nerve injuries of upper limb

8/10/2019 Nerve Injuries of Upper Limb

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DR TATHEER ZAHRA

ASSISTANT PROFESSOR ANATOMY

NERVES OF UPPER LIMB &

THEIR LESIONS


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NERVE SUPPLY OF UPPER LIMB

MOTOR

SENSORY

AUTONOMIC

SympatheticPreganglionic FibersT2-T6

Ascends alongSympathetic Trunk

Middle & Inf.Cervical Ganglion +

1stThoracicSympathetic Ganglia

Through BrachialPlexus & its Branches

Vasomotor &Secretomotor


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CUTANEUS NERVE SUPPLY


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DERMATOMES

(FOERSTER, 1933)

(KEEGAN &

GARRETT, 1948)


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BRACHIAL PLEXUS

Between Scalene

Muscles

Arranged Around 2nd Part

of Axillar Artery in Axilla

In Post.

Triangle

Behind

Clavicle


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SURGICAL APPROACH

SUPRACLAVICULAR

APPROACH

In Angle Between SCM &Clavicle

Inf. Belly of Omohyoid & LateralBranches of ThyrocervicalTrunk

are Divided

Roots of Brachial Plexus areidentified Behind Scalenus Ant.

Scalenus Ant. Retracted /Severed to display Lower Trunk

of Brachial Plexus

INFRACLAVICULAR

APPROACH

Deltopectoral Groove is openedup

Pectoralis Minor is detachedfrom Coracoid Process

Plexus Branches AroundAxillary Artery can be dissected

Around Axillary Sheath


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Middle Part of Clavicle may be removed if a more Proximal Approachis needed


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TYPES OF NERVE LESIONS

COMPRESSION

STRETCH

SECTION

BRACHIAL PLEXOPATHY

Can refer to involvement of the Entire

Plexus, or Parts of the Plexus

Trunk Lesion

Cord Lesion

Distribution of Weakness & Numbness

depends upon the Part of the Plexus affected


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PATTERN OF INJURY

Pattern of Root

Contribution to the Plexus:

Upper Trunk Lesion:

Sensory Loss in C5 & C6

Middle Trunk Lesion:

Sensory Loss in C7

Lower Trunk Lesion:Sensory Loss in the

Combined C8 & T1

Dermatomes


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PRINCIPLES OF LOCALIZATION

Certain Sites are Prone to Nerve Entrapments/Injuries

Nerve Opposing Bone ~ Ulnar Nerve at the Elbow

Closed Spaces ~ Carpal Tunnel

Adjacent Structures ~ Median Nerve at the Elbow,

adjacent to the Brachial Artery

Order in which Branches arise

Movements at Specific Joints

Single NerveoElbow Extension ~ Radial N.

Multiple Nerves

oElbow Flexion ~ Musculocutaneous N., Median N.


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A: VARIATIONS IN BRACHIAL PLEXUS:

Variations in Origin & or Combination of Branches

Prefixed Brachial Plexus (C4-C8) ~ 10%

Post Fixed Brachial Plexus (C6-T2) ~ 10% T2

compressed by First Rib Neurovascular Symptoms of

Upper Limb

Variations in Formation of Trunks, Divisions & Cords

Variations in relationship to Axillary Artery & Scalene

Muscles


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B: BRACHIAL PLEXUS INJURIES:

Incomplete Paralysis (Weak Movement)

Complete Paralysis (No Movement + Horners Syndrome)

~ Rare Devastating Motorbike Accident

Erb-Duchenne Palsy/ Backpackers Palsy

Klumpke Paralysis

C: BRACHIAL PLEXUS BLOCK:

D: BRACHIAL PLEXUS NEURITIS:


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ERB-DUCHENNE PALSY (WAITERS TIP)

Mode of Injury:

o Angle Between Neck & Shoulder (e.g., APerson thrown from Motorcycle or Horse &

Lands on Shoulder)

o Person thrown Shoulder often hitssomething e.g., Tree or the Ground & stops ,

but the Head & Trunk continue to move

Stretches or Ruptures Sup. Part of Brachial

Plexus or avulses the Roots of the Plexusfrom Spinal Cord

oNewborns when Excessive Stretching of the

Neck occurs during Delivery


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Mechanism of Injury:

Clinical Features:

o Upper Limb with Adducted Shouldero Medially rotated Arm

o Extended Elbow

o Loss of Sensation in Lateral Aspect of Upper Limb

o Waiters Tip Position

Paralysis of Muscles of Shoulder & Arm supplied by C5-C6

DeltoidSupraspinatus &

InfraspinatusSubclavius

Biceps, Brachialis,Brachioradialis

Injury to C5-C6

Axillary N. Suprascapular N. N. to Subclavius MusculocutaneousN.


