PLASTIC SURGERY | ORIGINAL ARTICLE

STUDY OF PATIENT AND INJURY RELATEDPROGNOSTIC PREDICTORS OF MOTOR AND

SENSORY RECOVERY IN ULNAR NERVE INJURIES - ATHREE-YEAR EXPERIENCE AT TERTIARY CARE

HOSPITAL IN HIMALAYAN REGIONTanveer Ahmed Bhat∗, Mir Mohsin∗, Nahida Wani∗∗, Haroon Rashid Zargar∗,1 and Adil Hafeez Wani∗

∗Department of Plastic Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, JK, India., ∗∗Department of Radiation Oncology, GMC,Srinagar, JK, India.

ABSTRACT Background: Ulnar nerve integrity is a prerequisite for normal hand function. The ulnar nerve is frequentlyinjured, and recent evidence indicates that nerve repair may produce acceptable outcomes. The present study providesthe surgical outcome of ulnar nerve injuries and specifies patient and injury-related prognostic predictors of motor andsensory recovery. Materials and Methods: In this prospective study, patients with ulnar nerve injuries due to trauma,undergoing primary surgical repair by a single microsurgeon over a period of 3 years (Aug 2014 – Jul 2017) were selected.The demographic data, injury characteristics were studied, and their impact on the surgical outcome assessed at 2- yearfollow-up. Results: A total of 62 patients (48 males and 14 females with a male: female ratio of 3.42:1) fulfilled theinclusion criteria. Majority of them [39/62 (62.90%)] were in the age group of 16 to 40 years. Glass cut and knife cutswere the most common modes of injury in males 24/62(50%) and females 9/14(64.28%) respectively. At 2-year follow up,80% of children had good sensory and motor recoveries while as the best recovery grade achieved in patients above 60years of age was fair that too in only 30%. In 85% of injuries at the wrist level, the outcome was good while in 70% ofproximal forearm injuries, it was fair. Sensory and motor recovery was good only in 32% of sharp injuries while as in therest it was fair. In 70% of the subjects with associated injuries involving the median nerve, both radial and ulnar arteriesand all flexor tendons, recovery was fair while as 30% of such cases had poor results. Conclusions: Distal clean-cut ulnarnerve injuries operated early to have a good functional outcome. Isolated ulnar nerve injury has a good outcome, butwhen associated with median nerve injury, tendon injury or double vessel injury, the outcome was poor.

KEYWORDS Hand trauma, nerve, tendon, artery, recovery

Copyright © 2020 by the Bulgarian Association of Young SurgeonsDOI:10.5455/ijsm.prognostic-predictors-motor-and-sensory-recovery-in-Ulnar-nerveFirst Received: July 13, 2020Accepted: September 13, 2020Associate Editor: Ivan Inkov (BG);1Department of Plastic Reconstructive Surgery, Sheri Kashmir Institute of MedicalSciences, Srinagar, JK, India; mchthesis4@gmail.com

Introduction

Possession of prehensile hand is unique to human species, andfor a man a good hand function is essential to living his nor-mal daily life, to earn his livelihood and to take care of himselfand his family. Its importance can be recognized by the factthat some authors have regarded a good hand function evenmore important than ambulation, urinary and faecal controland sexual function in patients with tetraplegia [1]. Most of theperipheral nerve injuries have been observed to occur in upper

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38

limbs [2,3]. Such injuries in patients may lead to irreversibledisabilities if not addressed timely or if managed improperlyand eventually result in impairment of the function of hand andquality of life [3]. To optimize motor and sensory recoveriesand to minimize pain with the final goal to improve the qual-ity of life, the peripheral nerve injuries must be appropriatelymanaged by the operating microsurgeon to yield optimal results.Since Ulnar nerve is a composed of motor and sensory nerves,it makes its repair even more difficult and functional recoveryless predictable than pure sensory or motor nerves. Althoughwith time, the microsurgery has advanced and the availability ofdifferent clinical advancements have enhanced the accuracy ofthe surgical repair. Yet, the outcome in terms of motor and sen-sory function is still not promising [4]. To obtain better results,ulnar nerve injuries require early repair as compared to otherperipheral nerve injuries [5,6]. Unfortunately, the results of ulnarnerve repair and the ultimate functional recovery achieved aremuch less than those achieved after radial nerve and mediannerve repairs [5,7,8]. Various reports have been worked out todisplay different variables that influence the outcome. Patient-related characteristics like age, gender and education level, aswell as the injury-related factors including site, depth, extent,mechanism and type of the injury, number of injured arteriesand damaged median nerve, besides the surgical technique usedto repair the nerve and the delay till surgery, have a bearing onthe outcome [5]. However, to precisely study the impact of anyindividual variable can be possible only when the effect of othervariables is controlled or eliminated but unfortunately isolationof one variable for analysis while keeping all other variablescontrolled is very difficult. To get rid of these shortcomings, wehave conducted this study where all the patients were operatedby a single surgeon primarily within the first day after injuryusing only one technique of repair and same suture material inall patients. Primary repair is the optimal approach for periph-eral nerve injuries taking place within the first couple of days[9]. Intra-operative findings dictate the method of repair. If theepineurium is found to be neatly divided, then tension free endto end primary repair is usually performed but if the ends arecrushed then a graft may be required [10].

