D e c e m b e r, 1965 P H Y S I O T H E R A P Y Page 3 THE d i a g n o s i s a n d i n v e s t i g a t i o n o f P E R I P H E R A L N E R V E I N J U R I E S J. H. M A R K S, M.B., Ch.B., D ip. Surg., Senior Medical Officer, H arm ony, R and Mines, Limited. Lecture delivered to the S .A .S.P . P ost Registration Course, M ay, 1965, a t the Ernest Oppenheimer Hospital, Welkom. The Causation o f Nerve Injuries There are many different ways in which- a nerve may be matised—by open w ounds—sustained blunt pressure— a c t i o n — chemical irritation, by misplaced injections and 'schaema and, m oreover, a nerve may become paralysed In the various forms o f peripheral neuritis. [t is rare to find a complete lesion in a closed fracture, but in c o m p o u n d fractures nerve injuries are com m on. One may see a nerve crossing a wound apparently intact, yet divided lower down. Glass is a com m on cause o f nerve dam age and one of the r e a s o n s the Americans are said to have gone in for cardboard milk bottles is the num ber of cases where dairy firms have been sued as a result o f children falling and cutting their hands on bottles. According to Jo h n C halm ers, in the presence o f paralysis with an open w ound the chances o f a nerve being severed are 90 per cent; in a closed injury the chance is 90 per cent of its not being severed. With a severe varus strain o f the knee and dislocation, one can get the popliteal nerve stretched out o f existence and I have seen the ulna nerve torn in a simple fracture of the distal radius. Peroneal palsies are com m on due to the stretching o f the nerve across the acetabulum in fracture displacements of the hip joint and where there is a fracture in the posterior part of the acetabulum . Usually only the lateral popliteal nerve is damaged because this p art is closest to the bone. Prolonged non-violent stretching o f a nerve can cause paralysis. In some cases patients with fractured fem ora on traction show a delayed onset of foot drop. This is a true paralytic phenom enon with sensory loss and the biceps femoris is often paralysed as well. Straight leg raising is know n to throw tension on the peroneal nerve and its diagnostic value in cases o f prolapsed intervertebral disc stems from this. The cause o f the paralysis is sitting up in bed with the knee straight or by excessive elevation o f the straight leg. By avoiding suspending the T hom as splint above an angle of 20° with the bed no fu rth er cases of foot drop have occurred. Cast palsy is com m on, affecting the radial and popliteal nerves. This betokens technical errors—neglect of padding, etc. A badly placed injection can paralyse a nerve, rarely in the axillary but com m only in the sciatic. This is surprising when one considers the num ber o f people, semi-trained, injecting the muscle w ithout even knowing where the axillary nerve lies. The drunk’s paralysis, due to sustained pressure whilst comatosed, affects the radial nerve or the entire plexus according to the site o f pressure—over the radial nerve across a bed, or in the axilla over the back o f a chair. Similar negligent paralysing effects are reported following the administration o f anaesthetics, with the arm allowed to overhang the table. The Varieties of Nerve Injuries The generally accepted classification o f nerve injuries is as follows: Neurotmesis—a cutting—a separation o f parts which m ay be united by fibrous tissue; Axonotmesis—a complete division w ithin the intact neural sheath; Neuropraxia— or non-action o f a nerve—following com m otion of the fibres o f the axon. The Reaction of Nerves to Injury W ithin a few m inutes o f interference with th e conductivity o f the nerve the denervated skin feels hot and dry. All reflexes are inhibited and all innervated muscles are p a ra ­ lysed. A trophy is very rapid in the smaller intrinsic muscles but less so in the larger. A nom alous innervation may con­ fuse; sensory loss follows a fairly definite anatom ic pattern but overlap may occur. There are certain autonom ous zones for each nerve where overlap is not seen—these are as follows: The Radial Nerve—a small area on the dorsum o f the first interosseous space; The Median Nerve—th e volar aspect o f the terminal phalanx o f the index; The Ulna Nerve—the lateral border o f the 5th finger on the anterior surface; The Popliteal Nerve—a small area on the outer aspect o f the fo