We desire here to acknowledge our indebtedness to Mr. James Sherren's work on Injuries of Nerves and their Treatment.
The Brachial Plexus.—Lesions of the brachial plexus may be divided into those above the clavicle and those below that bone.
In the supra-clavicular injuries, the violence applied to the head or shoulder causes over-stretching of the anterior branches (primary divisions) of the cervical nerves, the fifth, or the fifth and sixth being those most liable to suffer. Sometimes the traction is exerted upon the plexus from below, as when a man in falling from a height endeavours to save himself by clutching at some projection, and the lesion then mainly affects the first dorsal nerve. There is tearing of the nerve sheaths, with hæmorrhage, but in severe cases partial or complete severance of nerve fibres may occur and these give way at different levels. During the healing process an excess of fibrous tissue is formed, which may interfere with regeneration.
Post-anæsthetic paralysis occurs in patients in whom, during the course of an operation, the arm is abducted and rotated laterally or extended above the head, causing over-stretching of the plexus, especially of the fifth, or fifth and sixth, anterior branches.
A cervical rib may damage the plexus by direct pressure, the part usually affected being the medial cord, which is made up of fibres from the eighth cervical and first dorsal nerves.
When a lesion of the plexus complicates a fracture of the clavicle, the nerve injury is due, not to pressure on or laceration of the nerves by fragments of bone, but to the violence causing the fracture, and this is usually applied to the point of the shoulder.
Penetrating wounds, apart from those met with in military practice, are rare.
In the infra-clavicular injuries, the lesion most often results from the pressure of the dislocated head of the humerus; occasionally from attempts made to reduce the dislocation by the heel-in-the-axilla method, or from fracture of the upper end of the humerus or of the neck of the scapula. The whole plexus may suffer, but more frequently the medial cord is alone implicated.
Clinical Features.—Three types of lesion result from indirect violence: the whole plexus; the upper-arm type; and the lower-arm type.
When the whole plexus is involved, sensibility is lost over the entire forearm and hand and over the lateral surface of the arm in its distal two-thirds. All the muscles of the arm, forearm, and hand are paralysed, and, as a rule, also the pectorals and spinati, but the rhomboids and serratus anterior escape. There is paralysis of the sympathetic fibres to the eye and orbit, with narrowing of the palpebral fissure, recession of the globe, and the pupil is slow to dilate when shaded from the light.
The upper-arm type—Erb-Duchenne paralysis—is that most frequently met with, and it is due to a lesion of the fifth anterior branch, or, it may be, also of the sixth. The position of the upper limb is typical: the arm and forearm hang close to the side, with the forearm extended and pronated; the deltoid, spinati, biceps, brachialis, and supinators are paralysed, and in some cases the radial extensors of the wrist and the pronator teres are also affected. The patient is unable to supinate the forearm or to abduct the arm, and in most cases to flex the forearm. He may, however, regain some power of flexing the forearm when it is fully pronated, the extensors of the wrist becoming feeble flexors of the elbow. There is, as a rule, no loss of sensibility, but complaint may be made of tickling and of pins-and-needles over the lateral aspect of the arm. The abnormal position of the limb may persist although the muscles regain the power of voluntary movement, and as the condition frequently follows a fall on the shoulder, great care is necessary in diagnosis, as the condition is apt to be attributed to an injury to the axillary (circumflex) nerve.
The lower-arm type of paralysis, associated with the name of Klumpke, is usually due to over-stretching of the plexus, and especially affects the anterior branch of the first dorsal nerve. In typical cases all the intrinsic muscles of the hand are affected, and the hand assumes the claw shape. Sensibility is usually altered over the medial side of the arm and forearm, and there is paralysis of the sympathetic.
Infra-clavicular injuries, as already stated, are most often produced by a sub-coracoid dislocation of the humerus; the medial cord is that most frequently injured, and the muscles paralysed are those supplied by the ulnar nerve, with, in addition, those intrinsic muscles of the hand supplied by the median. Sensibility is affected over the medial surface of the forearm and ulnar area of the hand. Injury of the lateral and posterior cords is very rare.