The aim of the study was to evaluate the prognostic predic-tors of motor and sensory recovery in patients with ulnar nerveinjuries, which would help in predicting the outcome in suchinjuries.

Materials and Methods

This is a prospective study conducted on 62 subjects over aperiod of 3 years from Aug 2014 to Jul 2017 in the Departmentof Plastic and Reconstructive Surgery, of a tertiary care centre inNorth India.

Inclusion Criteria

• Completely transected ulnar nerve (confirmed intra-operatively),

• Primary nerve repair,• Informed consent,• Complete 2-year follow up.

Exclusion criteria

• Associated injuries to other body systems.• Children < 6years,• Uncooperative patients,

• Mentally unstable patients,• Bilateral ulnar nerve injuries,• Delayed primary and secondary nerve repair,• Ipsilateral ring and little finger amputations,• Need for nerve grafts.• History was suggestive of previous associated ulnar nerve

pathologies like Guyon’s canal syndrome, leprosy.• Patients who didn’t consent to participate in the study or

who were lost to follow up.

A total of 78 patients consented to be a part of this study,but 16 patients were lost to follow up, and only 62 patientsfulfilled the inclusion criteria (complete two years follow up).The patients were enrolled in the study after obtaining informedconsent from him/her by anyone of the authors on duty at thetime of his arrival in casualty ward based on the inclusion/exclusion criteria. Demographic and clinical data regarding age,gender, mechanism and level of injury (arm, forearm, elbow,wrist), type of injury (sharp or crush) and the time intervalbetween injury and surgery were recorded. Tetanus prophylaxisand broad-spectrum antibiotics were given.

Surgery was performed within 12 hours of injury, under re-gional /general anaesthesia and tourniquet control. The pri-mary end-to-end tension-free epineural repair was done in allthe cases. To ensure clean-cut, the nerve ends were prepared tillhealthy pouting fascicles were visible using a sharp blade withthe nerve end held on the back of an Adson’s forceps, wrappedwith moist gauze to prevent slipping of the nerve and resultantmultiple cuts. For approximation and to ensure tension-free re-pair, limited mobilization of the nerve ends was performed, andduring this process of approximation, care was taken to avoidextensive dissection [11]. Blood vessels were aligned, and properrotational alignment is undertaken. The nerve repair was per-formed by epineural micro suturing using 8-0 non-absorbableNylon suture and micro-instruments under 4x loupe magnifi-cation. Postoperatively nerve repairs were protected by immo-bilization for three weeks using a dorsal splint [12]. After thisperiod, gradual passive and active range of motion exerciseswere started for rehabilitation.

All the patients were followed up weekly for first 6 weeksand then after every 3 months for a minimum period of 2 years(till July 2019). Outcome measures were the sensory and mo-tor recovery. Sensory nerve function was graded using theMackinnon-Dellon scale, and muscle strength was graded usingthe Manual Muscle Test, (the palmar adduction of thumb withgrading “0” for no contraction to “5” for normal power) andmotor nerve function was evaluated according to the criteria ofthe Nerve Injuries Committee of the British Medical ResearchCouncil (BMRC)[13,14]. The results were graded as excellent,good, fair and poor. Grades excellent and good were consid-ered satisfactory both for sensory and motor recovery. In thissystem, the two-point discrimination test (2-PD) was used toassess the sensory recovery in the subjects objectively. Two-pointdiscrimination measures the individual’s ability to perceive twopoints of stimuli presented simultaneously. The procedure wasdemonstrated to the patient with his/her eyes open until heunderstood. The patient was asked to close his/her eyes. Usingthe disc discriminator stimulus was provided by light and equalpressure across the two pressure points. The patient was askedif he felt one or two points. The two points were moved closertogether across consecutive trials until the patient could not feelthe two points as separate. The distance was measured betweenthe two points and the findings documented.

