Alexis Thomson and Alexander Miles - Manual of Surgery

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In the _brachial birth-paralysis_ met with in infants, the lesion is due
to over-stretching of the plexus, and is nearly always of the
Erb-Duchenne type. The injury is usually unilateral, it occurs with
almost equal frequency in breech and in vertex presentations, and the
left arm is more often affected than the right. The lesion is seldom
recognised at birth. The first symptom noticed is tenderness in the
supra-clavicular region, the child crying when this part is touched or
the arm is moved. The attitude may be that of the Erb-Duchenne type, or
the whole of the muscles of the upper limb may be flaccid, and the arm
hangs powerless. A considerable proportion of the cases recover
spontaneously. The arm is to be kept at rest, with the affected muscles
relaxed, and, as soon as tenderness has disappeared, daily massage and
passive movements are employed. The reaction of degeneration can rarely
be satisfactorily tested before the child is three months old, but if it
is present, an operation should be performed. After operation, the
shoulder should be elevated so that no traction is exerted on the
affected cords.

#The long thoracic nerve# (nerve of Bell), which supplies the serratus
anterior, is rarely injured. In those whose occupation entails carrying
weights upon the shoulder it may be contused, and the resulting
paralysis of the serratus is usually combined with paralysis of the
lower part of the trapezius, the branches from the third and fourth
cervical nerves which supply this muscle also being exposed to pressure
as they pass across the root of the neck. There is complaint of pain
above the clavicle, and winging of the scapula; the patient is unable to
raise the arm in front of the body above the level of the shoulder or to
perform any forward pushing movements; on attempting either of these the
winging of the scapula is at once increased. If the scapula is compared
with that on the sound side, it is seen that, in addition to the lower
angle being more prominent, the spine is more horizontal and the lower
angle nearer the middle line. The majority of these cases recover if the
limb is placed at absolute rest, the elbow supported, and massage and
galvanism persevered with. If the paralysis persists, the sterno-costal
portion of the pectoralis major may be transplanted to the lower angle
of the scapula.

The long thoracic nerve may be cut across while clearing out the axilla
in operating for cancer of the breast. The displacement of the scapula
is not so marked as in the preceding type, and the patient is able to
perform pushing movements below the level of the shoulder. If the
reaction of degeneration develops, an operation may be performed, the
ends of the nerve being sutured, or the distal end grafted into the
posterior cord of the brachial plexus.

#The Axillary (Circumflex) Nerve.#--In the majority of cases in which
paralysis of the deltoid follows upon an injury of the shoulder, it is
due to a lesion of the fifth cervical nerve, as has already been
described in injuries of the brachial plexus. The axillary nerve itself
as it passes round the neck of the humerus is most liable to be injured
from the pressure of a crutch, or of the head of the humerus in
sub-glenoid dislocation, or in fracture of the neck of the scapula or of
the humerus. In miners, who work for long periods lying on the side, the
muscle may be paralysed by direct pressure on the terminal filaments of
the nerve, and the nerve may also be involved as a result of disease in
the sub-deltoid bursa.

The deltoid is wasted, and the acromion unduly prominent. In recent
cases paralysis of the muscle is easily detected. In cases of long
standing it is not so simple, because other muscles, the spinati, the
clavicular fibres of the pectoral and the serratus, take its place and
elevate the arm; there is always loss of sensation on the lateral aspect
of the shoulder. There is rarely any call for operative treatment, as
the paralysis is usually compensated for by other muscles.

When the _supra-scapular nerve_ is contused or stretched in injuries of
the shoulder, the spinati muscles are paralysed and wasted, the spine of
the scapula is unduly prominent, and there is impairment in the power of
abducting the arm and rotating it laterally.

The _musculo-cutaneous nerve_ is very rarely injured; when cut across,
there is paralysis of the coraco-brachialis, biceps, and part of the
brachialis, but no movements are abolished, the forearm being flexed, in
the pronated position, by the brachio-radialis and long radial extensor
of the wrist; in the supinated position, by that portion of the
brachialis supplied by the radial nerve. Supination is feebly performed
by the supinator muscle. Protopathic and epicritic sensibility are lost
over the radial side of the forearm.

