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Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Peripheral nerve lesions of the upper extremity are common and are associated with devastating limitations for the patient. Rapid and accurate diagnosis of the lesion by electroneurography, neurosonography, or even MR neurography is important for treatment planning. There are different therapeutic approaches, which may show individual differences depending on the injured nerve. If a primary nerve repair is not possible, several strategies exist to bridge the gap. These may include autologous nerve grafts, bioartificial nerve conduits, or acellular nerve allografts. Tendon and nerve transfers are also of major importance in the treatment of nerve lesions in particular with long regeneration distances. As a secondary reconstruction, in addition to tendon transfers, there is also the option for free functional muscle transfer. In amputations, the prevention of neuroma is of great importance, for which different strategies exist, such as target muscle reinnervation, regenerative peripheral nerve interface, or neurotized flaps. In this article, we give an overview of the latest methods for the therapy of peripheral nerve lesions., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Nerve transfer for motor nerve paralysis is an established technique for treating complex nerve injuries. However, nerve transfer for sensory reconstruction has not been widely used, and published research on this topic is limited compared to motor nerve transfer. The indications and outcomes of nerve transfer for the restoration of sensory function remain unproven. This scoping review examines the indications, outcomes and complications of sensory nerve transfer. In total, 22 studies were included; the major finding is that distal sensory nerve transfers are more successful than proximal ones in succeeding protective sensation. Although the risk of extension of the sensory deficit with donor site loss and morbidity from neuromas remain a barrier to wider adoption, these complications were not reported in the review. Further, the scarcity of studies and small patient series limit the ability to determine sensory nerve transfer success. However, sensory restoration remains an opportunity for surgeons to pursue. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B120)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Peripheral nerve injuries present a complex clinical challenge, requiring a nuanced approach in surgical management. The consequences of injury vary, with sometimes severe disability, and a risk of lifelong pain for the individual. For late management, the choice of surgical techniques available range from neurolysis and nerve grafting to tendon and nerve transfers. The choice of technique utilized demands an in-depth understanding of the anatomy, patient demographics and the time elapsed since injury for optimized outcomes. This paper focuses on injuries to the radial, median and ulnar nerves, outlining the authors' approach to these injuries. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: When considering traumatic brachial plexus and upper extremity nerve injuries, iatrogenic nerve injuries, and nontraumatic nerve injuries, brachial plexus and upper extremity nerve injuries are commonly encountered in clinical practice. Despite this, data synthesis and comparison of available studies are difficult. This is at least in part due to the lack of standardization in reporting and a lack of a core outcome set (COS). Thus, there is a need for a COS for adult brachial plexus and upper extremity nerve injuries (COS-BPUE). The objective of this study was to develop a COS-BPUE using a modified Delphi approach., Methods: A 5-stage approach was used to develop the COS-BPUE: 1) consortium development, 2) literature review to identify potential outcome measures, 3) Delphi survey to develop consensus on outcomes for inclusion, 4) Delphi survey to develop definitions, and 5) consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations., Results: The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 23 participants, all neurological surgeons, representing 13 countries. The final COS-BPUE consisted of 36 data points/outcomes covering demographic, diagnostic, patient-reported outcome, motor/sensory outcome, and complication domains. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 24 months, with the consensus optimal time points for assessment being preoperatively and 3, 6, 12, and 24 months postoperatively., Conclusions: The COINS Consortium developed a consensus COS and provided definitions, methods of implementation, and time points for assessment. The COS-BPUE should serve as a minimum set of data that should be collected in all future neurosurgical studies on adult brachial plexus and upper extremity nerve injuries. Incorporation of this COS should help improve consistency in reporting, data synthesis, and comparability, and should minimize outcome reporting bias.

Aim of Work: The type of traumatic peripheral nerve injury is a key factor for determining optimal treatment. Proper assessment of peripheral nerve injury facilitates appropriate treatment, significantly affects prognosis, and reduces disabilities. This study evaluated ultrasonography (US) to assess upper limb traumatic nerve injuries and compared the US with electrodiagnostic studies as the gold standard., Materials and Methods: Participants were 69 adults (57 [83%] men, 12 [17%] women; mean age 36.3 ± 13.5 years) with a total of 96 peripheral nerve injuries (duration of 1 month-3 years). High-frequency US examinations and electro-physiologic studies confirmed upper limb peripheral nerve injury., Results: Nerve discontinuation was diagnosed in 15 (15.6%) nerves; the cross-sectional area was increased in 33 (34.4%) nerves. Of 96 injuries, 54 (56.3%) were median, 24 (25%) were ulnar, and 18 (18.8%) were radial nerves. No statistically significant difference was found between US and electro-physiologic studies for nerve injury diagnosis (p = 0.054)., Conclusion: No significant differences were found between US and electro-physiologic studies for diagnosis of nerve injuries; however, US was valuable to assess surrounding tissue and supplied muscles. The capabilities to detect nerve injury and associated distal muscular, vascular, and other regional structures position the US as a complementary diagnostic tool., (© 2022. The Author(s).)

