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Abstract
Differences of opinion exist regarding the desirability of early nerve suture at the
time of débridement after a relatively clean incised wound. While many British surgeons
disagree, the majority of Americans recommend this course and their statistics appear
to justify the resultant saving of time. When a nerve is severed by a high velocity
projectile, however, all neurosurgeons trained in the recent wars agree that suture
should be deferred to a second stage to be performed at least 1 month after the primary
débridement. This delay is mandatory, for a well-executed nerve repair immediately
after injury by gunshot is not possible. The softened epineurium cannot be counted
on to hold sutures, and there is no way of telling how much to trim off the injured
stumps. Adequate proximal and distal neurolysis to insure a suture free of tension
is not justified, because it exposes healthy tissue planes to the risk of spreading
infection. The suture is therefore threatened by the risk of separation and, if it
holds, by an endoneural barrier of scar tissue.
A typical gunshot injury is described which illustrates the cause of failure of early
nerve repair. The only result of suturing the blast-softened, seminecrotic ends of
the divided median nerve was the development of neuroma-incontinuity. No regenerating
axons could have penetrated the 3 cm. barrier of scar, which had to be excised and
resutured after 3 months had been wasted. Attempts at primary suture under such conditions
can delay recovery many months before failure of regeneration becomes a certainty
and forces the surgeon to resect the neuroma and resuture the nerve.
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References
- Peripheral Nerve Injuries: Principles of Diagnosis.in: ed. 2. W. B. Saunders Company, Philadelphia1953: 123-132 (chap. 7)
- Damage to Peripheral Nerves by High Velocity Missiles Without a Direct Hit.J. Neurosurg. 1946; 3: 294-305
- Seddon H.J. Peripheral Nerve Injuries. Medical Research Council, Nerve Injuries Committee, Her Majesty's Stationery Office, London1954
- Three Types of Nerve Injury.Brain. 1943; 66: 237-288
- Peripheral Nerve Regeneration: A Follow-up Study of 3,656 World War II Injuries. Veterans Administration Medical Monograph. United States Government Printing Office, Washington1956
Article info
Publication history
Received:
June 28,
1960
Identification
Copyright
© 1960 Published by Elsevier Inc.
