Nerve Injuries Leg

Nerves are the "electrical wiring" system of the body that carries messages between the brain and the rest of the body.

Nerve Injuries Leg

Nerves are the "electrical wiring" system of the body that carries messages between the brain and the rest of the body. There are two types of nerves- motor and sensory nerves. Motor nerves carry messages between the brain and muscles to make the body move. Sensory nerves carry messages between the brain and different parts of the body to signal pain, touch and temperature.

The nerves can malfunction if compressed, stretched or injured.

When the nerve is compressed or stretched, outer cover of the nerve remains intact, but the ability of the nerve to send and receive signals from various parts of the body is compromised. If this compression is unrelieved, it can cause permanent damage to the nerve

When the nerve is cut or injured, fascicles within the nerve and its outer cover both are damaged with partial or complete loss of motor power and sensory input from the area of the distribution of nerve. If the nerve is not repaired, the growing nerve fibers may form a painful nerve scar, or neuroma at the cut ends.

Think of nerve as an electric wire And injury to nerve as a cut electric wire. The cut ends of the electric wire should be brought and glued together so that the electricity can travel through the wire uninterrupted and reach its destination like fan, tubelight. Similarly, cut ends of the nerve should be brought together surgically and sutured under microscope with very fine sutures so that signals from the brain can reach to different parts of the body.

But there is a big difference!!! There is immediate flow of electricity through the repaired wire in contrast to the nerve repair which takes a much longer time. Nerve fibers typically begin to regrow about three or four weeks after surgery. The nerve grows at a constant speed of one inch per month after it is repaired. So, the results of nerve repair can take months to a year to appear. During the process of recovery, feeling of pins and needles in area of distribution of the nerve is common. While this can be uncomfortable, it usually passes and is a sign of recovering nerve.

Timing of Nerve Repair

After nerve repair, new fibers grow beneath the covering layer until it reaches a muscle or sensory receptor. The nerve fibers should reach the target muscle within 18 months of the injury otherwise the muscle receptor degenerates. For this reason, repair should be done as early as possible after injury to allow maximum time period for growth of the nerve.

The sensory receptor does not degenerate, therefore, sensory nerve repair can be done anytime or years after the injury also.

Management of Nerve Injury

If the nerve is compressed or stretched, removal of the offending structure or situation will help in spontaneous healing and recovery of the nerve.
If the nerve is cut and wound is clean, covering around both the cut ends of the injured nerve is sewn together. The goal in repairing the nerve is to suture the covering layer with minute sutures so that new fibers can grow forward across the injured site towards its target organ and the nerve can work again.

Nerve repair with realignment of bundles.

If a nerve is cut and wound is dirty or crushed, surgery may be delayed until the skin has healed.
If there is a space between the ends of the nerve, it may be necessary to take a piece of nerve (nerve graft) from another part of the body to repair the injured nerve.
The results of nerve repair depends on a number of factors like age of the patient, presence of other diseases and the level of injury etc.
Nerve fibers typically begin to regrow about three or four weeks after surgery. During this time, patients must wear a splint to prevent the repaired nerve from stretching apart.
Physiotherapy is must after nerve repair to keep the joints supple
Care must be taken to prevent oneself from burn or other injuries till the sensation returns back in cases of sensory nerve repair.

Nerve Injuries Leg

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Sciatic Nerve Injuries

Sciatic nerve branches from the lower back region passes through the gluteal region, thigh and divides into 2 main branches in the lower part of the thigh-common peroneal nerve and tibial nerve.

Sciatic nerve supplies muscles of the back of thigh and apparently to all the muscle of whole of leg and foot viaits two main branches named above. Sciatic nerve is responsible for sensation in the whole of the leg and foot.

Sciatic nerve can be injured by accidents, compression or by stretching of the nerve. It can happen in fractures and dislocation of the hip. It is quite commonly wrongly injected with drugs and damaged while giving intramuscular injections by untrained professionals.

Injuries to the sciatic nerve can cause

Inability to move the foot and toes- upward or downward
Numbness on whole leg and foot.
Tingling and pain on the leg and foot region.
Loss of ability to move the foot forward due to weakness of the muscles of foot and leg.
Tinel's sign will be positive– Tapping on the site of injury will elicit tingling and pain sensation in the leg and foot region.
To confirm the diagnosis- Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG)of the affected limb is done.
In few cases, CT scan or MRI is also indicated.

Sciatic nerve injury is a very debilitating condition, mainly because of 2 major deficiencies-

complete loss of muscle power in foot and toes
loss of sensation on sole of the foot -making patient prone to more injuries and burns over foot

Treatment of Sciatic Nerve Injury

If the sciatic nerve is damaged or cut, then surgical excision of the damaged part and nerve repair/grafting should be done as early as possible or within 3 months of the injury. The results of repair are not good for sciatic nerve injuries as the injury is most of the times so up and proximal that by the time nerve fibers grow and reach up to the leg region, motor end plates or receptors had already degenerated.

The results of sciatic nerve repair is relatively good in children and in patients who come early. The result is better if direct nerve repair is possible without the use of nerve grafting and if the level of injury is not higher up and is in the lower thigh.

More than 50% of the patients require secondary procedures in form of microvascular free functioning transfer or arthrodesis of the foot even after nerve repair.

If the patient has presented with sudden onset of paralysis of sciatic nerve, then other neurological causes or compression by tumor should be investigated for. In many of such cases, release of the nerve is done and a biopsy of the nerve fascicle and muscle is taken to confirm the diagnosis of neurological disease.
If the problem is caused by an underlying illness or some other fracture or dislocation or tumor, it is important to address that issue.
If the patient presents with gradual paralysis of sciatic nerve, then sciatic nerve compression - should be thought. Offending factor should be removed and release of the compression with creation of more space for the nerve should be done surgically.
If the patient has presented late beyond the timing suitable for sciatic nerve repair (after 3 months to 6 months of the accident), then also nerve repair and grafting should be done. It might not help in restoration of the muscle function but can help in restoring the sensation to the sole of the foot. Tendon transfers for restoring the muscle movements of the foot cannot be done in sciatic nerve injuries as all the muscles are paralysed and no tendon is left for transfer.

Free functioning muscle transfer can be attempted by microvascular surgical techniques to restore function of movement of the ankle and foot in upward direction. A strong muscle from the thigh is taken with its blood and nerve supply and fixed at 2 different points of the leg and foot. The blood and nerve supply of the muscle is joined with the blood and nerve supply in the region of leg by microsurgical techniques. The goal is to enable the patient to extend his or her foot and toes at their joints.

The surgery is usually done under spinal anaesthesia or general anaesthesia and a splint or slab is given for immobilization in the post operative period. The patient is usually discharged tenth day after the surgery. Sutures are removed3 weeks after surgery. Splint is removed 6 weeks after the surgery and gradual training of the transferred muscles is started so that they regain their newly assigned function.

Common Peroneal Nerve Injuries

Common peroneal nerve branches from the sciatic nerve in the lower part of the thigh and passes to the leg from its outer aspect. It then divides into 2 branches-, superficial and deep, which runs down the front of leg and foot region upto the tip of toes. This nerve provides sensation to the front and sides of the legs and to the top of the feet and toes. This nerve also controls the muscles in the leg that lift the ankle and toes upward.

Common peroneal nerve can be injured by accidents, compression or by stretching of the nerve. It can happen in fractures and dislocation of the knee and leg.

Injuries to the peroneal nerve can cause

Inability to point the toes upward or lift the ankle up (dorsiflexion)
Numbness on the front of leg, foot and dorsum of toes
Tingling and pain on the front of leg and foot region.
Loss of ability to move the foot due to weakness of the muscles of foot and leg
A distinctive style of walking is seen where the knee is raised higher than normal to clear the foot from the ground when the leg swings forward (also called step page or foot drop gait).
Tinel's sign will be positive– Tapping on the site of injury will elicit tingling and pain sensation in the foot region.
To confirm the diagnosis- Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG)of the affected leg is done
In few cases, CT scan or MRI is also indicated

Treatment of Peroneal Nerve Injury

If the peroneal nerve is damaged or cut, then surgical excision of the damaged part and nerve repair/grafting should be done as early as possible or within 6 months of the injury for best results.
If the patient has presented with sudden onset of paralysis of peroneal nerve, then other neurological causes, leprosy or compression by tumor should be investigated for. In many of such cases, release of tunnel under which it passes on the outer aspect of the leg, is done and a biopsy of the nerve fascicle and muscle is taken to confirm the diagnosis of neurological disease or leprosy.
If the problem is caused by an underlying illness or some other fracture or dislocation or tumor, it is important to address that issue.
If the patient presents with gradual paralysis of peroneal nerve, then peroneal nerve compression - should be thought. Offending factor should be removed and release of the compression with creation of more space for the nerve should be done surgically
If the patient has presented late beyond the timing suitable for peroneal nerve repair (after 6 months to 1 year of the accident) or in cases where nerve is damaged beyond repair, then tendon transfers should be done to strengthen the weak portions of the foot along with the nerve repair and grafting (only if feasible). A strong tendon of the leg is re-routed to substitute a weaker or lost movement of the foot.

During tendon transfers for peroneal nerve palsy, one functioning tendons from the inner side of the leg is taken, re-routed and sutured to the tendons of the front of foot and toes so that the patient can extend his or her foot and toes at their joints. This tendon transfer also enables and restores normal walking style.

Splint is removed 4 weeks after the surgery and gradual training of the transferred muscles or tendons is started so that they regain their newly assigned function.

Nerve Injuries Leg

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Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.

MS, DNB (General Surgery) MCh, DNB (Plastic Surgery),
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