Learning Objectives: After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers., Summary: Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Objective: The use of the prone position to treat patients with COVID-19 pneumonia who are critically ill and mechanically ventilated is well documented. This case series reports the location, severity, and prevalence of focal peripheral nerve injuries involving the upper limb identified in an acute COVID-19 rehabilitation setting. The purpose of this study was to report observations and to explore the challenges in assessing these patients., Methods: Participants were patients with suspected peripheral nerve injuries following discharge from COVID-19 critical care who were referred to the peripheral nerve injury multidisciplinary team. Data were collected retrospectively on what peripheral neuropathies were observed, with reference to relevant investigation findings and proning history., Results: During the first wave of the COVID-19 pandemic in the United Kingdom, 256 patients were admitted to COVID-19 critical care of Queen Elizabeth Hospital, Birmingham, United Kingdom. From March to June 2020, a total of 114 patients required prone ventilation. In this subgroup, a total of 15 patients were identified with clinical findings of peripheral nerve injuries within the upper limb. In total, 30 anatomical nerve injuries were recorded. The most commonly affected nerve was the ulnar nerve (12/30) followed by the cords of the brachial plexus (10/30). Neuropathic pain and muscle wasting were identified, signifying a high-grade nerve injury., Conclusion: Peripheral nerve injuries can be associated with prone positioning on intensive care units, although other mechanisms, such as those of a neuroinflammatory nature, cannot be excluded., Impact: Proning-related upper limb peripheral nerve injuries are not discussed widely in the literature and could be an area of further consideration when critical care units review their proning protocols. Physical therapists treating these patients play a key part in the management of this group of patients by optimizing the positioning of patients during proning, making early identification of peripheral nerve injuries, providing rehabilitation interventions, and referring to specialist services if necessary., Lay Summary: During the COVID-19 pandemic, patients who are very ill can be placed for long periods of time on their stomach to improve their chances of survival. The potential consequences of prolonged time in this position are weakness and pain in the arms due to potential nerve damage. There are some recommended treatments to take care of these problems., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Risk of intraoperative neuropathic injury in minimally invasive surgery has been established as a leading complication. Continuous intraoperative neuromonitoring (IONM), such as upper extremity somatosensory evoked potentials (ueSSEPs), to decrease peripheral nerve injury due to positional stress has been described. Robotic-assisted laparoscopic prostatectomy (RALP) requires steep Trendelenberg, which may predispose patients to upper extremity neuropraxia. Subdermal stimulating electrodes were placed on the patients' bilateral wrists over the ulnar nerve and the nerve was stimulated. Realtime waveforms were compared to baseline data to prevent and detect injury to the ulnar nerve. Established intervention criteria, indicating risk for neuropathic damage necessitating intraoperative patient repositioning, was a 50% loss in amplitude or a 10% increase in latency. One hundred and forty three patients received RALP with IONM. 17 of 143 patients (11.8%) met ueSSEP intervention criteria. Only weight was significantly different between the two groups (p = 0.04). Mean reduction in amplitude was 79.9% (SE 4.1). Average amplitude loss duration was 22 min (SE 4.0). Weight and BMI were correlated to the degree of amplitude reduction (p = 0.03 and < 0.01), while operative time and DM approached significance (p = 0.09 and p = 0.14). This is the first study to use IONM to reduce the risk of nerve injury during genitourinary surgery. Realtime nerve monitoring using ueSSEP allowed for upper extremity intraoperative monitoring and repositioning. This may decrease the risk of upper extremity neuropraxia due to malpositioning during RALP. Weight and BMI were identified as risk factors for possible nerve injury. Further data collection and analysis to preoperatively stratify patients for application of IONM during RALP is currently ongoing.

Background: The purpose of our study was to determine the incidence and average cost of nerve injuries in patients presenting with upper extremity trauma., Methods: The Nationwide Emergency Department Sample database was queried using International Classification of Diseases, Ninth Revision codes specific to peripheral nerve injuries of the upper extremity. Data on the incidence, patient demographics, average number of associated diagnoses, Injury Severity Scale (ISS) score, mechanism of injury, and average cost of care were collected and analyzed., Results: Of 1.58 million upper extremity traumatic injuries, there were 5244 nerve injuries, resulting in an annual incidence of 16.9 per 100,000 persons with an average age of 38.42 years. Ulnar nerve injuries were the most common (3.86 per 100,000) followed by digital nerve (2.96 per 100,000), radial nerve (2.90 per 100,000), and median nerve (2.01 per 100,000). Injuries to the brachial plexus had the highest average ISS score (9.79 ± 0.71) and number of presenting diagnoses (8.85 ± 0.61) while having a lower than average emergency department (ED) cost. Patients with digital nerve injuries had the highest average ED cost ($8931.01 ± $847.03), whereas their ISS score (2.82 ± 0.19) and number of presenting diagnoses (4.92 ± 0.22) were the lowest. The most commonly reported mechanism of injury in this study population was from a laceration (29.2%) followed by blunt injury, fall (14.8%), and being struck (7.20%). Males were 2.14 (2.01-2.28) times more likely to have an injury to an upper extremity nerve and 3.25 (2.79-3.79) times more likely to injure a digital nerve., Conclusions: While there was a low incidence of upper extremity nerve injuries associated with upper extremity trauma, the ulnar nerve was most frequently injured. Males were twice as likely to sustain a traumatic upper extremity nerve injury, with laceration being the most common mechanism of injury. The average ED cost associated with upper extremity nerve injuries in the United States was determined to be approximately $5779.

