Long-term results after primary microsurgical repair of ulnar and median nerve injuries

Clinical Neurology and Neurosurgery 109 (2007) 263–271

Long-term results after primary microsurgical repair of ulnar and median nerve injuries A comparison of common score systems Thomas Vordemvenne ∗ , Martin Langer, Sabine Ochman, Michael Raschke, Marc Schult Department of Trauma and Hand Surgery, University Hospital of M¨unster, Waldeyerstr. 1, 48149 M¨unster, Germany Received 21 April 2006; received in revised form 8 November 2006; accepted 14 November 2006

Abstract Objective: The aim of this retrospective study was to analyze the long-term results of primary repair of median and ulnar nerve lesions. Clinical influence factors for nerve reconstruction were investigated. Furthermore, current score systems were inquired and evaluated on their effectiveness to illustrate the success of repair. Patients and method: Sixty-five patients with 71 lesions of the median and ulnar nerve were assessed on average 8.2 years after reconstruction. The results were classified according to the DASH (disability of arm, shoulder, and hand) Score, the Rosen’s hand protocol and the Highet Scale. Results: On average the patients regained 70% of their original hand function (evaluated by Rosen Score: median nerve 2.2/for ulnar nerve 1.92 out of 3.0). Although we noticed inferior motor recovery in ulnar nerve lesions, no significant differences between the overall results of both nerves were observed. Neither accompanying artery and flexor tendon injuries nor the suture technique influenced the recovery. The age of the patient was confirmed as an important influence factor. The results of the DASH Score, Rosen Score and Highet Score correlated significantly. Conclusion: For a sufficient outcome measurement we underline the importance of evaluation of patient’s estimation of their impact on their activities of daily living. For this a combination of the functional Rosen Score and the DASH Score is suggested. © 2006 Elsevier B.V. All rights reserved. Keywords: Nerve injury; Long-term results; Outcome; Ulnar nerve; Median nerve; Score systems

1. Introduction In cases of complete severing of nerves the golden standard is primary reconstruction [6,24,29,11,34]. Even with microsurgery advances, complete restitution of hand function is rarely attainable. By known cellular and biochemical mechanism of nerve regeneration [18,33,41] the identification of clinical influence factors for the outcome is very important. It is difficult to ascertain the success of nerve repair. Regeneration time is unknown as comparable long-term results are uncertain. Therefore, the success of reconstructive ∗

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surgery cannot be measured by sensory and motor recovery alone. Also, a critical factor is a patient’s opinion of the impact of the nerve injury on their activities of daily living. The aim of the study was to investigate the long-term results of nerve lesions with common score systems, that can consider both recovery factors sufficiently. Furthermore we present the outcome of our patients and identify influence factors. 2. Patients and methods Sixty-five patients, 43 male and 22 female, were examined who had suffered a lesion of the median and/or ulnar nerve of the forearm and hand in the timeframe of 01.01.1990 until 12.31.2002. All patients were treated in the University Hospital of M¨unster, Germany.

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Table 1 Characteristics of patients included in the study Patients

No. of patients (%)

Men Women

43 28

Total Median age (year) at time of repair (range) Median age (year) at time of examination (range)

71 28.4 (2.3–69.3) 8.2 (1.0–12.9)

Type of injury Median nerve Complete transection Partial transection

43 (60.6) 35 (49.3) 8 (11.3)

Ulnar nerve Complete transection

28 (39.4)

Reason for injury Fracture Iatrogen Cut

1 (1.4) 1 (1.4) 69 (97.2)

Location of injury Prox. third of forearm Middle third of forearm Dist. third of forearm Wrist

3 (4.2) 5 (7.0) 13 (18.3) 50 (70.4)

Additional artery injury Median nerve Ulnar nerve Total

13 (37.1) 12 (42.9) 25 (35.2)

Additional flexor tendon injury Median nerve Ulnar nerve Total

25 (71.4) 17 (60.7) 44 (62.0)

Suture technique Epineural Group fascicular

52 (73.2) 19 (26.8)