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Motor grade (Level of recovery)

[The British Medical Research Council’s rating system]

M0 No recovery

M1 Flicker is perceptible in the muscle

M2 Contraction with gravity eliminated

M3 Contraction against gravity

M4 Contraction against resistance

M5 Full recovery in all muscles

Sensory grade (Level of recovery)

[Mackinnon-Dellon scale]

S1 No recovery

S1 Recovery of deep cutaneous sensibility

S1+ Recovery of superficial pain and sensibility

S2 Recovery of superficial pain and some touch

S2+ S2 recovery with hypersensitivity

S3 Recovery of pain and touch without hypersensitivity

S3+ Recovery with localization and some two-point discrimi-nation (6to 10mm)

S4 Complete recovery with normal two-point discrimination(<5mm)

Statistical analysis:

Data management and analysis was done using SPSS software(version 21, SPSS Inc., Chicago, IL, USA). Association and corre-lation of demographic and clinical data with motor and sensoryrecovery were assessed. P < 0.05 was considered statisticallysignificant.

Results

Out of 62 enrolled patients, 48(77.41) were male, and 14(22.59%)were female with a male to female ratio of 3.4:1. The averageage of study patients was 35 years. The youngest one was eightand the oldest 76 years old. Majority of the patients (72.59%)were 26 to 70 years old (Table 1). Glass cut was the commonestmode of injury found in 25/62(40.32%) patients followed byInjury due to a knife in 15/62(24.29%) and machine injury in9/62(14.51%) patients. Most of the subjects with glass cut injurywere males 24/25 (96%), while as 9/15(60%) patients with a knifeinjury were females. Majority of the machine injured patients[8/9(88.88%)] were men (Table 2). Few [1/48(2.08%) males and2/14(14.28%) females] patients had self-inflicted knife injuries.

Among the 48 male patients, 40 were right hand dominantand eight left hand dominant. 34/40(85%) males had an injury inthe dominant right hand while as 4/8 (50%) left-hand dominantmales had Injury in their left hands. Eleven out of 14(78.57%)females were right hand dominant, and only 3/11(27.27%) hadan injury in the dominant right hand while 8/11(72.72%) had aninjury in their left non-dominant hands. 3/14 (31.42%) femaleswere left hand dominant, and 2/3(66.66%) had Injury in rightnon-dominant hand while only 1/3(33.34%) had an injury in

Fig. 1: Laceration along ulnar aspect of right wrist due to a tinsheet; explored; ulnar neurovascular bundle and flexor carpiulnaris found injured and repaired.

Fig. 2: Deep glass cut injury right distal forearm in a youngmale with all flexor tendons, both Median, Ulnar nerves andboth Radial, Ulnar artery cut; structures repaired and woundclosed primarily.

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38

Table 1 Demographic profile of patients.

Age (Yrs) GenderTotal

(n)

Percentage

(%)

Male

(n)

Percentage

(%)

Female

(n)

Percentage

(%)

6-15 3 4.8 2 3.2 5 8.06

16-30 20 32.25 4 6.45 24 29.03

31-45 12 19.35 3 4.8 15 24.19

46-60 4 6.45 2 3.2 6 19.35

61-75 6 9.67 1 1.61 7 11.29

>75 3 4.8 2 2.48 5 8.06

Total 48 77.41 14 22.59 62 100

Table 2 Injury inflicting agent.

Injuring

agentGender

Total

(n)

Percentage

(%)

Male

(n)

Percentage

(%)

Female

(n)

Percentage

(%)

Glass 24 38.70 1 1.61 25 40.32

Tin 6 9.67 2 3.21 8 12.90

Knife 6 9.67 9 16.10 15 24.19

Machine 8 12.90 1 1.61 9 14.51

RTA 4 6.45 1 1.61 5 9.67

Total 48 77.41 14 22.58 62 100

Table 3 Relationship of the hand dominance and injured hand.

GenderHand

Dominance

No.

of

patients

Injured hand

Right

(Number

and percentage)

Left

(Number

and percentage)

Male Right 40 34(85%) 6(15%)

Left 8 4(50%) 4(50%)

Female Right 11 3(27.27%) 8(72.72%)

Left 3 2(66.66%) 1(33.33%)

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Table 4 Level of injury.