Purpose: Fixation with a cortical button is the biomechanically strongest surgical approach for distal biceps repair, and utilization of the 2-incision approach may provide a more anatomical repair and improved terminal supination strength. The risk of injury to the posterior interosseous nerve (PIN) associated with this approach requires further investigation., Methods: A distal biceps repair with a cortical button was performed on 10 cadavers, 5 utilizing the single-incision approach and 5 utilizing the 2-incision approach. Contrast was injected into the radial nerve and computed tomography scans were obtained. The distance between the drilled cortical perforation and the PIN was measured., Results: The mean distance from the cortical perforation to the PIN was not significantly different between approaches (9.4 mm and 8.8 mm). A PIN entrapment was seen in 0 out of 5 for the single-incision approach and 1 out of 5 for the 2-incision approach., Conclusions: Distal biceps repair with cortical button fixation places the PIN at risk of injury regardless of the approach used. Methods of fixation that require bicortical drilling should be especially avoided when using the 2-incision approach., Clinical Relevance: Distal biceps repair utilizing bicortical drilling for fixation through a 2-incision approach poses high risk of injury to the PIN and should be avoided., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Introduction: Lower motor neurons are the only neurons of the central nervous system (CNS) with the ability to regenerate without any intervention after an axotomy., Aim: This present study was conducted to analyze clinical and electrophysiological parameters in four groups of upper limb peripheral neuropathies, before and after treatment, comparing the results obtained after three cures of complex rehabilitation therapy., Materials and Methods: We selected a number of 107 patients (66 women and 41 men) aged between 29 and 77 years (mean age = 49.6). Clinical (muscular strength, sensitivity) and electrophysiological parameters (accommodation coefficient α, nerve conduction velocity) were analyzed. All patients received 3 comprehensive treatment cures, each cure of 14 days and a rest period of 3 months between the cures., Results: From the total of 107 patients included in the study, 52 were diagnosed with brachial plexus palsy, 27 with radial nerve palsy, 18 with median nerve palsy and 10 with ulnar nerve palsy. We did not observe a statistically significant difference between the mean age of males (47.2) and females (51.2) (p = 0.07), but peripheral neuropathies were more common in young males. At the end of the rehabilitation treatment all patients achieved better outcomes in muscle strength, sensitivity, adjustment coefficient α and nerve conduction velocity (p < 0.001).CONCLUSIONThe intervention of a physical therapy program in patients with peripheral neuropathies provided significantly better outcomes in clinical and electrophysiological parameters. Our rehabilitation protocol can be considered an alternative in order to stimulate and accelerate the nerve regeneration process.

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.

Objective: To evaluate the potential of electrical impedance myography (EIM), which is sensitive to the changes in muscle structure and physiology, in discriminating traumatic peripheral nerve injury (TPNI) in the upper extremity. To identify factors that primarily influence muscle atrophy secondary to nerve injury., Methods: Thirty-nine patients with TPNI underwent EIM measurement and standard electromyography tests for multiple muscles in the upper extremity. The side-to-side differences in EIM parameters were calculated for each subject and compared with the compound motor action potential (CMAP) amplitude, which is a measure of injury severity, and the time since injury., Results: The reactance and phase values of the affected muscles were consistently lower than those of healthy muscles, with an average side-to-side difference of approximately -50% (p<0.001) and -45% (p<0.001), respectively. The CMAP amplitude, rather than the time since injury, had a greater effect on the side-to-side difference of phase values., Conclusions: EIM discriminates TPNI by revealing asymmetries in reactance and phase values. The severity of injury had a larger influence than the time since injury on muscle atrophy secondary to nerve injury., Significance: These results demonstrate the putative use of EIM in discriminating TPNI and deserves further study., (Copyright © 2016 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Cabled sensory nerve autografts are the historical gold standard for overcoming gaps in larger diameter nerves as repair utilizing large-diameter autograft risks central graft necrosis. Commercially available processed nerve allograft (PNA) is available in diameters up to 5 mm but represents an acellular 3-dimensional matrix as opposed to viable tissue. The purpose of this study is to specifically evaluate whether similar concerns regarding the use of large-caliber PNA are warranted. Methods: The RANGER Registry is an active database designed to collect injury, repair, safety, and outcomes data for PNAs (Avance® Nerve Graft; AxoGen, Inc, Alachua, Florida) according to an institutional review board-approved protocol. The database was queried for patients presenting with large-caliber nerve allograft repairs in the upper extremity. Identified patients reporting quantitative outcomes with a minimum of 9-month follow-up were included in the data set. Results: The large-caliber PNA subgroup included 13 patients with 15 injuries. The mean ± SD age was 36 ± 22 years. Large-caliber single-stranded repairs included twelve 4- to 5-mm-diameter grafts. Large-caliber cabled repairs included the combined use of 3- to 4-mm and 4- to 5-mm-diameter nerve allografts in 3 repairs. The mean nerve gap was 33 ± 10 mm with a mean follow-up time of 13 months. Available quantitative data reported meaningful recovery of sensory and motor function in 67% and 85% of the repairs, respectively. Conclusion: Although based on a small subset of patients, PNAs of up to 5 mm in diameter appear capable of supporting successful nerve regeneration., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Both Jonathan Isaacs and Bauback Safa have received speaking fees and partial research support from AxoGen, Inc. Jonathan Isaacs has received educational support from AxoGen, Inc. Jonathan Isaacs is a co-principal investigator in an AxoGen, Inc–sponsored study (grant through Jonathan Isaacs’s institution).

