What is the treatment for a median nerve injury?

Treatment of Median Nerve Injury

For acute median nerve lacerations, immediate or early primary microsurgical repair within 3 weeks is the treatment of choice, while iatrogenic injuries from vascular access require initial conservative management with MRI evaluation, pain control, and wrist splinting unless progressive deficits develop. 1, 2, 3

Acute Traumatic Median Nerve Injuries

Timing of Surgical Repair

• Clean-cut nerve injuries without defects should undergo immediate primary repair using trunk-to-trunk coaptation with epineurial sutures, which offers optimal outcomes 3

• Early secondary repair during the third week is an equally valid alternative, particularly when severe concomitant injuries exist or in combined nerve-tendon lesions where delayed nerve repair prevents adhesions between repaired flexor tendons 3

• Motor recovery quality decreases steadily after 6 months delay, making this the critical window for repair, though sensory recovery can still be achieved after longer intervals 3

Surgical Technique Selection

• For distal median nerve injuries (wrist level) where motor and sensory fascicles are already separated, fascicular dissection with coaptation of fascicle groups should be performed rather than simple trunk-to-trunk repair 3

• Nerve grafting is indicated when nerve stumps cannot be coapted easily after limited mobilization and slight flexion, as approximation under tension damages stumps and creates larger defects 3

• Microsurgical techniques should be applied as current widespread use leads to reasonable results in most individuals, though many patients still experience permanent sequelae 2

Iatrogenic Median Nerve Injury (Vascular Access)

Initial Diagnostic Evaluation

• MRI of the brachial plexus is the preferred imaging modality to evaluate for nerve compression and surrounding soft tissue abnormalities 1

• Ultrasound duplex Doppler should assess vascular status and identify hematoma or pseudoaneurysm formation that may be compressing the nerve 1

Conservative Management Approach

• For partial deficits without progression, initial conservative management with close monitoring is appropriate 1

• Wrist splinting in neutral position to avoid excessive flexion that could exacerbate compression within the carpal tunnel 1

• Appropriate analgesic pain management should be provided 1

Prevention of Iatrogenic Injury

• Careful technique during brachial artery access procedures, proper hemostasis after catheter removal, and vigilant post-procedure monitoring for signs of hematoma formation or neurovascular compromise are essential 4, 1

• The median nerve is adjacent to brachial veins in the upper arm, making it vulnerable during vascular access procedures 4

Level-Specific Considerations

High-Level Injuries (Upper Arm/Elbow)

• Results of delayed repair are poor for high-level median nerve injuries, with only 25% achieving good outcomes and 61% achieving fair outcomes 5

• Early nerve transfer may be a better choice for some delayed high-level median nerve injuries in appropriate candidates 5

Distal Injuries (Wrist Level)

• Carpal tunnel syndrome is the most common cause of median nerve injury at the wrist, requiring incision of the volar carpal ligament 6

• Primary repair should be performed if possible for acute lacerations at this level 6

• Results show 4.8% excellent, 17.7% good, 58% fair, and 19.4% poor outcomes with delayed repair at wrist level, though delayed repair methods show significantly better results than other approaches 5

Anterior Interosseous Nerve Injuries

• All anterior interosseous nerve injuries had good results regardless of repair method, making this the most favorable injury pattern 5

Functional Reconstruction

• Thenar muscle recovery is typically poor across all injury levels, though only 5.5% of patients require reconstruction 5

• Various opponensplasty techniques are available to restore thumb opposition when thenar function does not recover 6

• Tendon transfers can compensate for lost function and may be combined with nerve repair in long-standing cases 6, 3

Common Pitfalls

• Avoid approximating nerve stumps under tension in cases with larger defects, as this damages stumps and creates even larger defects; use nerve grafts instead 3

• Do not delay repair beyond 6 months when motor recovery is the primary goal, as quality steadily decreases after this timeframe 3

• Recognize that median nerve injuries impair pinching ability, requiring careful evaluation and treatment planning 6