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Surgical Disorders of the Peripheral Nerves (eBook)

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2011 | 2nd ed. 2011
XXIII, 645 Seiten
Springer London (Verlag)
978-1-84882-108-8 (ISBN)

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Surgical Disorders of the Peripheral Nerves -  Rolfe Birch
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Since the highly praised first edition of Surgical Disorders of the Peripheral Nerves was published in 1998, greater understanding of the the molecular and cellular events which underlie the response of nerves to injury, regeneration and neuropathic pain has been achieved.

This second edition has been fully updated in line with new clinical knowledge, and also incorporates the extensive study of thousands of surgical case studies spanning repairs of the supraclavicular plexus in the adult, the birth lesion of the brachial plexus,compound nerve injury and iatrogenous injury.

Beginning with the fundamentals of the anatomy and function of the peripheral nervous system, and working its way through various types of injury, operative methods, the regeneration and recovery of nerves, surgical reconstruction, pain, and rehabilitation, this eloquently written work provides the reader with the solid understanding required to successfully perform surgery on the peripheral nervous system.

Dr Shelagh Smith, joined by Dr Ravi Knight, has rewritten the chapter Electrodiagnosis.  Professor Tara Renton has written a new chapter on injuries to the trigeminal nerve in maxilla-facial and dental work.  The drawings, by Mr Philip Wilson, are new.  Most of the 700 illustrations are also new.

This thorough and authoritative look at the surgical treatment of the peripheral nerves is fully illustrated throughout with exquisite line diagrams and clear, instructive photographs.



Rolfe Birch, M.Chir FRCP&S (Glas) FRCS (Edin) FRCS (Eng) by election, is a well known nerve repair specialist, and he teaches all levels of doctors in training. He is Professor in Neurological Orthopedic Surgery, University College London; Visiting Professor, Department of Academic Neurology, Imperial College London, and Honorary Orthopaedic Consultant, Hospital for Sick Children at Great Ormond Street, London.  He also holds posts at The National Hospital for Nervous Diseases, Queen Square, London and at Raigmore Hospital in Inverness. 

He is also involved in military medicine, as Honorary Orthopaedic Surgeon to the Royal Navy and Consultant in Charge, War Nerve Injuries Clinic at the Defence Medical Rehabilitation Centre, Headley Court, Leatherhead in Surrey.

From 1979 to 2008 he was Orthopaedic Surgeon to the Royal National Orthopaedic Hospital.  In 1983 he was appointed the Head of Department of the Peripheral Nerve Injury Unit there and from 1984 to 2000 he was Co-Director of the Rehabilitation Unit.

From 1979 to 1991 he was also Orthopaedic Surgeon to St. Mary's Hospital in London, and Consultant in Charge of the Accident and Emergency Department until 1984.

He is also involved in military medicine, as Honorary Orthopaedic Surgeon to the Royal Navy and Consultant in Charge, War Nerve Injuries Clinic at the Defence Medical Rehabilitation Centre, Headley Court, Leatherhead in Surrey.

From 1979 to 2008 he was Orthopaedic Surgeon to the Royal National Orthopaedic Hospital.  In 1983 he was appointed the Head of Department of the Peripheral Nerve Injury Unit there and from 1984 to 2000 he was Co-Director of the Rehabilitation Unit.

From 1979 to 1991 he was also Orthopaedic Surgeon to St. Mary's Hospital in London, and Consultant in Charge of the Accident and Emergency Department until 1984.


