor
carpi radialis brevis. It gives three short branches to extensor
digitorum, extensor digiti minimi and extensor carpi ulnaris.
It also gives two long branches—one to abductor pollicis
longus and extensor pollicis brevis; another to extensor
pollicis longus and extensor indicis.
Clinical Features
Wrist drop because of inability of extending the wrist.
Inability to extend metacarpophalangeal joint, but extensions
of the interphalangeal joints are normal.
Inability to extend the forearm.
Inability to extend the thumb.
Flexion of the elbow against resistance with forearm in mid-
prone position is difficult because of the weakness of the
brachioradialis muscle.
Loss of sensation in back of the arm, forearm, hand and
lateral three and half fingers.
Posterior interosseous nerve is purely motor and so sensation
is intact when it gets injured. It causes only dropped fingers.
Investigations: X-ray of the part; Nerve conduction studies.
Treatment: Nerve suturing or nerve graft; Tendon transfer.
Radial nerve is derived from the posterior cord of the brachial
plexus (C
in front of the sub
and T1). It descends behind the axillary artery
5, 6, 7, 8
scapularis, latissimus dorsi and teres major.
It passes through the medial and lateral heads of the triceps
muscle, winds round the humerus through the radial groove
and enters the forearm in front of the lateral epicondyle in
relation to brachio
radialis, brachialis and extensor carpi
radialis longus muscles.
In the arm it supplies triceps, anconeus, brachio radialis,
extensor carpi radialis longus and part of brachialis. It gives
posterior and lower lateral cutaneous nerves of the arm and
posterior cutaneous nerve of the forearm.
Superficial branch of the radial nerve from the elbow runs
in the forearm in relation to supinator and brachioradialis
and ends by forming five digital nerves which gives sensory
supply to lateral three and half fingers on the dorsal aspect—
except skin over the distal phalanges.
CoNdItIoNS WHERE RAdIAL NERVE IS AFFECtEd
B
In the axilla
x Crutch palsy. It is neuropraxia
x Fracture upper end of the humerus
x Bony or soft tissue growth
In the radial groove
x Pressure on the arm from the edge of the operating table
x Saturday night palsy—an individual with excessive alcohol
consumption compresses his arm over the chair or by fall. It is
neuropraxia
x Prolonged tourniquet application—tourni quet palsy
x Fracture of the shaft of the humerus
x Rarely intramuscular injection of drugs can cause radial nerve
palsy
In the elbow
x Dislocation or fracture neck of the radius
Fig. 1.470: Wrist drop—due to radial nerve palsy.
CoMMoN PERoNEAL NERVE INJURY
This nerve supplies the extensor and peroneal group of
muscles and sensory supply to the skin over the front and
lateral aspect of the leg and dorsum of the foot.
Common peroneal nerve is affected in: Fracture neck of the
fibula; Leprosy; Lead poisoning; Iatrogenic.
Features:
Foot drop with high stepping gait; Talipes equinovarus deformity; Loss of sensation on the lateral side of the
leg and dorsum of the foot.
Management: Treating the foot drop; MCR chappals.
Foot dRoP
Inability to dorsiflex and evert the foot due to paralysis of
the peroneal and extensor group of muscles, as a result of
common peroneal nerve injury.
Causes: Fracture neck of the fibula; Leprosy; Lead poisoning;
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Iatrogenic; Direct incised wound
Features: High stepping gait; Loss of sensation over lateral
and dorsum of the foot.
Treatment
Tendon transfer using tibialis posterior muscle. Tendon of
the muscle is detached from its navicular insertion and with
a tendon graft (from plantaris) it is transferred to cuboid and
cuneiform bones to get dorsiflexion and eversion.
a. Ober’s procedure.
b. Barr’s procedure.
Fig. 1.471: Foot drop with claw toes. It is due to peroneal nerve
injury (Lateral popliteal nerve).
MEdIAL PoPLItEAL NERVE INJURY
It supplies the soleus, gastrocnemius, popliteus, plan taris, tibialis posterior, flexor digitorum longus and flexor hallucis longus.
Medial popliteal nerve is rarely involved by any disease
process. Trauma can cause medial popliteal nerve palsy.
Axillary nerve is affected in: Fracture neck of the humerus;
Dislocation of humeral head; Following IM injection into the
deltoid.
Clinically, there will be loss of abduction of the shoulder and
anaesthesia of the skin over the lateral part of the arm.
LoNG tHoRACIC NERVE INJURY
(Nerve of Bell)
It supplies serratus anterior muscle. It arises from C
cervical roots. The nerve is injured commonly in malignancy,
during breast, axillary or chest wall surgeries.
Clinically, when outstretched (elbow extended) arm is pushed
against the wall, the inferior angle of the scapula will become
prominent (Winging of the scapula).
MERALGIA PARAEStHEtICA
(Meralgia – Greek – thigh)
It is entrapment neuropathy of lateral cutaneous nerve of
thigh. Nerve gets compressed while passing through the
inguinal ligament. It arises from posterior divisions of lumbar
plexus (L
muscles; emerges behind the lateral part of the inguinal ligament; divides into anterior and posterior branches, supplying
skin over anterolateral part of the thigh and anterior part of
the gluteal region.
It causes hyperaesthesia, tingling over upper lateral aspect
of the thigh along the distribution of the nerve. Symptoms
get worsened on standing or walking; it is relived by sitting.
It mimics disc prolapse or Hansen’s disease or neuropathies.
It is treated by reassurance; carbamazepine; steroids. Often
release of inguinal ligament fibres that are compressing the
nerve is needed.
); runs over the quadrates lumborum and iliacus
2, 3
265
CHAPTER 1P General Surgery: Peripheral Nerves
5, 6, 7
CLINICAL FEAtURES
B
x Inability to plantar flex the foot
x Claw toes
x Sensory loss in the sole of the foot
AXILLARY NERVE INJURY
Axillary nerve supplies the deltoid and teres minor muscle
and also sensory supply to the skin over the upper lateral
aspect of the arm.
Fig. 1.472: Lumbar plexus showing origin of lateral
cutaneous nerve of thigh.
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