GUNSHOT WOUND OF ARM; RESECTION OF ULNAR NERVE; SUTURE AFTER DISPLACEMENT; RECOVERY

William Gardner
1891 The Lancet  
OPERATIONS involving resection of a nerve and junction of the resected ends are still of sufficient rarity to possess many points of interest to surgeons. The case which I intend to bring forward in this paper is of importance as another example tending to prove that union by first intention can occur in a divided nerve, the ends of which have been closely approximated by the surgeon. Letievant, Arloing, and Tripier (according to Mr. Bowlby) have objected to recurrence of sensation in parts
more » ... sation in parts supplied by the divided nerve as offering proof of its restoration, for they argue that the other nervous trunks take the place in part of that which is injured, and convey the sensations in question. Mr. Bowlby, however, says that this supplementary sensibility is by no means so perfect as the sensations conducted by the normal nerve, at any rate for a considerable time after the section, if ever ; and moreover, though the surrounding muscles may more or less supply the part of those paralysed, the latter are themselves absolutely powerless, and rapidly degenerate and atrophy. It is also stated by the same author that a rapid restoration of perfect sensation, together with an absence of wasting and a retention of the contractility of the muscles, may be liaKen as certain proor or tne restoration or me continuity of the divided nerve. On these grounds my case may probably be considered an example of nerve union by first intention, and the method of displacement by which the divided nerve ends were approximated is one not mentioned by Bowlby in his excellent work. In the chapter on the treatment of complicated wounds of nerves he enumerates the following as the only methods which have been previously adopted in cases in which the divided ends of nerves could not be brought into contact :-1. Stretching of the proximal and peripheral ends, and fixation by sutures. 2. Letievant's method of grafting the peripheral end on to a freshened surface of some sound neighbouring trunk. 3. Splitting of the proximal end longitudinally to a sufficient extent, and then making a cross section of one half of the nerve at the highest point to which the splitting is carried. The split portion is then turned down and placed as a sort of graft between the divided ends. 4. Nerve-grafting. In this method the sciatic nerve of a dog or a piece of nerve from some amputation case is inserted between the divided ends. This last method has been several times performed with more or less success, and to Mr. Bowlby I am again --indebted for notes of the recorded cases. Tillemans used portions of a rabbit's nerve, and Kaufmann grafted with a portion of the sciatic nerve of a dog. In the latter case the result was doubtful at the end of two months. Mr. Mayo Robson's classical case is well known to all British surgeons. He used part of the posterior tibial nerve from a recently amputated leg, and sensation returned in thirty-,six hours. The patient was shown at the Clinical Society on Jan. 25th, 1889. 5. Bergmann once overcame the separation of the divided ends by resecting a portion of the humerus, and so shortening the arm and enabling the nerve ends to be approximated. This case was unsuccessful. A sixth method which occurred to me during the course of an operation consists in freeing the nerve both upwards and downwards for some considerable distance, and then altering the course so as to shorten it, and do away alto. gether with the gap between the divided ends.-In my <case the ulnar nerve was thus removed from its usual site behind the internal condyle, and made to descend over the front of the elbow, the skin over which had been reflected to enable the nerve to be successfully stowed away. The plan answered admirably, and the restoration of sensation and function in the affected parts was as nearly as possible perfect. The accompanying engravings, from photo. graphs taken in March, 1891, show the arm and fingers both flexed and extended; and when I started from Australia for England in April the patient had decided t) return to his work as a miner. Appended are short notes of the case, for which I am indebted to my friend, Mr. Anstey Giles, M.B. Edin. "J. R-first consulted Dr. Gardner on Dec. 8tb, 1890, and stated that he had received a gunshot wound of the forearm on Aug. 19th, 1890, and had been treated in the Broken Hill Hospital, New South Wales, for six weeks, when he was discharged. Examination showed a wound on the inner side of the flexor surface of the forearm nearly cicatrised, and on the inner aspect of the arm another cicatrised irregular wound deeply stained with powder. There was absolute loss of sensation on the extensor surface of the hand over an area including the whole of the little finger and the half of the ring finger, and an equivalent surface on the ulnar side of the dorsum up to the wrist. On the palmar surface the whole of the little finger and half of the next, with the corresponding part of the palmar aspect of the hand as far as the hypo. thenar eminence were anaesthetic. On Dec. 9th the patient was anaesthetised with ether, and the wound on the anterior surface of the forearm was reopened throughout its whole extent. Nothing abnormal was discovered, so the ulnar nerve was cut down upon at the back of the arm through the deeply stained cicatrix, and when exposed was apparently completely destroyed and deeply stained of a bluish-green colour. In its substance was a pellet of No. 4 shot, which was removed, and also the dis. organised portion of nerve, which was an inch and a half in length. An attempt was then made to bring the ends together, but the strain was so great that the stitches would not hold, but cut out almost immediately. It was then determined to make use of a plan which had once before been used in a case of division of the musculo. spiral nerve by a kick from a horse's hoof. The e method adopted consists in dissecting the nerve from its bed for about six inches up the arm and an equal distance down the forearm. The skin over the front of the elbow was then reflected and the nerve brought across the anterior aspect, where it was readily united by three catgut sutures passed through the sheath and the nerve substance of the proximal and distal ends. The nerve thus joined was placed under the flap of skin which had been dissected up from the anterior aspect
doi:10.1016/s0140-6736(01)88449-x fatcat:z7arcjuy7ffljo4n4izl46bv4e