Since the highly praised first edition of Surgical Disorders of the Peripheral Nerves was published in 1998, greater understanding of the the molecular and cellular events which underlie the response of nerves to injury, regeneration and neuropathic pain has been achieved. This second edition has been fully updated in line with new clinical knowledge, and also incorporates the extensive study of thousands of surgical case studies spanning repairs of the supraclavicular plexus in the adult, the birth lesion of the brachial plexus,compound nerve injury and iatrogenous injury.Beginning with the fundamentals of the anatomy and function of the peripheral nervous system, and working its way through various types of injury, operative methods, the regeneration and recovery of nerves, surgical reconstruction, pain, and rehabilitation, this eloquently written work provides the reader with the solid understanding required to successfully perform surgery on the peripheral nervous system. Dr Shelagh Smith, joined by Dr Ravi Knight, has rewritten the chapter Electrodiagnosis. Professor Tara Renton has written a new chapter on injuries to the trigeminal nerve in maxilla-facial and dental work. The drawings, by Mr Philip Wilson, are new. Most of the 700 illustrations are also new.This thorough and authoritative look at the surgical treatment of the peripheral nerves is fully illustrated throughout with exquisite line diagrams and clear, instructive photographs.

Rolfe Birch, M.Chir FRCP&S (Glas) FRCS (Edin) FRCS (Eng) by election, is a well known nerve repair specialist, and he teaches all levels of doctors in training. He is Professor in Neurological Orthopedic Surgery, University College London; Visiting Professor, Department of Academic Neurology, Imperial College London, and Honorary Orthopaedic Consultant, Hospital for Sick Children at Great Ormond Street, London.  He also holds posts at The National Hospital for Nervous Diseases, Queen Square, London and at Raigmore Hospital in Inverness.  He is also involved in military medicine, as Honorary Orthopaedic Surgeon to the Royal Navy and Consultant in Charge, War Nerve Injuries Clinic at the Defence Medical Rehabilitation Centre, Headley Court, Leatherhead in Surrey.From 1979 to 2008 he was Orthopaedic Surgeon to the Royal National Orthopaedic Hospital.  In 1983 he was appointed the Head of Department of the Peripheral Nerve Injury Unit there and from 1984 to 2000 he was Co-Director of the Rehabilitation Unit.From 1979 to 1991 he was also Orthopaedic Surgeon to St. Mary's Hospital in London, and Consultant in Charge of the Accident and Emergency Department until 1984.He is also involved in military medicine, as Honorary Orthopaedic Surgeon to the Royal Navy and Consultant in Charge, War Nerve Injuries Clinic at the Defence Medical Rehabilitation Centre, Headley Court, Leatherhead in Surrey.From 1979 to 2008 he was Orthopaedic Surgeon to the Royal National Orthopaedic Hospital.  In 1983 he was appointed the Head of Department of the Peripheral Nerve Injury Unit there and from 1984 to 2000 he was Co-Director of the Rehabilitation Unit.From 1979 to 1991 he was also Orthopaedic Surgeon to St. Mary's Hospital in London, and Consultant in Charge of the Accident and Emergency Department until 1984.