Treatment is carried out on the lines already laid down for nerve injuries in general. It is impossible to diagnose between complete and incomplete rupture of the nerve cords, until sufficient time has elapsed to allow of the establishment of the reaction of degeneration. If this is present at the end of fourteen days, operation should not be delayed. Access to the cords of the plexus is obtained by a dissection similar to that employed for the subclavian artery, and the nerves are sought for as they emerge from under cover of the scalenus anterior, and are then traced until the seat of injury is found. In the case of the first dorsal nerve, it may be necessary temporarily to resect the clavicle. The usual after-treatment must be persisted in until recovery ensues, and care must be taken that the paralysed muscles do not become over-stretched. The prognosis is less favourable in the supra-clavicular lesions than in those below the clavicle, which nearly always recover without surgical intervention.
In the brachial birth-paralysis met with in infants, the lesion is due to over-stretching of the plexus, and is nearly always of the Erb-Duchenne type. The injury is usually unilateral, it occurs with almost equal frequency in breech and in vertex presentations, and the left arm is more often affected than the right. The lesion is seldom recognised at birth. The first symptom noticed is tenderness in the supra-clavicular region, the child crying when this part is touched or the arm is moved. The attitude may be that of the Erb-Duchenne type, or the whole of the muscles of the upper limb may be flaccid, and the arm hangs powerless. A considerable proportion of the cases recover spontaneously. The arm is to be kept at rest, with the affected muscles relaxed, and, as soon as tenderness has disappeared, daily massage and passive movements are employed. The reaction of degeneration can rarely be satisfactorily tested before the child is three months old, but if it is present, an operation should be performed. After operation, the shoulder should be elevated so that no traction is exerted on the affected cords.
The long thoracic nerve (nerve of Bell), which supplies the serratus anterior, is rarely injured. In those whose occupation entails carrying weights upon the shoulder it may be contused, and the resulting paralysis of the serratus is usually combined with paralysis of the lower part of the trapezius, the branches from the third and fourth cervical nerves which supply this muscle also being exposed to pressure as they pass across the root of the neck. There is complaint of pain above the clavicle, and winging of the scapula; the patient is unable to raise the arm in front of the body above the level of the shoulder or to perform any forward pushing movements; on attempting either of these the winging of the scapula is at once increased. If the scapula is compared with that on the sound side, it is seen that, in addition to the lower angle being more prominent, the spine is more horizontal and the lower angle nearer the middle line. The majority of these cases recover if the limb is placed at absolute rest, the elbow supported, and massage and galvanism persevered with. If the paralysis persists, the sterno-costal portion of the pectoralis major may be transplanted to the lower angle of the scapula.
The long thoracic nerve may be cut across while clearing out the axilla in operating for cancer of the breast. The displacement of the scapula is not so marked as in the preceding type, and the patient is able to perform pushing movements below the level of the shoulder. If the reaction of degeneration develops, an operation may be performed, the ends of the nerve being sutured, or the distal end grafted into the posterior cord of the brachial plexus.
The Axillary (Circumflex) Nerve.—In the majority of cases in which paralysis of the deltoid follows upon an injury of the shoulder, it is due to a lesion of the fifth cervical nerve, as has already been described in injuries of the brachial plexus. The axillary nerve itself as it passes round the neck of the humerus is most liable to be injured from the pressure of a crutch, or of the head of the humerus in sub-glenoid dislocation, or in fracture of the neck of the scapula or of the humerus. In miners, who work for long periods lying on the side, the muscle may be paralysed by direct pressure on the terminal filaments of the nerve, and the nerve may also be involved as a result of disease in the sub-deltoid bursa.