#Radial (Musculo-Spiral) Nerve.#--From its anatomical relationships this
trunk is more exposed to injury than any other nerve in the body. It is
frequently compressed against the humerus in sleeping with the arm
resting on the back of a chair, especially in the deep sleep of
alcoholic intoxication (drunkard's palsy). It may be pressed upon by a
crutch in the axilla, by the dislocated head of the humerus, or by
violent compression of the arm, as when an elastic tourniquet is applied
too tightly. The most serious and permanent injuries of this nerve are
associated with fractures of the humerus, especially those from direct
violence attended with comminution of the bone. The nerve may be crushed
or torn by one of the fragments at the time of the injury, or at a later
period may be compressed by callus.

_Clinical Features._--Immediately after the injury it is impossible to
tell whether the nerve is torn across or merely compressed. The patient
may complain of numbness and tingling in the distribution of the
superficial branch of the nerve, but it is a striking fact, that so long
as the nerve is divided below the level at which it gives off the dorsal
cutaneous nerve of the forearm (external cutaneous branch), there is no
loss of sensation. When it is divided above the origin of the dorsal
cutaneous branch, or when the dorsal branch of the musculo-cutaneous
nerve is also divided, there is a loss of sensibility on the dorsum
of the hand.

The motor symptoms predominate, the muscles affected being the extensors
of the wrist and fingers, and the supinators. There is a characteristic
"drop-wrist"; the wrist is flexed and pronated, and the patient is
unable to dorsiflex the wrist or fingers (Fig. 90). If the hand and
proximal phalanges are supported, the second and third phalanges may be
partly extended by the interossei and lumbricals. There is also
considerable impairment of power in the muscles which antagonise those
that are paralysed, so that the grasp of the hand is feeble, and the
patient almost loses the use of it; in some cases this would appear to
be due to the median nerve having been injured at the same time.

[Illustration: FIG. 90.--Drop-wrist following Fracture of Shaft of
Humerus.]

If the lesion is high up, as it is, for example, in crutch paralysis,
the triceps and anconeus may also suffer.

_Treatment._--The slighter forms of injury by compression recover under
massage, douching, and electricity. If there is drop-wrist, the hand and
forearm are placed on a palmar splint, with the hand dorsiflexed to
nearly a right angle, and this position is maintained until voluntary
dorsiflexion at the wrist returns to the normal. Recovery is sometimes
delayed for several months.

In the more severe injuries associated with fracture of the humerus and
attended with the reaction of degeneration, it is necessary to cut down
upon the nerve and free it from the pressure of a fragment of bone or
from callus or adhesions. If the nerve is torn across, the ends must be
sutured, and if this is impossible owing to loss of tissue, the gap may
be bridged by a graft taken from the superficial branch of the radial
nerve, or the ends may be implanted into the median.

Finally, in cases in which the paralysis is permanent and incurable, the
disability may be relieved by operation. A fascial graft can be employed
to act as a ligament permanently extending the wrist; it is attached to
the third and fourth metacarpal bones distally and to the radius or ulna
proximally. The flexor carpi radialis can then be joined up with the
extensor digitorum communis by passing its tendon through an aperture in
the interosseous membrane, or better still, through the pronator
quadratus, as there is less likelihood of the formation of adhesions
when the tendon passes through muscle than through interosseous
membrane. The palmaris longus is anastomosed with the abductor pollicis
longus (extensor ossis metacarpi pollicis), thus securing a fair amount
of abduction of the thumb. The flexor carpi ulnaris may also be
anastomosed with the common extensor of the fingers. The extensors of
the wrist may be shortened, so as to place the hand in the position of
dorsal flexion, and thus improve the attitude and grasp of the hand.

_The superficial branch of the radial_ (radial nerve) _and the deep
branch_ (posterior interosseous), apart from suffering in lesions of the
radial, are liable to be contused or torn is dislocation of the head of
the radius, and in fracture of the neck of the bone. The deep branch may
be divided as it passes through the supinator in operations on old
fractures and dislocations in the region of the elbow. Division of the
superficial branch in the upper two-thirds of the forearm produces no
loss of sensibility; division in the lower third after the nerve has
become associated with branches from the musculo-cutaneous is followed
by a loss of sensibility on the radial side of the hand and thumb. Wounds
on the dorsal surface of the wrist and forearm are often followed by
loss of sensibility over a larger area, because the musculo-cutaneous
nerve is divided as well, and some of the fibres of the lower lateral
cutaneous branch of the radial.

[Illustration: FIG. 91.--To illustrate the Loss of Sensation produced by
Division of the Median Nerve. The area of complete cutaneous
insensibility is shaded black. The parts insensitive to light touch and
to intermediate degrees of temperature are enclosed within the dotted
line.