Level Number Of patients Percentage (%)

Proximal forearm and above 4 6.4

Middle forearm 12 18.75

Distal forearm and wrist 46 74.19

Total 62 100

Table 5 Type of Injury.

Type of Injury Number of Patients Percentage (%)

Sharp clean cut 42 64.74

Blunt cut 15 25.19

Crush injury 5 8.06

Total 62 100

Table 6 Pattern of associated structures cut along with Ulnar nerve.

Associated cut structure/s Number of patients Percentage (%)

FCU 62 100

FCU +UA 54 87.09

FCU +UA+MN 24 38.75

FCU+UA+ MN+RA 20 32.25

MN+RA+UA+upto 4 flexor tendons 14 22.58

MN+RA+UA+5-9 flexor tendons 12 19.35

MN+RA+UA+all 12 flexor tendons 10 16.12

FCU- flexor carpi ulnaris, MN- median nerve, UA- ulnar artery, RA- radial artery

Table 7 Relationship of motor and sensory recovery with age of patient, site and depth of injury.Recoveryafter repairof nerveinjury

Statisticalvalue

Age ofthepatient

Depthof theInjury

Proximityof injury tonerve body.

Correlationcoefficient(r)

-0.6 -0.7 -0.4

p <0.025 <0.040 0.034

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her left dominant hand (Table 3). Forty-six patients (74.19%)had injuries in the distal forearm including the wrist while in12/62(18.75%) and 4/62(6.4%) proximal forearm and arm wereinvolved respectively (Table 4). Forty-two patients (64.74%) hadsharp clean-cut injuries, included all the tin and knife inflicted in-juries. Fifteen patients (25.19%) had sustained blunt injuries. Be-sides, all the road traffic trauma cases (5/62(8.06%) were havinga mild to moderate crush element (Table5). Flexor carpi ulnaris(FCU) tendon was cut in all patients with ulnar nerve injury.Both FCU and ulnar artery were cut in 54/62(87.09%) (Fig.1),while as the triad of FCU, ulnar artery and median nerve injurywas present in 24/62(38.70%). Injury to FCU, Ulnar artery, Me-dian nerve and Radial artery injury was present in 20/62(32.25%)patients. The median nerve, Radial artery, Ulnar artery and 5to 9 digital flexor tendons were cut in 12/62(19.35%) patients.In contrast, as Median nerve, Radial artery, Ulnar artery and allthe 12 flexor tendons were cut in 10/62(16.13%) cases (Table 6).Median nerve injury was seen in 24/62(32.25%) patients withother concomitant injured structures (Fig.2). Only 8/62(12.90%)cases were seen without any associated vessel injury. At twoyears follow up, 80% of children aged below 16 years had thebest recovery grade of M4 and S3+ compared to best recoverygrade of M3 and S2+ in only 30% of patients older than 60 yearsfor the same degree of nerve injury. Rest (20% of children and70% of older people) had (M3 and S2+) and (M2 and S2) as theirbest recovery results respectively. We had a statistically signifi-cant negative correlation between both the motor and sensoryrecovery with that of the age of the patient.

In proximal nerve injuries, the recovery was Fair (70%) toPoor (30%). In 70% proximal nerve injuries, we had M3 and S2+recovery grades compared to M4 and S3+ in 85% of the patientswith injuries at the distal forearm, including the wrist level.We experienced a statistically significant negative correlationbetween recovery after nerve repair and the proximity of theinjury (Table 7).

We experienced M4 and S3+ level in 32% of the patients andM3 and S2+ in 68% of the patients with sharp injuries. In pa-tients with sharp Ulnar nerve injuries with knives, the resultswere excellent with M4 to M5 and S4 recovery level in 80% of thesubjects while in the rest 20% the results were fair with S2+andM3 values. In all the five patients with road traffic accidents, thegrade of recovery was Fair with M2 and S2 results. Six out ofeight (75%) patients with associated Flexor carpi ulnaris tendoninjuries had Good results while the rest 2/8(25%) had fair results.Ulnar nerve injuries associated with Median nerve injuries hadfair results with a recovery level of M3 and S2+ in 80% subjects.Ulnar nerve injuries associated with injuries of other soft tissuestructures including Median nerve, both Radial and Ulnar arter-ies and all long flexors had a fair outcome in 70% patients withrecovery level of M3 and S2+. In comparison, in the remaining30%, it was poor with M2 and S2 results. A statistically signif-icant negative correlation was reported between the depth ofinjury and nerve recovery after repair

Discussion

Despite advancement, in microsurgical techniques, the results ofperipheral nerve repair after trauma are often disappointing andnot predictable [15] and the independent predictors governingthe good prognosis are still controversial [16]. Thus, we plannedthe present study to assess the surgical outcomes of the ulnarnerve injuries and its association with patient’s demographicfactors, injury characteristics and concomitant injured structures.