The deltoid is wasted, and the acromion unduly prominent. In recent cases paralysis of the muscle is easily detected. In cases of long standing it is not so simple, because other muscles, the spinati, the clavicular fibres of the pectoral and the serratus, take its place and elevate the arm; there is always loss of sensation on the lateral aspect of the shoulder. There is rarely any call for operative treatment, as the paralysis is usually compensated for by other muscles.
When the supra-scapular nerve is contused or stretched in injuries of the shoulder, the spinati muscles are paralysed and wasted, the spine of the scapula is unduly prominent, and there is impairment in the power of abducting the arm and rotating it laterally.
The musculo-cutaneous nerve is very rarely injured; when cut across, there is paralysis of the coraco-brachialis, biceps, and part of the brachialis, but no movements are abolished, the forearm being flexed, in the pronated position, by the brachio-radialis and long radial extensor of the wrist; in the supinated position, by that portion of the brachialis supplied by the radial nerve. Supination is feebly performed by the supinator muscle. Protopathic and epicritic sensibility are lost over the radial side of the forearm.
Radial (Musculo-Spiral) Nerve.—From its anatomical relationships this trunk is more exposed to injury than any other nerve in the body. It is frequently compressed against the humerus in sleeping with the arm resting on the back of a chair, especially in the deep sleep of alcoholic intoxication (drunkard's palsy). It may be pressed upon by a crutch in the axilla, by the dislocated head of the humerus, or by violent compression of the arm, as when an elastic tourniquet is applied too tightly. The most serious and permanent injuries of this nerve are associated with fractures of the humerus, especially those from direct violence attended with comminution of the bone. The nerve may be crushed or torn by one of the fragments at the time of the injury, or at a later period may be compressed by callus.
Clinical Features.—Immediately after the injury it is impossible to tell whether the nerve is torn across or merely compressed. The patient may complain of numbness and tingling in the distribution of the superficial branch of the nerve, but it is a striking fact, that so long as the nerve is divided below the level at which it gives off the dorsal cutaneous nerve of the forearm (external cutaneous branch), there is no loss of sensation. When it is divided above the origin of the dorsal cutaneous branch, or when the dorsal branch of the musculo-cutaneous nerve is also divided, there is a loss of on the dorsum of the hand.
The motor symptoms predominate, the muscles affected being the extensors of the wrist and fingers, and the supinators. There is a characteristic “drop-wrist”; the wrist is flexed and pronated, and the patient is unable to dorsiflex the wrist or fingers (Fig. 90). If the hand and proximal phalanges are supported, the second and third phalanges may be partly extended by the interossei and lumbricals. There is also considerable impairment of power in the muscles which antagonise those that are paralysed, so that the grasp of the hand is feeble, and the patient almost loses the use of it; in some cases this would appear to be due to the median nerve having been injured at the same time.
If the lesion is high up, as it is, for example, in crutch paralysis, the triceps and anconeus may also suffer.
Treatment.—The slighter forms of injury by compression recover under massage, douching, and electricity. If there is drop-wrist, the hand and forearm are placed on a palmar splint, with the hand dorsiflexed to nearly a right angle, and this position is maintained until voluntary dorsiflexion at the wrist returns to the normal. Recovery is sometimes delayed for several months.
In the more severe injuries associated with fracture of the humerus and attended with the reaction of degeneration, it is necessary to cut down upon the nerve and free it from the pressure of a fragment of bone or from callus or adhesions. If the nerve is torn across, the ends must be sutured, and if this is impossible owing to loss of tissue, the gap may be bridged by a graft taken from the superficial branch of the radial nerve, or the ends may be implanted into the median.
Finally, in cases in which the paralysis is permanent and incurable, the disability may be relieved by operation. A fascial graft can be employed to act as a ligament permanently extending the wrist; it is attached to the third and fourth metacarpal bones distally and to the radius or ulna proximally. The flexor carpi radialis can then be joined up with the extensor digitorum communis by passing its tendon through an aperture in the interosseous membrane, or better still, through the pronator quadratus, as there is less likelihood of the formation of adhesions when the tendon passes through muscle than through interosseous membrane. The palmaris longus is anastomosed with the abductor pollicis longus (extensor ossis metacarpi pollicis), thus securing a fair amount of abduction of the thumb. The flexor carpi ulnaris may also be anastomosed with the common extensor of the fingers. The extensors of the wrist may be shortened, so as to place the hand in the position of dorsal flexion, and thus improve the attitude and grasp of the hand.