ot; The Posterior Tibial Nerve—the sole o f the foot; The Sciatic Nerve—a com bination of the popliteal and tibial areas. O ther nerves will be discussed later on in this lecture. T he autonom ous zone is anaesthetic; around this is an interm ediate zone where sensation is reduced. This is the gross anatom ic distribution o f the nerve. A round this is a slightly larger zone—the maximal zone which is found when the adjacent nerves are blocked out and the nerve under exam ination rem ains intact. This is the area o f overlap. Sympathetic fibres enter the brachial plexus far proximally as post ganglionic fibres an d follow sensory paths to the periphery. If a peripheral nerve is divided the sym pathetic fibres are likewise divided. W ith paralysis due to lesions proximal to the entrance o f the sym pathetic fibres, the sudom otor function is intact and hence the bad prognosis is easily diagnosed. D im inution of the blood supply of periphera. nerves causes a decrease in the rate of passage of the nerve impulse and finally to complete nerve block. The exam ination o f the peripheral nerve involves ap art from a careful history, the general inspection o f the affected m em ber and a com parison with the norm al side if possible. The exam ination o f muscles innervated and a check of sensory defects. The Investigation o f Peripheral Nerve Injury First one must take a reasonable history—cause o f the injury—w hether paralysis was im mediate at the onset or delayed. One m ust also investigate the progress o f the w ound—w hether sepsis occurred and also w hat treatm ent was given—physiotherapy, etc. Pain is an im portant thing to discuss—the situation o f the pain—radiation and time relationship to injury. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y December, 1965 O ne notes the line o f entrance and exit w ounds and thereby gains an idea o f the nearness o r risk to adjacent nerves. One should feel along the line o f a nerve fo r—query neurom a form ation. A w ound in the area o f a nerve often w arrants exploration o f th a t nerve. W hat can th e p atient d o ? A re there any changes in the function o f the p a rt being exam ined? W ithin a few minutes o f interruption o f nerve conductivity, unless above the entrance o f the sym pathetic fibres, whatever the cause, the denervated skin becomes flushed and dry. T his is the m ost reliable and easily observed sign o f nerve injury. One can diagnose anaesthesia by feeling the dry skin w ithin mom ents o f the lesion being produced if one dries the fingers first, an d also one can confidently prognosticate success in a recovering ulna lesion by feeling the m oisture on the pulp o f the little finger. M any tests are based upon this sudom otor activity. The Histamine Diphosphate Test H istam ine D iphosphate 1/100 is used to test for evidence o f intact post ganglionic fibres. D ro p a few drops on the area to be tested an d m ake multiple small superficial scari­ fications through th e drops. A wheal appears if the nerve is intact o r if it is severed above th e ganglion station. I f you can get a wheal w ith paralysis, the prognosis is p o o r because th e roots are dam aged. T est all muscles innervated by each nerve in nerve lesions. D iagnose the level an d also the possibility o f escape o f certain branches o f the injured nerve. It is im portan t to know the anatom y an d surface m arkings o f nerves as well as their autonym ous zones. A n anaes­ thetic area is satiny sm ooth and the finger glides over it. T he pulp atrophies and the skin lines disappear. Guttman's Quinazora! Test has been used to dem onstrate the persistence o r absence o f the sudom otor effects o f the nerves but is messy a n d is not often used these days. T he test which has replaced it is called th e Ninhydrin Test. There are ten different am ino acids in the sweat and these stain w ith N inhydrin. A moist finger passed over paper leaves a p rin t th a t may be brought u p by N inhydrin m any years later. It consists o f punctiform representation o f the glandular orifices o f the sweat glands. I f the fingers are w et the am ino acids are high an d they tend to spread over the skin and spoil the test. Details o f the Test R oll the finger tips, which have been dried, across the paper and outline w ith a pencil. One should not. handle the p ap er except at the perforated end. I f the hands are moist, wash