Brown PW in his study reported that the factors which influencethe outcome after the repair of nerve injuries were: (1) the nerve-injured; (2) the age of the patient; (3) the level of the injury; (4) thelength of the defect; (5) associated injuries; (6) surgical technique;and (7) the time of surgery[17]. Many clinical studies supportedmost of his findings [18]. However, there is a wide variationin the quality of the published reports. Various grading scaleshave been used for assessing outcomes after repair of peripheralnerve injuries [19].

Age has been reported to have a bearing on sensory recov-ery following the repair of nerve injuries and better outcome inyounger patients than older patients have been found [20,21].Lohmeyer JA et al. [22] conducted a postoperative follow-upstudy of 90 patients (4–88 years old, mean 41 years) with 101upper limb nerve injuries. They found significant differencesin outcome between patients aged < 20 years and those aged> 20 years (P = 0.01), and in their study, the authors concludedthat nerve regeneration was poorest in patients aged > 50 years.Hundepool CA et al. also showed that age, gender, and associ-ated injuries are strong predictors of surgical outcomes [16]. Inour study, we had good recovery in 80 percent of the childrenaged below 16 years compared to fair recovery in only 30 per-cent of older people while in the rest 20 percent children and70 percent older people the recovery grade was fair and poorrespectively. Possibly the reasons for the difference in the resultsare that in children there is inherent strong regenerative poten-tial and because of their relatively short limb length comparedto adult’s shorter length of the nerve regeneration is needed forthe same site of the nerve injury. In older patients, the regenera-tive potential and compensatory phenomenon are weaker andhence functional recovery has been reported to be significantlypoorer in older patients. Besides the relatively poor state of nu-tritional status, impaired local tissue perfusion and inevitableage-related pathologies like atherosclerosis decrease the capacityfor nerve regeneration in these patients [23]. According to someauthors like Segalman KA et al. [24], better outcomes in youngerpatients are due to better axonal regeneration and greater adapt-ability. The central nervous system (CNS) in older patients mayhave fewer receptors because of the age-related degenerationresulting in younger patients having better sensitivity than olderpatients [25].

In our study, we had an excellent recovery in 11 patientsout of which 7 were females, and only 4 were males. In thesefemales, the injury was a sharp cut inflicted accidentally withknives on their non-dominated distal forearms while performinglight work. It was not a deeper injury as the impact of the knifewas not heavy, thereby resulting in an excellent outcome be-cause of the favourable injury type and site, while in males, thebulk of the injuries were due to glass and tin which were deep,as the impact was heavy, and associated with injuries to otherstructures hence compromising the results. While searching therelevant literature, we could not find any published studies thatreported the impact of gender on functional recovery after therepair of peripheral nerve injuries. Women are usually involvedin performing light work at home, especially in kitchens, andin our experience had less severe injuries than men. Besides,women comply more with postoperative adjuvant treatmentsand physiotherapy protocols (possibly because of greater avail-ability of time, as women are not primarily involved in earningthe livelihood for the family unlike men) and this may explainthe better outcome in them. However, to scientifically know theinfluence of the gender on the nerve repair outcome, further

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38

multicentre studies need to be conducted in coming times tovalidate these possibilities in studies with larger sample sizes.

Sharp injuries in males inflicted with glass yielded fair togood recovery results, unlike our expectations for excellent re-sults, as most of these injuries were deep thereby involving otherdeep structures including the median nerve and the arteries thuscompromising the expected results of these injuries. These in-juries were mostly sustained by workers while working withbig heavy glass panels. Though these injuries were sharp innature, they were deep because of the greater impact of traumaof the inflicting agent, while free falling on the patient’s forearm,because of its heavyweight and sharp edges thereby injuringdeeper structures including radial artery, median nerve andadjoining tendons.