(After Head and Sherren.)]

#The Median Nerve# is most frequently injured in wounds made by broken
glass in the region of the wrist. It may also be injured in fractures of
the lower end of the humerus, in fractures of both bones of the forearm,
and as a result of pressure by splints. After _division at the elbow_,
there is impairment of mobility which affects the thumb, and to a less
extent the index finger: the terminal phalanx of the thumb cannot be
flexed owing to the paralysis of the flexor pollicis longus, and the
index can only be flexed at its metacarpo-phalangeal joint by the
interosseous muscles attached to it. Pronation of the forearm is feeble,
and is completed by the weight of the hand. After _division at the
wrist_, the abductor-opponens group of muscles and the two lateral
lumbricals only are affected; the abduction of the thumb can be feebly
imitated by the short extensor and the long abductor (ext. ossis
metacarpi pollicis), while opposition may be simulated by contraction of
the long flexor and the short abductor of the thumb; the paralysis of
the two medial lumbricals produces no symptoms that can be recognised.
It is important to remember that when the median nerve is divided at the
wrist, deep touch can be appreciated over the whole of the area
supplied by the nerve; the injury, therefore, is liable to be over
looked. If, however, the tendons are divided as well as the nerve, there
is insensibility to deep touch. The areas of epicritic and of
protopathic insensibility are illustrated in Fig. 91. The division of
the nerve at the elbow, or even at the axilla, does not increase the
extent of the loss of epicritic or protopathic sensibility, but usually
affects deep sensibility.

[Illustration: FIG. 92.--To illustrate Loss of Sensation produced by
complete Division of Ulnar Nerve. Loss of all forms of cutaneous
sensibility is represented by the shaded area. The parts insensitive to
light touch and to intermediate degrees of heat and cold are enclosed
within the dotted line.

(Head and Sherren.)]

#The Ulnar Nerve.#--The most common injury of this nerve is its division
in transverse accidental wounds just above the wrist. In the arm it may
be contused, along with the radial, in crutch paralysis; in the region
of the elbow it may be injured in fractures or dislocations, or it may
be accidentally divided in the operation for excising the elbow-joint.

When it is injured _at or above the elbow_, there is paralysis of the
flexor carpi ulnaris, the ulnar half of the flexor digitorum profundus,
all the interossei, the two medial lumbricals, and the adductors of the
thumb. The hand assumes a characteristic attitude: the index and middle
fingers are extended at the metacarpo-phalangeal joints owing to
paralysis of the interosseous muscles attached to them; the little and
ring fingers are hyper-extended at these joints in consequence of the
paralysis of the lumbricals; all the fingers are flexed at the
inter-phalangeal joints, the flexion being most marked in the little and
ring fingers--claw-hand or _main en griffe_. On flexing the wrist, the
hand is tilted to the radial side, but the paralysis of the flexor carpi
ulnaris is often compensated for by the action of the palmaris longus.
The little and ring fingers can be flexed to a slight degree by the
slips of the flexor sublimis attached to them and supplied by the median
nerve; flexion of the terminal phalanx of the little finger is almost
impossible. Adduction and abduction movements of the fingers are lost.
Adduction of the thumb is carried out, not by the paralysed adductor
pollicis, but the movement may be simulated by the long flexor and
extensor muscles of the thumb. Epicritic sensibility is lost over the
little finger, the ulnar half of the ring finger, and that part of the
palm and dorsum of the hand to the ulnar side of a line drawn
longitudinally through the ring finger and continued upwards.
Protopathic sensibility is lost over an area which varies in different
cases. Deep sensibility is usually lost over an area almost as extensive
as that of protopathic insensibility.

When the nerve is _divided at the wrist_, the adjacent tendons are also
frequently severed. If divided below the point at which its dorsal
branch is given off, the sensory paralysis is much less marked, and the
injury is therefore liable to be overlooked until the wasting of muscles
and typical _main en griffe_ ensue. The loss of sensibility after
division of the nerve before the dorsal branch is given off resembles
that after division at the elbow, except that in uncomplicated cases
deep sensibility is usually retained. If the tendons are divided as
well, however, deep touch is also lost.

Care must be taken in all these injuries to prevent deformity; a splint
must be worn, at least during the night, until the muscles regain their
power of voluntary movement, and then exercises should be instituted.