w ith soap an d w ater and clean w ith E ther-A lcohol m ixture before testing. T o encourage perspiration the patient may be given hot tea or salicylates but this is usually unnecessary. D ip the papers in 1 per cent N inhydrin solution (acidified w ith a few drops o f glacial acetic acid which keeps for several m onths); dry pap er strips—they dry quickly—and then w arm them in air between 100 to 120°C. T he dots become visible. W ait a few days before fixing to get a m ore distinct p rin t. Fix by dipping in 1 per cent solution o f C opper N itrate in 5/95 mixture o f w ater an d M ethyl A lcohol o r A cetone, acidfied w ith a few drops o f concentrated N itric Acid per 100 c.c.’s. T he better the tactile gnosis the closer the dots. T w o p oint discrim ination is 12— 12 m .m . ap art in the fingers. T actile G nosis does not, as a rule, retu rn to skin grafts, but sud o m o to r function does retu rn within about one or tw o years, even if sensation does not. O ne can use this N inhydrin Test to determ ine the efficiency o f one’s local anaesthetic a n d .a ls o to get an idea o f the possibility o f recovering nerve function. W here the lesion is incom plete an d associated w ith a causalgia, sweating is excessive. It may be difficult for one to diagnose the level o f the lesion where the innervation has overlapped and consequently one has to resort to the block­ ing o f the overlapping nerve. This m ethod o f exam ination is know n as Highets Procane Block. 5— 10 c.c.’s o f 5 per cent procane w ith A drenalin m ust be injected close to the nerve. It is also im portant to note the presence o f associated skin changes such as oedema and cyanosis. W hen you stick a pin into the finger it moves the finger an d causes pain. You should use a h air—never a pin. One can often feel pin pricks with a severed m edian nerve because the radial and ulna nerves overlap to a certain extent. I recom m end th a t anyone testing peripheral nerves should use an aesthesiom eter. This is a very expensive instrum ent— I have one here. It consists o f a bicycle spoke and a piece of nylon bristle. (It is a sort o f Von Frey’s hair.) One should test with the side of the bristle—no t with the point because then it ends to mimic the effects o f the pin. One should always test for branches o f the nerve that might have been intact after severance o f the main trunk. I f one uses cotton w ool to try and test for sensation one might not even know if one is touching the skin oneself. T innell’s sign is the elicitation o f tingling by the tapping on a nerve with open ends, but it is useless at the level of injury; if below, it shows that the nerve has crossed the level an d is a good guide to the progress o f recovery. I f Tinnell’s sign cannot be elicitated w ithin tw o m onths o f injury, below j the site o f the lesion, one m ust consider the lesion to be complete. By testing the pulp for pin sensation w ith fingers flat on the table, the pin pressure is transm itted to the norm ally innervated skin on the dorsum o f the hand, and the patient truly feels the prick. Also, if pressure moves the I.P. joints, he will be aw are o f deep sensation. H old the part circum- ferentially in a firm grip and avoid all movement. In muscle tests it is im portant to see o r feel the contraction o f the muscle (if one can) by testing against resisted move­ m ent or getting the patient to do som e allied test. M uscle biopsy, by showing the em pty axon sheaths, allows one to differentially diagnose from the M yopathies; also th e presence of the intact end organs gives one a guide to prognosis. O ne can also test sensory deficiency by means o f two point discrim ination. Exam ine jo in ts—note the passive range, a ttitu d e and gait. One should grade m otor functions accord­ ing to the 0-5 system. E ach muscle, as I said before, should be seen an d felt to contract, if possible. O ne should measure the limbs for wasting. T h e arm is usually measured 10 cm. above and below the medial epicondyle, the calf at its m axim um diam eter an d the thigh 20 cm. below the anterior superior spine. All reflexes should be tested. D irect electrical stim ulation above the lesion may show a flicker o f contraction in distally innervated muscles, in w hich case spontaneous recovery is likely. A hard lesion implies intraneural scar tissue an d one must resect. Two form s o f electricity are often