The proximity of the site of the nerve injury to the cell bodyhas a bearing on the outcome [17]. The closer the nerve injuryto the cell body, the poorer the outcome. Functional recoveryafter nerve repair is poor when the injury is close to the proximalend of the nerve as compared to cases in which it is closer tothe distal end. Multiple possible reasons may account for thisdifference. In cases where the injury is close to the central bodyof the nerve, massive necrosis may occur which seriously affectfunctional outcome. As the functional recovery depends onthe regeneration of nerve fibres, from proximal to distal end,from the location of the injury to the nerve endings, thereforemore proximal injuries take a longer time to regenerate thanthe distal ones and in these cases there is increased difficulty inrestoring muscle function after re-innervation as the muscle isre-innervated after an extended period of denervation. Even inthe skin receptors, poor post-surgical functional recovery hasbeen documented because of the degenerative changes in these[26]. One more reason which contributes to the poor outcomein proximal nerve injuries is the risk of crossover growth. Thisrisk is more in the proximal segment because the it containsthe nerve tract composing of both sensory and motor fibres. Incontrast, as at the distal end, the nerve has already divided intosensory and motor tracts, and these tracts can be identified. Theprecise epineural repair can be done between the respective endsof the motor and sensory tracts to achieve satisfactory functionalresults. In our study we noted good to excellent results in 85%of the patients with injuries at wrist level and fair results in 75%and poor in 30% of patients with proximal injuries. Secer HIet al. studied 455 patients with ulnar nerve injuries and foundthat the rate of good to excellent results was 15.06% in high-levelinjuries, 29.60% in mid-level injuries, and 49.68% in low-levelinjuries [27].

The presentation of concomitant soft tissue injuries surround-ing the nerve injury varied from patient to patient. Severe soft tis-sue injuries are often associated with high-energy blunt traumaas seen in machine injuries and road traffic accidents. If thetissue bed isn’t good, the outcome after nerve repair is poor.Incompletely debrided devitalized tissue in severe crush injuriesresults in poor local perfusion. We observed Excellent resultsin 80% and Good results in 20% of the patient with knife in-juries. In all the 5 patients of road traffic accidents, we had fairresults in view of associated crush injuries. We noticed that thepresence of Median nerve injury with associated vessel injuriescompromises the results of Ulnar nerve repair, compared to iso-lated ulnar nerve injury. Murovic JA studied 1,837 patients withupper extremity nerve injuries and found that the rate of Goodto Excellent results after knife injuries were 91% after the repairof Median and Radial nerve injuries, and 73% after the repair of

Ulnar nerve injuries [8]. Secer HI et al. studied 455 patients withgunshot or shrapnel injuries to the ulnar nerve and found thatthe rate of good to excellent results was < 32% [27].

As all our repairs were operated within 12 hours after injury,so we have not studied the impact of this factor on the outcome.Outcomes are poorer when the repair is delayed by more than 1year because muscle atrophy becomes irreversible at 1.5–2 yearsafter the loss of innervation. Barrios C et al. suggested thatnerve repair should be performed within 3 months of the injuryand that the time from injury to repair should not exceed 1 year[28]. Among the microsurgeons, presently, there is no generalconsensus regarding the optimal period of the follow-up for theassessment of maximum recovery after the surgical repair ofperipheral nerve injuries. The functional recovery may continueto improve for a longer period as the nerve regeneration is aslow process and dependant on different factors which varywith patients so the precise timing of final outcome evaluationafter the nerve repair is therefore very important and at the sametime very difficult .

The opinion regarding this varies among the authors alsowhile some authors like Ruijs AC et al [13] recorded that sig-nificant functional recovery could be assessed at 3 years afterthe repair of median and ulnar nerve injuries, Rosén B et al.[29] opined that patients should be evaluated till years also todocument the finally achieved maximum functional recoveryas the results generally improve with an increased with longerduration of follow-up. The final and the maximum achievablerecovery cannot be assessed precisely if the duration of the fol-low up is short. A minimum follow-up duration of around 2 -3years is generally required.

Conclusion

Ulnar nerve injuries are usually accidentally sustained at theworkplace with distal forearm being the commonest site. Glassinjury and knife injury were the most common mode of injuriesin men and women, respectively. Nerve injuries in children havea better recovery than those in older patients. Sharp, clean-cutdistal isolated ulnar nerve injuries, have excellent recovery whilecrushed, proximal injuries, especially those with concomitantmedian nerve, vessel and tendon injuries, contribute to a pooroutcome.

