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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

 

 

25-NOVEMBER-2006  IBRAHEEM MUHAMED ABDEL-RAHMAN  21 YEARS  NON-FUNCTIONING POSTTRAUMATIC  LEFT MEDIAN AND ULNAR NERVES UPPER THIRD FOREARM.

The patient came to the clinic 12-October-2006  complaining of non-function of both median and ulnar nerves left forearm  after cut deep wound by sharp instrument 18 days ago. The patient was hospitalized elsewhere and closure of the wound was performed and we could not obtain records about the nature of surgical interference.

The patient on examination cannot flex his left hand. Complete non-function of both nerves was noted with absent radial and ulnar pulsation. The patient had trophic ulcers at the tips of the fingers, but the common circulation was adequate.

The patient was sent for EMG and ECS of the major nerves, which confirmed complete non-function of the left median and ulnar nerves. The patient was advised to wait for 2 months to observe the nerve condition, but he insisted to perform surgery earlier and repeat ECS was performed 23-November-2006 which confirmed another time complete non-function of both nerves.

Part of the old incision was refreshed and the heavy scars were noted and both median and ulnar nerves were explored above and below the scar and identified. Neurolysis of both nerves down to the scar revealed that both were cut with neuroma formation of the ulnar nerve. The gap between the proximal and distal healthy appearing parts of the left ulnar nerve, was 6 cm.  The gap between the healthy looking median nerve was 3cm.  The site of the injury of the median nerve was 10 mm above the point of emergence of the common interosseus nerve and the scarous motor branch to the teres major was left untouched, because the muscle was scarous also.

Left sural nerve 35 cm length was harvested and cut into 4 bundles and the gap between the ulnar nerve was bridged by these grafts. 6 zero nylon was used and maximum coaptation of the nerve fibers was achieved.  After mobilization of the proximal and distal parts of the median nerve it was possible to perform primary repair using 4 zero nylon  with 12 sutures. Routine closure of the wound with complete cast above elbow in flexion position for preventing  possible dehiscence of the median nerve suture.

Comments:

1. In clean cut wounds it is preferable to repair the nerves during the first procedure. When it is not known what was done during the procedure and the doctors are not informative, then exploration of the nerves must be considered not planned and done and early intervention must be done, as in this case, when erroneously, the patient urged for early intervention.

2. Simple anastamosis is superior than putting grafts, but when the gap is a major one, the only option remain to use grafts. The median nerve could be repaired by simple suturing and considering that the median nerve is more important to the patient , this choice was for his favor.

 

 


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved