Fellowship-Trained Expertise in Complex Nerve Surgery
Peripheral nerve repair is among the most delicate and technically demanding procedures in hand surgery. When a nerve in the hand, wrist, or upper extremity is injured, sensation and motor control are often lost, creating functional deficits that can significantly affect daily activities.
Dr. Thomas Neustein, a board-certified and fellowship-trained orthopedic hand and upper extremity surgeon, specializes in peripheral nerve repair, nerve grafting, and nerve transfer procedures. Patients throughout North Georgia trust Dr. Neustein for his advanced microsurgical technique, thoughtful bedside manner, and commitment to restoring normal function after devastating nerve injuries.
Understanding Peripheral Nerves
Peripheral nerves connect the brain and spinal cord to the muscles and sensory receptors throughout the body. These nerves control both movement and sensation. In the hand and wrist, major peripheral nerves such as the median nerve, ulnar nerve, and radial nerve allow precise motion and tactile feedback that make everyday tasks possible.
When a nerve is cut, stretched, or compressed, communication between the brain and the affected area is interrupted. Depending on the type and location of the injury, patients may experience numbness, tingling, weakness, or severe pain.
What Are Peripheral Nerve Injuries
Peripheral nerve injuries involve damage to the nerve fibers or supporting nerve tissue. These injuries can result from lacerations, crush trauma, fractures, or dislocations of nearby bones and joints.
Common causes include:
- Deep cuts from glass, tools, or machinery
- Crush injuries to the hand, wrist, or forearm
- Elbow trauma affecting the ulnar nerve
- Wrist lacerations involving the median or digital nerves
- Sports or workplace accidents
- Surgical disorders or complications after previous procedures
If left untreated, damaged nerves can lead to permanent loss of sensation or motor function.
Symptoms of a Nerve Injury
The signs of a nerve injury vary depending on which peripheral nerves are involved. Typical symptoms include:
- Numbness or tingling in the fingers or hand
- Loss of sensation in a specific area of skin
- Weakness or inability to move part of the hand
- Burning or severe pain near the site of injury
- Inability to perform fine motor tasks
- Cold intolerance or hypersensitivity
When sensory nerves are affected, patients often notice loss of feeling or poor two-point discrimination. When motor branches are injured, muscles may waste away from disuse.
Commonly Involved Nerves in the Hand and Wrist
Peripheral nerve injuries in the upper extremity most often involve:
- Ulnar nerve: Controls sensation to the ring finger and small finger and powers many small hand muscles.
- Median nerve: Provides sensation to the thumb, index, and middle fingers and controls grip and pinch strength.
- Radial nerve: Controls wrist and finger extension.
- Digital nerves: Provide feeling to the fingertips and are often injured in lacerations.
- Lateral antebrachial cutaneous nerves: Supply sensation to the forearm and may be injured during trauma or prior surgery.
Each nerve has a specific sensory and motor function, and precise diagnosis determines the best treatment strategy.
Diagnosis and Evaluation
Accurate diagnosis begins with a detailed medical history, physical examination, and functional testing. Dr. Neustein assesses muscle strength, sensory loss, and nerve continuity to identify the level and severity of injury.
Additional studies may include:
- Nerve conduction studies and EMG to assess electrical activity
- High-resolution ultrasound or MRI to visualize nerve continuity
- Diagnostic exploration for suspected complete lacerations
Early identification is crucial, since surgical repair within the optimal time window produces the best outcomes for functional recovery.
Types of Nerve Injuries
Nerve injuries are classified by severity:
- Neuropraxia: Temporary conduction block with full recovery expected.
- Axonotmesis: Axons are disrupted, but the connective tissue framework remains intact.
- Neurotmesis: Complete severing of the nerve, requiring surgical repair or grafting.
Following injury, the damaged nerve segment undergoes Wallerian degeneration, where the nerve fibers distal to the injury break down. Regeneration begins once the nerve ends are reconnected and Schwann cells guide new axonal growth across the repair site.
Surgical Treatment Options
When spontaneous recovery does not occur, surgical intervention is required. Options include:
- Primary repair (end-to-end repair): Direct suturing of the nerve ends when tension-free approximation is possible.
- Nerve graft: Placement of a donor nerve segment (often the sural nerve) to bridge a nerve gap.
- Nerve transfer: Redirecting a nearby healthy motor branch to restore lost function when direct repair is not possible.
- Epineural repair: Meticulous alignment of the outer nerve sheath under magnification to promote axonal regeneration.
The choice of procedure depends on the type of nerve injury, the length of the nerve gap, and the timing of surgery.
The Surgical Procedure
Peripheral nerve repair is typically performed under regional or general anesthesia using an operating microscope and fine microsurgical instruments.
- The surgeon exposes the injured nerve through a precise incision.
- The nerve ends are carefully trimmed to remove scarred tissue and expose healthy fascicles.
- Under magnification, the nerve ends are aligned and sutured using fine nylon sutures smaller than a human hair.
- If a nerve gap exists, a nerve graft—most commonly the sural nerve—is harvested and interposed between the nerve ends.
- The coaptation site is reinforced with fibrin glue or microclips.
- The wound is irrigated and closed, and the extremity is immobilized to protect the repair.
The entire procedure may take several hours, depending on the complexity and number of nerves involved.