Direct repair and nerve autografting are primary options in the treatment of upper extremity peripheral nerve injuries. Deciding between these surgical options depends on the mechanism of injury, time since injury, and length of repair defect. Principles of direct repair and nerve autografting are reviewed. Finally, a literature-based review of the outcomes of upper extremity peripheral nerve repair and autografting is provided. Taken together, this article provides relevant and recent data for surgeons regarding patient selection, technique selection, surgical technique, surgical outcomes, and prognostic factors that will aid surgeons treating patients with upper extremity peripheral nerve injuries., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Free functional muscle transfer provides an option for functional restoration when nerve reconstruction and tendon transfers are not feasible. To ensure a successful outcome, many factors need to be optimized, including proper patient selection, timing of intervention, donor muscle and motor nerve selection, optimal microneurovascular technique and tension setting, proper postoperative management, and appropriate rehabilitation. Functional outcomes of various applications to the upper extremity and the authors' algorithm for the use of free functional muscle transfer are also included in this article., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Peripheral nerve injury is a significant perioperative problem. Intraoperative position-related neurapraxia may indicate impending peripheral nerve injury and can be detected by changes in somatosensory evoked potentials (SSEP). The purpose of this retrospective analysis of spine surgeries performed under general anesthesia with SSEP monitoring was to determine the relationship between intraoperative mean arterial blood pressure (MAP) and intraoperative upper extremity position-related neurapraxia in the prone surrender (superman) position., Methods: We reviewed a computerized database of spine surgeries performed on adult patients in the prone surrender position. The authors reviewed intraoperative SSEP monitoring reports to identify the patients who developed intraoperative upper extremity position-related neurapraxia (case group) and patients who did not (control group). Propensity matching was performed to derive 2 demographically matched groups. Preoperative and intraoperative variables were included in the univariate Cox regression analysis of risk factors associated with neurapraxia. Multivariate Cox regression models were used to identify the independent risk factors., Results: One hundred fifty-two patients were included in the analysis. The case group included 32 patients, whereas the control group included 120 matched patients. Intraoperative MAP <55 mm Hg for a total duration of ≥5 minutes was an independent risk factor associated with a greater incidence of upper extremity position-related neurapraxia compared with a duration of <5 minutes with MAP <55 mm Hg (hazard ratio, 3.43; confidence interval, 1.445-8.148; P = 0.0052). Intraoperative MAP >80 mm Hg for a total duration of >55 minutes was an independent predictor associated with a lower incidence of neurapraxia compared with a total duration ≤55 minutes (hazard ratio, 0.341; confidence interval, 0.163-0.717; P = 0.0045)., Conclusions: In this study, we identified the changes in intraoperative MAP as independent predictors associated with upper extremity position-related neurapraxia in the prone surrender position under general anesthesia.

Background: This is a systematic review for evaluating the evidence for functional outcomes after decellularized nerve use in clinical setting. Decellularized nerves are allografts whose antigenic components have been removed, leaving only a scaffold that promotes the full regeneration of axons., Methods: Literature research was performed using the PubMed/MEDLINE database for English language studies with the keywords "decellularized nerve" and "processed nerve allograft." Inclusion criteria were prospective and retrospective case reviews in clinical settings. Exclusion criteria were case reports and case series., Results: We retrieved six level VIII studies and one level VI study (classified according to the Jovell and Navarro-Rubio scale) with a total of 131 reconstructions. The basic data ranges of the studies were as follows: patient age, 18 to 86 years; duration between initial injury and nerve reconstruction procedure, 8 hours to 4 years; and follow-up period, 40 days to 2 years. The maximum lengths of the nerve gap for chemically washed decellularized nerves and cryopreserved decellularized nerves were 50 and 100 mm, respectively. Quantitatively, the functional outcome ranges were as follows: static two-point discrimination, 3 to 5 mm; and moving two-point discrimination, 2 to 15 mm. For motor assessment, all patients had a > M3 Medical Research Council score. It is also important to notice that a large variability occurs in almost every factor in the reviewed studies., Conclusion: Our study is the first to summarize the clinical results of decellularized nerves. Decellularized nerves have been used to bridge nerve gaps ranging from 5 to 100 mm with associated satisfactory outcomes in static and moving two-point discriminations., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: The evaluation of motor and sensory function of the upper extremity after a peripheral nerve injury is critical to diagnose the location and extent of nerve injury as well as document functional recovery in children., Purpose: The purpose of this paper is to describe an approach to the evaluation of the pediatric upper extremity peripheral nerve injuries through a critical review of currently used tests of sensory and motor function., Methods: Outcome studies on pediatric upper extremity peripheral nerve injuries in the Medline database were reviewed., Results: The evaluation of the outcome in children less than 10 years of age with an upper extremity peripheral nerve injury includes careful observation of preferred prehension patterns, examination of muscle atrophy and sudomotor function, provocative tests, manual muscle testing and tests of sensory threshold and tactile gnosis., Conclusion: The evaluation of outcome in children with upper extremity peripheral nerve injuries warrants a unique approach., (Copyright © 2015 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.)

Purpose: Nerve gap injuries may be associated with lesions in other structures, like tendons or bones; in these cases, it is common to plan a second surgery to improve functional recovery. Since macroscopic observations of nerve regeneration in humans are rare, we exploited these second surgeries for the purpose of studying nerve regeneration in humans., Methods: We assessed the clinical outcomes of 50 implants of collagen-based nerve guides in the upper limb. We performed a second look at 20, assessing macroscopically both nerve regeneration and collagen degradation., Results and Conclusions: Pain was never recorded in these patients. An adequate sensory recovery took place whenever nerve regeneration was found inside the guide. Motor recovery seemed to occur only when the gap lesion was shorter than 10 mm. The degree of degradation appeared to be variable and was not directly correlated with time; we hypothesize that it could be associated with the site of implantation. Such a large number of second looks in humans has never been previously reported in the literature.

Background: Surgical techniques for proximal biceps tenodesis that include penetration of the posterior humeral cortex for fixation may pose risk to the surrounding neurovascular structures., Hypothesis: The risk of neurologic injury with techniques that involve penetration of the posterior humeral cortex for fixation in proximal biceps tenodesis will increase as the tenodesis site moves proximally from the subpectoral to the suprapectoral location., Methods: Proximal biceps tenodesis was performed on 10 cadaveric upper extremities with 3 separate techniques. The proximity of the hardware to the relevant neurovascular structures was measured. The distances between the tenodesis site and the relevant neurovascular structures were measured., Results: The guide pin was in direct contact with the axillary nerve in 20% of the suprapectoral tenodeses. The distance between the axillary nerve and the tenodesis site was 10.5 ± 5.5 mm for the suprapectoral location, 36.7 ± 11.2 mm in the subpectoral scenario, and 24.1 ± 11.2 mm in the 30° cephalad scenario (P = .003). The distance between the radial nerve and the anterior tenodesis site was 41.3 ± 9.3 mm for the suprapectoral location and 48.0 ± 10.7 mm for the subpectoral location. The distance of the musculocutaneous nerve from the tenodesis site was 28.4 ± 9.2 mm for the suprapectoral location and 37.4 ± 11.2 mm for the subpectoral location., Conclusion: In a cadaveric model of open biceps tenodesis, penetration of the posterior humeral cortex at the suprapectoral location results in proximity to the axillary nerve and should be avoided. Subpectoral bicortical button fixation drilled perpendicular to the axis of the humerus was a uniformly safe location with respect to the axillary nerve., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort's cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Background: Psychological symptoms frequently accompany severe injuries of the upper extremities and are described to influence functional outcome. As yet, little knowledge is available about the occurrence of posttraumatic psychological stress and the predictive characteristics of peripheral nerve injuries of the upper extremity for such psychological symptoms. In this prospective study, the incidence of different aspects of early posttraumatic stress in patients with peripheral nerve injury of the forearm is studied as well as the risk factors for the occurrence of early psychological stress., Methods: In a prospective study design, patients with a median, ulnar or combined median-ulnar nerve injury were monitored for posttraumatic psychological stress symptoms with the Impact of Event Scale (IES) questionnaire up to 3 months postoperatively., Results: Psychological stress within the first month after surgery occurred in 91.8% of the population (IES mean=22.0, standard deviation (SD)=17.3). Three months postoperatively, 83.3% (IES mean=13.3, SD=14.1) experienced psychological stress. One month postoperatively 24.6% and 3 months postoperatively 13.3% of the patients had IES scores indicating for the need for psychological treatment. Female gender, adult age and combined nerve injuries were related to the occurrence of psychological stress symptoms 1 month postoperatively., Conclusions: In the majority of these patients, peripheral nerve injury of the forearm is accompanied by early posttraumatic psychological stress, especially in female adults who suffered from combined nerve injuries., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Laceration and irrecoverable stretch, crush, or avulsion of a major peripheral nerve in the upper extremity causes substantial impairment in an adult patient. Hand care professionals who treat these patients encounter a wide range of coping strategies leading to varied courses of recovery and strikingly different final outcomes. There is evidence that the cognitive, emotional, and behavioral aspects of recovery (not to mention the circumstantial aspects such as worker compensation and litigation) are as important as the physical aspects. Awareness of the factors that facilitate or hinder these aspects of recovery might improve the quality and effectiveness of our care., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Evaluation of outcomes after peripheral nerve surgeries include several assessment methods that reflect different aspects of recovery, including reinnervation, tactile gnosis, integrated sensory and motor function, pain and discomfort, and neurophysiologic and patient-reported outcomes. This review lists measurements addressing these aspects as well as the advantages and disadvantages of each tool. Because of complexities of neurophysiology, assessment remains a difficult process, which requires researchers to focus on measurements best relevant to specific conditions and research questions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Object: Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer., Methods: In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity., Results: The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation., Conclusions: The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.

This article describes the normal anatomy of the brachial plexus and its major terminal branches, as well as the major causes and clinical presentations of lesions of these structures. An approach to electrodiagnosis of brachial plexopathies and proximal upper extremity neuropathies is provided, with an emphasis on those nerve conduction studies and portions of the needle examination, which permit localization of lesions to specific trunks, cords, and terminal branches. The importance of specific sensory nerve conduction studies for differentiating plexopathies from radiculopathies and mononeuropathies is emphasized., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Reconstruction of peripheral nerve discontinuities with processed nerve allograft has become increasingly relevant. The RANGER Study registry was initiated in 2007 to study the use of processed nerve allografts in contemporary clinical practice. We undertook this study to analyze outcomes for upper extremity nerve repairs contained in the registry database., Methods: We identified an upper extremity-specific population within the RANGER Study registry database consisting of 71 nerves repaired with processed nerve allograft. This group was composed of 56 subjects with a mean age of 40 ± 17 years (range, 18-86 y). We analyzed data to determine the safety and efficacy of processed nerve allograft. Quantitative data were available on 51 subjects with 35 sensory, 13 mixed, and 3 motor nerves. The mean gap length was 23 ± 12 mm (range, 5-50 mm). We performed an analysis to evaluate response-to-treatment and to examine sensory and motor recovery according to the international standards for motor and sensory nerve recovery., Results: There were no reported implant complications, tissue rejections, or adverse experiences related to the use of the processed nerve allografts. Overall recovery, S3 or M4 and above, was achieved in 86% of the procedures. Subgroup analysis demonstrated meaningful levels of recovery in sensory, mixed, and motor nerve repairs with graft lengths between 5 and 50 mm. The study also found meaningful levels of recovery in 89% of digital nerve repairs, 75% of median nerve repairs, and 67% of ulnar nerve repairs., Conclusions: Our data suggest that processed nerve allografts offer a safe and effective method of reconstructing peripheral nerve gaps from 5 to 50 mm in length. These outcomes compare favorably with those reported in the literature for nerve autograft, and exceed those reported for tube conduits., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Upper extremity muscle and nerve injuries in athletes are important causes of lost playing time and suboptimal performance. Although most muscle injuries are self-limited, imaging may be indicated in select situations for diagnostic and prognostic purposes, to investigate potential complications of injury, and for instituting prompt therapy to hasten recovery. MRI is particularly sensitive to soft tissue abnormalities seen in muscle injury, and it can reliably diagnose and stage direct injuries such as contusions and lacerations, and indirect injuries such as strains, delayed-onset muscle soreness, and exertional compartment syndrome. Upper extremity peripheral nerve injuries may be compressive or noncompressive in etiology, with certain sports and activities rendering particular nerves vulnerable to characteristic injuries. Initial evaluation includes a complete history, physical examination, and electrodiagnostic studies. MRI and ultrasound assessment of the nerves, surrounding tissues, and innervated muscles can provide localizing, diagnostic, and prognostic information that complements clinical and electrodiagnostic testing., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Although autografts are the gold standard for failed primary nerve repairs, they result in donor-site morbidity. Nerve conduits and decellularized allografts are a novel solution for improved functional outcomes and decreased donor-site morbidity. Unfortunately, previous reconstructive algorithms have not included the use of decellularized allograft nerve segments, either for repair of the primary injury or reconstruction of the autograft donor site. To identify the optimal sequence of techniques and resources, we reviewed our cases of upper extremity peripheral nerve reconstruction., Methods: A retrospective review was performed on consecutive patients who underwent upper extremity nerve reconstruction between August 2003 and September 2009. Outcomes were evaluated with the QuickDASH (disabilities of the arm, shoulder, and hand) questionnaire. Grouped outcome results were evaluated with analysis of variance analysis. A literature review of available options for nerve reconstruction was performed., Results: In all, 47 patients were identified. Complete demographic/injury data were obtained in 41 patients with 54 discrete nerve repairs: 8 were repaired primarily, 27 with nerve conduits, 8 with allografts, and 11 with autografts. Time from injury to repair averaged 22.3 ± 38.3 weeks, with 12 repairs occurring immediately after tumor resection. Average QuickDASH score was 23.2 ± 19.8. An analysis of variance between repair-type outcomes revealed a P value of 0.58, indicating no outcome difference when each repair was applied for an appropriate gap. No comparable algorithm was identified in the literature analyzing the use of allograft in conjunction with conduit and autografts., Conclusion: To restore maximal target-organ function with minimal donor-site morbidity, we have created an algorithm based on evidence for nerve reconstruction using allograft, conduit, and autologous donor nerve. Based on our clinical outcomes, despite small sample study, the adoption of the proposed algorithm may help provide uniform outcomes for a given technique, with minimal patient morbidity. Individualized reconstructive technique, based not only on nerve gap size but also on functional importance and the anatomical level of the nerve injury are important variables to consider for optimal outcome.

Purpose: Nerve injuries from missile and gunshot wounds often produce significant disability, and their management is controversial. The role of the surgeon in cases of missile wounds with neurologic deficits is not well defined. Enhancing the trauma team's ability to recognize treatable nerve injuries will lead to improved outcomes. Further, raising awareness of the time-sensitive nature of these injuries will also improve results in these cases., Methods: We reviewed a consecutive series of 17 pediatric patients with peripheral nerve injuries caused by missile and gunshot wounds in a tertiary care children's hospital. We examined the indications for surgery, presence of associated injuries, mechanisms of injury, demographic characteristics and clinical outcomes., Results: Urban victims were significantly more likely to have been intentionally assaulted than rural or suburban victims and they were also less likely to have completed follow-up care. High-energy weapons were more likely to require surgery compared with low-energy weapons. Patients presenting with tendon injuries were more likely to have a high-grade nerve injury requiring surgery., Conclusions: Patients presenting with tendon lacerations or high-energy mechanisms were significantly more likely to require surgery. Early exploration should be undertaken in cases where transection is likely to have occurred. Early decompression of common entrapment sites distal to repairs or injuries should be performed. Because follow-up is poor in this population, treatment should be prompt and thorough.