Surgical Disorders of the Peripheral Nerves 2
Preface to the First Edition 5
Preface to the Second Edition 8
Contents 10
Contributors 19
1: The Peripheral Nervous System: Gross Anatomy 20
1.1 The Cranial Nerves (Figs. 1.6–1.9, 1.12 and 1.14–1.16) 23
1.2 The Spinal Nerves 26
1.2.1 The Anterior Primary Rami 26
1.2.2 Thoracic Anterior Primary Rami 37
1.2.3 Lumbar and Sacral Anterior Primary Rami (Fig. 1.30) 37
1.2.4 The Posterior Primary Rami 51
1.3 The Autonomic Nervous System 52
1.3.1 The Sympathetic System 53
1.3.2 The Parasympathetic Nervous System 55
1.3.3 Afferent Autonomic Pathways 56
1.4 Nerves at Risk from Musculo Skeletal Injury 56
References 60
2: The Microscopic Structure of the Nervous System: Its Function 61
2.1 The Neurotrophins 62
2.1.1 Nerve Growth Factor 62
2.2 The Peripheral Nerve Fibres 64
2.2.1 Conduction 72
2.2.2 The Basis of the Action Potential: Ion Channels 74
2.2.3 Axonal Transport 75
2.2.4 The Blood Supply of Nerves 76
2.2.5 The Nervi Nervorum 77
2.2.6 Changes in Nerves with Ageing 77
2.3 The Somatic Motor System 79
2.4 The Somatic Sensory System 80
2.4.1 Cutaneous Sensibility 80
2.4.2 The Skin 82
2.4.3 Cutaneous Sensory Receptors 83
2.4.3.1 Low Threshold Mechanosensors 83
2.4.3.2 Thermoreceptors 83
2.4.3.3 Nociceptors 83
2.4.4 Deep Sensibility 84
2.4.5 The Muscle Spindles 84
2.4.6 The Golgi Tendon Organs 86
2.4.7 Central Connections 87
2.4.8 Visceral Afferents 88
2.5 Cortical Maps 89
2.6 Synaptic Activity 90
References 90
3: Reactions to Injury 95
3.1 Axonotmesis – Neurotmesis 99
3.2 The Cell Body and Proximal Stump 100
3.2.1 Wounds of the Perineurium 102
3.2.2 Contralateral Effects 103
3.3 The Distal Stump 103
3.4 Types of Lesion Produced by Different Physical Agents 105
3.4.1 Acute Ischaemia 105
3.4.2 Ischaemia from Tamponade 107
3.4.3 Ischaemia and Acute Compression Within Neurovascular Fascial Compartments 108
3.4.4 Ischaemia by Acute Compression from Swollen Muscle 110
3.4.5 Ischaemia Caused by Traction 113
3.4.6 Reperfusion Injury 114
3.4.7 Chronic Ischaemia 115
3.4.8 Crush 115
3.4.9 Compression – Acute 116
3.4.10 Chronic Nerve Compression 117
3.4.11 Traction or Stretch Injury 118
3.4.12 Thermal Injury 121
3.4.13 Electric Shock 122
3.4.14 Percussion Injury 124
3.4.15 Injection Injury 124
3.4.16 Vibration Injury 125
3.5 The Perineurium and Neoplasm or Infiltration 125
3.6 Radiation and Peripheral Nerves 126
3.7 Envenomation 126
3.8 The Peripheral Effects of Denervation 127
3.9 Changes at the Higher Levels: The Phantom Limb 128
References 129
4: Regeneration and Recovery 133
4.1 The Response of the Nerve and Axon to Transection 134
4.2 The Repair of Large Gaps 141
4.2.1 Other, Non Neural, Material for Grafts: Entubation 144
4.3 Nerve Transfer 146
4.3.1 Recovery of Cutaneous Sensation after Nerve Transfer 148
4.3.2 Recovery of the Deep Afferent Pathways after Nerve Transfer 148
4.3.3 Complications of Regeneration 150
4.4 Regeneration after Intradural Injury 153
4.5 Recovery of Function after Nerve Repair 155
4.5.1 Methods 156