Digital Nerve Lacerations
Digital nerve lacerations are common hand injuries involving the small sensory nerves that supply the fingertips. These nerves are crucial for fine tactile sensation and two-point discrimination.
Surgical repair of digital nerve lacerations involves epineural repair under magnification. Once the nerve is repaired, sensation gradually returns as nerve fibers regenerate at approximately one millimeter per day. Early exploration and repair provide the best outcomes for functional recovery.
Nerve Graft Techniques
When direct end-to-end repair is not possible, nerve grafting bridges the defect. The sural nerve, taken from the lower leg, is the most common donor because it provides sufficient length and minimal functional loss.
The graft is placed between the nerve ends to allow regenerating axons to cross the gap. In certain cases, processed allograft materials may be used as an alternative, reducing the need for a donor site incision.
Nerve grafting is the gold standard for repairing large defects and restoring continuity in complex peripheral nerve injuries.
Nerve Transfers and Reconstructive Options
For chronic or high-level injuries where the nerve cannot be repaired directly, nerve transfer procedures may restore function. This involves connecting a nearby functional nerve branch to a denervated target muscle.
Common examples include:
- Transfer of an anterior interosseous nerve branch to the ulnar motor branch
- Median-to-ulnar nerve transfers to restore intrinsic hand strength
- Radial-to-axillary nerve transfer for elbow flexion or wrist extension
Nerve transfers can be highly effective in brachial plexus or delayed injuries when traditional repair is no longer viable.
The Role of Physical Therapy and Rehabilitation
After surgery, physical therapy and occupational therapy play a vital role in recovery. Therapy begins once the initial healing phase is complete and focuses on maintaining joint mobility, preventing stiffness, and promoting muscle re-education.
Therapists guide patients through sensory re-education exercises to help retrain the brain to interpret new sensory signals as the nerve fibers regenerate. Functional recovery often continues for several months and depends on the distance between the injury and the sensory end organs.
Recovery and Regeneration Process
Following surgical repair, axonal regeneration begins within weeks. Nerve fibers grow through the repair site toward their target muscles and sensory receptors. Recovery depends on several factors:
- Type and location of the nerve injury
- Time from injury to surgical intervention
- Age and health of the patient
- Length of the nerve graft or repair distance
Most patients begin noticing the return of sensation and movement after several months. Continued improvement may occur for up to one or two years after surgery.
Functional Outcomes and Expectations
With proper technique and early rehabilitation, functional recovery after nerve repair can be excellent. Patients regain protective sensation, strength, and fine motor control in the fingers and hand.
Outcomes are typically evaluated through sensory tests such as two-point discrimination and motor function assessments. Long-term follow-up ensures continued improvement and identifies any residual deficits that may benefit from additional reconstructive surgery or therapy.
Complications and Risk Factors
While success rates are high, potential complications include infection, neuroma formation, scarring at the coaptation site, and incomplete recovery. These risks are minimized by working with a skilled hand surgeon experienced in microsurgical technique.
Dr. Neustein’s meticulous approach ensures precise alignment of nerve ends, preservation of blood supply, and optimal conditions for axonal regeneration and long-term nerve health.
Why Choose Dr. Thomas Neustein
Dr. Neustein is a fellowship-trained orthopedic hand and upper extremity surgeon with advanced expertise in microvascular and peripheral nerve surgery. He is board certified by the American Board of Orthopaedic Surgery and completed rigorous training in both orthopedic and reconstructive hand surgery.
Patients describe him as a compassionate doctor with excellent bedside manner who takes time to explain treatment options in great detail. His surgery center team is known for professionalism, efficiency, and top-notch patient care.
Whether performing primary repair, nerve grafting, or complex nerve transfer, Dr. Neustein’s focus is to restore functional independence, reduce pain, and help every patient return to daily activities.
Preventing Long-Term Complications
Timely surgical intervention offers the best chance for recovery. Waiting too long after injury can result in degeneration of muscle fibers and sensory end organs, reducing the potential for meaningful repair.
Dr. Neustein emphasizes early referral and evaluation after any suspected nerve injury to preserve nerve tissue and optimize outcomes.
Research and Advances in Nerve Repair
Modern microsurgical techniques continue to evolve. Studies published in journals such as J Hand Surg and J Bone Joint Surg have demonstrated the effectiveness of early primary repair and nerve grafting using microsutures and fibrin sealants.
Emerging technologies, including bioengineered nerve conduits and Schwann cell-based scaffolds, show promise in improving axonal regeneration and reducing donor site morbidity.
Returning to Daily Activities
Most patients can resume light daily activities within several weeks after surgery. As strength and sensation return, more demanding tasks are gradually introduced. Physical therapy continues to reinforce motion and function while ensuring protection of the repair site.
Patients often report significant relief from numbness, tingling, and severe pain as the nerves heal, resulting in a marked improvement in quality of life.
Schedule an Appointment for Nerve Evaluation
If you have sustained a hand or wrist injury and experience numbness, weakness, or loss of sensation, schedule an evaluation with Dr. Thomas Neustein. Early diagnosis and timely nerve repair can make a lasting difference in your recovery.
Dr. Neustein provides comprehensive evaluation, surgical repair, and personalized rehabilitation plans at all Specialty Orthopaedics locations across North Georgia.