The superficial branch of the radial (radial nerve) and the deep branch (posterior interosseous), apart from suffering in lesions of the radial, are liable to be contused or torn is dislocation of the head of the radius, and in fracture of the neck of the bone. The deep branch may be divided as it passes through the supinator in operations on old fractures and dislocations in the region of the elbow. Division of the superficial branch in the upper two-thirds of the forearm produces no loss of sensibility; division in the lower third after the nerve has become associated with branches from the musculo-cutaneous is followed by a loss of sensibility on the radial side of the hand and thumb. Wounds on the dorsal surface of the wrist and forearm are often followed by loss of sensibility over a larger area, because the musculo-cutaneous nerve is divided as well, and some of the fibres of the lower lateral cutaneous branch of the radial.
The Median Nerve is most frequently injured in wounds made by broken glass in the region of the wrist. It may also be injured in fractures of the lower end of the humerus, in fractures of both bones of the forearm, and as a result of pressure by splints. After division at the elbow, there is impairment of mobility which affects the thumb, and to a less extent the index finger: the terminal phalanx of the thumb cannot be flexed owing to the paralysis of the flexor pollicis longus, and the index can only be flexed at its metacarpo-phalangeal joint by the interosseous muscles attached to it. Pronation of the forearm is feeble, and is completed by the weight of the hand. After division at the wrist, the abductor-opponens group of muscles and the two lateral lumbricals only are affected; the abduction of the thumb can be feebly imitated by the short extensor and the long abductor (ext. ossis metacarpi pollicis), while opposition may be simulated by contraction of the long flexor and the short abductor of the thumb; the paralysis of the two medial lumbricals produces no symptoms that can be recognised. It is important to remember that when the median nerve is divided at the wrist, deep touch can be appreciated over the whole of the area supplied by the nerve; the injury, therefore, is liable to be over looked. If, however, the tendons are divided as well as the nerve, there is insensibility to deep touch. The areas of epicritic and of protopathic insensibility are illustrated in Fig. 91. The division of the nerve at the elbow, or even at the axilla, does not increase the extent of the loss of epicritic or protopathic sensibility, but usually affects deep sensibility.
The Ulnar Nerve.—The most common injury of this nerve is its division in transverse accidental wounds just above the wrist. In the arm it may be contused, along with the radial, in crutch paralysis; in the region of the elbow it may be injured in fractures or dislocations, or it may be accidentally divided in the operation for excising the elbow-joint.
When it is injured at or above the elbow, there is paralysis of the flexor carpi ulnaris, the ulnar half of the flexor digitorum profundus, all the interossei, the two medial lumbricals, and the adductors of the thumb. The hand assumes a characteristic attitude: the index and middle fingers are extended at the metacarpo-phalangeal joints owing to paralysis of the interosseous muscles attached to them; the little and ring fingers are hyper-extended at these joints in consequence of the paralysis of the lumbricals; all the fingers are flexed at the inter-phalangeal joints, the flexion being most marked in the little and ring fingers—claw-hand or main en griffe. On flexing the wrist, the hand is tilted to the radial side, but the paralysis of the flexor carpi ulnaris is often compensated for by the action of the palmaris longus. The little and ring fingers can be flexed to a slight degree by the slips of the flexor sublimis attached to them and supplied by the median nerve; flexion of the terminal phalanx of the little finger is almost impossible. Adduction and abduction movements of the fingers are lost. Adduction of the thumb is carried out, not by the paralysed adductor pollicis, but the movement may be simulated by the long flexor and extensor muscles of the thumb. Epicritic sensibility is lost over the little finger, the ulnar half of the ring finger, and that part of the palm and dorsum of the hand to the ulnar side of a line drawn longitudinally through the ring finger and continued upwards. Protopathic sensibility is lost over an area which varies in different cases. Deep sensibility is usually lost over an area almost as extensive as that of protopathic insensibility.
