Ulnar, Median and Radial Nerve Injuries in Ankara, Turkey

Ulnar, median, and radial nerve injuries are major neurological problems that can cause motor and sensory loss in the upper extremity. They may develop due to trauma, surgical complications, or compression. Symptoms and treatment approaches vary depending on which nerve is affected.

Ulnar nerve injuries typically occur at the elbow level or at the wrist and present with numbness in the little finger and ring finger, decreased grip strength, and a claw hand deformity. Elbow trauma and entrapment are among the most common causes.

Median nerve injuries lead to sensory and motor function loss affecting the thumb and the first three fingers. Carpal tunnel syndrome is the best-known form. Decreased hand dexterity and thenar muscle atrophy may be seen. Both surgical and conservative treatments can be applied.

Radial nerve injuries most commonly develop due to humeral fractures or prolonged pressure. They are characterized by loss of wrist and finger extension and a “wrist drop” deformity. The rehabilitation process may be long, and nerve repair may be required.

What Are Ulnar, Median, and Radial Nerve Injuries?

Ulnar, median, and radial nerve injuries occur when the three main peripheral nerves that enable arm and hand function are damaged due to trauma, laceration, compression, or fractures. These injuries may lead to sensory loss, muscle weakness, and restricted motion. Depending on the affected nerve, wrist drop, claw hand deformity, or impaired fine motor skills may develop. Early diagnosis and appropriate treatment are important to prevent permanent functional loss.

How Does the Nerve Network and “Wiring System” in the Arm Work?

If we liken the body to a complex electronic system, the brain is the main processor and power source. The muscles in our arms are the motors that do the work. The cables that carry electricity to these motors and also return data from external sensors (the skin) back to the processor are called peripheral nerves. But these cables are far more complex than copper wires in a house: they are living structures, they need blood supply, and when they are cut, they engage in a major biological repair effort.

In the upper extremity—from the shoulder to the fingertips—there are three main “highways” that direct this traffic. Each is responsible for sensation in different regions and movement in different muscle groups. These nerves are:

• Radial nerve
• Median nerve
• Ulnar nerve

These three structures start near the armpit and travel all the way to the fingertips. Along the way, they branch to muscles to deliver the command “move,” while also collecting sensory information such as “this is hot” or “this is sharp” from the skin. A cut or crush at any point in this system can shut down all function at the end of the line.

What Happens When a Nerve Is Cut, and What Is the Healing Process Like?

When a nerve is cut or severely crushed, a dramatic process begins in the body. The cell body of the nerve (the central part) sits in the spinal cord or brainstem, but the part extending into the arm (the axon) can be meters long. After an injury, the segment from the injury site to the fingertips can no longer be nourished by the central system and cannot survive.

At this point, a “clean-up” process called Wallerian degeneration begins. The conducting core inside the injured segment breaks down and is cleared by immune cells. What remains is only the sheath—the hollow tube through which the core used to run. Surgically, what we try to do is help the living proximal nerve end find and enter this empty tube. If the ends are aligned correctly, the living nerve begins to sprout and advance through the tube.

However, this advancement is not fast. Nerve recovery is limited by biological speed constraints. Factors that affect the recovery rate include:

• Patient’s age
• Level of injury
• Cleanliness of the wound
• Smoking

On average, a nerve fiber advances only about 1 millimeter per day (around 3 centimeters per month). So after a laceration at the elbow level, reaching the fingertips may take months, and sometimes up to a year. This process is a serious test of patience for both physician and patient.

How Is the Severity of Nerve Damage Graded and How Is the Surgical Decision Made?

Not every nerve injury requires immediate surgery. Sometimes the nerve is only “shaken,” sometimes crushed, and sometimes completely severed. When planning treatment, physicians use specific classifications to understand the severity of damage. These classifications help determine whether surgery is needed.

From the mildest to the most severe, the patterns we encounter are:

• Neuropraxia
• Axonotmesis
• Neurotmesis

In neuropraxia, the nerve remains intact but conduction is temporarily blocked—like a hose that stops flowing when stepped on even though it is not damaged. When compression resolves or swelling subsides, conduction returns. This usually improves with follow-up and physical therapy.

The group we deal with most as plastic surgeons is neurotmesis—complete transection. In cases such as knife or glass cuts and occupational accidents, nerve continuity is disrupted. In this situation, spontaneous recovery is not possible because the severed ends retract and scar tissue forms between them. That is where microsurgical repair becomes essential.

How Is Wrist Drop and Radial Nerve Injury Managed?

The radial nerve is the power line that controls the muscles lifting the wrist and extending the fingers, starting from the triceps on the back of the arm. Because it winds around the humerus, it is the nerve most frequently injured by bone fragments in arm fractures.

When the radial nerve is damaged, the resulting picture is called “wrist drop.” The patient cannot lift the wrist, extend the fingers, or pull the thumb back. The hand hangs down under gravity. A patient in this state cannot make a “stop” gesture or open the hand to grasp an object.

Our treatment approach for radial nerve injuries depends on how the injury occurred. If there is an open wound such as a glass cut or knife injury, we repair it without waiting. However, if it occurs after a closed arm fracture, we take a more cautious approach.

