surgeris at Nerves , Tendons , Muscles Flashcards
Explain the structure of Nerve
— its including roots and rami and plexuses
- its start with Axons/nerve fibers and each Axon consist of Schwann cells in case of mylanted fiber , and then connective tissue and blood vessels
-Capsules ( from inner most to outer most )
1-Endoneurium: surrounds neuron and its form by loose CT with Capillaries
2-Perineurium : several Neuron its fascicl and this fascicl surrounded by perineurium its Loose CT and its consist of blood vessels
3-Epinurium : surrounded the entire nerve and its Dense CT
what is the Classification of Nerve injures
-its based On Seddon and they are 3
1-Neuropraxia : its temporary interruption of conduction without loss of Axonal Continuity , and its mildest type of peripheral nerve Injury
-Etiology : Compresstion , traction
there are sensory-motor problems distal to the site of injury
- the 3 layers which are Endonuroim , perineurium , Epineurium still intact
-Recovery of the nerve conduction deficit is full , requiring day to week
( no surgery )
2-Axonomtesis : its when axons and their myelin sheath are damaged but the 3 layer still intact
-Etiology: Compression ,
traction ,ischemia
-there are sensory - motor deficits distal to the site of lesion
-Axonal regeneration occurs and recovery is possible without surgical treatment , some time surgical intervention is required bcs of scar tissue formation
3-Neurotmesis : its total disruption of the entire nerve fiber .
sensory-motor problems and Autonomic function defect are sever
- because lack of nerve , surgical intervention is necessary
NB! Axonamtesis and Neuromatesis. are followed by wallerian degeneration inthe distal end of injured nerve
explain the Pathomorphology of the nerve injury
—we have 2 part proximal and distal
1-Proximal: it goes one by one like steps
1.1 partial axinak degeneration
1.2 regeneration of axon
1.3 formation of a trumatic neuroma ( if the nerve wasn’t sutured )
—trumatic Neuroma or puesdoneuroma or Amputation neuroma its posttrumatic hyperregnation of the nerve
and it occures if the distal part was absence
2-distal Part :
2.1 complete degeneration of axons
2.2 regeneration of Schwann cells
2.3 Atrophy of the nerve ( if wasnt sutured )
list the type of operation on nerve trunk
-in operation of Nerve we use the indirect approach which is we go away from the projectional line , to avoid the formation of a common scar between nerve membrane and other dissecting tissues
-The most common operations Are :
1-Neurolysis
2.Neurotomies
3.resection of neuroma
4-Nerve suture ( neurorraphy )
5-Neuroplasty ( nerve grafting ) in vase of large diastase
explain the Neurotomy ( Neurotomies ) Df,method , Ex of operation
-Neurotomy : is the intersection of the nerve
-the method : the nerve trunk is isolated for 2 cm and taken in wet gauze strips and its crossed by blade of safe razor ( bcs its allow us to avoid maicrotruma in the end of the nerve )
-Ex of operation : vagotomy for peptic ulcer of the stomach and duodenum its deccetion of the vagus nerve which is goes to the stomach or duodenum , we do it bcs stimulation of parasympathetic cause secretion of HCL , so we block the formation of peptic ulcer
Explain the Neurolysis , DF , how we do it ?
-Neurolysis : is an operation aimed at releasing the nerve from scaring that occurs after blunt effect or bone fracture located near the passage of the nerve
-how we do it :
1-Excised the pathological altered tissue
2-Creat anatomical condition that promotes nerve regeneration
3-Under the microscope , the tissues compressing the nerve are cut with a scalpel according to the projection of the nerve , try to not disturb the integrity of its branches
explain suture of the nerve ( Neurorraphy ) , Goal , Classification, Primary suture and its contraindications, Secondary Suture
-Goal : is to decrease the diastases and let the con from proximal part to enter the distal part and regenerate
-Classification: we have 2
1- Time based :
1.1 primary suture applied during primary surgical treatment, while early secondary ( delayed ) within 3-4 weeks after healing of the wound by primer tension
1.2 late secondary are applied after 4 weeks after the injury or wound healed by secondary tension
2- method based:
2.1 Epinueral
2.2 Perinural
–Primary suture :
-Condition for it is
1. Absence of infection
2. sufficient time for surgical intervention
3-proper technical equipment of an operation theater
4-Opportunity of neurological examination of patient before surgery
5-Qualified surgeon
-Contraindications:
1-hemorregic shock
2. infection
3-crushing of the wound
4- not Qualified surgeon
—Advantage of secondary nerve suture :
1-Clean operation
2-performing of the surgery by highly qoulfied doctor