Limitations of the study

Relatively short follow-up, Single centre study, limited samplesize.

Recommendations

While explaining the prognosis to the patients and the atten-dants, a guarded prognosis should be offered to those withcrushed, proximal ulnar nerve injuries especially in cases whohave associated injuries to median nerve, vessels and tendons.

Ethics approval and informed consent:

The work was conducted according to the principles of the Decla-ration of Helsinki after obtaining clearance from the institutionalethical committee (IEC-SKIMS). Written informed consent wastaken from all the patients for participation in this study.

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38

Consent for publication

Written informed consent was taken from the patients for publi-cation of their pictures.

Conflict of interest

There are no conflicts of interest to declare by any of the authorsof this study.

Author contributions:

All the authors participated actively in conception and designof the work, the acquisition, analysis, interpretation of data,drafting the work and final approval of the version sent for pub-lication and agreed to be accountable for all aspects of the workin ensuring that questions related to the accuracy or integrity ofthe work are appropriately investigated and resolved.

Acknowledgements

We would like to acknowledge the help provided by all thedoctors and paramedical staff of the department in conductingthis study.

References

1. Emamhadi M, Andalib S. Double nerve transfer for restora-tion of hand grasp and release in C7 tetraplegia followingcomplete cervical spinal cord injury. Acta Neurochir (Wien).2018;160(11):2219-2224. doi:10.1007/s00701-018-3671-0

2. Martins RS, Bastos D, Siqueira MG, Heise CO, TeixeiraMJ. Traumatic injuries of peripheral nerves: a reviewwith emphasis on surgical indication. Arq Neuropsiquiatr.2013;71(10):811-814. doi:10.1590/0004-282X20130127

3. Emamhadi M, Alijani B, Ghadarjani S. Surgical outcome ofulnar nerve lesions: Not always disappointing. J NeurolStroke 2015;3:115. doi:10.15406/JNSK.2015.03.00115

4. Pfaeffle HJ, Waitayawinyu T, Trumble TE. Ulnar nervelaceration and repair. Hand Clin. 2007;23(3):291-v.doi:10.1016/j.hcl.2007.06.003

5. Woo A, Bakri K, Moran SL. Management of ulnarnerve injuries. J Hand Surg Am. 2015;40(1):173-181.doi:10.1016/j.jhsa.2014.04.038

6. Lad SP, Nathan JK, Schubert RD, Boakye M. Trends inmedian, ulnar, radial, and brachioplexus nerve injuriesin the United States. Neurosurgery. 2010;66(5):953-960.doi:10.1227/01.neu.0000368545.83463.91

7. Vordemvenne T, Langer M, Ochman S, Raschke M, SchultM. Long-term results after primary microsurgical repair ofulnar and median nerve injuries. A comparison of commonscore systems. Clin Neurol Neurosurg. 2007;109(3):263-271.doi:10.1016/j.clineuro.2006.11.006

8. Murovic JA. Upper-extremity peripheral nerve injuries: aLouisiana State University Health Sciences Center literaturereview with comparison of the operative outcomes of 1837Louisiana State University Health Sciences Center median,radial, and ulnar nerve lesions. Neurosurgery. 2009;65(4Suppl):A11-A17. doi:10.1227/01.NEU.0000339130.90379.89

9. Slutsky, DJ, Hentz, VR. Philadelphia: Churchill LivingstoneElsevier; 2006. Peripheral nerve surgery — Practical appli-cations in the upper extremity.

10. Seddon HJ, editor. 2nd ed. Edinburgh: Churchill Living-stone; 1972. Surgical Disorders of the Peripheral Nerves.

11. Mackinnon SE, Dellon AL, editors. New York: TheimeMedical Publishers; 1988. Surgery of the peripheral Nerve.

12. Young L, Wray RC, Weeks PM. A randomized prospec-tive comparison of fascicular and epineural digitalnerve repairs. Plast Reconstr Surg. 1981;68(1):89-93.doi:10.1097/00006534-198107000-00018

13. Ruijs AC, Jaquet JB, Kalmijn S, Giele H, Hovius SE. Me-dian and ulnar nerve injuries: a meta-analysis of predictorsof motor and sensory recovery after modern microsurgi-cal nerve repair. Plast Reconstr Surg. 2005;116(2):484-496.doi:10.1097/01.prs.0000172896.86594.07

14. He B, Zhu Q, Chai Y, et al. Safety and efficacy evaluationof a human acellular nerve graft as a digital nerve scaffold:a prospective, multicentre controlled clinical trial. J TissueEng Regen Med. 2015;9(3):286-295. doi:10.1002/term.1707

15. Ozdemir HM, Biber E, Ogün T. The results of nerve repairin combined nerve-tendon injuries of the forearm. UlusTravma Acil Cerrahi Derg. 2004;10(1):51-56.