used in testing. T he Faradic (interrupted) and the G alvanic (constant) currents. I f healthy Faradism causes a contraction as long as the current passes. T he G alvanic causes contraction only when th e current is m ade or broken. T he cathode applied to the muscle gives a better response than the anode an d the. induction current is m ore effective than the break. In degeneration o f the nerves the anode may give a brisker contraction than the cathode a n d the reaction may be sluggish. T he F aradic current acts on the Nerve. T he Galvanic on the Muscle. Reaction o f Degeneration—N o response to Faradism . Galvanic Reaction is to a lesser current but the muscle contracts sluggishly and the anode contraction is greater than the cathode. R eaction o f degeneration takes over a week to develop. U sually the muscles return to power before the nerves respond to electrical stim ulation. These test are not o f much use. Two ordinary hypoderm ic needles attached to two 1^ volt dry cell batteries with a polarity reversal switch are all one really needs to test nerve conductivity. I show here the ap p aratu s we use at H arm ony kindly devised by M r. V. S. G o re o f this mine. In a recent complete division o f a sensory nerve the skin R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) D e c e m b e r , 1965 P H Y S I O T H E R A P Y Page 5 is pinkish because o f vascular dilation (depending on the division o f sym pathetic fibres). A few days later the skin area may show fine scaling. W here the lesion is older the skin is bluish mottled and dry. W here the lesion is irritative the skin may be red and perspiring. Muscle power is graded on the 0-5 system. 0 is no function; 1 is a flicker only; 2 is movement w ith gravity elim inated; 3 is contraction against gravity only; 4 is contraction against m oderate resistance; 5 is norm al power. Pain sensation is often readily tested with a pin. Ask if he feels sharp or blunt using opposite ends. Hot or cold sensation can be tested using test tubes, with hot water and ice but is usually not needed. The Limbs as a Whole Muscles th at are innervated by the nerve under exam ina­ tion must all be checked— seen o r felt to co ntract—and their strength investigated according to the 5-0 m ethod. W hen it can be shown th a t a paralysed o r weakened muscle has regained function o r strength it is a definite sign th at there has been nerve recovery. W here one o f the muscles that are innervated below the site o f a lesion is functioning it proves the incompleteness of the lesion. Also where the level o f a lesion is in doubt the decision as to which o f its muscles are and which of its muscles are not functioning will aid in locating the level o f section. In the time allotted to me I now briefly wish to m ention the m ethods o f checking up on special nerves. A n easy way o f ruling out an injury to a nerve in the upper limb is to test the sensation o f the autom ym ous zones o f the m edian and ulna nerves by means o f a Von Frey’s hair and com pare w ith the opposite side. T he anterior aspect o f the index and little fingers—the radial nerve is tested by getting the patient to open the hand widely and extend the digits. For the Lower Limb Test the sensation between the H allux and the second toes and compare. This tests the tibial nerve. I f he can extend the great toe strongly, the perioneal nerve is no t affected. A limb may take up a characteristic position after injury. The Policeman’s tip o f the E rb D uchenne paralysis and the radial nerve wrist d ro p or the Benediction attitu d e of the median nerve when the hand is outstretched due to the lack of flexion o f the index. The skin is im portant— in a recent injury w ith complete severance o f sym pathetic fibres the skin is flushed due to dilation and often a fine desquam ation occurs after a few days. A fter several days the skin is dry and m ottled. T rophic ulceration m ay occur. W ith an irritative lesion the skin is moist and glossy. Muscle Examination It is most im portant to know w hat muscles are involved in any lesion—the presence of function in the territory o f an involved nerve is of note. After about 4-6 weeks the characteristic deformities o f the various lesions are apparent. It is wise to look fo r tendon dam age as a possible cause of muscle failure th a t might mimic paralysis. Assess the range o f jo in t movements. It is o f no avail to repair nerves supplying muscles that w ork on “ frozen” joints. Skin tem perature is controlled by the rate o f blood flow in the skin vessels. The p atien t’s disabilities are m ore im por­ tant than the objective findings. A paralysed limb becomes warmer in hot and colder in cold surroundings than the normal limb. A fter successful suture there is often a sensa­ tion o f increased w arm th in the part. T he retu rn o f sweating is a late feature an d indicates extensive regeneration. W ith paralysis the nails are brittle and tend to incurving. Trophic changes are particularly com m on in the skin of the m edian and posterior tibial distribution. More Detailed Description o f the Various Nerves, etc. T he innervation o f movement is segmental in develop­ ment. A ny movement is innervated by two adjacent seg­ ments an d the antagonistic movements by tw o adjoining segments. T he entire group o f movements o f a jo in t is con­ trolled by four segments in series and, passing distally, the four seried segments start one segment lower. The spinal centre for the hip is thus L um bar 2, 3, 4 and 5; for the knee L um bar 3, 4, 5 an d S .l; and for the ankle L um bar 4, 5, S .l and 2. T he anterior muscles are controlled by the upper 2 segments, thus in the hip— L u m b ar 2 and 3— control flexion, adduction and medial ro ta tio n ; L um bar 4 and 5— the opposite; extension, abduction and external rotation. In the knee, the extension is L u m b ar 3 an d 4 ; flexion is L um bar 5 and S .l. In the ankle, dorsi flexion is L um bar 4 and 5, and planti flexion is S .l an d 2. To rem em ber the innervation o f a muscle, rem em ber its prime function. In the upper limb—alas for memory— the rule is not 100 per cent reliable. Shoulder—abduction and external ro tatio n is C .5 ; adduction and internal ro tatio n is C .6, 7 an d 8. The elbow has the sam e 4 segments. Flexion is C.5 an d 6 and extension is C.7 an d 8. Pronation and supination is C .6 ; wrist movement is C .6 and 7; T hum b and finger movement is C.7 and 8 ; intrinsic mechanism o f the hand is T .l. One rem embers the innervation o f Reflexes as above. The reflex th at extends the knee—the knee jerk is thus L.3 and 4. The reflex th at plantiflexes the foot is thus S .l and S.2. E ither get the patient to perform actions against resistance or to resist movem ent in th e opposite direction. See and feel the muscle bellies. The Brachial Plexus: often injured in birth accidents. Two m ain types ap art from a total paralysis. T he E rb D uchenne—upper roots C.5 and 6 affecting m ainly the upper arm . T he arm hangs limply by the side and th e wrist is flexed and the forearm pronated. “The Policem an’s T ip ” position. The Klumpke Paralysis: C.8 and T .l. A paralysis o f the muscles o f the hand and true claw. Loss o f sensation along th e ulnar side o f arm , forearm and hand an d a H o rn er’s syndrom e is seen. Claw hand is seen in lesions o f the inner cord o f the Brachial Plexus—Syringo­ myelia—in combined m edian and ulna nerve lesions at the wrist an d also after V olkm an’s ischaemic contracture. The Accessory Nerve: C. 1, 2, 3 and 4— the supply o f the sterno-m astoid ( 1) and the trapezius muscles. (1) T u rn the head to the side o f the lesion and get him to resist the movem ent of the chin. See o r feel the muscle contract. (2) G et him to shrug his shoulders and brace them back, against resistance. The paralysed side does not shrug and if o f longish duration the shoulder is flattened. C an feel as well as see the contraction. We m ention here H orner’s syndrom e which is caused by interference with the cervical sym pathetic arising per T .l and T.2. It consists o f a small pupil (myasis); a dry skin (anhidrosis); a partial ptosis o f the upper eye lid and a slight sinking in of the eyeball—enophalm os. It also carries a serious prognosis in upper cord lesions. The Cervical Rib Syndrome M ostly a cervical rib gives rise to no sym ptom s at all. W here it does have effects these are vascular or neurogenic. The vascular are those o f defective circulation extending to gangrene. The nerve sym ptom s are chiefly originated in the T .l segments via the ulna nerve w ith wasting o f the small muscles o f the hand an d the T henar Eminence. Sensory changes are not comm on. The A xillary Nerve (Circumflex) C.5 and 6 supplies the deltoid and may be involved in injuries o f the