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«A Practical Approach to Nerve Grafting in the Upper Extremity David J. Slutsky, MD, FRCS(C) Private Practice, South Bay Hand Surgery Center, 3475 ...»

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coracobrachialis, it courses posteriorly to lie in the spiral groove of the humerus. In the lower arm, it pierces the lateral intermuscular septum to run between the brachialis and the brachioradialis. It divides 2 cm distal to the elbow into a superficial sensory branch and a deep motor branch, the PIN.

The radial nerve gives off branches to the extensor carpi radialis longus and brevis, brachioradialis, and anconeus before giving off the PIN branch. The PIN continues on between the superficial and deep head of the supinator muscle, to exit on the dorsal forearm. After it emerges from the distal border of the supinator, the PIN sends branches to the extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, extensor pollicis longus and brevis, and extensor indicis proprius in descending order, although there may be considerable variation [69].

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Fig. 15. Posterior Interosseous Nerve (PIN) injury. (A) Dorsal approach to left forearm showing a PIN injury after plating of a proximal radius fracture. (B) Proximal and distal nerve ends isolated. (C) Interposed nerve grafts. ECRL, extensor carpi radialis longus.

the radial artery must be divided to gain access to both nerve branches. Separate grafting of the superficial and deep branch are relatively straightforward (see Fig. 9).

Injury in the forearm and wrist The PIN nerve is approached through a dorsolateral approach, developing the plane between the extensor carpi radialis brevis and the extensor digitorum communis. At this level, the PIN contains motor fibers only; separate fascicle identification is unnecessary (Fig. 15). The PIN also has a short distance to travel to reinnervate the motor end plates, which accounts for the generally favorable results [70]. Lacerations of the superficial branch in the forearm are not usually grafted, which allows harvest of the SRN for grafting adjacent nerve injuries. Some authors advocate grafting the SRN at the wrist, mostly to prevent symptomatic neuroma formation [71].

Summary

Nerve grafting is a century-old art [72] that is honed by experience and limited only by the imagination. Myriad factors may influence the type of graft and manner in which it is used. A sound knowledge of the intrafascicular topography combined with intraoperative aids for motor and sensory differentiation can lead to superior clinical results, especially with large nerve deficits. The basic tenets of managing the nerve gap will undoubtedly remain in vogue until the results of reinnervation through the use of synthetic conduits can reliably match the time-tested standards of the autogenous nerve graft.

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A PRACTICAL APPROACH TO NERVE GRAFTING IN THE UPPER EXTREMITY

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