16. Hundepool CA, Ultee J, Nijhuis TH, Houpt P; ResearchGroup ‘ZERO’, Hovius SE. Prognostic factors for outcomeafter median, ulnar, and combined median-ulnar nerveinjuries: a prospective study. J Plast Reconstr Aesthet Surg.2015;68(1):1-8. doi:10.1016/j.bjps.2014.09.043

17. Brown PW. Factors influencing the success of the surgi-cal repair of peripheral nerves. Surg Clin North Am.1972;52(5):1137-1155. doi:10.1016/s0039-6109(16)39832-2

18. He B, Zhu Z, Zhu Q, et al. Factors predicting sensoryand motor recovery after the repair of upper limb periph-eral nerve injuries. Neural Regen Res. 2014;9(6):661-672.doi:10.4103/1673-5374.130094

19. Wang Y, Sunitha M, Chung KC. How to measure outcomesof peripheral nerve surgery. Hand Clin. 2013;29(3):349-361.doi:10.1016/j.hcl.2013.04.004

20. Efstathopoulos D, Gerostathopoulos N, Misitzis D, Bouch-lis G, Anagnostou S, Daoutis NK. Clinical assessment ofprimary digital nerve repair. Acta Orthop Scand Suppl.1995;264:45-47. doi:10.3109/17453679509157166

21. Tadjalli HE, McIntyre FH, Dolynchuk KN, Murray KA. Dig-ital nerve repair: relationship between severity of injuryand sensibility recovery. Ann Plast Surg. 1995;35(1):36-40.PMID: 7574284

22. Lohmeyer JA, Sommer B, Siemers F, Mailänder P. Nerveinjuries of the upper extremity-expected outcome andclinical examination. Plast Surg Nurs. 2009;29(2):88-95.doi:10.1097/01.PSN.0000356867.18220.73

23. Lundborg G. Brain plasticity and hand surgery: anoverview. J Hand Surg Br. 2000;25(3):242-252.doi:10.1054/jhsb.1999.0339

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38

24. Segalman KA, Cook PA, Wang BH, Theisen L. Digital neu-rorrhaphy after the age of 60 years. J Reconstr Microsurg.2001;17(2):85-88. doi:10.1055/s-2001-12695

25. Weber RA, Breidenbach WC, Brown RE, Jabaley ME,Mass DP. A randomized prospective study of polygly-colic acid conduits for digital nerve reconstruction inhumans. Plast Reconstr Surg. 2000;106(5):1036-1048.doi:10.1097/00006534-200010000-00013

26. Enin LD, Nozdrachev AD, Chumasov EI. Dinamikavosstanovleniia funktsii retseptornogo apparata kozhi poslekriogennogo povrezhdeniia sedalishchnogo nerva [Dynam-ics of the restoration of the function of the skin receptorapparatus after cryogenic damage to the sciatic nerve]. Pa-tol Fiziol Eksp Ter. 1997;(4):6-8. PMID: 9471603.

27. Secer HI, Daneyemez M, Tehli O, Gonul E, Izci Y. Theclinical, electrophysiologic, and surgical characteristics ofperipheral nerve injuries caused by gunshot wounds inadults: a 40-year experience. Surg Neurol. 2008;69(2):143-152. doi:10.1016/j.surneu.2007.01.032

28. Barrios C, Amillo S, de Pablos J, Cañadell J. Sec-ondary repair of ulnar nerve injury. 44 cases followedfor 2 years. Acta Orthop Scand. 1990;61(1):46-49.doi:10.3109/17453679008993065

29. Rosén B, Lundborg G. The long term recovery curvein adults after median or ulnar nerve repair: a ref-erence interval. J Hand Surg Br. 2001;26(3):196-200.doi:10.1054/jhsb.2001.0567

Tanveer Ahmed Bhat et al./ International Journal of Surgery and Medicine (2020) 6(6):30-38