shoulder. There is a small area o f anaesthesia over the deltoid and abduction o f the arm is impossible. Test by abducting the th e arm between 15° and 85° and get him to try and m aintain the position against resistance. C an see and feel the muscles contract. The Dorsal Scapular Nerve (C.5) is the nerve to the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y December, 1965 rhom boids. P ut the hands on the hip and brace the elbow back against resistance. C an see and feel the muscles co n ­ tract. The Supra Scapular Nerve: C.5 and 6 supplied the super­ ior and inferior scapular muscles. There is wasting above and below the spine of the scapula. The muscles are tested separately. T he arm tjangs by the side and when he tries to abd uct it can feel the supraspinatus contract. T o test the infraspinatus bend the elbow to a right angle and externally ro tate the shoulder against resistance. The Long Thoracic Nerve: C.5, 6 and 7, supplies the subscapularis. W hen the patient pushes against some im movable object (as a wall) the scapulae stay close to the chest wall unless the muscle is paralysed when one gets winging o f the scapula. The Long Subscapular Nerve (or T horacodorsal nerve) derived from C .6, 7 and 8 supplies the latissimus dorsi. G rasp the muscle and let him cough. T he muscle can be felt to contract under the fingers. Little disability is caused by dysfunction o f this muscle. The Ulna Nerve: C .8 and T . l —may be paralysed due to disease (Leprosy) or traum a. The interossei waste and the m etacarpals stand out. Clawing occurs if th e lesion is at the wrist level. T he little finger is abducted due to the unopposed avion o f the exten­ sors. In clawing the long extensors extend the M .P. joints. T he interphalangeal jo in ts are extended by interossei and the lum bricals an d these are paralysed. The unopposed long flexors pull the fingers into a claw. Obviously this cannot happen if the long flexors are paralysed by an high lesion. In ulna loss one may only get skin sensation loss on the anterior aspect in the midline o f the little finger. By putting the 5th finger ap art and pushing them together, you will be able to dem onstrate even the most m inor degrees of ulna paralysis, as in ulna neuritis. One can do the same with the index finger fo r the first interrosseous. W hen testing the interrossei get him to move his fingers from side to side, holding the other fingers apart, but make sure that the fingers are fully extended o r the long flexors will confuse the issue by mimizing the movement. The Card Test fo r the Interossei See that the fingers are kept straight and n o t flexed at all and get him to try and grip a card between the fingers and resist fully. T he card slides out. The Adductor PoIUcis— U lna nerve G et him to hold a card between index and thum b o f each hand w ith the thum b straight. D ue to weakness o f the ad d u cto r the flexor pollicis longus (median nerve) takes over and flexes the I.P . joint. i. The Radial Nerve This supplies the Triceps—all extensors of the forearm, and the Supinator. I t is derived from C. 5, 6 and 7 and often T . l . A t the elbow it divides into tw o branches—T he Posterior Interrosseous nerve (muscular) and the Superficial R adial (sensory). If the lesion is above the upper/m iddle third of the arm the Triceps are spared. I f above the elbow the Brachior- adialis is spared. T he characteristic wrist d ro p is often missed unless the elbow is bent and the forearm pronated. Where the posterior interrosseous nerve is affected there is no wrist drop but an inability to extend the M .P. joints. This is a serious disability for pianists, typists, etc. The Median Nerve (C.6, 7, 8 and T .l) may be injured at either elbow o r wrist. If divided in the region of the elbow there is an inability to flex the thum b. T he thenar muscles waste and the palm ar surface o f the thum b rotates to face forw ards—the Ape-like hand. Tactile Gnosis—o r T ouch Sight W ith im paired sensibility o f the m edian nerve, the patient picks up articles betwen his thum b and his ring and little fingers, instead o f between index and thum b. Let him pick up a num ber o f articles with each hand, under vision, and notice how he uses his hand. G et him to identify these articles blindfolded— screw, a cap, a paper clip and so on. One m ust have tactile gnosis to do fine w ork— to use a screwdriver, wind a watch, etc. Areas deficient in tactile gnosis are, of course, obviously deficient in the ability to perspire. T he loss of tactile gnosis is the crippling effect o f a m edian lesion. G et him to clasp his fingers together. The index stands out due to paralysis of the flexor. Test the flexor pollicis longus —fix the M .P. joint o f the thum b and get him to bend the terminal phalanx. A t the wrist the abductor pollicis brevis will be affected. G et the patient to place his hands palms dow n with the index and thum b touching in the Oriental Prayer position and raise the hands before the face. T he tip o f the affected thum b touches the base of the palm ar aspect o f the pulp and not the tip. The abductor pollicis brevis is not working. T he sensory loss may be the classical lateral 3^ digits but may only be the autonym ous zone of the pulp o f the index. The Carpal Tunnel Syndrome—A progressive weakness of the finer movements of the han d — hyperaesthesia o f the m edian nerve distribution and an aching pain th at may extend up as far as the shoulder. T he thenar eminence muscles waste and the abductor pollicis brevis and the opponens pollicis atrophy. If one gets the patient to keep his wrists flexed for a m inute the pain is exaggerated. N early 90 per cent of the cases get pain on percussion o f the m edian nerve at the wrist. The Lower Lim b—Nerve damage is com m on in the gluteal region, the Inguinal region and the knee and ankle. The Femoral Nerve (L.2, 3 and 4) Any of its branches to the quadriceps may be severed See if he can extend the knee—feel the heads contract. A naesthesia in the anterior aspect o f the thigh and down the middle of the leg may be seen. The Obturator Nerve (L.2, 3 and 4) O n his back w ith the knee extended feel the muscles attem pting to adduct the limb against resistance. The Sciatic Nerve is often involved in disc lesions. The history is im portant—injury or strain must be described fully bearing in mind th at trivial injuries may cause marked disc lesions. The history o f the pain starting in the buttock w ith spreading down to the thigh and foot is im portant. N o te the posture—the scoliosis—the semi-flexed position when standing. T he thigh is flexed and the patient lies w ith the heel as high up on the opposite thigh as can be com fortably placed. N ow press the knee down and out in the bed. If there is pain before the knee touches the bed this is not a nerve pain but due to arthritic changes in the hip on sacro-iliac joints. T he sciatic nerve is really two nerves in a single sheath— the com m on peroneal and the tibial nerves. Total Sciatic Palsy: Paralysis o f all muscles below the knee joint. The Inferior Gluteal Nerve—from L.5 and S .l and 2 G et the patient to lie on his face and extend the thigh. Feel the gluteus maximus muscle contract. The Superior Gluteal Nerve (L.4 and 5 an d S .l) supplies the G luteus M edius and M inim us and the T ensor Fasciae Latae. C an be tested by getting the patient to stand and raise the leg. W here the gluteus medius is paralyzed there is a d ro p o f the hip of the affected side. This causes a charac­ teristic gluteal gait. The drop of the hip is the Trend- allenburg Test. If the patient lies supine w ith the thigh straight and tries to abduct the thigh against resistance the muscle bellies can be seen and felt. I f he lies prone with the knee bent at a right angle and attem pts to internally ro tate the leg against resistance one can see and feel the muscles contract. Common Peroneal Nerve: This can be rolled between the fingers where it crosses the head of the fibula. In neuritis it is very tender. Paralysis o f th e nerve causes foot drop. Continued on Page 14 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 14 P H Y S I O T H E R A P Y December, 1965 This small book should be of great assistance to the student in understanding th e abnorm alities which arise from injury to the cerebral nervous system and also to the physio­ therapist in assessing and planning treatm ent for patients. M. H O R SL E Y , M .C .S.P. H AV IN G A BABY. By J. F . R obinson, M.B., Ch.B. 3rd Edition. Publishers: E. & S. Livingstone Ltd., 15/17 Tevoit Place, Edinburgh. 