Evaluation of Rehabilitation Techniques for Traumatic Ulnar Nerve Injuries After Surgical Repair: A Systematic Review

BACKGROUND

Traumatic ulnar nerve injuries often result in significant loss of motor and sensory function, negatively impacting patients' quality of life. Physical rehabilitation is crucial for recovery, but standardized treatment protocols are lacking. This study aims to systematically review rehabilitation techniques to identify future research direction and improve existing protocols for ulnar nerve injury patients.

METHODS

PubMed, Embase, CINAHL, Cochrane CENTRAL, Web of Science, and Scopus were queried from inception until July 31, 2023. Articles containing axonotmesis or neurotmesis injuries of the ulnar nerve were included. Reviews, opinions, editorials, technical reports without clinical outcomes, conference abstracts, non-English text, nonhuman studies, and studies without adult patients were excluded. Three independent reviewers performed screening and data extraction using Covidence, and risk of bias assessments utilizing Cochrane and JBI tools. Because of article heterogeneity, a narrative review was conducted. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number CRD42023442016.

RESULTS

This systematic review included one randomized controlled trial and four observational studies (103 patients), which exhibited differences in study quality. Overall, motor and sensory outcomes improved after rehabilitation. Rehabilitation techniques varied widely, and early sensory reeducation appeared to improve sensory function. Only two studies included patient-reported outcomes.

CONCLUSIONS

Diverse rehabilitation techniques are used to address ulnar nerve injuries. The low number of included studies, differences in study quality, and small sample size underscore the need for larger and more inclusive studies to improve functional recovery after ulnar nerve injuries. Future research should consider the impact of patient and injury characteristics to develop comprehensive treatment guidelines for these patients.

Comparative Effectiveness Systematic Review and Meta-analysis of Peripheral Nerve Repair Using Direct Repair and Connector-assisted Repair

Background

This clinical literature systematic review and meta-analysis were performed to assess differences in outcomes between nerves repaired with direct repair (DR) and connector-assisted repair (CAR).

Methods

A systematic literature review for DR and CAR was performed. Studies from 1980 through August 2023 were included if DR or CAR repairs were performed in upper extremities with nerve gaps less than 5 mm and reported sensory Medical Research Council Classification (MRCC) outcomes or equivalent. Comparative analyses were planned for meaningful recovery (MR) rate (at both S3 and S3+ or better), postsurgical neuroma, cold intolerance, altered sensation, pain, and revision rate.

Results

There were significant differences in MR rates for CAR and DR. At the MRCC S3 threshold, 96.1% of CAR and 81.3% of DR achieved MR (P < 0.0001). At the MRCC S3+ threshold, 87.1% of CAR and 54.2% of DR achieved this higher threshold of MR (P < 0.0001). There were no differences in neuroma rate or pain scores in our dataset. Altered sensation (dysesthesia, paresthesia, hyperesthesia, or hypersensitivity) was not discussed in any CAR studies, so no analysis could be performed. The revision rate for both procedures was 0%. The proportion of patients with cold intolerance was 46.2% in the DR studies, which was significantly higher than the 10.7% of patients in the CAR group.

Conclusions

Significantly more patients achieved sensory MR and fewer had cold intolerance when the CAR technique, instead of the DR technique, was performed to repair peripheral nerve injuries.

Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations

This study aimed to investigate whether ultrasonographic inspection of the repair site of median nerve lacerations may provide useful evidence about the functional outcome in the affected hand. Forty-three patients with complete transection of the median nerve at the distal forearm were examined at a median of 40.9 months after operation by detailed ultrasonographic imaging and clinical assessment of the affected hand by the Michigan Hand Questionnaire and Rosén-Lundborg Protocol to investigate the quality of nerve healing. The continuity of individual nerve fascicles was assessed and the cross-sectional area of the enlarged nerve at the repair site was measured and compared with the contralateral median nerve at the same level. An enlargement ratio for the repair site of each nerve was calculated and compared with the numeric results obtained from the two clinical tests. A statistically significant reverse correlation was observed between nerve enlargement and the functional results of the repaired nerve.Level of evidence: IV.

Traumatic peripheral nerve injuries: a classification proposal

BACKGROUND

Peripheral nerve injuries (PNIs) include several conditions in which one or more peripheral nerves are damaged. Trauma is one of the most common causes of PNIs and young people are particularly affected. They have a significant impact on patients' quality of life and on the healthcare system, while timing and type of surgical treatment are of the utmost importance to guarantee the most favorable functional recovery. To date, several different classifications of PNIs have been proposed, most of them focusing on just one or few aspects of these complex conditions, such as type of injury, anatomic situation, or prognostic factors. Current classifications do not enable us to have a complete view of this pathology, which includes diagnosis, treatment choice, and possible outcomes. This fragmentation sometimes leads to an ambiguous definition of PNIs and the impossibility of exchanging crucial information between different physicians and healthcare structures, which can create confusion in the choice of therapeutic strategies and timing of surgery.

MATERIALS

The authors retrospectively analyzed a group of 24 patients treated in their center and applied a new classification for PNI injuries. They chose (a) five injury-related factors, namely nerve involved, lesion site, nerve type (whether motor, sensory or mixed), surrounding tissues (whether soft tissues were involved or not), and lesion type-whether partial/in continuity or complete. An alphanumeric code was applied to each of these classes, and (b) four prognostic codes, related to age, timing, techniques, and comorbidities.

RESULTS

An alphanumeric code was produced, similar to that used in the AO classification of fractures.

CONCLUSIONS

The authors propose this novel classification for PNIs, with the main advantage to allow physicians to easily understand the characteristics of nerve lesions, severity, possibility of spontaneous recovery, onset of early complications, need for surgical treatment, and the best surgical approach.

LEVEL OF EVIDENCE

according to the Oxford 2011 level of evidence, level 2.

The role of arm volumes evaluation in the functional outcome and patient satisfaction following surgical repair of the brachial plexus traumatic injuries

OBJECTIVE

Brachial plexus injuries are among the most complex injuries of the peripheral nervous system and among the most devastating injuries overall. In complete lesions, functional priorities include the reinnervation of the musculocutaneous and axillary nerves for proximal functions restoration. Three major nerves - radial, median, and ulnar - and the corresponding muscles remain denervated, which results in subsequent muscle atrophy. This study was aimed at the evaluation of arm volumes in surgically treated patients with brachial plexus injuries, in correlation with the type of palsy, recovery and associated factors.

METHODS

The study included 36 patients with brachial plexus injuries who were surgically treated in our institution over a 15-year-long period. The evaluation of arm and arm segments volumes was carried out using water displacement testing, based on the Archimedes principle.

RESULTS

Statistically significant differences were noted between the operated arm and the healthy arm in all of the measured segments (hands, forearms and upper arms), as well as between the patients with complete and upper palsy, and in correlation with the shoulder abduction recovery.

CONCLUSIONS

Previous studies were mainly focused on the functional outcome and quality of life; although related to both, arm volumes in patients with brachial plexus injuries were not analyzed before. Significant differences between the operated arm and the healthy arm volumes, as well as between the various types of palsy, found in the present study should trigger further prospective research in relation to neurophysiology, useful functional recovery and quality of life.

Chronic neuropathic pain after traumatic peripheral nerve injuries in the upper extremity: prevalence, demographic and surgical determinants, impact on health and on pain medication

Background and aims Aside from the long term side effects of a nerve injury in the upper extremity with devastating consequences there is often the problem of chronic neuropathic pain. The studies concerning the prevalence of persistent pain of neuropathic origin after peripheral nerve injuries are sparse. The prevalence and risk factors associated with chronic neuropathic pain after nerve injuries in the upper extremity were assessed. Methods A standardized data collection template was employed prospectively and retrospectively for all patients with traumatic nerve injuries accepted at the Hand Surgery Department, Uppsala, Sweden between 2010 and 2018. The template included demographic data, pain diagnosis, type of injured nerve, level of injury, date of the lesion and repair, type of procedure, reoperation, time since the procedure, S-LANSS questionnaire (Self report-Leeds Assessment of Neuropathic Symptoms and Signs), RAND-36 (Item short form health survey), QuickDASH (Disability of Shoulder, Arm and Hand) and additional questionnaires concerned medication, pain intensity were sent to 1,051 patients with nerve injuries. Partial proportional odds models were used to investigate the association between persistent pain and potential predictors. Results More than half of the patients undergoing a surgical procedure developed persistent pain. Prevalence of neuropathic pain was 73% of the patients with pain (S-LANSS ≥ 12 or more). Multivariate analysis indicated that injury of a major nerve OR 1.6 (p = 0.013), years from surgery OR 0.91 (p = 0.01), younger age OR 0.7 (p < 0.001), were the main factors for predicting pain after surgery. The type of the nerve injured was the strongest predictor for chronic pain with major nerves associated with more pain (p = 0.019). Conclusions A high prevalence of chronic pain and neuropathic pain with a negative impact on quality of life and disability were found in patients after traumatic nerve injury. Major nerve injury, younger age and less time from surgery were predictors for chronic pain.