The mean age at time of injury was 28.4 years (range 2.3–69.3). Post-reconstructive examination was performed on average at 8.1 ± 3.3 years (range 1–12.9). All patients were treated by a primary microsurgical epineural or group fascicular 10–0 suture within the first 24 h after trauma. In case of additional tendon injury early controlled motion began in a dorsal hand splint with elastic traction to passively flex the fingers while allowing active extension against resistance. Whereas in the case of singular nerve lesion immobilization of the wrist was completed by a cast for 3 weeks. Thirty-five patients (49.3%) suffered from a complete lesion of the median nerve, 8 patients (11.3%) had a partial lesion of the median nerve, and 28 patients (39.4%) a complete lesion of the ulnar nerve. These three groups were categorized and analyzed by the following described score systems. Six patients (4.3%) suffered injuries of both nerves. Additional artery injury occurred in 33.8% of the cases. Additional flexor tendon injury was detected in 59.5%. In most cases the lesion was located at the wrist (70.4%) (Table 1). Questionnaires used to measure health may be generic or specific [8,46]. Generic instruments assess patients’ overall health and can therefore be used to compare the status of

patients with different diseases. One example of a generic instrument is SF-36. In contrast, specific instruments belong either to pathological entities, called disease-specific or condition-specific scales, or anatomical regions, called region-specific scales [8,25]. Disability of arm, shoulder, and hand (DASH) is one example of a more specific instrument. Over the last years, the DASH has recently attracted more and more interest as an outcome instrument to measure disability of the upper extremity. One of the reasons for this increasing interest might be its broader applicability for disorders of the whole upper extremity [45,23,31,21]. The DASH is now available in several languages and studies of reliability and validity have been published [3,5,15,20,43,44,48,49]. For that reasons we decided to use the German Disability of Arm, Shoulder, Hand (DASH-G) Version 2.0 questionnaire referring to Germann and Offenbacher et al. [20,43] to capture the subjective experience of the patient regarding the successes of reconstruction. The DASH Score serves to evaluate the patient’s estimation according to their activities in daily living and symptoms. The main part of the DASH is a 30-item disability/symptom scale concerning the patient’s health status during the preceding week. The items ask about the degree of difficulty in performing different physical activities because of the arm, shoulder, or hand problem (21 items), the severity of each of the symptoms of pain, activity-related pain, tingling, weakness and stiffness (5 items), as well as the problem’s impact on social activities, work, sleep, and self-image (4 items). Each item has five response options. The scores for all items are then used to calculate a scale score ranging from 0 (no disability) to 100 (most severe disability). Rosberg et al. indicated in their study about costs and health after hand and forearm injury that a higher Hand Injury Severity Score (HISS) was significantly associated with duration of sick leave for patients with injuries to the hand and forearm. However, the DASH score was not significant in the analysis of duration of sick leave. One year after injury 90% were back at work when the study closed, at that time the DASH score was 20 on average in the severe and major injury subgroup [49]. This fact shows that the DASH score is a subjective instrument for estimate the patient’s view of disability. However, the DASH cannot score the ability of work as this question depends on various factors (kind of work, education, sozioepidemographic factors, etc.). Furthermore, in our study the functional outcome was summarized with the hand protocol referring to Rosen et al. (Rosen Score) [50,51]. This instrument contains three parts: sensory domain, motor domain and pain/discomfort domain. The first part measures the recovery of sensory innervation, tactile gnosis, and finger dexterity of the injured nerve. This is performed with Semmes–Weinstein filaments (Touch Test Sensory Evaluator, North Coast Medical Inc.) ranging from strength 6.65 to 2.83, static two-point discrimination according to Moberg [39], Shape/Texture Identification (STI) Test

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[51] and three tasks of the Sollerman Test [56] (picking up coins from a purse, putting nuts on bolts, and using buttons). The motor recovery is analyzed with the MRC muscle power grading (grades 0–5) (motor innervation) and with Jamar Dynamometer (Smith&Nephew Inc.) (grip strength) comparing the injured with the unaffected side [9,35,36]. The pain/discomfort domain contains two questions that summarize a patient’s estimation of problems caused by cold intolerance and hypaesthesia. The maximum overall score, called Total Score is 3.0, where every of the three domains is assessed with a maximum of 1.0. The Rosen Score was validated with a similar number of patients in a follow-up timeframe of 24 months and 60 months [50,52]. Additionally, sensory and motor recovery was analyzed with the most common Highet Scale (Figs. 1 and 3) modified by Dellon et al. [12,54]. As this scale had become standard

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over the last years we used it as an additional control for the senso-motoric measurements in this study. The median nerve motor function was estimated by abduction of the thumb (extension of the IP joint, M. abductor pollicis brevis) and by flexion of PIP joints (M. flexor digitorum superficialis). The ulnar nerve was tested by abduction of the small finger (M. abductor digiti minimi) and by performing adduction of the interosseus muscles. Statistical data analysis was performed with the SPSS Program Version 10.0.7 for Microsoft Windows (SPSS Inc., 1989–1999).

3. Results In 96.5% of the cases the reason for laceration of the peripheral nerve was due to a cut by sharp object. In one case an ulnar nerve lesion resulted from a dislocated elbow fracture. There were reported no blunt injuries. Three patients (4.2%) experienced a laceration within the proximal third of the forearm, 5 cases (7.0%) occurred in the middle third and 13 cases were located in the distal third (18.3%). Fifty patients (70.4%) suffered the lesion at the wrist (Table 1). We found no significant differences in the overall results between epineural and group fascicular sutures techniques. 3.1. Results of sensory recovery

Fig. 1. Sensory recovery (percentage of patients) after complete median nerve, incomplete median nerve and complete ulnar nerve transection classified by Highet Scale S0–S4a [54]: Sensory recovery

Quality

S0 S1

Absence of sensibility in the autonomous area Recovery of deep cutaneous pain sensibility within the autonomous of the nerve Recovery of some degree of superficial pain and tactile sensibility within the autonomous area of the nerve, persisting paraesthesia Return of superficial cutaneous pain and tactile sensibility throughout the autonomous area with disappearance of any previous overresponse; static two point-discrimination: >15 mm Return of sensibility as in S3; in addition there is some recovery of two-point discrimination within the autonomous area; static two-point discrimination: 7–15 mm Complete recovery; static two-point discrimination: 2–6 mm

S2

S3

S3+

S4 a

From: Mackinnon SE, Dellon AL. Results of nerve repair and grafting. Surgery of the peripheral nerve. Thieme; 1988, p. 115.

In the Highet Score analysis of sensory recovery after complete transection of the median nerve 11% of the patients attained level S4, 29% level S3+, 7% level S3, 46% level S2 and 7% level S1. In cases with incomplete lesions of the median nerve 57% assessed level 3+. Patients with a severed and primary reconstructed ulnar nerve recovered in 20% of the cases level S3+, in 20% level S3 and in 55% level S2. Excellent results (S4) did not occur in this group (Fig. 1). In the analysis with the Rosen Score the complete lesions of the median and ulnar nerve resulted in an average sensibility score of 0.61 ± 0.251 (range 0.05–0.98). The patients with incomplete lesions of the median nerve recovered on average 77% (0.77) of their sensory function. This result was significant in comparison to the complete lacerations (p < 0.05) (Fig. 2). Overall on average the results of the Highet Score and Rosen Score were closely related. The differences were not significant. We can conclude for our patients that after primary reconstruction of the ulnar and median nerve 60% (0.61) of the sensory hand function was recovered (Table 2). 3.2. Results of motor recovery In the analysis of motor recovery with the Highet Score 14% of the patients with median nerve lesions received good results (M4) and 43% excellent results (M5). In case of

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Table 2 Results of nerve repair classified by the scores Score

Median nerve (complete transection) Median (range)

Median nerve (partial transection) Median (range)

Ulnar nerve (complete transection) Median (range)

Total

DASH Score (0–100)

23.85**

13.44 (0.0–32.50) ± 12.47

22.08**

21.98**

(0.0–81.67) ± 24.34

Median

(0.0–80.83) ± 20.75

Rosen Score Total Score (0–3) Sensory domain (0–1) Motor domain (0–1) Discomfort/pain domain (0–1)

2.2 (0.93–2.93)** 0.59 (0.05–0.98) 0.83 (0.34–1.00) 0.79 (0.33–1.00)

2.49 (2.11–2.81) 0.77 (0.47–0.98) 0.91 (0.77–1.00) 0.81 (0.49–1.00)

1.92** (0.77–2.53) 0.60 (0.13–0.98) 0.58 (0.14–0.86) 0.75 (0.33–1.00)

2.12** 0.61** 0.74** 0.77**

Highet Scale Sensory Motor

2.89** (1–4) 3.96* (2–5)

3.43 (2–4) 4.43 (3–5)

2.55* (1–4) 3.05** (1–5)

2.82*** 3.66***

* **

p < 0.05 correlation according to Pearson. p < 0.01.

incomplete laceration of the median nerve 71% regained excellent motor function (M5). In the group of ulnar nerve lesions most of the patients received a fair result (M3/55%). In 20% of the cases a good result was documented (M4). Only 5% attained the excellent level M5 (Fig. 3). The average value using the Rosen Score was 0.74. Overall complete lesions of the median nerve showed on average a score of 0.83 ± 0.16 (range 0.34–1.0). Incomplete lesions resulted in 0.91 ± 0.09 (range 0.77–1.0). Whereas, lacerations of the ulnar nerve attained on average a score of 0.58 ± 0.17 (range 0.14–0.86). These differences between motor recovery of the median and ulnar nerve were significant (p < 0.01) (Fig. 4). The results were reproduced with the Highet Score and the Rosen Score. In complete lacerations of the median nerve on average 80% of the motor function was recovered. In contrast, lesions of the ulnar nerve attended only 60% of the motor Fig. 3. Motor recovery (percentage of patients) after complete median nerve, incomplete median nerve and complete ulnar nerve transection classified by Highet Scale M0–M5a [54]: Motor recovery

Quality

M0 M1

No contraction Return of perceptible contraction in the proximal muscles Active movement without gravity, return of contraction in both proximal and distal muscles Active movement against gravity, return of function in both proximal and muscles of such a degree that all important muscles are sufficiently powerful to act against gravity Active movement against resistance return of function as in Stage 3; in addition, all synergistic and independent movements are possible Complete motor recovery

M2

M3

M4

Fig. 2. Sensory results classified by Rosen Score. Maximum Rosen Score 1.0, box plots with mean, range and 95% confidence interval, n: number of patients, * significance p < 0.05.

M5

a From: Mackinnon SE, Dellon AL. Results of nerve repair and grafting. Surgery of the peripheral nerve. Thieme; 1988, p. 115.

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Fig. 4. Motor recovery classified by Rosen Score (* significance p < 0.05), significant inferior motor of ulnar nerve.

function. As noted before for the sensory recovery the best motor results were assessed in the group of incomplete lesions of the median nerve. 3.3. Results of the DASH score and discomfort score In the examination of patient’s satisfaction the DASH Score and the Pain/Discomfort Score referring to Rosen was used. Overall, the DASH Score received an average value of 21.98 ± 21.89. Patients with a complete lesion of the median nerve scored on average 23.85 (range 0.0–81.67) using the DASH Score. Incomplete lesions resulted in a DASH Score of 13.43 (range 0.0–32.5). Lacerations of the ulnar nerve received a score of 22.09 (range 0.0–22.08). No significant differences were observed between the ulnar and median nerve groups (Fig. 5 and Fig. 6).

Fig. 5. Overall results classified by DASH Score (no significance observed).

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Fig. 6. Results of the pain and discomfort domain classified by Rosen Score (no significance was observed). cM: complete median nerve transection; pM: partial nerve transection; cU: complete ulnar nerve transection.

In contrast, the age of the patient at the time of injury proved to be a significant factor in the DASH Score. The younger the patient at the time of lesion the better the DASH Score results. The same correlation was documented with the Rosen Score (Fig. 7a and b).

Fig. 7. (a) Comparison of DASH Score and patient’s age at time of injury (* significance p < 0.05). (b) Comparison of Rosen Score (Total Score maximum 3.0) and patient’s age at time of injury (* significance p < 0.05).

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All analyzed scores were not influenced by additional artery or tendon injuries. In the group of complete lesions of the median nerve a mean Discomfort score of 0.79 ± 0.23 (range 0.33–1.00) was observed. Patients with ulnar nerve lesions attained a mean Discomfort Score of 0.75 ± 0.21 (range 0.33–1.00). A significant correlation between the DASH Score and the Discomfort Score were determined (p < 0.05). Comparing both scores, we can conclude that overall peripheral nerve lesions cause a 22% handicap in the activities of daily life (0.79 versus 21.98).

Table 3 Results from factor analysis to identify groups of variables related to each othera Factor

Rosen Score/sensory domain Highet Score/sensory Rosen Score/motor domain Highet Score/motor Rosen Score/discomfort domain DASH Score a b

Sensory

Motor

ADLb

0.874 0.863 0.188 0.351 0.044 0.552

0.292 0.239 0.906 0.874 0.031 0.190

0.195 0.123 0.231 0.079 0.712 0.753

A three-factor analysis explained 83.5% of the variance. Impact on activities of daily living.

3.4. Score comparison of the total results For all observed nerve lesions the Total Rosen Score (Total Score) attained a value of 2.12 ± 0.47. For lesions of the median nerve a Total Score of 2.2 (range 0.93–2.93) was documented. Incomplete lesions of the median nerve resulted in a mean score of 2.49 (range 2.11–2.81). Lesions of the ulnar nerve attained on average a Total Score of 1.92 (range 0.77–2.53). No significant values were observed between complete lacerations of the median and ulnar nerves. Whereas the Total Score results of the incomplete lesions of the median nerve were determined to be significant (p < 0.05) (Fig. 8). Documented by the Total Score, patients with complete lesions of the median and ulnar nerve regained on average 70% of their hand function after primary nerve repair (2.2/2.49/1.92 out of 3.0). The Highet Score coincides with the Rosen Score in respect to the 70% recovery rate of motor and sensory function. The results of the Rosen Score correlate closely to the results of the DASH Score and the Highet Score (p < 0.01). Furthermore a three-factor analysis was performed. The combination of the DASH Score and the Rosen Score serves to provide 83.5% of the variance of the results (Table 3).

Fig. 8. Overall results classified by Rosen Score (Total Score) no significance was observed, but inferior recovery of the ulnar nerve.

4. Discussion Over the last four decades a number of clinical and experimental studies of nerve repair have been reported [6,10,12–14,17,19,28,30,38,42,54,58,61]. Because of different goals and timeframes of follow-up the results are difficult to summarize. Furthermore, motor and sensory recovery was estimated by different score systems. Most results were classified by the Highet’s method modified by Dellon [12] and has become standard over the years. For that reason in this study we used the Highet Score as a control of our senso-motoric measurements. But this common instrument for documentation is not entirely satisfactory, because it is difficult and unclear to classify a patient according to a scale that is based on subjective findings without any attempt to standardize defined methods for evaluation. For that reason this Highet’s method was criticized. Additionally, the outcome after nerve reconstruction is significantly influenced by the patient’s estimation of impact on their activities of daily living [50]. For that reason in 2000 the Rosen Score was introduced as a new model instrument to evaluate that influence additionally to its functional measurement. In this study, the Rosen Score was complemented by the DASH Score to satisfy more precisely the need of measurement of this important factor. Our suggestion of improvement attained in a three-factor analysis 83.5% of the variances of the results, compared with 73% reported in the use of the Rosen Score exclusively [50]. In our opinion and experience in this combination the Rosen’s hand protocol is still a clinically useful instrument. Furthermore, in this study the Rosen Score was tested again with 71 patients in a long-term follow-up. All analyzed scores correlated significantly. We can consider that the Rosen Score is a reliable instrument for the documentation of long-term outcome after nerve injury. Additionally, the purpose of this study was to analyze the influence factors of nerve reconstruction. Regarding the age of patient as a predicting factor, our results are in agreement with those of previous studies [4,13,27,30,55]. It is commonly accepted, that nerve recovery in younger patients is superior to that in older patients. The reasons are still discussed. On the one hand, it is documented in clinical,

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experimental and histological studies, that there is a better nerve regrowth in children [1,7,11,57]. On the other hand, some findings gave evidence for a superior cerebral adaptation in a child [4,62]. Weiss postulated in 1936, that central disorganization of the synaptic control ingrowths in the peripheral could be compensated after nerve lesion [63]. This central reorganization progress is closely related to the age, which has been proven in research studies of mammalian embryos [32]. Furthermore, it is reported, that a polyneural muscle innervation exists in the early stages of mammalian ontogeny. These muscle fibre innervations decrease after birth to a predominately mononeural innervation [22]. We assume, that depending on the age central relicts of these neural patterns are able to activate after nerve lesion to recover motor and sensor function. Dellon et al. documented a re-education in adults with daily sensory exercises [12]. Additionally, it was suggested, that children have a superior capability of re-education of sensitivity, as clinical differences were found between motor and sensor recovery [16]. Although we also observed in the motor recovery of ulnar nerve lacerations significant differences to the results of the median nerves, these findings persisted in all groups of age. In median nerve lesions no differences between motor and sensor recovery were attained. Evidently, age is not the influence factor for the inferior motor recovery in ulnar nerves. In conclusion, for the overall superior results in younger patients both explanations, better nerve regeneration and cerebral plasticity, are still relevant. Concerning the motor recovery in our study the median nerve was superior to the ulnar nerve. The Total Score was not influenced significantly by these results, but after ulnar lesion the patients regained only 1.92 versus 2.2 (Total Rosen Score) after median injury. An inferior motor recovery in ulnar nerves was also reported in another long-term follow-up with the use of the hand protocol by Rosen et al. [52]. We agree, that this evidence illustrates the larger motor component of the ulnar nerve. Supporting our findings several authors found a better motor recovery in median nerve injuries compared with ulnar nerve injuries [2,40,26,29,59] and no difference for sensory recovery [60]. In general, a muscle can become atrophic and irreversibly damaged in 1.5–2 years. Nerve regeneration occurs with a speed of approximately 1 mm/day, and if in the meantime innervation is not restored, motor recovery will be poor [17]. In a meta-analysis Ruijs et al. [53] pointed out, that there are a numerous of factors influencing the recovery, e.g. good cooperation and motivation of the patient, specialized hand therapy, cognitive capacity, early psychological stress experienced because of the trauma, and comorbidity such as diabetes and alcoholism. Furthermore, site has been identified as significant predictor for motor recovery [13]. Clinically, primary repair of ulnar and median nerve lesions has produced results clearly superior to those of delayed suture [6,37]. In a large reviewed series of 2181 fresh nerve injuries a primary repair was achieved in 87%

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with end-to-end approximation [11]. The degree of functional localization, the mix of sensory and motor fibres, the number and size of fascicles, and the percentage of epineural tissue all influence the choice of repair technique. Evidently, in our study the choice of epineural versus group fascicular suture bears no effect on recovery. To improve the outcome, nerve reconstruction was attempted by histochemical identification of motor fibres. Based on a collective study, an average of 71.9% regained hand function of the median nerve was reported [14]. These results are in accordance to our assessed values of motor function without sensory–motor differentiation. Therefore, an essential improvement of the outcome by this method can be contradicted. Obviously, the advantages of the accuracy of anatomic reconstruction disappear with the disadvantages of a delayed suture, as the histochemical detection of acetyl cholinesterase (AchE) is still a time-consuming procedure. Accompanying artery and flexor tendon injuries were not identified as an influence factor to the outcome. This evidence is confirmed by an evaluation of patients who suffered a simultaneous transection of both nerves and flexor tendons at the wrist [47]. However, most patients of this small survey returned to employment the good results were not reliable. We conclude to our patients, that dynamic splinting in simultaneous lesions of flexor tendons and nerves at the wrist bears no influence to the outcome of nerve repair. According to our results in clinical practice we suggest to evaluate the clinical outcome with the Rosen Score. This test battery is a reliable and precise functional measurement with good correlation to the common but more subjective Highet Scale. The patient should answer additionally the DASH in order to express his own view of disability. We indicated that there is a significant correlation between both measurements. In clinical consequence if functional improvement measured by Rosen Score after conservative or operative treatment is achieved, it is reflected by DASH. If the scores appearing contradictly, therapeutic changes are necessary.

5. Conclusion We conclude that the Rosen Score is a reliable instrument for outcome measurement of nerve lesions at the upper extremity, also for long-term results of primary repair. Our suggestion of improvement, the combination of the DASH Score and the Rosen Score, allows to sufficiently estimating the patient’s opinion about their impact on the activities of daily living after nerve reconstruction. Furthermore, the age of patient has been identified as an important influence factor. The suture techniques, additional artery or flexor tendon injuries did not influenced the overall results. All analyzed score systems correlated significantly. In the primary repair we obtained good clinical results for both nerves, significant differences were only observed in the motor recovery of the median und ulnar nerves. The inferior

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