3-bounderis of the nerve resection are easy to determine
NB! in case of the secondary suture we use indirect approach
explain the requirements and stages of Neurorraphy
—requirements:
1-connection the end of the nerve without tension
2-suture shouldn’t involve nerve fibres ( only pass through CT membrane) and impair blood supply
3-Distasis between Proximal and distal part should be 0,5-1 mm
4- nerve fascicles should be adapted
5-Knots of the suture shouldn’t be located in between proximal and distal end of the nerve
—Stages :
1-Exposure of the nerve
2-Neurolysis ( in case of secondary suture )
3-Examntion and detrmnation of the boundaries
4-Moblazation
5-resection of the damaged nerve areas of the nerve trunk perpendicularly to the longitudinal axis of the nerve
6-nerve suturing , monofilament nylon suture is perferd beca easy to use and minimal forgein body reactivity , needle is atraumatic , piercing
7-Closure of the wound and immoblazation of the wound for 2-3 weeks
explain the method based suture
1-Epinural :
1.1 isolation begins from the unchanged portion if the proximal end of the nerve
1.2 excised the neuroma at level if healthy tissue
1.3 moblization of epinurium
1.4 we injects the needle at distance of 1mm from the edge of of the nerve starting from outside to inside then to the distal part inside then outside ( all this are performed in the epinurium
-tie knot 3 cm long bcs the myoflimnt nylon is very sloopy
2-Perineurial :
2.1 exposure of the nerve
2.2 Remove Epineurium on plot of 5-8 mm at the both end of nerve to open access to bundle of the fsascicls
2.3 we stitch each fascicle separately
2,4 the restoration of integrity start from the deep most to outer most
NB! its more favorable the Epinerual repair bcs :
1-not to much suture
2-perinural repair prevents growth of nerouns
explain methods of Neuroplasty , in case of large distance , Neuroplasty nerve grafting
-in case id large distance these method are applied:
1-stitching in flexion position of the limb if the distance less then 8-10cm
2-changing the course of the nerve
3-bone resection ( not used )
—-Neuroplasty :
1- its performed when diastasis is at least 2-3 cm when mobalzation of the nerve are harmful
2-its more effective when the diastasis is not more then 5 cm
3-we only use Auto-grafting
—Autografting sites :
1-Sural N
2-Ant.branch of the medial anteriorbrachial cutanous N
3-Lateral Femoral Coutenous N
4-superfasical redial Sensory N
NB : the graft should be approximately 10-20% longer then the gap , as the graft is shortens with CT Fibrosis
explain requirements for tendon surgeries, main indication for tendon surgeries
—requirements:
1-indirect approach
2-Strict asepticity
3-delicate manipulation on the tendon : lead to sever postoprative edema
4-prevention of dry
5-immoblazation of the limb after surgery
—Main indecations :
1-Trauma
2-deformateis of locomotor apparatus
( innate and acquired )
explain the classification of tendons and
—there is two classification topoghrpical and anatomical
- topographical : divided into 2
1-Extensor tendons : which they are
1.1 superfascially
1.2 flattened in the transverse section
1.3 extrasynoval in most parts
1.4 proximal end of the tendon after rupture doesn’t move proximally ( duo to intertnedouns connection )
1.5 get damged duo to open and close injuries
2-flexor tendons :
2.1 deeply located
2.2 round or oval in transversction
2.3 intrasynovial
2.4 proximal end move proximally after rupture
2.5 damaged mainly duo to open injury’s
——-
-Anatomical : they are 2
1-Synovial Coatd or intrasynovial
Ex> floxor digitorm
2- unseald or oaratenon coated ( extrasynovial )
Ex> Achillous Tendon
Structure of Synovial Sheath , sources if blood supply of tendon
-synovial coated thats mean there is synovial sheath
—Synovial sheath : Consist of 2 layers
1-Vasciral = epitnonuim
2.Parietal = preitoninum
-between these two layers there is which is so called mesatenodn which is form vincula
-mestanidon : there is vessels and nerves , its the main blood supply for coated tendon
—Sources of blood supply of the tendon :
1-from the muscles belly
2-from largest arteries which is passing along the tendon
3-from peristoium where the tendon insertion
explain no mans lands
- its zone between palmar fold and distal interphalangeal joint , tendon repair in this zone has the least success rate
list the types of tendon surgeries and requirements for tenorraphy
-tendon surgeries:
1-Tenorraphy
2-Tenotomy
3-Tenolysis
4-tenodesis
5-tenoplasty
6-Transpostion
—-requirements:
1-suture should be simple
2-the sutur shouldn’t be impair the blood supply
3-limitation of theards
4-the suture should hold the ends if the tendon , for long time
5-it should be Atrumatic
6-it shouldn’t create barrier between connecting surfaces