Outcomes and Return to Work Following Complex Nerve Lacerations in the Volar Forearm in an Underserved Spanish-Speaking Population

Purpose

Lacerations to the ulnar and median nerve in the volar forearm have demonstrated considerable long-term clinical and socioeconomic impacts on patients. The purpose of this study was to evaluate the outcomes of complex volar forearm lacerations involving one or more major peripheral nerves in an economically disadvantaged patient population.

Methods

In this study, a retrospective analysis of 61 patients who sustained lacerations to the median nerve, ulnar nerve, or both with volar wrist lacerations was performed. Each patient’s preinjury and postinjury occupation, dominant extremity, and demographic variables were evaluated. Sensation recovery, motor recovery, Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale scores, cold intolerance, and return to work were evaluated at 3, 6, and 12 months after the injury.

Results

Patients with isolated median nerve injuries demonstrated improved motor recovery compared with patients with isolated ulnar nerve injuries. Patients with combined nerve injuries had worse sensation recovery and motor recovery, and lower rates of return to work than either group of patients with isolated nerve injuries. Manual laborers had worse motor recovery and lower rates of return to work than did patients who were office workers.

Conclusions

Patients with combined median and ulnar nerve injuries have worse functional recovery and lower rates of return to work than do patients with isolated median or isolated ulnar nerve injuries at 1 year. Manual laborers demonstrated worse functional recovery and lower rates of return to work compared with office workers at 1 year.

Type of study/level of evidence

Therapeutic III.

Outcomes of Reconstructive Surgery in Traumatic Brachial Plexus Injury with Concomitant Vascular Injury

OBJECTIVE

To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions.

METHODS

A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular group) and without (control group) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome.

RESULTS

Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. The vascular group was more likely to have pan-plexus lesions (P < 0.0001), with significantly more associated upper extremity injuries (P < 0.0001). The control group underwent more nerve transfers, whereas the vascular group underwent more nerve grafting (P = 0.003). Complete outcome data were obtained in 139 patients, which included 111 control (43% of all control subjects) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the 2 groups. However, 73% of control subjects had grade 3 or greater postoperative elbow flexion, whereas only 43% of vascular patients achieved this strength (P = 0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (P = 0.004). Shoulder external rotation strength was grade 0 in most patients, with no difference between the 2 groups.

CONCLUSIONS

Concomitant vascular injury leads to worse functional outcome after reconstructive surgery of traumatic brachial plexus injury.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part I: traumatic nerve injuries

OBJECTIVE

This article reviews the clinical results that can be obtained after repair of a traumatic peripheral nerve injury in the pediatric population.

METHODS

A systematic review of the published literature has been made.

RESULTS

Functional outcome after major nerve injuries is sometimes disappointing in adults. However, children have been reported to experience much better functional results after nerve repair than adults. Moreover, recovery generally is faster in children. The superior capacity of children's central nervous system to adapt to external or internal environmental changes (neural plasticity) and the shorter recovery distance from the axon repair site to the target muscle are claimed to be crucial determinants of their favorable outcomes. Moreover, even in the pediatric population, it has been demonstrated that functional results are better the younger the patient is, including better clinical results in those injured in early childhood (< 6 years old) than in those injured in adolescence. Other favorable prognostic factors include the type of nerve injury (with complete transections doing less well than crush injuries) and the timing of surgery (with better outcomes after early repairs).