8s. 6d. net, England. This is a w onderfully w ritten book for “ young m arrieds” . I t deals clearly and concisely with problems which many do not like to discuss. Provided th a t the reader has adequate ante- and post-natal physiotherapy training this book cannot fail to be o f considerable help. The ante- and post-natal exercises m entioned are well chosen, bu t because o f the danger of persistent sacro-iliac strain occurring post-natally it is generally believed that “ double leg-raising” is contra-indicated in all ante- and post-natal w ork. I t is particularly dangerous to include post-natally “ double-leg raising” as the abdom inal muscles are less able to control the lum bar lordosis which occurs in m ost cases. A lthough the au th o r does indicate this exer­ cise to be perform ed later in the peuperium , he does not give any earlier progression o f abdom inal exercises. B R E N D A K A ST E LL , M .C.S.P. R EH A B ILITA T IO N O F T H E L O W ER L IM B A M PU T E E . By W. H um m , M .S .R .G . 84 pages, 40 illustrations, Price 18s. Publishers: Bailliere Tindall and Cassell Ltd., 7 and 8 H enrietta Street, L ondon, W.C.2. This comprehensive book comes to the aid o f the rehabili­ tation therapist who is entrusted not only w ith the re­ am bulation of th e am putee, but also w ith the psychological adjustm ent of the patient to his artificial limbs. The book is divided in tw o p arts: the pre-prosthetic phase, and th e prosthetic and late phase treatm ent. Psycholo- logical problem s, stum p exercise routine, and stum p bandaging are th e m ain items dealt with in the first part. All stages o f re-am bulation for single and double amputees, as well as the care of stum ps and prostheses are extensively described in the second p art of the book. T he accent thro u g h o u t is on the practical approach. O ur well-trained physiotherapy students, and those already qualified will find th a t the book is adding to their thorough grounding those practical hints which can only come from an expert w ith great experience. The au th o r is a perfectionist who does not accept a second-class result. H e knows well th a t the beginning o f prosthesis-walking are not easy for th e patient and th a t the am putee tries to get away w ith any am ount o f easier, but incorrect movem ents, which produce an unsightly gait, early fatigue and harm to th e equipm ent for all of which in the end nobody but th e instructor would be blam ed. T he attention o f the reader is directed tow ards such possible mistakes by the amputee and he is show n how to avoid them . Every point is m ade clearly by way o f succinct description, clever line drawings and carefully selected photographs. Being a guide to rehabilitation, the book does not stop a t re-am bulation, but adds to this in the final stages, under separate headings fo r unilateral and bi-lateral am putees, such functional activities as stair-climbing, getting on and off public transport, falling and getting up from the floor and num erous o ther moves. T he book should be o f great benefit to many who are concerned with the re-am bulation o f am putees o f all age- groups. A. R O T H B E R G C L A Y T O N 'S E LE C T R O T H E R A PY A ND A C T IN O - T H ER A PY . A Textbook for Student Physiotherapists. 5th E dition, by Pauline M. Scott, M .C .S.P., T .E .T ., T .M .M .G . School o f Physiotherapy, Kings College H ospital, London. Publishers: Bailliere, Tindall and Cassell, 7 and 8 H enrietta Street, L ondon, W.C.2. 390 pages, 205 illustrations, 35s. net. 1st Septem ber, 1965 publication date. (To be reviewed later.) Diagnosis and Investigation of Peripheral Nerve Injuries. — Continued fr o m page 6. There is a highstepping flapping gait due to inability to dorsifiex the ankle. The Tibial Nerve Paralysis here leads to paralysis o f all th e muscles o f the calf and the foot is pulled up by the Peroneal group so that he stands on his heel. The ankle Jerk is absent because the muscle concerned is paralysed. A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS Manufacturers and Suppliers of: O R T H O P A E D IC A PPLIA N C E S, A R T IF IC IA L LIM BS, TRU SSE S, SU R G IC A L CORSETS, U R IN A L S, A R C H SU PPO R T S, C OLO STO M Y BELTS, E LA STIC ST O C K IN G S, A N K L E G U A R D S , W R IST G U A R D S , ELBOW G U A R D S, K N E E G U A R D S, L IG H T D U R A L C R U T C H E S F O R C H IL D R E N , W O O D EN C R U T C H E S , A N D M E T A L ELBOW C R U T C H E S. Phone 23-2496 P.O. Box 3412 312 Bree Street, Johannesburg ------------- ------ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )