evaluate for the presence of axon regeneration and muscle reinnervation. If there is no evidence of recovery within 3-4 months, then a neurot-metic injury is more probable and a surgical exploration is indicated. This recommendation for surgical exploration in the 3-4 months following injury is not arbitrary but is predicated on the observation that muscles not reinner-vated within 2 years following nerve injury have poor recovery of useful motor function [4]. After 2 years, muscles undergo irreversible atrophy and are replaced by adipose tissue. Thus, regenerating nerves must be allowed adequate time to reinnervate to their appropriate target, remembering that regeneration occurs at the rate of approximately 1 inch per month [3].

In nerve injuries associated with skin disruption, clinical evaluation of the wound is important, in addition to identifying the source of injury, as this will largely determine the management of these patients. An open lesion with the nerve in continuity should be managed with surgical repair of the wound and serial neurological, electrodiagnostic and imaging examinations, as this nerve injury most likely represents either a neurapraxic or an axonotmetic injury. In situations where the nerve is clearly disrupted, a neurotmetic injury is evident and, in those lesions, the mechanism of injury determines the timing of surgical management. In a situation where there is a sharp transection of the nerve, such as occurs with lacerations from glass or a knife, immediate surgical repair with an end-to-end suture repair, where possible, without producing tension, is indicated. In situations where blunt trauma is responsible for the transection, as occurs in complex extremity fractures or power saw injuries, then a delayed repair is indicated. This delay should be for at least 2-3 weeks following the injury, as this allows for the maturation of the injury so that the damaged, scarred, non-viable nerve can be readily distinguished from the undamaged, unscarred nerve. The damaged, scarred nerve segment can then be resected and the nerve, with viable proximal and distal ends, can be surgically repaired with or without a nerve graft, depending on the gap length.

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