Istvan Frendl MD
Vessel injuries, nerve injuries, tunnel
syndromes
Department of Trauma and Hand Surgery
University of Debrecen
Medical and Health Science Center
Hungary
www: traumatologia.deoec.hu
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Patient examination:
 inspection
 palpation
 functional examination (Moberg test on hand)
 active and passive range of motion
of the joints (Neutral-O-Methode)
 innervation
 blood supply (Allen test)
Examination of the hand, Moberg test
Vessel injuries
Wound treatment on the site:
Wound:
Bleeding:
steril bandage
Compresson bandage or
pneumatic cuff
(max. 2 hours)
Anatomy
 Blood supply to the hand: radial and ulnar artries
 The ulnar artery forms the superficial palmar arterial
arch and the radial artery forms the deep palmar
arterial arch.
 Variations
 The superficial palmar arterial arch is more important.
The superficial and deep palmar arterial arches
Types of vessel injury:
Types of vessel injuries
 Arterial and venous bleeding
 Open and closed vessel injuries
 Cutting and puncture arterial injuries (knife, glass)
 Crush - Destruction injuries
(the adventitia is intact but the intima injured)
 Explosion (vessel defect !)
 Displaced fracture (i.e. closed supracondylar humeral
fracture)
Symptoms, Diagnosis:
 Open vessel injury
arterial: pulsative, shoot out type bleeding,
venous: darker colour, slowly flowing bleeding
 Weak or no peripheral pulse
 No capillar refill
Diagnosis:
 Allen-test
 Angiography

Doppler - ultrasound

Operative exploration
Allen test
Allen test
Treatment of bleeding:
On the site, first responder
 Compresson bandage or pneumatic cuff
(max. 2 hours) + elevation of the extremity
 Never use vessel clamp on the site
(only in operation room)
Types of vessel injury:
Macrovessel injury: proximal from wrist
Microvessel injury: distal from wrist
Treatment of vessel injury:
Operative techniques for macrovessel anastomosis:

Preparation of vessel stumps, removal of adventicia,
vessel clips, heparin
 Anastomosis: after sharp injury, with 5/0-8/0
atraumatical suture material, running suture
 Vena graft: after destructive injury or defect
(vena saphena magna, cephalica, basilica)
Treatment of vessel injury:
Operative techniques for microvessel anastomosis:
 Microvessel: vessel with 2-0,3 mm lumen.
Magnification: Operation microscope or glasses
Microsurgical suture materials and instrumets.
Preparation of vessel stumps, removal of
adventicia, vessel clips, heparin. Simple
interrupted sutures with (8/0-11/0) suture materials.
End-to-end arterial anastomosis
(removal of the adventicia, stay stitches)
End-to-end arterial anastomosis
(back wall sutures)
End-to-end anastomosis
(front wall sutures)
End-to-end arterial anastomosis
(the completed anastomosis)
Interpositional vein graft
Nerve injuries
Anatomy of the peripheral nerve
Fascicles in a peripheral nerve
Sensation of the hand
A: Dorsal
B.: Palmar
Sensation of the hand
Classification of nerve lesions:
Neurapraxia: (conduction block) the axon is intact.
Axonotmesis: the axon is divided and the process of
wallerian degeneration ensues, but the Swann
membrane is intact.
Neurotmesis: the axon is divided and the process of
wallerian degeneration ensues. The Swann membrane
injured too. Complete dissection of the peripheral nerve.
Neuroma formation after nerve injury
A: neuroma proximally, glioma distally
B: neuroma „in continuity”
Physical Examination of Nerve Injury
The Tinel Sign
The examiner lightly percusses along the course of the affected nerve from distal to
proximal. When the finger percusses over the zone of regenerating fibers the
patient will announce the sensation of pins and needles, which may be quite
painful, into the cutaneous distribution of the nerve. The clinical significance of
the Tinel sign might be summarized as follows:
A strongly positive Tinel sign over a lesion soon after injury indicates rupture or
severance. Regularly finding on the day of injury, most especially in closed
traction rupture.
After repair that is going to be successful, the centrifugally moving Tinel sign is
persistently stronger than that at the suture line.
After repair that is going to fail, the Tinel sign at the suture line remains stronger
than that at the growing point.
Failure of distal progression of the Tinel sign in a closed lesion indicates rupture or
other lesion impeding regeneration.
Epi-perineural nerve suture
Nerve transplantation
Sural nerve graft
Brachial plexus injuries:
Closed injuries:
- violent lateral flexion of the neck with depression of
the shoulder, motorcyclist accident.
- Birth injuries associated with difficult deliveries.
Upper cords of the plexus are damaged (Erb’s palsy).
Open injuries: caused by glass or steel.
Patterns of lesion:
- Supraclavicular lesions, which can be preganglionic
or postganglionic.
- Infraclavicular lesions.
Brachial plexus injuries:
Normal anatomy of brachial plexus
Obstetric palsy, Erb’s palsy:
Upper cords (C5 and C6) of the brachial plexus is damaged at
birth, the supinator, deltoid, wrist extensor and elbow flexors will
be weak, causing the „waiter’s tip” position of the arm.
Traumatic brachial plexus injuries:
Varying severity injuries of the brachial plexus:
Horner’s sign:
(avulson of C8 and/or T1 roots)
Ptosis, myosis, anhidrosis, enophthalmos
caused by paralysis of the sympathetic nerves
Horner’s Syndrome:
Severe pain, anesthetic and flail extremity, winging scapula,
head shifted away from the injured side (evidence of
denervation of paraspinous muscles), shoulder dislocation ,
Management of brachial plexus lesions:
1. Identification the level of lesion by neurological
examination, EMG and myelography.
2. Decide if the lesion is preganglionic or postganglionic.
3. Preganglionic lesions (Horner’s syndrome, absent axonal
reflex) cannot be repaired.
4. Postganglionic lesions have a better prognosis: the more
distal, the better outlook.
5. Surgical repair or grafting is sometimes possible for clean
cuts and distal lesions.
6. Late reconstruction: muscle and tendon transfers
Nerve grafting in brachial plexus injuries:
Tunnel syndromes
(Compression neuropathies)
Median nerve in the carpal tunnel
Median nerve and 9 tendons in the carpal tunnel
Sensation of the hand
Carpal tunnel syndrome
(median nerve compresson at the wrist):
- Paresthesia and pain in the madian nerve
distribution
- Weakness and atrophy of thenar muscles
- Awakened by pain from sleep at night
- ENG (nerve conduction studies)
- Phalen’ test (wist flexion to increase pressure)
- Treatment: nerve decompression, incision of the
volar carpal ligament, nerve release
Guyon’s tunnel syndrome
(Guyon’s canal compression):
 Ulnar nerve and ulnar artery at wrist region are in the
Guyon’s canal
 Paresthesia, pain in the ulnar nerve distribution, motor
disfunction
 Causes: space-occupying lesions, anomalous muscles,
ganglia, thrombosis, pseudoaneurism
 ENG
 Treatment: decompresson and release
Cubital tunnel syndrome:
 Ulnar nerve compression at elbow region (sulcus nervi
ulnaris)
 Paresthesia, pain in the ulnar nerve distribution, motor
disfunction
 Causes: triceps muscle, arcade of Struthers, flexor carpi
ulnaris (FCU)
 ENG
 Treatment: decompresson and release,
anterior transposition of nerve
Thank you for your attention!