In closed fractures, the radial nerve often does not fully rupture; it is more commonly bruised or stretched. The radial nerve’s motor recovery capacity can be higher than that of other nerves. Therefore, in closed injuries, we often prefer waiting 2–3 months, allowing swelling to resolve and giving the nerve a chance to recover on its own.

If the nerve does not recover, or if there is a defect too large to repair, we use a method called tendon transfer. This is one of the most rewarding operations in hand surgery. We take tendons of functioning, healthy, but “expendable” muscles and attach them to the tendons of paralyzed muscles—using the body’s own spare parts.

With tendon transfer, the functions we aim to restore include:

• Wrist extension
• Finger extension
• Thumb extension
• Thumb abduction

After surgery, the patient undergoes rehabilitation, and the brain learns to use the transferred muscle for its new role.

How Does a Median Nerve Injury Affect Sensation—the “Eye of the Hand”?

We call the median nerve “the eye of the hand” because it is the key structure that allows the hand to perceive the world. It carries sensation from the thumb, index finger, middle finger, and half of the ring finger. When you close your eyes and reach into your pocket, it is the median nerve that helps you recognize whether you touched a coin or a key.

When this nerve is cut, the patient cannot feel objects in the hand. This is not only numbness—it is also dangerous. Because pain is not felt, serious injuries can occur from cuts, burns, or crushing.

The median nerve also controls fine and precise motor movements rather than brute force. In particular, the “opposition” movement—bringing the thumb across to meet the other fingers for grasping—is governed by this nerve.

Typical signs of median nerve palsy include:

• Sensory loss in the first three fingers
• Reduced grip strength
• Wasting of thumb muscles
• Loss of opposition

Over time, the thenar muscles at the base of the thumb waste away, the hand becomes flattened, and this is called an “ape hand” deformity. In glass lacerations at the wrist level (suicide attempts or accidents), the median nerve may be cut along with the flexor tendons—this is sometimes referred to as “spaghetti wrist,” requiring urgent and very meticulous microsurgical repair.

What Are Microsurgical Repair Techniques and How Are They Performed?

Nerve repair is not a procedure that can be done with the naked eye. Nerve fibers are extremely delicate, soft, and complex structures. In this surgery, we must use a high-magnification operating microscope or special magnifying surgical loupes. The suture materials we use are so fine that they are even thinner than a human hair and are nearly impossible to see without magnification.

Our main goal during the operation is to align the severed nerve ends as accurately as possible. Within a nerve, motor fibers (movement) and sensory fibers (feeling) are bundled separately. If we mistakenly connect motor fibers to sensory fibers, function will not return even if healing occurs. Therefore, it is vital to assess the nerve cross-section, map it, and connect the correct “cable” to the correct place.

The repair techniques we use include:

• Epineurial repair
• Fascicular repair
• Group fascicular repair

The most critical rule is “tension-free repair.” If we pull the two nerve ends together under tension and suture them, blood supply at the repair site is compromised and scar tissue forms, blocking nerve conduction. The ends should meet comfortably without stretch.

If the Nerve Ends Cannot Be Joined, Are Nerve Grafting or Transfers Performed?

Sometimes trauma is so severe that a segment of the nerve is torn away or must be excised because it is crushed beyond viability. When a gap larger than about 2–3 centimeters remains between the ends, end-to-end repair becomes impossible. That is when we use a method called nerve grafting.

Nerve grafting involves taking a segment of a nerve from another part of the body that causes minimal functional loss and suturing it as a bridge to span the defect. The most commonly used donor is the sural nerve behind the leg. When this nerve is harvested, the patient may have a small area of numbness on the outer heel, but walking and leg movements are not affected.

Another method that has become more popular in recent years is nerve transfer. This technique is like an electrician rewiring a building: instead of trying to repair a severely damaged nerve, we take a nearby, functioning branch of a less critical nerve and connect it to a more important nerve that is not working.

The key advantage is that we can connect the nerve source much closer to the target. For example, while regrowth from a proximal shoulder-level injury to the fingers may take years, a transfer performed at the wrist level can yield results within months.

Common donor sources for grafting or transfers include:

• Sural nerve
• Antebrachial cutaneous nerve
• Motor nerve branches

How Does Postoperative Recovery and Physical Therapy Progress?

When the surgery ends, our job does not end—it actually begins. Nerve recovery is a long-distance marathon. Successful surgery is only half of treatment; the other half is patient compliance and a solid rehabilitation program.

For the first 3–4 weeks, we protect the repair site with a cast or splint. The goal is to prevent tension on the suture line. Then passive movements begin, followed by supervised exercises with a physiotherapist.

When regenerating nerve fibers reach the skin, the brain may initially misinterpret signals. For example, when your finger is touched, you might feel it as if another area was touched. This is when sensory re-education becomes important. With the patient’s eyes closed, we use different textures and objects to retrain the brain.

Follow-up typically includes these phases:

• Protection phase
• Mobilization phase
• Strengthening phase
• Sensory re-education