1. Non-surgical therapy The purpose of non-surgical therapy is to create conditions for the recovery of nerve and limb functions. Treatment measures can be taken to prevent muscle atrophy and joint stiffness after injury and operation:
(1) Relieve the nerve injury caused by the compression of the fracture end. Firstly, the fracture was reduced and fixed by hand to relieve the compression of the fracture end on the nerve. If the nerve is not broken, 1 ~ 3 months later is expected to restore function, otherwise it should be explored as soon as possible. Some nerves are embedded between fracture ends, such as middle and lower humeral fractures with radial nerve injury. At this time, surgery should be performed as soon as possible to avoid nerve rupture during manual reduction.
(2) In order to prevent excessive traction of paralyzed muscles, proper splint can be used to keep paralyzed muscles in a relaxed posture. For example, radial nerve paralysis can use suspension spring splint, foot drop with anti-falling bracket and so on.
(3) Maintaining joint mobility can prevent deformities caused by muscle imbalance, such as plantar flexion caused by common peroneal nerve injury and claw-like fingers caused by ulnar nerve paralysis. Should be passive activities, exercise joint mobility, many times a day. If the joint is stiff or contracture, although the nerve has recovered, the limb function will be unsatisfactory, especially the hand.
(4) Physical therapy can maintain muscle tension, reduce muscle atrophy and prevent muscle fibrosis through massage and electrical stimulation.
(5) Physical therapy to restore muscles and improve limb function.
(six) to protect the injured limb from scalding, frostbite, squeezing and other injuries.
Second, the timing of surgical treatment after nerve injury is very important. In principle, the sooner the better, but time is not an absolute factor, and later repair can also achieve certain results.
Early debridement of sharp instrument injury can be performed by primary nerve suture. The unrepaired nerve was debrided in the early stage of firearm injury, and the nerve was anastomosed again 1 ~ 3 months after wound healing. The effect of nerve repair is better in young people than in the elderly, pure sensory and pure motor nerves are better than mixed nerves, and the proximal part is better than the central part. Better to fix it early than late.
(1) Neurolysis
There are two methods: neurolysis and neurolysis. The former is to relieve the compression of the bone end and free and remove the scar tissue around the nerve. In addition to neurolysis, the latter needs to cut or cut off the outer membrane of the diseased nerve to separate the scar adhesion between nerve bundles.
1. Neurolysis
Indications: the fracture end compresses the nerve or the fracture is displaced greatly. When the nerve is embedded between the fracture ends, the nerve should be released and the fracture should be fixed. If the nerve is compressed for too long and there are scars around it, it is necessary not only to relieve the compression at the fracture end, but also to release the nerve. When a large area of scar formation occurs due to peripheral nerve trauma or infection, the nerves have different degrees of adhesion and compression, and neurolysis is also needed.
Anesthesia: Choose the appropriate anesthesia method according to the surgical site and the patient's age. In the upper limbs, adults can use brachial plexus block anesthesia; Children can use basic anesthesia plus brachial plexus block anesthesia.
Application of tourniquet: If you can operate under an inflatable tourniquet, you can get a clear surgical field, which is convenient for identifying and dissecting nerves and blood vessels, and avoid damaging nerve bundles, nerve branches and important nutrient vessels on the nerve trunk. However, the pressure and binding time of tourniquet should be well controlled, which should not exceed 65,438+0 hours each time, and should not exceed 40 minutes after taking a rest of 65,438+00 minutes to prevent tourniquet paralysis.
Surgical steps: Make a long enough incision around the lesion and expose the nerve according to the conventional nerve exposure method. When the nerve is dissociated, it should start from the normal parts of the distal and proximal nerves of the incision and gradually dissociate to the injured part, so as to avoid blindly separating and cutting at the scar of the injured part from the beginning and injuring the nerve by mistake. After separating the nerve at both ends of the incision from the normal part, gently pull the nerve with a rubber band, and carefully separate the nerve from the scar with a sharp knife or scissors. When the scar is dense and difficult to separate, normal saline can be injected between the scar and the nerve membrane and separated while injecting. In the process of nerve separation, we should pay attention to protect the nerve branches, be careful not to damage them, and try to preserve the nutrient vessels on the nerve trunk. The scar tissue around the nerve should be completely removed, and the free nerve should be placed in the nerve bed with healthy tissue to protect and improve the nerve circulation. Do not put it back into the scar tissue, so as to avoid postoperative scar adhesion and compression, which will affect the nerve repair effect. After nerve release, loosen the tourniquet, stop bleeding completely, rinse repeatedly with normal saline, and suture layer by layer. Limbs don't need external fixation.
2. Neurolysis
Indications: After neurolysis, if the lesion is found to be thick, hard to touch or induration, it means that there is scar adhesion and compression in the nerve, and further neurolysis is needed.
Surgery: It should be performed under an operating microscope or a magnifying glass. Cut the epicardium of the lesion vertically along the longitudinal axis of the nerve with a sharp knife, separate it and pull it to both sides, carefully separate the scar adhesion between nerve bundles, and be careful not to damage the diagonal cross fibers between nerve bundles. When separating nerve bundles, normal saline can also be injected between the bundles and separated while injecting. In order to separate the scar adhesion between nerve bundles accurately, it can be done under the operating microscope. After the nerve bundle is released, it is advisable to remove the adventitia of the diseased segment. Other requirements are the same as neurolysis.
(2) Nerve anastomosis
1. Anesthesia, posture, application of tourniquet, nerve exposure and separation are the same as those of neurolysis.
2. Expose the nerve and separate it from the normal part of the nerve to the broken part. Be careful not to damage the nerve branches.
3. Remove the neuropathy and prepare for suture. First, the pseudoneuroma at the proximal end is removed until the normal nerve bundle is exposed on the cross section, and then the scar tissue at the distal end is removed. In order to achieve good suture effect, it is necessary to remove the diseased tissue into normal tissue. However, it is not advisable to remove too much, so as to avoid the defect being too large and difficult to suture.
4. The way to overcome the nerve defect is to separate the distal end and proximal end of the nerve, or flex the joint, and gently stretch the nerve to lengthen it gradually if necessary. Nerve transfer can also be used to change the position of the nerve, such as moving the ulnar nerve from the back of the elbow to the front of the elbow, shortening the distance, so that the two broken ends of the nerve can be close, and there is no tension when sewing. The maximum length of median nerve and ulnar nerve that can be overcome by free nerve and flexion joint is: upper arm 5 ~ 6 m, elbow 8 ~ 9 cm, forearm 3 ~ 4 cm and wrist 3 ~ 4 cm.
Before resection of pseudoneuroma, it is estimated whether it can be sutured after resection. If the length is not enough, it is best to temporarily anastomose or even sew unhealthy tissues on the pseudoneuroma, and fix the joint in the flexion position, and ensure that the anastomosis does not bear tension. After 6 weeks, the plaster was removed, the joints were gradually straightened and the nerves were prolonged. Unhealthy nerve tissue can be removed and sutured again after the second operation. When the severed limb is replanted or the fracture is not connected, if the nerve defect is large, we can consider shortening the trunk to strive for nerve end-to-end anastomosis.
5. Suture methods can be roughly divided into two types: epineurium suture and fascia suture. The former method only sutures the outer membrane of nerve, and if it can be accurately anastomosed, the effect will be better. In the later legal system, the nerve bundles broken at both ends were separated under the operating microscope, and the corresponding nerve bundles were sutured by the nerve bundles. This method can improve the accuracy of both ends of the nerve bundle. However, at present, there is no fast and reliable method to accurately identify the functional properties of two severed nerve bundles during surgery. Therefore, the suture of fiber bundles may be wrong, and the extensive separation between fiber bundles will increase scar formation and even damage nerve branches between fiber bundles.
Our experimental results show that there is no obvious difference between the two anastomosis methods under good repair conditions. Generally, the outer membrane suture method is used, because it is simple and easy to operate and does not require special equipment. According to long-term clinical practice, its effect is better than other methods. Bundle suture can be used for thick and easily recognizable nerve bundles. For some nerve injuries, after separating the normal and injured nerve bundles, it is advisable to repair the injured nerve bundles by bundle suture. In addition, nerve bundle suture can also be used according to the situation.
(1) Epidural suture
Suture with human hair or 7-0 or 8-0 nylon thread, only suture the outer membrane of nerve, not neurotic. First sew a fixed-point traction line on both sides of the nerve stump, then sew the front, then wrap a fixed-point line around the back of the nerve, and pull the fixed-point line to turn the nerve over 180, and sew the back. When sewing, it should be aligned accurately and not distorted. According to the position of blood vessels on the nerve surface and the shape of nerve bundles on the cross section, accurate alignment can be achieved. The distance between the two needles makes the broken ends align well. In order to observe whether the nerve suture is broken after operation, a thin stainless steel wire can be sewn on the nerve membrane with a distance of 1cm on both sides of the broken end, and the knots can be marked. The positions of two metal knots can be observed through X-ray film.
(2) The neurofascial suture was performed under the operating microscope. First, the epicardium of 1 ~ 2 cm was removed at both nerve ends. According to the thickness and distribution of the nerve bundle at the broken end, several groups of corresponding nerve bundles were separated, and the scar tissue at the broken end of each nerve bundle was removed until it was normal. The cross section of each nerve bundle may not be in the same plane. Suture the corresponding nerve bundle with 10-0 nylon thread, only suture the nerve bundle, not the neuroticism. The number of stitches should be such that the ends of the two nerve bundles can be aligned. Generally, 2-3 stitches per bundle is enough.
(3) Nerve bundle suture method Many nerve bundles with the same function in the nerve trunk gather to form a bundle, surrounded by connective tissue extending from the adventitia, which is easy to separate. When suturing the bundle group, it is only necessary to separate the nerve trunk into several bundle groups with the same function, and then suture the fiber bundle of each corresponding bundle group with the tissues around the nerve bundle, without suturing the nerve bundles one by one, thus reducing trauma.
(4) The suture of partial nerve rupture is performed under an operating microscope or a magnifying glass. Carefully identify the injured part and the normal part of the nerve, cut the outer membrane of the nerve longitudinally along the longitudinal axis between them, separate the nerve bundle of the normal part for protection, cut off the diseased part of the broken nerve, and sew it accurately with the nerve bundle suture method. (5) After operation, the joint was fixed with plaster and kept in flexion position to reduce the tension of nerve suture. Generally, after 6 weeks, the plaster is removed and the joints gradually straighten. Don't be too hasty, lest the nerve suture break. Clinical examination and evoked potential instrument were used to evaluate the recovery of neurological function. X-rays can be taken to observe the distance between the metal markers sewn on the nerve membrane and judge whether there is separation at the suture. During the recovery period, we should pay attention to protect the affected limb, prevent trauma, scald and frostbite, and adopt various non-surgical treatments to achieve the best functional recovery.
(3) The elasticity of nerve transfer and nerve transplantation is limited. If the tension during suture is too high or the joint needs excessive flexion, the suture site is prone to separation or injury after operation, or excessive traction leads to ischemic necrosis, which leads to the proliferation of fiber tissue between nerve bundles and affects the recovery of nerve. Therefore, if the defect is too large to achieve tension-free anastomosis between free nerve and flexion joint, nerve transfer and nerve transplantation should be considered.
1. Nerve transplantation can be used to repair the nerve injury of other fingers after hand injury. In the upper limb, if the median nerve and ulnar nerve are damaged in different planes at the same time, nerve transplantation should be tried to repair the two nerves; However, if the defect is too large to repair two nerves at the same time, the long proximal ulnar nerve can be transferred and sutured with the distal median nerve to restore the function of the median nerve.
2. Nerve transplantation In nerve transplantation, finger nerve or other major nerves are mostly repaired with autologous secondary cutaneous nerve, such as sural nerve, saphenous nerve, medial forearm cutaneous nerve, lateral femoral cutaneous nerve and superficial branch of radial nerve. Nerves with a length of 20 ~ 40 cm can be used for transplantation, but the superficial branch of the ipsilateral radial nerve cannot be used to repair the ulnar nerve, so as to avoid the numbness area of the affected hand being too large.
When several great nerves are injured at the same time, one of them can be used to repair other more important nerves. For example, when the upper arm is injured, the median nerve, ulnar nerve, radial nerve and musculocutaneous nerve have great defects, and when the opposite ends cannot be anastomosed, ulnar nerve can be transplanted to repair the median nerve, musculocutaneous nerve and radial nerve respectively. When the defects of forearm, median nerve and ulnar nerve are large and the ends cannot be anastomosed, ulnar nerve transplantation can be used to repair median nerve. In the lower limbs, when the sciatic nerve defect is too large to be repaired, the tibial nerve can be separated from the common peroneal nerve and repaired by transplantation of the common peroneal nerve.
There are several methods of nerve transplantation, which can be selected according to the specific situation.
(1) The nerve with the same thickness as the nerve to be repaired should be used for free transplantation of single-stranded nerve. For example, using cutaneous nerve or residual finger nerve to repair finger nerve. Epidural suture can be used, and the length of transplanted nerve should be slightly longer than the length of defect, so that there is no tension at the suture after nerve repair.
(2) Cable nerve free transplantation If the nerve used for transplantation is thin, several strands must be combined to repair the defective nerve. When repairing, the transplanted nerve is cut into multiple segments, and the outer membrane of the nerve is sutured to form a larger nerve, which is then sutured with the nerve to be repaired. Because of the development and application of microsurgery technology, it is gradually replaced by free transplantation between nerve bundles.
3. Free nerve bundle transplantation was performed under the operating microscope. The operation technique is the same as fasciocutaneous suture, that is, excising the outer membrane of the two nerve ends 1 ~ 2 cm, separating the corresponding nerve bundles, excising the scar tissue of the nerve bundle ends to the normal parts, and then placing the transplanted nerve bundles between the corresponding nerve bundles for fasciocutaneous suture.
4. Nerve pedicle transplantation After nerve transplantation, nerve necrosis generally does not occur. When using the thick nerve for transplantation, the nerve center necrosis often occurs due to the ischemia of the nerve free segment, which leads to the scar between bundles and affects the effect.
If the median nerve and ulnar nerve rupture at the same time, the defect is too large to be repaired, and the ulnar nerve can be used to repair the median nerve. Pseudoneuromas of the proximal median nerve and ulnar nerve were resected and anastomosed at the opposite end, then the proximal ulnar nerve was cut off and its blood vessels were preserved as much as possible. Six weeks later, the proximal ulnar nerve was sutured with the distal median nerve. 5. Free nerve transplantation with vascular pedicle usually adopts sural nerve with small saphenous vein.
Postoperative management of nerve transfer, nerve transplantation and nerve anastomosis