CONCLUSIONS

All efforts should be done to repair in a timely and adequate fashion traumatic peripheral nerve injuries in children, as the results are good.

Association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale in hand functional evaluation of patients with leprosy diagnosis

PURPOSE

To evaluate the association of results from the Rosén and Lundborg Score and the screening activity limitation and Safety Awareness scale for the assessment of hand in patients diagnosed with leprosy.

METHOD

An association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale for hand was evaluated in a cross-section study with 25 people of a mean age of 51 years old (SD 14), undergoing drug treatment for leprosy.

RESULTS

The mean quantitative score in the Screening Activity Limitation and Safety Awareness scale was 27.9 (SD 10.5). Rosén and Lundborg Score for the median nerve were 2.43 (SD 0.38) on the right hand and 2.41 (SD 0.54) on the left hand whilst for the ulnar nerve, the scores observed were 2.33 (SD 0.42) for the right hand and 2.31 (SD 0.61) for the left hand. Significant correlations between the two instruments in assessment of the median and ulnar nerves on both hands were found.

CONCLUSIONS

Due to the association found between the scales, the Rosén and Lundborg Score may be used in assessment of the hand in patients diagnosed with leprosy, as a tool to assist the result evaluation after the drug treatment, surgical treatment, rehabilitation and follow-up in the hand dysfunction in leprosy. Implications for Rehabilitation The leprosy inflammatory neuropathy may cause limitations and disabilities related to hand functions of patients. Instruments with quantitative scores provide a reliable basis for therapeutic intervention prognosis. New evaluation methods promote a better monitoring of treatment and hand function evolution of people with leprosy.

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.

Enhanced early sensory outcome after nerve repair as a result of immediate post-operative re-learning: a randomized controlled trial

We assessed the use of guided plasticity training to improve the outcome in the first 6 months after nerve repair. In a multicentre randomized controlled trial, 37 adults with median or ulnar nerve repair at the distal forearm were randomized to intervention, starting the first week after surgery with sensory and motor re-learning using mirror visual feedback and observation of touch, or to a control group with re-learning starting when reinnervation could be detected. The primary outcome at 3 and 6 months post-operatively was discriminative touch (shape texture identification test, part of the Rosen score). At 6 months, discriminative touch was significantly better in the early intervention group. Improvement of discriminative touch between 3 and 6 months was also significantly greater in that group. There were no significant differences in motor function, pain or in the total score. We conclude that early re-learning using guided plasticity may have a potential to improve the outcomes after nerve repair. LEVEL OF EVIDENCE II.

Management of ulnar nerve injuries

Injuries to the ulnar nerve result in both sensory and motor deficits within the hand. Functional outcomes following repair of this nerve have not performed as well as outcomes following repair of the median or radial nerves. Advances in imaging modalities may provide earlier means of identifying and diagnosing closed nerve injuries. Early neurorrhaphy of acute nerve injuries provides the best outcome, but consideration should also be given to performing distal motor nerve transfers to preserve hand intrinsic motor function when injuries occur at or above the proximal forearm. This article attempts to summarize the most recent trends within ulnar nerve repair.

Differential recovery of touch thresholds and discriminative touch following nerve repair with focus on time dynamics

Introduction

The purpose of this secondary analysis of pooled data from two randomised controlled trials was to explore the differential rate of recovery of sensory and motor functions over time following repair of median or ulnar nerve.

Methods

Recovery over two years following median or ulnar nerve repair at wrist level using the Rosen score was analysed in 67 patients.

Results

Within the sensory domain of the Rosen score, a substantial gap was observed between recovery of touch thresholds and discriminative touch. Within the motor domain, manual muscle strength and grip strength showed a closer and more parallel recovery rate.

Conclusion

The differential recovery rates in touch thresholds and discriminative touch after a peripheral nerve injury are likely due to neurobiological factors that cannot be influenced by surgical interventions. However, new knowledge about brain plasticity opens up the possibility that this differential recovery may diminish through the use of revised rehabilitation programs focused on the use of guided plasticity, and the timing of onset of sensory re-learning.

Median nerve injury and repair

Median nerve injuries in the forearm are reasonably common and can lead to devastating functional sequelae for the hand if they are not managed in a timely and appropriate fashion. Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques should lead to reasonable results in most individuals. Despite these advances, many patients do not have ideal outcomes from injuries to the median nerve and are often left with permanent sequelae. This article will discuss current techniques in the management of median nerve injuries, with the goal of preventing or alleviating the potential negative sequelae of these injuries.

Consequences and adaptation in daily life - patients' experiences three decades after a nerve injury sustained in adolescence

Background

To explore the patients’ experiences during the three decades following repair of a nerve injury in the forearm and its consequences for daily life. Strategies that were used to facilitate adaptation were also investigated.

Methods

Fifteen participants with a complete median and/or ulnar nerve injury repaired in the ages from 13–20 years were interviewed using a semi-structured interview guide. The median follow-up time was 31 years (range 23–40). The participants were asked to describe the past and present symptoms of the injured hand, the consequences of the injury for daily life, personal qualities and support from others. In addition, they were asked to describe strategies used to facilitate adaptation. The interviews were subjected to content analysis.

Results

The nerve injury lead to sensory and motor deficits in the injured hand, as well as sensitivity to cold and secondary back problems. Emotional reactions to trauma and symptoms related to post-traumatic stress disorder were described, as well as how they managed to cope with such reactions. There was a noticeable impact on education, leisure, professional or domestic life for some, while others could continue by changing e.g. their performance pattern. The participants’ life roles and relations were also affected. Both emotion- and problem-based strategies were used to manage challenges in daily life.

Conclusions

The present qualitative study can help us to provide the patient with honest and realistic information about what to expect after a nerve injury at forearm level, without eliminating hope. Emotional reactions to trauma should be identified and dealt with. In addition, health-care professionals can promote a variety of coping mechanisms to facilitate daily living for the injured patients.

Major peripheral nerve injuries

Major peripheral nerve injuries in the upper extremities can result in significant morbidity. Understanding the pathophysiology of these injuries aids in the assessment and planning of appropriate treatment. With limited nerve mobilization, tension-free repairs can often be performed using sutures, fibrin glue, or nerve connectors. Acellular allograft and autograft reconstruction are better for bridging any gaps greater than a few millimeters. Adherence to proper principles of nerve repair improves the chances of achieving a favorable result, although in general these injuries portend a guarded prognosis.

Outcome following nerve repair of high isolated clean sharp injuries of the ulnar nerve

OBJECTIVE

The detailed outcome of surgical repair of high isolated clean sharp (HICS) ulnar nerve lesions has become relevant in view of the recent development of distal nerve transfer. Our goal was to determine the outcome of HICS ulnar nerve repair in order to create a basis for the optimal management of these lesions.

METHODS

High ulnar nerve lesions are defined as localized in the area ranging from the proximal forearm to the axilla just distal to the branching of the medial cord of the brachial plexus. A meta-analysis of the literature concerning high ulnar nerve injuries was performed. Additionally, a retrospective study of the outcome of nerve repair of HICS ulnar nerve injuries at our institution was performed. The Rotterdam Intrinsic Hand Myometer and the Rosén-Lundborg protocol were used.

RESULTS

The literature review identified 46 papers. Many articles presented outcomes of mixed lesion groups consisting of combined ulnar and median nerves, or the outcome of high and low level injuries was pooled. In addition, outcome was expressed using different scoring systems. 40 patients with HICS ulnar nerve lesions were found with sufficient data for further analysis. In our institution, 15 patients had nerve repair with a median interval between trauma and reconstruction of 17 days (range 0-516). The mean score of the motor and sensory domain of the Rosen's Scale instrument was 58% and 38% of the unaffected arm, respectively. Two-point discrimination never reached less then 12 mm.

CONCLUSION

From the literature, it was not possible to draw a definitive conclusion on outcome of surgical repair of HICS ulnar nerve lesions. Detailed neurological function assessment of our own patients showed that some ulnar nerve function returned. Intrinsic muscle strength recovery was generally poor. Based on this study, one might cautiously argue that repair strategies of HICS ulnar nerve lesions need to be improved.