#Dislocation of the ulnar nerve# at the elbow results from sudden and
violent flexion of the joint, the muscular effort causing stretching or
laceration of the fascia that holds the nerve in its groove; it is
predisposed to if the groove is shallow as a result of imperfect
development of the medial condyle of the humerus, and by cubitus valgus.

The nerve slips forward, and may be felt lying on the medial aspect of
the condyle. It may retain this position, or it may slip backwards and
forwards with the movements of the arm. The symptoms at the time of the
displacement are some disability at the elbow, and pain and tingling
along the nerve, which are exaggerated by movement and by pressure. The
symptoms may subside altogether, or a neuritis may develop, with severe
pain shooting up the nerve.

The dislocated nerve is easily replaced, but is difficult to retain in
position. In recent cases the arm may be placed in the extended position
with a pad over the condyle, care being taken to avoid pressure on the
nerve. Failing relief, it is better to make a bed for the nerve by
dividing the deep fascia behind the medial condyle and to stitch the
edges of the fascia over the nerve. This operation has been successful
in all the recorded cases.

#The Sciatic Nerve.#--When this nerve is compressed, as by sitting on a
fence, there is tingling and powerlessness in the limb as a whole, known
as "sleeping" of the limb, but these phenomena are evanescent. _Injuries
to the great sciatic nerve_ are rare except in war. Partial division is
more common than complete, and it is noteworthy that the fibres destined
for the peroneal nerve are more often and more severely injured than
those for the tibial (internal popliteal). After complete division, all
the muscles of the leg are paralysed; if the section is in the upper
part of the thigh, the hamstrings are also paralysed. The limb is at
first quite powerless, but the patient usually recovers sufficiently to
be able to walk with a little support, and although the hamstrings are
paralysed the knee can be flexed by the sartorius and gracilis. The
chief feature is drop-foot. There is also loss of sensation below the
knee except along the course of the long saphenous nerve on the medial
side of the leg and foot. Sensibility to deep touch is only lost over a
comparatively small area on the dorsum of the foot.

#The Common Peroneal (external popliteal) nerve# is exposed to injury
where it winds round the neck of the fibula, because it is superficial
and lies against the unyielding bone. It may be compressed by a
tourniquet, or it may be bruised or torn in fractures of the upper end
of the bone. It has been divided in accidental wounds,--by a scythe, for
example,--in incising for cellulitis, and in performing subcutaneous
tenotomy of the biceps tendon. Cases have been observed of paralysis of
the nerve as a result of prolonged acute flexion of the knee in certain
occupations.

When the nerve is divided, the most obvious result is "drop-foot"; the
patient is unable to dorsiflex the foot and cannot lift his toes off the
ground, so that in walking he is obliged to jerk the foot forwards and
laterally. The loss of sensibility depends upon whether the nerve is
divided above or below the origin of the large cutaneous branch which
comes off just before it passes round the neck of the fibula. In course
of time the foot becomes inverted and the toes are pointed--pes
equino-varus--and trophic sores are liable to form.

#The Tibial (internal popliteal) nerve# is rarely injured.

#The Cranial nerves# are considered with affections of the head and neck
(Vol. II.).

NEURALGIA

The term neuralgia is applied clinically to any pain which follows the
course of a nerve, and is not referable to any discoverable cause. It
should not be applied to pain which results from pressure on a nerve by
a tumour, a mass of callus, an aneurysm, or by any similar gross lesion.
We shall only consider here those forms of neuralgia which are amenable
to surgical treatment.

#Brachial Neuralgia.#--The pain is definitely located in the
distribution of one of the branches or nerve roots, is often
intermittent, and is usually associated with tingling and disturbance of
tactile sensation. The root of the neck should be examined to exclude
pressure as the cause of the pain by a cervical rib, a tumour, or an
aneurysm. When medical treatment fails, the nerve-trunks may be injected
with saline solution or recourse may be had to operative measures, the
affected cords being exposed and stretched through an incision in the
posterior triangle of the neck. If this fails to give relief, the more
serious operation of resecting the posterior roots of the affected
nerves within the vertebral canal may be considered.

_Neuralgia of the sciatic nerve_--#sciatica#--is the most common form of
neuralgia met with in surgical practice.

