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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. |