When the nerve is divided at the wrist, the adjacent tendons are also frequently severed. If divided below the point at which its dorsal branch is given off, the sensory paralysis is much less marked, and the injury is therefore liable to be overlooked until the wasting of muscles and typical main en griffe ensue. The loss of sensibility after division of the nerve before the dorsal branch is given off resembles that after division at the elbow, except that in uncomplicated cases deep sensibility is usually retained. If the tendons are divided as well, however, deep touch is also lost.
Care must be taken in all these injuries to prevent deformity; a splint must be worn, at least during the night, until the muscles regain their power of voluntary movement, and then exercises should be instituted.
Dislocation of the ulnar nerve at the elbow results from sudden and violent flexion of the joint, the muscular effort causing stretching or laceration of the fascia that holds the nerve in its groove; it is predisposed to if the groove is shallow as a result of imperfect development of the medial condyle of the humerus, and by cubitus valgus.
The nerve slips forward, and may be felt lying on the medial aspect of the condyle. It may retain this position, or it may slip backwards and forwards with the movements of the arm. The symptoms at the time of the displacement are some disability at the elbow, and pain and tingling along the nerve, which are exaggerated by movement and by pressure. The symptoms may subside altogether, or a neuritis may develop, with severe pain shooting up the nerve.
The dislocated nerve is easily replaced, but is difficult to retain in position. In recent cases the arm may be placed in the extended position with a pad over the condyle, care being taken to avoid pressure on the nerve. Failing relief, it is better to make a bed for the nerve by dividing the deep fascia behind the medial condyle and to stitch the edges of the fascia over the nerve. This operation has been successful in all the recorded cases.
The Sciatic Nerve.—When this nerve is compressed, as by sitting on a fence, there is tingling and powerlessness in the limb as a whole, known as “sleeping” of the limb, but these phenomena are evanescent. Injuries to the great sciatic nerve are rare except in war. Partial division is more common than complete, and it is noteworthy that the fibres destined for the peroneal nerve are more often and more severely injured than those for the tibial (internal popliteal). After complete division, all the muscles of the leg are paralysed; if the section is in the upper part of the thigh, the hamstrings are also paralysed. The limb is at first quite powerless, but the patient usually recovers sufficiently to be able to walk with a little support, and although the hamstrings are paralysed the knee can be flexed by the sartorius and gracilis. The chief feature is drop-foot. There is also loss of sensation below the knee except along the course of the long saphenous nerve on the medial side of the leg and foot. Sensibility to deep touch is only lost over a comparatively small area on the dorsum of the foot.
The Common Peroneal (external popliteal) nerve is exposed to injury where it winds round the neck of the fibula, because it is superficial and lies against the unyielding bone. It may be compressed by a tourniquet, or it may be bruised or torn in fractures of the upper end of the bone. It has been divided in accidental wounds,—by a scythe, for example,—in incising for cellulitis, and in performing subcutaneous tenotomy of the biceps tendon. Cases have been observed of paralysis of the nerve as a result of prolonged acute flexion of the knee in certain occupations.
When the nerve is divided, the most obvious result is “drop-foot”; the patient is unable to dorsiflex the foot and cannot lift his toes off the ground, so that in walking he is obliged to jerk the foot forwards and laterally. The loss of sensibility depends upon whether the nerve is divided above or below the origin of the large cutaneous branch which comes off just before it passes round the neck of the fibula. In course of time the foot becomes inverted and the toes are pointed—pes equino-varus—and trophic sores are liable to form.
The Tibial (internal popliteal) nerve is rarely injured.
The Cranial nerves are considered with affections of the head and neck (Vol. II.).