DIGITAL NERVE LACERATION (PALM & FINGER)

Introduction

Lacerations of the digital nerves are the most frequently seen of all the peripheral nerves in the upper extremity. Most of these are seen in the proper digital nerves, while common digital nerve lacerations occur less often. These injuries typically result from penetrating trauma—like stab wounds or falls into/onto glass—and they may or may not involve concomitant damage to other skeletal or soft-tissue structure(s). The complete transection of a common digital nerve remains a challenging problem for hand surgeons and their patients. Despite advances in microsurgical nerve repair, repairs often leave patients with functional deficits, especially in adults. However, it is still possible for most patients to achieve an adequate recovery of sensibility in the affected digit(s) when they are treated early and appropriately.^1-6

Pathophysiology

When a nerve is transected, the distal segment of the nerve undergoes Wallerian degeneration.
- Distal axons degenerate secondary to calcium-activated calpain enzymes;^7,8 degenerating myelin is phagocytized by Schwann cells and macrophages. In the proximal stump, degeneration also occurs in a proximal direction for a distance of ≥1 nodes of Ranvier. In the distal segment, Schwann cells proliferate forming the bands of Bunger after nerve transection. In the proximal segment, the axon cone develops and grows distally at a rate of 1-2mm/day (1 inch/mo) after the cut ends of the nerve have been approximated and realigned by microsurgical repair.
Common digital nerve and digital nerve lacerations are usually classified as complete or partial.
- Partial: some intact nerve tissue connections between the nerve endings
- Complete: no physical connection between the nerve endings (neurotomesis)
Axonotomesis: nerve is subjected to severe crush, stretch, or blast injury; axon can be severed with distal degeneration, while the Schwann cell basil lamina remains intact
Neuropraxia: nerve is stretched and stops conducting impulses while the neural anatomy remains intact; there is no Wallerian degeneration after this type of stretch injury, and they usually recover without surgical intervention.⁸

Related Anatomy

The digital nerves supply sensation to the pulp and sides of the finger, and are composed of 3 terminal branches from the radial, median, and ulnar nerves.^9,10
- The volar branch of the ulnar nerve crosses the transverse carpal ligament and ends by dividing into a superficial and a deep branch. The superficial branch supplies the skin on the ulnar side of the hand by dividing into proper and common volar digital branches. The common volar digital branch innervates the 4th web space and goes to the proper digital nerves that in turn innervate the ulnar aspect of the ring finger and radial aspect of the little finger.
- The common digital nerve to the thumb splits into a radial and ulnar digital branch. The second common digital nerve supplies a motor branch to the index lumbrical and sensation to the radial side of the index finger.
- In the distal palm, the medial branch of the median nerve divides into 2 common volar digital nerves: One innervates the second lumbrical and runs toward the index and long fingers, where it divides into 2 proper digital nerves. The other runs toward the long and ring fingers and divides into 2 proper digital nerves.¹⁰
The common digital nerves are composed of nerve fibers and axons covered by connective tissue called epineurium.
The axon has a cell membrane (axolemma) surrounding a tube of neural cytoplasm (axoplasm).⁸Axons are encased by the endoneurium.
Axons are grouped in fascicles that are surrounded by the perineurium.^11.Perineurium provides a diffusion and conduction barrier between the fascicles.⁸
In the common digital nerves, groups of fascicles are arranged in fascicular groups, defined by the connective tissue called the internal epineurium.
In the distal part of the nerve, there are few connections between the fascicular groups; thus, the internal epineurium provides a surgical plane that can be dissected with microsurgical techniques.¹¹
These fascicular groups together compose the common digital nerves; external surface of each common digital nerve is the external epineurium.
When a common digital nerve is cut, the nerve ends separate producing a functional gap due to fascicular group inherent elasticity.
There is no loss of nerve tissue, ie, no true defect; therefore, these ends can be repaired without excessive tension even if a few millimeters of neuroma are resected.¹¹
If there is a long delay between laceration and nerve repair, the functional elastic gap may become more of a true defect because of scarring.
Most surgeons recommend mobilizing the nerve and gentle flexion of adjacent joints and end-to-end repair; if the true defect is 3-4 cm in a major nerve like the median nerve in the distal forearm, nerve grafting would be indicated.^12,13For digital nerve lacerations, nerve loss of 1-1.5cm with the wrist and finger joints in neural extension should be considered for a graft or conduit.¹⁰

Incidence

Peripheral nerve injury remains a common injury in civilian life.
In one report, an estimated 20 million Americans suffer peripheral nerve injuries annually.¹⁴
Upper extremity nerve injuries—excluding the brachial plexus—account for 3-10% of all hand injuries that require surgical treatment, and the proper and common digital nerves are the most frequently injured of the upper extremity nerves.^15-17
- Common digital nerve lacerations are relatively rare compared to proper digital nerve lacerations: in a series of 173 upper extremity peripheral nerve injuries that required repair, 125 were of digital nerves (72.3%)—making them the most common nerve laceration - while only 10 (5.8%) were of common digital nerves.¹⁸
- The incidence of complete or partial transection of digital nerves has been found to be 6.2/100,000 persons/year in a moderate-sized city. If this incidence was applied the U.S., it would amount to ~18,600 new cases of digital nerve injuries annually.¹⁷
The vast majority of common digital nerve lacerations occur in men between 16-35 years,¹⁶and they occur less frequently in children.¹⁹
The incidence of digital nerve lacerations has been steadily rising in recent years, primarily in relation to industrial and traffic accidents.⁴
Isolated digital nerve injuries and concomitant tendon injuries have been found to be equally common.¹⁶

Differential Diagnosis

Complete nerve laceration
Partial nerve laceration
Neuropraxia (stretch injury)
Neuroma-in-continuity

ICD-10 Codes

DIGITAL NERVE LACERATION (PALM & FINGER)

Diagnostic Guide Name

DIGITAL NERVE LACERATION (PALM & FINGER)

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS	SINGLE CODE ONLY	LEFT	RIGHT	BILATERAL (If Available)
DIGITAL NERVE LACERATION (PALM & FINGER)
- INDEX		S64.491_	S64.490_
- MIDDLE		S64.493_	S64.492_
- RING		S64.495_	S64.494_
- LITTLE		S64.497_	S64.496_
- THUMB		S64.32X_	S64.31X_

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69

A - Initial Encounter

D - Subsequent Routine Healing

S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams

Digital Nerve Injury

Patient cut her finger on a broken drinking glass. Lacerated and thrombosed digital artery (1); lacerated digital nerve (2); Flexor tendon (3).
Note the anhydrous of the skin in the 4-5 web area after a neglected common digital nerve laceration

Pathoanatomy Photos and Related Diagrams

Nerve Anatomy and Repairs

Digital Nerve with axons enclosed in endoneurium (1); Fascicle enclosed in perineurium (2); Fascicular groups enclosed in connective tissue called internal epineurium (3); Internal epineurium (4); External epineurium (5); Epineural blood vessels (6).
Epineural repair of lacerated digital nerve. Insert shows microsurgical lab exercise for practicing epineural repair in a turkey wing model.
Digital nerve grafting with a donor graft from the ipsilateral antebrachial cutaneous nerve.
Small digital nerve partial nerve laceration treated with a single epineural micro-suture.

Symptoms

History of trauma with a laceration in the area of the digital nerves or common digital nerves

Wound pain and paresthesias

Sensory loss in digits affected by laceration

Typical History

A 17-year-old male was skateboarding with some friends in an abandoned warehouse that was boarded up with “no trespassing” signs when a cop car pulled up and flashed its lights outside. He then ran to a rear window and started to climb out of it, but in his rush he failed to notice that the window had been shattered and the frame was lined with jagged glass. His grabbing onto the frame had caused a deep laceration of the palm of his left hand, which began bleeding profusely. His friends responded by placing a jacket over the glass and helped him out of the window, then took him immediately to the ED, where they examined the injury and noticed that he had lost some sensation in his index and long fingers. The wound was subsequently anesthetized with 1% local, and the wound exploration showed a lacerated common digital nerve. The wound was irrigated, debrided, the skin sutured and a dressing and splint applied. The patient saw a hand surgeon who did a microsurgical common digital nerve repair in the local ambulatory surgery center the following week.

Positive Tests, Exams or Signs

Work-up Options

Treatment Options

Treatment Goals

Identify the presence of a complete common digital nerve laceration or a complete digital nerve laceration, a partial nerve laceration, or a neuropraxia.
Repair the complete or partial nerve laceration.
Carefully follow the patient with a digital nerve stretch injury; a few patients with neuropraxia will require neurolysis.
Improve function of injured upper extremity with a digital nerve laceration.

Conservative

Nonoperative treatment of common digital nerve complete or partial lacerations is appropriate when the patient’s associated injuries or medical comorbidities prevent anesthesia and a lengthy microsurgical repair.
Isolated common digital nerve complete and partial lacerations should be repaired early, but repair is not an emergency.
Irrigation, debridement, and closure of the skin laceration with a scheduled operative nerve repair in 1-3 few weeks is reasonable.
Neuropraxia of the common digital nerve secondary to a stretch injury is rare, but these cases can be watched for signs of spontaneous recovery. Surgery, however, should not be delayed for any more than 3 weeks, as the likelihood of needing a nerve graft increases after 1 month.¹⁰

Operative

Complete common digital nerve lacerations in civilian practice are usually seen acutely and are usually caused by sharp lacerations from broken glass, knives, saws, or vehicular accidents.
Complete nerve lacerations should be repaired with microsurgical procedures.
Choices for microsurgical repair include:
1. Epineural repair
2. Group fascicular repair (very rarely indictated for digital or common digital nerve lacerstions)
3. Nerve repair with nerve grafts
4. Nerve repair with nerve conduit
Partial nerve lacerations can be repaired by dissecting the internal epineurium and isolating the transected fascicular groups, gently looping the intact fascicular groups and then repairing the cut fascicular groups by suturing the internal epineurial sheaths. However, these repairs are rare in digital or common digital nerve lacerations.
If there is a significant true defect, for example after a bullet wound, then repairing the cut fascicular groups with nerve grafts between the cut fascicular groups is indicated.
Neurolysis of a common digital nerve for a neuropraxia is uncommon.^1,8
Primary end-to-end tension-free nerve repair is considered the standard-of-care for common digital nerve lacerations, and it should therefore be performed whenever possible.^9,20
- This intervention is particularly recommended when there is a clean, sharply incised wound and both nerve ends are easily seen and mobilized without excessive extension of the wound.⁶
- The conditions for a successful nerve repair consist of generous trimming of the nerve until healthy substance is observed, minimal handling, a tension-free coaptation, and maintaining a well-vascularized wound bed.²¹
Primary nerve repair by end-to-end coaptation can be performed in about 82% of patients with common digital nerve lacerations. In other cases a tension-free repair may not be possible, which is particularly common in crushing or avulsing injuries with a wide zone of nerve injury. These cases will require nerve reconstruction by means of nerve grafting, conduits, or nerve transfer.^17,21
When tensionless coaptation cannot be achieved, the gold standard of treatment is autologous nerve grafting.Common donor nerves include the sural and lateral antebrachial cutaneous nerves but autografts do leave a sensory deficit in the donor area.^10,17
- The antebrachial nerve is the best match in caliber and fascicle number for digital nerve deficits between the metacarpophalangeal (MP) and distal interphalangeal (DIP) joints, and from the common digital nerve bifurcation to the MP joint
- The sural nerve is most appropriate when grafting defects between the wrist and the common digital nerve bifurcation.
- Alternatives to autologous nerves include synthetic or autogenous non-nerve conduits and nerve allografts.²⁰
Conduits are indicated for reconstruction of small-diameter, noncritical sensory nerves with a gap of <3 cm.
- Contraindications include uncertainty about the viability of the nerve ends, especially with avulsion injuries, blast injuries and gunshot wounds, local or systemic infection, and inadequate soft tissue coverage.¹⁰

Treatment Photos and Diagrams

Microdigital Nerve Repair (Neurorrhaphy)

Insert show common digital nerve to the ring -little web(1); ulnar digital nerve to the ring finger(2); radial digital nerve to the little finger(3); common digital artery (4); ulnar digital artery to the ring finger (5); radial digital artery to little finger (red dot) under skin flap. Arrows show planned microsurgical neurorrhaphies of the common digital nerve to the two digital nerves.
Right little finger ulnar digital microneurorrhaphy
Unrepairable index radial digital nerve avulsion injury (arrow)
Digital nerve microsurgical repairs are usually done with an operative microscope.
Digital nerve microsurgical repairs can be done with surgical loopes.
Microsurgical instruments used for digital nerve microsurgical repairs
Microsurgical sutures used for digital nerve microsurgical neurorrhaphy.

CPT Codes for Treatment Options

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Common Procedure Name

Nerve repair (digital nerve), each additional nerve 64832

CPT Description

Suture of digital nerve, hand or foot, 1 nerve

CPT Code Number

64831

Common Procedure Name

Median nerve repair

CPT Description

Suture 1 nerve; hand or foot, median motor thenar

CPT Code Number

64835

Common Procedure Name

Ulnar nerve repair

CPT Description

Suture 1 nerve; hand or foot, ulnar motor

CPT Code Number

64836

CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications

Loss of sensation²⁰
Persistent pain and/or paresthesias
Neuroma-in-continuity
Infection
Complex regional pain syndrome
Cold intolerance
Loss of strength
Reduced tactile dexterity
Dysesthesia
All patients who undergo common digital nerve repair should be informed that some persistent sensory deficits and paresthesia are likely to occur.²²

Outcomes

Permanent deficits after nerve repair remain a problem, especially for adults.¹
Since World War II, the results of nerve repair also have been classified using a grading system designed by the British Medical Research Council.^8,23,24

THE MEDICAL RESEARCH COUNCIL SYSTEM^8,23,24
Motor Recovery
M0	No contraction
M1	Return of perceptible contraction in the proximal muscles
M2	Return of perceptible contraction in both the proximal muscles and distal muscles
M3	Return of perceptible contraction in both the proximal muscles and distal muscles of such a degree that all important muscles are sufficiently powerful to act against resistance
M4	Return of function as in stage 3 with the addition that all synergic and independent movements are possible
M5	Complete recovery

Sensory Recovery
S0	Absence of sensibility in the autonomous area
S1	Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve
S2	Return of some degree of cutaneous pain and tactile sensibility within the autonomous area
S3	Return of some degree of superficial cutaneous pain and tactile sensibility within the autonomous area with disappearance of any previous overreaction within the autonomous area
S3+	Return of some sensibility as in stage 3 with the addition that there some recovery of two point discrimination within the autonomous area
S4	Complete recovery

Factors that affect the outcome of common digital nerve repair include the age of patient (young patients do better); the level of the laceration (distal lacerations do better); the type of nerve (pure motor or pure sensory nerves do better); the delay between injury and repair (earlier repairs do better); and the cause of the digital nerve laceration (sharp clean cuts do better).^1,8
- Children aged 0-15 years typically have an excellent prognosis and can experience a complete recovery.¹⁹
- It’s been suggested that the better results in younger patients are due to better axonal regeneration and a greater adaptability, as older patients have fewer receptors because of age-related changes.⁶
Other prognostic factors that have been associated with worse outcomes include smoking and concomitant tendon, bone, and/or vascular injuries.⁹
When treated appropriately, most patients can achieve excellent or good recovery of their sensibility after a common digital nerve laceration, but a complete, near normal, recovery should only be expected in children.^5,16
One study evaluated the outcomes of patients with common digital nerve lacerations after nerve grafting and primary repair:
- Delay of nerve reconstruction after transection is also detrimental to functional outcomes, and when there is a delay of >6 months between injury and reconstruction, the chance of a satisfactory recovery declines slowly.¹⁷
- Common digital nerve lacerations have been found to have little consequence on the ability to return to work and the time off from work when compared to more proximal lacerations.¹⁶
  - 7 patients underwent nerve grafting, with 1 achieving S3+, 5 achieving S3, and 1 achieving S2+.
  - 6 patients underwent primary repair, with 2 achieving S3+, 3 achieving S2+, and 1 achieving S2.¹⁸
Conduits appear to provide comparable results to autologous nerve grafting given a gap length of <3 cm, but even if longer distances can be bridged by grafting, recovery deteriorates with nerve grafts measuring >3-5 cm in length.¹⁷
Other prognostic factors that have been associated with worse outcomes include smoking and concomitant tendon, bone, and/or vascular injuries.⁹

Video

Microdigital Nerve Repair

Key Educational Points

Dry skin (anhydrosis) in the sensory distribution of a potentially cut nerve suggests a complete or partial laceration.
Most common and proper digital nerve injuries can either be repaired by direct suture or feature gaps of <10-15 mm. Due to the relative scarcity of injuries with gaps >25 mm, there is a paucity of data on the relative effectiveness of different reconstruction techniques, and making informed clinical decisions is therefore difficult.²¹
Although patients usually have good active finger motion after common digital nerve lacerations, they sometimes do not use their digits normally due to either the lack of sensation or painful paresthesias when the fingers are stimulated.⁹
After the age of 12, the outcomes in children after common digital nerve lacerations begin to more closely resemble those in adults. This is likely related to extensive changes during puberty in which the brain alters its adaptation to injury.¹⁹
Although small in size, common digital nerve injuries are of critical importance since they with discriminatory touch from the finger pulps, and lack of sensation may dramatically reduce hand function and dexterity.¹⁶
A common digital nerve laceration to the thumb will result in a sensory defect along the radial and ulnar aspects of the distal thumb, while a common digital nerve injury to the palm will present with a sensory deficit along the adjacent sides of the second or third web space (median nerve) or the fourth web space (ulnar nerve).¹⁰
Nerve regeneration occurs because the proximally located nerve cell bodies start a regeneration process that grows new axons.
Sensory end organs remain intact for a lengthy period; therefore, delayed sensory nerve repair, although not ideal, can still provide some useful sensory recovery.
Tension-free repairs are important because tension causes ischemia in the nerve and poor recovery; however, nerves are elastic and only true nerve tissue loss should require a nerve graft.

References

New and Cited Articles

Pederson, WC. Median nerve injury and repair.J Hand Surg Am 2014;39(6):1216-22. PMID: 24862118
Galanakos, SP, Zoubos, AB, Ignatiadis, I, et al. Repair of complete nerve lacerations at the forearm: an outcome study using Rosen-Lundborg protocol. Microsurgery 2011;31(4):253-62.PMID: 21557303
Chemnitz, A, Bjorkman, A, Dahlin, LB, et al. Functional outcome thirty years after median and ulnar nerve repair in childhood and adolescence. J Bone Joint Surg Am 2013;95(4):329-37. PMID: 23426767
Andelkovic, SZ, Lesic, AR, Bumbasirevic, MZ, et al. The Outcomes of 150 Consecutive Patients with Digital Nerve Injuries Treated in a Single Center. Turk Neurosurg 2017;27(2):289-293. PMID: 27593752
Wang, WZ, Crain, GM, Baylis, W, et al. Outcome of digital nerve injuries in adults. J Hand Surg Am 1996;21(1):138-43. PMID: 8775209
Mermans, JF, Franssen, BB, Serroyen, J, et al. Digital nerve injuries: a review of predictors of sensory recovery after microsurgical digital nerve repair. Hand (N Y) 2012;7(3):233-41. PMID: 22899895
Fernandez, L, Komatsu, DE, Gurevich, M, et al. Emerging Strategies on Adjuvant Therapies for Nerve Recovery. J Hand Surg Am 2018;43(4):368-373. PMID: 29618417
Birch R. Nerve Repair. In: Green’s Operative Hand Surgery, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds), Philadelphia, Elsevier Churchill Livingstone, 2011, pp. 1035-1092.
Bulut, T, Akgun, U, Citlak, A, et al. Prognostic factors in sensory recovery after digital nerve repair. Acta Orthop Traumatol Turc 2016;50(2):157-61.PMID: 26969950
Slutsky, DJ. The management of digital nerve injuries. J Hand Surg Am 2014;39(6):1208-15.PMID: 24862117
Hurst, LC, Dowd, A, Sampson, SP, et al. Partial lacerations of median and ulnar nerves. J Hand Surg Am 1991;16(2):207-10. PMID: 2022827
Millesi, H. The nerve gap. Theory and clinical practice. Hand Clin 1986;2(4):651-63.PMID: 3539948
Terzis, J, Faibisoff, B and Williams, B. The nerve gap: suture under tension vs. graft. Plast Reconstr Surg 1975;56(2):166-70. PMID: 1096197
Taylor, CA, Braza, D, Rice, JB, et al. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87(5):381-5. PMID: 18334923
Rosberg, HE and Dahlin, LB. Epidemiology of hand injuries in a middle-sized city in southern Sweden: a retrospective comparison of 1989 and 1997. Scand J Plast Reconstr Surg Hand Surg 2004;38(6):347-55. PMID: 15841802
Thorsen, F, Rosberg, HE, Steen Carlsson, K, et al. Digital nerve injuries: epidemiology, results, costs, and impact on daily life. J Plast Surg Hand Surg 2012;46(3-4):184-90.PMID: 22686434
Lohmeyer, JA, Sommer, B, Siemers, F, et al. Nerve injuries of the upper extremity-expected outcome and clinical examination.Plast Surg Nurs 2009;29(2):88-93. PMID: 19528777
Berger, A and Mailander, P. Advances in peripheral nerve repair in emergency surgery of the hand. World J Surg 1991;15(4):493-500. PMID: 1891935
Rosberg, HE, Hazer Rosberg, DB, Birkisson, I, et al. Age does not affect the outcome after digital nerve repair in children - A retrospective long term follow up. J Orthop Sci 2017;22(5):915-918. PMID: 28735880
Kim, JS, Bonsu, NY, Leland, HA, et al. A Systematic Review of Prognostic Factors for Sensory Recovery After Digital Nerve Reconstruction. Ann Plast Surg 2018;80(5S Suppl 5):S311-S316. PMID: 29596088
Rinker, B, Zoldos, J, Weber, RV, et al. Use of Processed Nerve Allografts to Repair Nerve Injuries Greater Than 25 mm in the Hand. Ann Plast Surg 2017;78(6S Suppl 5):S292-S295. PMID: 28328632
Fakin, RM, Calcagni, M, Klein, HJ, et al. Long-term clinical outcome after epineural coaptation of digital nerves. J Hand Surg Eur Vol 2016;41(2):148-54. PMID: 25827143
Seddon HJ. Surgical Disorders of the Peripheral Nerves, ed 7. Edinburgh, Churchill-Livingstone, 1975, pp. 276-280.17.
Seddon HJ (ed): Peripheral Nerve Injuries, Medical Research Council Special Report Series No. 282, London, Her Majesty’s Stationery Office, 1954.

Review

Slutsky, DJ. The management of digital nerve injuries. J Hand Surg Am 2014;39(6):1208-15.PMID: 24862117

Classics

Lewin ML. Repair of digital nerves in lacerations of the hand and the fingers. Clin Orthop1960;16:227-34. PMID: 14416478
Wallace WA. The damaged digital nerve. Hand1975;7(2):139-44. PMID: 1205347

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