4.6 Factors in Prognosis 157
4.7 Severity of Injury 158
4.8 Delay 158
References 158
5: Clinical Aspects of Nerve Injury 163
5.1 Associated Symptoms and Signs 166
5.2 Recognition of the Level and the Depth of Injury 169
5.3 Signs 172
5.4 Tinel’s Sign 174
5.5 Eliciting the Tinel Sign in Closed Lesions 177
5.6 Tinel’s Sign and Recovery 179
5.7 Examination of Sensibility 179
5.8 Quantitative Sensory Testing 181
5.9 Examination of Muscles 184
5.9.1 Some Pitfalls 184
5.9.2 Our Methods 186
5.9.3 Clinical Examination 186
5.9.4 The Lower Limb 192
5.9.5 Late Signs of Nerve Injury 195
5.9.6 Signs of Reinnervation 198
5.10 Records 200
5.11 Aids to Diagnosis 203
References 206
6: Clinical Neurophysiology in Peripheral Nerve Injuries 209
6.1 Introduction 209
6.2 Electrodiagnostic Techniques 209
6.2.1 Glossary of Electrodiagnostic Procedures 210
6.2.2 Intra-operative Neurophysiological Procedures 215
6.2.3 Electrodiagnostic Techniques and Localisation 217
6.3 Limitations and Pitfalls of Electrodiagnostic Investigation 217
6.4 Safety Aspects 219
6.5 Pathophysiological Correlates 219
6.5.1 Types of Nerve Lesion: the Electrophysiological Consequences 220
6.5.1.1 Special Types of Neural Injury 222
6.5.2 Regeneration and Reinnervation 223
6.6 Clinical Applications 224
6.6.1 Upper Limb Neuropathies 224
6.6.1.1 Median Nerve 224
6.6.1.2 Ulnar Nerve 226
6.6.1.3 Radial Nerve 229
6.6.1.4 Suprascapular Nerve 230
6.6.1.5 Spinal Accessory Nerve 231
6.6.1.6 Axillary (Circumflex) Nerve 231
6.6.1.7 Long Thoracic Nerve 231
6.6.1.8 Brachial Plexus Lesions 232
6.6.2 Lower Limb Neuropathies 237
6.6.2.1 Sciatic Nerve 237
6.6.2.2 Common Peroneal Nerve 237
6.6.2.3 Tibial Nerve and its Branches 238
6.6.2.4 Femoral Nerve 239
6.6.2.5 Other Lower Limb Nerve Disorders 239
6.6.2.6 Lumbosacral plexopathy 240
6.6.2.7 Electrodiagnosis in Root Lesions 241
6.6.3 Diffuse Problems 241
References 243
7: Operating on Peripheral Nerves 248
7.1 Indications and Objects of Intervention 248
7.1.1 Special Units: Their Role 249
7.2 General Principles of Operation 250
7.2.1 Control of Bleeding 250
7.3 Apparatus and Instruments 251
7.4 Methods of Repair 256
7.4.1 The Vascular Repair 256
7.4.2 The Nerve Operations 258
7.4.2.1 Neurolysis 258
7.4.2.2 Biopsy 260
7.5 The Nerve Repair 261
7.5.1 Methods of Suture 262
7.5.2 Grafting 264
7.5.3 Indications For and Methods of Nerve Transfer 266
7.5.3.1 The Intercostal Nerves 267
7.5.3.2 Direct Muscular Neurotisation 269
7.5.4 Immobilisation 269
7.6 Approaches to Individual Nerves 271
7.6.1 The Transverse Supraclavicular Approach: (Anterior, or Anterolateral) 271
7.6.2 The Transclavicular Exposure 273
7.6.3 The Postero-Lateral Route 276
7.7 Repair of the Roots of the Spinal Nerves in an Avulsion Lesion 279
7.7.1 The Spinal Accessory Nerve 281
7.7.2 The Suprascapular Nerve 282
7.7.3 The Infraclavicular Part of the Brachial Plexus 282
7.7.4 The Circumflex Nerve 283
7.7.5 Median and Ulnar Nerves in the Arm and the Axilla 283
7.7.6 The Radial Nerve 283
7.7.7 The Posterior Interosseous Nerve 284
7.7.8 The Lower Part of the Median Nerve 284
7.7.9 The Lower Part of the Ulnar Nerve 286
7.7.10 Nerves in the Abdomen and Pelvis 287
7.7.11 The Sciatic Nerve 288
7.7.12 The Tibial and Common Peroneal Nerves in the Popliteal Fossa and Below 289
7.7.13 The Lower Tibial Nerve and the Plantar Nerves 290
7.8 Entrapment Neuropathy 290
7.8.1 The Thoracic Outlet Syndromes 292
7.8.2 The Suprapleural Membrane (Sibson’s Fascia) 293
7.8.3 The First Rib 293
7.8.4 The Seventh Cervical Rib 293
7.8.5 Considerations About Operation 297
7.8.6 Carpal Tunnel Syndrome 299
7.8.7 Technique of Operation (Open Method) 299
7.8.8 Operations for Ulnar Neuropathy at the Elbow 301
7.8.9 The Less Common Entrapment Syndromes – Upper Limb 301
7.8.10 Some Entrapment Neuropathies in the Lower Limb 302
7.8.11 Meralgia Paraesthetica 302
7.8.12 Entrapment of the Pudendal Nerve 302
7.8.13 The Piriformis Syndrome 303
7.8.14 The Tarsal Tunnel Syndrome 303
7.8.15 “Morton’s Metatarsalgia” 304
7.9 Pitfalls in Operating on Tumours of Peripheral Nerves 304
7.9.1 The Solitary Benign Schwannoma (Neurolemmoma, Neurinoma) 304
7.9.1.1 Treatment 305
7.9.2 The Intraneural Ganglion 306
7.9.3 The Solitary Neurofibroma 307
7.9.4 Malignant Peripheral Nerve Sheath Tumours (MPNST) 310
7.9.4.1 Clinical Features 311
7.9.4.2 Pathology 311
7.9.4.3 Principles of Operation 311
References 315
8: Compound Nerve Injury 320
8.1 The Wound 321
8.1.1 War Wounds: Current Practice 322
8.2 The Vascular Lesion 323
8.2.1 The Shoulder 326
8.2.2 The Elbow 329
8.2.3 The Knee 329
8.2.4 The False Aneurysm and Arteriovenous Fistulae 330
8.2.5 Ischaemia and the Nerve 333
8.2.6 Iatrogenous Ischaemic Injury 336
8.3 Skin 337
8.4 Penetrating Missile Injuries 339
8.4.1 Suture and Grafting During World War Two: The MRCR Evidence 340
8.4.2 Grafts 341
8.4.3 Experience from St Mary’s and the Royal National Orthopaedic Hospitals 343
8.4.4 The Brachial Plexus 343
8.4.5 Pain 345
8.4.6 The Peripheral Nerves 345
8.4.7 Recent Experience 347
8.5 Neurovascular Injuries: Amputation Revascularisation 349
8.5.1 The Brachial Plexus 350
8.5.2 The Closed Infraclavicular Lesion 351
8.6 Nerves and Bone and Joint Injuries 356
8.6.1 The Nerve and the Pattern of Fracture 358
8.6.2 The Shoulder Girdle and Gleno-Humeral Joints 360
8.6.2.1 The Spinal Accessory Nerve 360
8.6.2.2 The Nerve to Serratus Anterior 361
8.6.3 The Clavicle 361
8.6.4 Dislocation of the Gleno-Humeral Joint 362
8.6.4.1 Vascular Injuries 362
8.6.4.2 The Lesion of the Nerves 363
8.6.4.3 Pain 363
8.6.5 The Radial Nerve and Fractures of the Humerus 368
8.6.6 Incidence 368
8.6.6.1 The Open Fracture 369
8.6.6.2 Recovery in Favourable Lesions 369
8.6.6.3 Experience at St Mary’s and the Royal National Orthopaedic Hospital 369
8.6.6.4 More Recent Findings 370
8.6.6.5 The Tinel Sign 370
8.6.6.6 Results of Operation 371
8.6.6.7 Iatrogenous Lesions 371
8.6.7 Conclusions 372
8.6.8 The Musculocutaneous Nerve 372
8.6.9 Elbow 373
8.6.9.1 Volkmann’s Contracture and the Supracondylar Fracture 374
8.6.9.2 Prevention 375
8.6.10 Iatrogenous Injuries in the Adult 376
8.6.10.1 Conclusions 376
8.6.11 The Forearm 376
8.7 The Lower Limb 377
8.7.1 The Femoral Nerve 377
8.7.2 The Lumbo Sacral Plexus 378
8.7.3 The Hip 380
8.7.3.1 Incidence 381
8.7.4 The Common Peroneal and Tibial Nerves 382
8.7.5 More Recent Experience at the Royal National Orthopaedic Hospital 384
References 386
9: The Closed Supraclavicular Lesion 391
9.1 Mechanisms of Injury 392
9.2 Anatomy 394
9.2.1 Course in the Neck 394
9.2.2 Micro Anatomy 395
9.2.3 Functional Distribution 395
9.2.3.1 Blood Supply 395
9.3 Lesions of the Spinal Cord 396
9.4 The Evolution of Our Policy of Treatment of Closed Traction Lesions of the Brachial Plexus 400
9.5 The Definition of Pre and Postganglionic Lesion: Prognosis for Recovery 401
Sec10_9 402
9.6 Epidemiology 404
9.7 Diagnosis 405
9.7.1 Conduction studies: The Current Situation 408
9.7.1.1 Radiographs and Imaging 408
9.7.2 The Operation 414
9.8 Some of the Techniques Used for Repair 414
9.9 Strategies of Repair 415
9.9.1 The Upper Lesion: Rupture or Avulsion of C5, C6 (C7) with Intact (C7) C8, T1 415
9.9.1.1 Preganglionic Injury C5 and C6 416
9.9.1.2 Preganglionic Injury C5, C6 and C7 418
9.9.1.3 Preganglionic C5, C6, C7, C8, Intact T1 418
9.9.2 The Lower Lesion: Intact C5, C6 (C7), Rupture or Avulsion C8, T1 420
9.9.3 The Middle Group 420
9.9.4 The Complete Lesion 420
9.9.5 Free Functioning Muscle Transfer (FFMT) 422
9.9.6 The Bilateral Lesion 423
9.10 Results 425
9.10.1 Methods 425
9.10.2 Definitions 425
9.10.3 Conventional Nerve Transfers 426
9.10.4 Repair of Avulsed Ventral Roots 426
9.11 Recovery of Function by Patients 427
9.11.1 Age 431
9.12 Relief of Pain by Repair 432
9.12.1 Return to Work 436
9.13 Reimplantation of Avulsed Spinal Nerves 437
9.13.1 The First Clinical Case – George Bonney, 1977 437
References 441
10: Birth Lesions of the Brachial Plexus 444
10.1 The Lesion of the Spinal Nerve in Birth Lesion of the Brachial Plexus (BLBP) 445
10.1.1 The Central Affect 446
10.2 Methods of Study 447
10.2.1 Diagnosis 447
10.3 Epidemiology 451
10.3.1 Incidence 451
10.3.2 Risk Factors 452
10.4 Recovery in the Complete Lesion 459
10.4.1 Group 3: 177 Children 460
10.4.2 Group 4: 114 Children 460
10.5 Treatment 462
10.6 Supplementary Investigations 463
10.6.1 Neurophysiological Investigations (NPI) 463
10.6.2 Imaging 468
10.7 Nerve Operations 468
10.8 The Indications for Operation 468
10.8.1 The Incomplete Lesion: Groups 1 and 2 469
10.9 The Operation 469
10.9.1 Methods of Repair 471
10.9.2 Post-operative Care 471
10.10 Results of Nerve Operations 472
10.10.1 Experience at St Mary’s – Royal National Orthopaedic Hospital 473
10.10.2 Late Reinnervation 477
10.10.3 Cocontraction 478
10.11 Deformities 478
10.12 Posterior Subluxation (PS) and Posterior Dislocation (PD) of the Gleno-humeral Joint with Related Contractures 481
10.12.1 Onset and Progression of the Secondary Deformities 482
10.12.2 Diagnosis and Classification 484
10.12.3 Medial Rotation Contracture 485
10.12.4 The Development of Our Preferred Operation for Posterior Subluxation or Dislocation of the Gleno-Humeral Joint 486
10.12.5 The Operation for Reduction of the Posterior Subluxation and Dislocation of the Gleno-Humeral Joint 488
10.12.5.1 Fixed Contracture of the Inferior Scapulo-Humeral Angle 493
10.12.6 Deformities at the Elbow and Forearm 493
10.12.6.1 The Supination Deformity 493
10.13 Conclusion 494
References 494
11: Iatrogenous InjuriesPart 1: General ConsiderationsRolfe Birch 497
11.1 Incidence and Audit 499
11.2 Causes 500
11.2.1 Generalised Disorders 500
11.2.2 Alcohol 501
11.2.3 Diabetes 501
11.2.3.1 Hypothyroidism and Acromegaly 502
11.2.4 Connective Tissue Disease 502
11.2.5 Warning and consent 504
11.2.6 Teaching and Training 506
11.2.7 Specialisation 507
11.2.8 Continuity of Care: Timing of Operation 507
11.3 Nerve Lesions in Total Hip Arthroplasty 508
11.3.1 The Nerve Lesion 508
11.3.2 Findings in the 110 Patients Seen Between 2001 and 2007 508
11.3.3 Indications for Urgent Reexploration 510
11.4 Radiation Neuropathy 511
11.4.1 The Place of Operation 512
11.5 Prevention of Iatrogenous Lesions 513
11.5.1 Teaching and Training 513
11.5.2 Audit and Consent 513
11.5.3 Conduct of Affairs 513
11.5.4 Recognition and Action 514
Iatrogenous InjuriesPart 2: Minimising and Managing Iatrogenous Trigeminal Nerve Injuries in Relation to Dental ProceduresT 515
11.6 Introduction 515
11.6.1 Signs and Symptoms 517
11.7 Mechanisms of Nerve Injuries 517
11.7.1 Local Analgesic Related Trigeminal Nerve Injuries 517
11.7.2 Implant Related Nerve Injuries 518
11.7.4 Endodontic Related Nerve Injury 521
11.7.5 Third Molar Surgery 523
11.7.6 Dental Extraction of Other Teeth Proximal to IAN Canal 527
11.7.7 Socket Medications 527
11.7.8 Post Operative Infection Related Nerve Injuries 527
11.7.9 Management of Trigeminal Nerve Injuries 527
11.7.10 Evaluation of Trigeminal Nerve Injuries 527
11.7.11 Possible Interventions and Timing 529
11.7.12 Possible Management Tools (Table 11.9) 529
11.7.13 Reassurance Counselling/Cognitive Behavioural Therapy 529
11.7.14 Medical Intervention 530
11.7.15 Surgical Intervention 530
11.7.16 Reasoning for Early Nerve Repair 531
11.7.17 Surgical Technique 531
11.7.18 Medico Legal Issues 532
11.7.19 Improved Consent 535
11.7.20 Improved Management of These Injuries 535
11.7.21 Can We Prevent These Injuries? 535
References 535
12: Pain 540
12.1 Nocicipient 541
12.1.1 The Gate Theory 543
12.1.2 Events After Nerve Injury 543
Transcutaneous Nerve Stimulation 552
12.1.3 Central Pain: The Preganglionic Injury of the Brachial Plexus 546
12.1.4 The Sympathetic Nervous System and Pain 547
12.2 Complex Regional Pain Syndrome (CRPS) Type 1 and (CRPS) Type 2 547
12.3 Diagnosis 551
12.3.1 Drugs and Other Measures Short of Operation 551
12.3.2 Indications for Operation 555
12.3.4 Neurostenalgia 562
12.3.5 Post Traumatic Neuralgia 564
12.3.5.1 Post Traumatic Neuralgia After Injury to a Main Nerve 566
12.3.5.2 PTN After Injury to Minor Nerves 567
12.4 Interventions upon the Central Nervous System 568
12.5 Summary 571
References 571
13: Reconstruction 575
13.1 Requirements 577
13.1.1 The Tension of Transfer 580
13.1.2 Fixed Deformity 581
13.1.2.1 Persisting Imbalance During Growth 581
13.1.2.2 Post Ischaemic Fibrosis 582
13.1.3 Correction of Fixed Deformity 583
13.1.3.1 Serial Splinting 583
13.2 Principles of Operation 584
13.2.1 The Equino-varus Deformity of Ankle and Foot 585
13.2.2 Flexor Muscle Slide, by the Technique of Brooks (1984) 585
13.2.3 Fixed Extension at the Metacarpo-phalangeal Joints 586
13.2.4 Release of Contracted Small Muscles of the Hand 587
13.3 Methods of Reconstruction 588
13.3.1 The Shoulder Girdle 588
13.3.1.1 The Thoraco-scapular Joint 588
13.3.1.2 The Gleno-humeral Joint 590
13.3.2 Extension of the Elbow 592
13.3.3 Flexion of Elbow 592
13.3.4 The Operations 594
13.3.4.1 Pectoralis Minor Transfer 594
13.3.4.2 Proximal Advancement of the Flexor Origin 595
13.3.4.3 Latissimus Dorsi Transfer 595
13.4 Paralysis of the Extensors to the Wrist and Fingers, and of the Abductors and Extensors to the Thumb 596
13.4.1 Pre and Post-operative Care 598
13.4.2 The Operations 599
13.4.2.1 Flexor Carpi Ulnaris Transfer to Extensor Carpi Radialis Brevis 600
13.4.2.2 Transfer of Flexor Digitorum Superficialis 600
The Operation 602
The Operation – ECRL for Flexion of MCPJ of Fingers 604
13.5 The High Median Palsy 601
13.5.1 Abduction and Opposition of the Thumb 601
13.6 The High Ulnar Palsy 603
13.7 Combined Nerve Lesions and the Hand 605
13.8 The Lower Limb 606
13.8.1 The Insensate Foot 608
13.8.2 Abduction and Flexion at the Hip 608
13.8.3 The Knee 609
13.8.3.1 Anterior Transfer of Hamstrings for Paralysis of Knee Extensors 609
13.8.4 Foot and Ankle: The Drop Foot from Common Peroneal Palsy 610
13.8.4.1 Tibialis Posterior (TP) Transfer to the Extensors of the Toes 610
13.8.4.2 Paralysis of the Dorsi Flexor Muscles of Ankle and Toes, with Intact Evertors of the Ankle 612
13.9 Vascularized Bone and Muscle Transfer 613
13.10 Amputation 613
13.11 Conclusion 614
References 615
14: Rehabilitation 618
14.1 Communication 619
14.2 History 620
14.3 The Rehabilitation Team 621
14.4 The Method of Work 622
14.5 Some Technical Aspects 623
14.6 Motivation 627
14.7 Rehabilitation in Progressive Neurological Disease 635
14.8 The Choice of Intervention 635
14.9 Patients with Neuropathic Pain 636
14.11 Rehabilitation in the War Wounded 639
14.11.1 Outcomes 640
References 641
Index 642

Erscheint lt. Verlag 21.1.2011
Zusatzinfo X, 502 p. 681 illus., 539 illus. in color.
Verlagsort London
Sprache englisch
Themenwelt Medizinische Fachgebiete Chirurgie Neurochirurgie
Medizin / Pharmazie Medizinische Fachgebiete Neurologie
Schlagworte anatomy • Brachial Plexus • Closed Supraclavicular Lesion • Compound Nerve Injury • iatrogenous • Injury • Neurophysiology • Pain • reconstruction • Rehabilitation • Surgery
ISBN-10 1-84882-108-5 / 1848821085
ISBN-13 978-1-84882-108-8 / 9781848821088
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