Ischemia leads to progressive sensory and motor dysfunction
Key clinical distinction
ACTS — initially normal sensation that progressively worsens with severe pain
Nerve contusion (neurapraxia) — immediate, nonprogressive sensory loss
Therapeutic Considerations
Surgical repair principles
Tension-free microsurgical epineurial repair — gold standard
Primary repair preferred when achievable without tension
Nerve autograft for gaps requiring bridging
Sural nerve most common donor
Bioengineered conduits for gaps <3 cm as alternative
Critical reconstruction window — within 6 months before irreversible motor endplate degeneration
Neuropathic pain evidence base
Gabapentinoids (gabapentin, pregabalin) — NNT approximately 7 for 50% pain reduction (Lancet Neurology 2015)
Duloxetine — NNT approximately 7 for neuropathic pain
Tricyclic antidepressants — effective but limited by anticholinergic side effects
Opioids not recommended as first-line per evidence-based guidelines
Rehabilitation and recovery
Sensory re-education programs accelerate functional recovery after nerve repair
Occupational therapy essential for hand function optimization
Neurotmesis with surgical repair — only ~50% of patients achieve full functional recovery even with microsurgery
Serial electrodiagnostic studies guide decision-making and surgical timing
Patient Discharge Instructions
copy discharge instructions
What happened and why you are going home
You have been diagnosed with an injury to the median nerve in your wrist or forearm
This nerve controls feeling and movement in your thumb, index finger, middle finger, and part of your ring finger
Your injury appears stable and does not require surgery at this time
You have been given a splint to protect the area and prevent further injury
How to care for yourself at home
Keep your wrist splint on as instructed — do not remove it unless told to do so
Keep your hand elevated above the level of your heart as much as possible to reduce swelling
Take pain medications as prescribed — take with food to protect your stomach
Keep any wounds clean and dry as instructed
Do not put any tight bandages or jewelry on your hand or wrist
Activity restrictions
Avoid activities requiring grip strength or fine pinch until cleared by your follow-up provider
Do not drive or operate machinery if your hand is weak or numb
Keep your follow-up appointment — this is critical for monitoring your nerve recovery
Return to the emergency department immediately if
Numbness or tingling in your thumb, index, or middle finger is getting worse
Pain is increasing — especially if it is getting worse under a cast or splint
New weakness develops in your hand (difficulty gripping or pinching)
Your fingers become cold, pale, blue, or significantly swollen
Fever, wound redness, drainage, or signs of infection develop
You feel your cast or splint is too tight
Follow-up plan
Return to see your hand specialist or surgeon in 48 to 72 hours for reassessment
Wound check at 1 to 2 weeks
Nerve conduction studies will be arranged at 3 to 4 weeks to assess your nerve function
References
Guidelines and key sources
Kim DH, Kam AC, Chandika P, Tiel RL, Kline DG. Surgical Management and Outcomes in Patients With Median Nerve Lesions. Journal of Neurosurgery. 2001. PMID 11596952
30-year surgical series establishing outcome benchmarks for neurolysis, suture repair, and graft repair
Thomson SE, Ng NY, Riehle MO, et al. Bioengineered Nerve Conduits and Wraps for Peripheral Nerve Repair of the Upper Limb. Cochrane Database of Systematic Reviews. 2022
Evidence base for nerve conduit use in gaps requiring bridging
Holbrook HS, Hillesheim RA, Weller WJ. Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review. Orthopedic Clinics of North America. 2022. PMID 35365264
Key distinction between ACTS (surgical emergency) and neurapraxia (conservative management)
Pederson WC. Median Nerve Injury and Repair. Journal of Hand Surgery. 2014. PMID 24862118
Comprehensive review of classification, management, and outcomes
Shields LBE, Iyer VG, Zhang YP, Shields CB. Proximal Median Nerve Neuropathy: Electrodiagnostic and Ultrasound Findings in 62 Patients. Frontiers in Neurology. 2024. PMID 39703354
Iatrogenic etiology in 48.4% of proximal median nerve injuries; ultrasound utility
Neuropathic pain and electrodiagnostic references
Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for Neuropathic Pain in Adults: A Systematic Review and Meta-Analysis. Lancet Neurology. 2015. PMID 25575710
Evidence base for gabapentinoids, duloxetine, and tricyclics in neuropathic pain
Pripotnev S, Bucelli RC, Patterson JMM, et al. Interpreting Electrodiagnostic Studies for the Management of Nerve Injury. Journal of Hand Surgery. 2022. PMID 35738957
Timing and interpretation of NCS and EMG for nerve injury assessment
Bateman EA, Pripotnev S, Larocerie-Salgado J, Ross DC, Miller TA. Assessment, Management, and Rehabilitation of Traumatic Peripheral Nerve Injuries for Non-Surgeons. Muscle and Nerve. 2025
Comprehensive non-surgical management and rehabilitation framework
Wassef C, Chrabolowski J, Cheng F, et al. The Risk of Acute Carpal Tunnel Syndrome in Lunate and Perilunate Dislocations. Journal of Hand Surgery. 2026. PMID 41934453
25% incidence of acute median neuropathy with lunate and perilunate dislocations
Silver S, Ledford CC, Vogel KJ, Arnold JJ. Peripheral Nerve Entrapment and Injury in the Upper Extremity. American Family Physician. 2021. PMID 33630556
Diagnostic test sensitivity and specificity for median nerve clinical tests
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.