Basic difficulties of the adequate and precise electrophysiological examination of radial nerve injuries are traditionally conditioned by the impossibility to separate the muscle, isolated from the muscles, innervated by the ulnar or medial nerves. The phenomenon of flexor motor units potentials propagation by the stimulating electroneuromyography and M-flow registration from extensor muscles has been described in literature. To prevent the false interpretation of the examination results, 98 patients with radial nerve injuries were examined using the original program of separate assessment of motor and sensor fibers.

Clinical examination and electrodiagnostic studies remain the gold standard for diagnosis of nerve injuries. Diagnosis of chronic nerve compression (CNC) injuries can be difficult in patients with confounding factors such as diabetes. The treatment of nerve entrapment ranges from medical to surgical management, depending on the nerve involved and on the severity and duration of compression. Considerable insights have been made at the molecular level, differentiating between nerve crush injuries and CNC injuries. Although the myelin changes after CNC injury were previously thought to be a mild form of Wallerian degeneration, recent evidence points to a distinct pathophysiology involving Schwann cell mechanosensitivity. Future areas of research include Schwann cell transplantation in the treatment regimen, the correlation between demyelination and the onset of pain, and the role of Schwann cell integrins in transducing the mechanical forces involved in nerve compression injuries to Schwann cells.

Peripheral nerve injury of the upper extremity commonly occurs in patients who participate in recreational (e.g., sports) and occupational activities. Nerve injury should be considered when a patient experiences pain, weakness, or paresthesias in the absence of a known bone, soft tissue, or vascular injury. The onset of symptoms may be acute or insidious. Nerve injury may mimic other common musculoskeletal disorders. For example, aching lateral elbow pain may be a symptom of lateral epicondylitis or radial tunnel syndrome; patients who have shoulder pain and weakness with overhead elevation may have a rotator cuff tear or a suprascapular nerve injury; and pain in the forearm that worsens with repetitive pronation activities may be from carpal tunnel syndrome or pronator syndrome. Specific history features are important, such as the type of activity that aggravates symptoms and the temporal relation of symptoms to activity (e.g., is there pain in the shoulder and neck every time the patient is hammering a nail, or just when hammering nails overhead?). Plain radiography and magnetic resonance imaging are usually not necessary for initial evaluation of a suspected nerve injury. When pain or weakness is refractory to conservative therapy, further evaluation (e.g., magnetic resonance imaging, electrodiagnostic testing) or surgical referral should be considered. Recovery of nerve function is more likely with a mild injury and a shorter duration of compression. Recovery is faster if the repetitive activities that exacerbate the injury can be decreased or ceased. Initial treatment for many nerve injuries is nonsurgical.

Purpose: To explore the relationship between upper extremity nerve damage and activity participation, pain, depression, and perceived quality of life., Methods: A total of 49 patients with upper extremity nerve damage completed standardized measures of activity participation, pain, depression, and quality of life. We analyzed scores for all subjects and for 2 diagnostic groups: patients with compressive neuropathy and patients with nerve injury (laceration, tumor, and brachial plexus injury), and explored predictors of overall quality of life., Results: Participants had given up 21% of their previous daily activities; greater activity loss was reported in patients with nerve injury. Pain was moderate and 39% had signs of clinical depression. Physical and psychological quality of life ratings were below the norms. Activity loss was strongly associated with higher levels of depression and lower physical and psychological quality of life. Higher depression scores correlated strongly with lower overall quality of life. Greater pain correlated moderately with higher depression scores and weakly with quality of life; no statistical relationship was found between pain and physical quality of life. Activity participation and depression predicted 61% of the variance in overall quality of life in patients with nerve damage., Conclusions: The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage., Type of Study/level of Evidence: Prognostic IV.

We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness. This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this.

Nerve injuries are common in trauma surgery and appear more frequently if the upper extremity is affected. The aim of this study is to estimate possible predictors of the outcome after nerve injury of the upper extremity and to demonstrate feasible tools to follow up postoperative nerve regeneration for the daily clinical practice. During January 2000 until December 2004, a total of 372 nerve lesions of the upper extremity have been treated in our clinic. Patient's age, site of nerve lesion, concomitant injuries, and the timing of surgical repair could be outlined to be significant predictors for clinical outcome. Digital nerve lesions showed the best regenerative capacity. Most predictors of clinical outcome such as patient's age, concomitant injuries, and site of lesion cannot be influenced. But knowing the predictors helps specify the prognosis of nerve regeneration. For the daily clinical practice, static two-point discrimination, location of Tinel's sign, and grip strength measurement seem to be fast and reproducible tools to follow up nerve regeneration at the upper extremity.

Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery. Lessons of tendon transfers have taught that nerves to specific musculotendinous units are expendable, and greater understanding of peripheral nerve topography has revealed redundant fascicles in peripheral nerves. Transfer of these redundant or expendable nerves to recipient nerves close to the end organ allows for earlier reinnervation and preservation of those musculotendinous units. Such nerve transfers provide significantly better treatment options in many cases of nerve injury where previous outcomes were expected to be poor, such as with proximal injuries, long nerve gaps, or unavailability of the proximal injured segment. This article will review current nerve transfers in the hand and upper extremity.

Objective: To systematically review the available evidence for the effectiveness of sensory re-education to improve the sensibility of the hand in patients with a peripheral nerve injury of the upper limb., Data Sources: Studies were identified by an electronic search in the databases MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, the Physiotherapy Evidence Database (PEDro), and the database of the Dutch National Institute of Allied Health Professions (Doconline) and by screening the reference lists of relevant articles., Review Methods: Two reviewers selected studies that met the following inclusion criteria: all designs except case reports, adults with impaired sensibility of the hand due to a peripheral nerve injury of the upper limb, and sensibility and functional sensibility as outcome measures. The methodological quality of the included studies was independently assessed by two reviewers. A best-evidence synthesis was performed, based on design, methodological quality and significant findings on outcome measures., Results: Seven studies, with sample sizes ranging from 11 to 49, were included in the systematic review and appraised for content. Five of these studies were of poor methodological quality. One uncontrolled study (N = 1 3 ) was considered to be of sufficient methodological quality, and one randomized controlled trial (N = 49) was of high methodological quality. Best-evidence synthesis showed that there is limited evidence for the effectiveness of sensory re-education, provided by a statistically significant improvement in sensibility found in one high-quality randomized controlled trial., Conclusion: There is a need for further well-defined clinical trials to assess the effectiveness of sensory re-education of patients with impaired sensibility of the hand due to a peripheral nerve injury.

Objective: To search for the best program for treatment of peripheral nerve incomplete injury., Methods: Ninety cases were randomly divided into a treatment group, a control group I and a control group II, 30 cases in each group. The treatment group were treated with electroacupuncture at Jianyu (LI 15), Hegu (LI 4), Quchi (LI 11), etc. plus functional training, and the control group I with electroacupuncture and the control group H with functional training. After treatment for 3 months, basic function, practical function, EMG, nerve conduction velocity were compared among the 3 groups., Results: The good rate of basic function of 50.0%, the curemarkedly effective rate of practical function of 50.0% and the total effective rate of neurophysiology of 64.3% in the treatment group were better than 20.7%, 17.2%, 41.4% in the control group I (P < 0.05) and 23.3%, 20.0% and 36.O7% in the control group II (P 0.05)., Conclusion: Electroacupuncture combined with functional training can accelerate nervous repair, promote functional recovery of the denervated muscles, so as to shorten the restoring time of nerve-muscle and increase life quality of the patient.

Nerve injuries in the upper extremity can result in severe disability. In the past three decades, progress in microsurgical techniques and instruments have resulted in improved outcomes for nerve injuries. If the prognosis is reasonably good, nerve repair is usually preferred over tendon or flap transfer procedures. However, lesions of peripheral stem nerves such as high radial nerve palsy may still yield unsatisfactory results, despite technically well-executed nerve repair. Prognosis further depends on the age of the patient; the regenerative process is delayed in older patients. Further criteria for the indication for tendon transfers are the personal and professional profiles of individual patients. Tendon or flap transfers to restore sensation can be performed at any time post trauma when it becomes clear that long-term rehabilitation is required. These procedures abbreviate the interval during which hand function is severely impaired, so that patients have alternatives to persistent nerve palsy with the need of permanent external splints, and long and costly rehabilitation can be shortened. Sophisticated techniques allow minimal donor site morbidity and leave options open in case function of the reconstructed nerve returns. The present article gives an overview of the most common procedures to restore hand function and sensation in the most important digits and provides help for decision making.

Objectives: The authors present their results of 44 microsurgical procedures of 47 nerves in 44 patients subjects over a period of 19 years, from 1985 to 2003., Study Group Subjects and Methods: 44 patients with injuries to peripheral nerves of the upper extremities underwent reconstructions of 47 nerves using autotransplants. The procedures effectivity results were analysed using the following indicators: the injury to the procedure time, the patient's age, the autotransplant length, the injury type, the injury site, the injured nerve type., Results: The best results were reached: in young patients up to the age of 20, in cases of early operations up to 3 months, in cases when grafts up to 5 cm were used. Clean, for instance incision injury, has much better prospects for successful nerve graft autotransplantation than others, more complicated injuries (e.g. lacerated injury or contusion).

In every child who has a fracture, neurologic examination is essential at initial assessment so that early diagnosis of nerve injury can be made. Electrodiagnostic studies may be helpful in diagnosis when the examination is equivocal and in follow-up to look for signs of recovery. In a patient who has neurologic deficits associated with a fracture, nerve exploration should be considered for open fractures, fractures that require open reduction, and palsies that develop after fracture reduction. For closed fractures associated with nerve palsy at the time of initial injury, observation and serial examination after reduction is recommended. If there is no return of nerve function on examination or electrodiagnostic testing by 4 months, operative exploration is indicated.