Principles of nerve repair in complex wounds of the upper extremity

Abstract

Peripheral nerve injuries are common in the setting of complex upper extremity trauma. Early identification of nerve injuries and intervention is critical for maximizing return of function. In this review, the principles of nerve injury, patient evaluation, and surgical management are discussed. An evidence-based approach to nerve reconstruction is reviewed, including the benefits and limitations of direct repair and nerve gap reconstruction with the use of autografts, processed nerve allografts, and conduits. Further, the principles and indications of commonly used nerve transfers in proximal nerve injuries are also addressed.

Keywords: mutilating injury of the hand; nerve conduit; nerve transfer; peripheral nerve injury; processed nerve allograft; upper extremity trauma.

Fig. 1

Intraoperative images of reconstruction of the median and partial radial nerves with nerve grafting in the setting of a brachial artery repair. (A) Right arm wound after vein grafting of the brachial artery. (B) Median and radial nerves identified. (C) Median and radial nerve repaired with autograft cables. (D) Repair of the biceps tendon to complete the reconstruction of the extremity after a complex laceration.

Fig. 2

Key principles of nerve management in complex trauma.