Primary Surgery Vol.2 – Trauma: TRIAL SECTION AND RESUTURE

TRIAL SECTION AND RESUTURE

INDICATIONS (1) A nerve which was completely transsected at the time of the patient’s original injury and was not repaired. (2) An injured nerve which is not recovering. If Tinel’s sign (55.9) shows that any recovery is taking place, don’t consider exploring a closed wound for several months. It is probably only contused, and will recover.

If possible refer the patient. If this is impossible, you may be justified in proceeding as follows.

Explore his healed wound and mobilize his injured nerve. Feel carefully for the parts of it that are hard and fibrosed.

Use a sharp scalpel, or a razor blade held in forceps, to cut thin slices across its thickest place.

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Figure 55.10: SECONDARY NERVE REPAIR BY TRIAL SECTION. A, a ragged recently injured nerve surrounded by blood clot. B, later, when the clot has organized and become fibrous tissue. C, taking successive sections of the thickened end of a cut nerve. D, an incompletely divided nerve with two thickened swellings. E, to I, taking trial sections down a thickened nerve. J, the motor area in a cut nerve shown schematically. K, the cut ends of a nerve aligned, and sutured with fine monofilament. Kindly contributed by Peter Bewes.

The first slice you cut from the neuroma (E, in Fig. 55-10) may show a uniform slab of fibrous tissue. In the second slice (F) a few little dots of nervous tissue have started to appear. In the third slice (G) there are more little dots. The fourth slice is mostly nerve tissue (H). The final one (I) has the normal fibrillary structure of a nerve. This is the point to stop cutting back and do ananstomosis (J and K) as for primary nerve suture (55.9). Try to bring the ends together without rotation, so that the motor areas in each end correspond. One such area has been shown hatched in the diagram (J).

Section the distal end in the same way, then join the two ends as above.

PARTICULAR NERVES FOR SECONDARY REPAIR

Ulnar nerve

Move the nerve anteriorly from behind the patient’s medial epicondyle. This will give you the extra length you need to make the anastomosis. Keep his elbow and wrist flexed and try not to injure its branches to flexor carpi ulnaris, and the medial half of his flexor digitorium profundus.

Median nerve at the wrist

Approach this by incising his carpal tunnel.

DIFFICULTIES WITH SECONDARY NERVE REPAIR

If the patient’s NERVE INJURY WAS NEVER DIAGNOSED and his wound is now healing, explore it as soon as the danger of infection is over. The longer you delay after 2 months, the worse the result. If you feel a neuroma, the nerve has been seriously injured.