It is chiefly met with in adults of gouty or rheumatic tendencies who
suffer from indigestion, constipation, and oxaluria--in fact, the same
type of patients who are liable to lumbago, and the two affections are
frequently associated. In hospital practice it is commonly met with in
coal-miners and others who assume a squatting position at work. The
onset of the pain may follow over-exertion and exposure to cold and wet,
especially in those who do not take regular exercise. Any error of diet
or indulgence in beer or wine may contribute to its development.

The essential symptom is paroxysmal or continuous pain along the course
of the nerve in the buttock, thigh, or leg. It may be comparatively
slight, or it may be so severe as to prevent sleep. It is aggravated by
movement, so that the patient walks lame or is obliged to lie up. It is
aggravated also by any movement which tends to put the nerve on the
stretch, as in bending down to put on the shoes, such movements also
causing tingling down the nerve, and sometimes numbness in the foot.
This may be demonstrated by flexing the thigh on the abdomen, the knee
being kept extended; there is no pain if the same manoeuvre is repeated
with the knee flexed. The nerve is sensitive to pressure, the most
tender points being its emergence from the greater sciatic foramen, the
hollow between the trochanter and the ischial tuberosity, and where the
common peroneal nerve winds round the neck of the fibula. The muscles of
the thigh are often wasted and are liable to twitch.

The clinical features vary a good deal in different cases; the affection
is often obstinate, and may last for many weeks or even months.

In the sciatica that results from neuritis and perineuritis, there is
marked tenderness on pressure due to the involvement of the nerve
filaments in the sheath of the nerve, and there may be patches of
cutaneous anaesthesia, loss of tendon reflexes, localised wasting of
muscles, and vaso-motor and trophic changes. The presence of the
reaction of degeneration confirms the diagnosis of neuritis. In
long-standing cases the pain and discomfort may lead to a postural
scoliosis (_ischias-scoliotica_).

_Diagnosis._--Pain referred along the course of the sciatic nerve on one
side, or, as is sometimes the case, on both sides, is a symptom of
tumours of the uterus, the rectum, or the pelvic bones. It may result
also from the pressure of an abscess or an aneurysm either inside the
pelvis or in the buttock, and is sometimes associated with disease of
the spinal medulla, such as tabes. Gluteal fibrositis may be mistaken
for sciatica. It is also necessary to exclude such conditions as disease
in the hip or sacro-iliac joint, especially tuberculous disease and
arthritis deformans, before arriving at a diagnosis of sciatica. A
digital examination of the rectum or vagina is of great value in
excluding intra-pelvic tumours.

_Treatment_ is both general and local. Any constitutional tendency, such
as gout or rheumatism, must be counteracted, and indigestion, oxaluria,
and constipation should receive appropriate treatment. In acute cases
the patient is confined to bed between blankets, the limb is wrapped in
thermogene wool, and the knee is flexed over a pillow; in some cases
relief is experienced from the use of a long splint, or slinging the leg
in a Salter's cradle. A rubber hot-bottle may be applied over the seat
of greatest pain. The bowels should be well opened by castor oil or by
calomel followed by a saline. Salicylate of soda in full doses, or
aspirin, usually proves effectual in relieving pain, but when this is
very intense it may call for injections of heroin or morphin. Potassium
iodide is of benefit in chronic cases.

Relief usually results from bathing, douching, and massage, and from
repeated gentle stretching of the nerve. This may be carried out by
passive movements of the limb--the hip being flexed while the knee is
kept extended; and by active movements--the patient flexing the limb at
the hip, the knee being maintained in the extended position. These
exercises, which may be preceded by massage, are carried out night and
morning, and should be practised systematically by those who are liable
to sciatica.

Benefit has followed the injection into the nerve itself, or into the
tissues surrounding it, of normal saline solution; from 70-100 c.c. are
injected at one time. If the pain recurs, the injection may require to
be repeated on many occasions at different points up and down the nerve.
Needling or acupuncture consists in piercing the nerve at intervals in
the buttock and thigh with long steel needles. Six or eight needles are
inserted and left in position for from fifteen to thirty minutes.

In obstinate and severe cases the nerve may be _forcibly stretched_.
This may be done bloodlessly by placing the patient on his back with the
hip flexed to a right angle, and then gradually extending the knee until
it is in a straight line with the thigh (Billroth). A general anaesthetic
is usually required. A more effectual method is to expose the nerve
through an incision at the fold of the buttock, and forcibly pull upon
it. This operation is most successful when the pain is due to the nerve
being involved in adhesions.