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BACK PACKERS PALSY

Superior Brachial Plexus Injury

In Hikers, who carry Heavy Backpacksfor Long Periods


Chronic Micro-trauma to Upper Trunkfrom Carrying Heavy Packs

Motor & Sensory Deficit in Areas supplied

by Radial & Musculocutaneous Nerves

Clinical Features:

Muscle Spasms

Sever Disability


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HYPERABDUCTION SYNDROME /

COMPRESSION OF CORDS OF BRACHIAL

PLEXUS & AXILLARY VESSELS Mode of Injury:

Axilla Pathology

Disease or Stretching Wounds in Lateral CervicalRegion (Post Triangle of Neck)


Cords impinged between Pectoralis Minor & Coracoid

Process

Hyperabduction of ArmManual Tasks over Head Painting a Ceiling


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Clinical Features:

Pain ~ Radiating down the Arm

NumbnessParaesthesia (Tingling)

Erythema (Redness of Skin due to Capillary Dilatation)

Weakness of Hands

Injury to Brachial Plexus Affects Nerve Roots

(Paralysis of Muscles) & Cutaneous sensation

(Anaesthesia) in Upper Limb


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KLUMPKE PALSY

Much Less Common ~ C8-T1

Mode of Injury:o Cervical Rib

o Malignant Metastasis from the Lungs in the Lower Deep

Cervical Lymph Nodes

o

When Upper Limb is Suddenly Pulled Superiorly e.g., A Person grasps something to break a fall

Babys Upper Limb pulled extensively during

Delivery

Nerves Affected: Ulnar & Median N.Clinical Features:

o Short Muscles of the Hand are affected ~ Claw Hand

o Loss of Sensation along the Medial Side of Arm, Forearm,

Hand & Medial 2 Fingers


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Affection of:

1- Most of the Small Muscles of the Hand (T1)

2- Ulnar Flexors of the Flexor Compartment of Forearm are

Partially affected (C8)

Complete claw

hand


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BRACHIAL PLEXUS BLOCK

Injection of AnAnesthetic Solution into

or Immediately

Surrounding theAxillary Sheath

Interrupts Conduction ofImpulses of Peripheral

Nerves

Produces Anaesthesia

Blocked Sensations in AllDeep Structures of theUpper Limb & the Skin

Distal to the Middle of theArm


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Combined with an Occlusive Tourniquet Technique

to retain the Anesthetic Agent, this Procedure

enables Surgeons to Operate on the Upper Limb

without using a General Anesthetic

Brachial Plexus Block By

using Other Approachese.g.,

Cervical Approach

Interscalene ApproachSupraclavicular Approach

Axillary Approach


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Neurological Disorder of Unknown Cause

Usually, Nerve Fibers of Upper Trunk are affected

Preceded by Some Event e.g., URTI, Vaccination, Non-specific

Trauma

Clinical Feature:

Pain

Onset: Sudden

Intensity: Severe

Site: Around Shoulder

Begins: At Night

Muscle Weakness & Muscular Atrophy (Neurologic Amyotrophy)

ACUTE BRACHIAL PLEXUS NEURITIS

(BRACHIAL PLEXUS NEUROPATHY)


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INJURY TO NERVE ROOTS &

BRANCHES


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DORSAL SCAPULAR N. INJURY

Injury to the Dorsal

Scapular Nerve, theN. to theRhomboids

Affects the Actionsof Rhomboids

Scapula on theAffected Side isLocated Farther

from the Midline


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LONG THORACIC N. INJURY

Blow/ Pressure on the

Post. of Neck, InjuryDuring Radical

Mastectomy

Injury to the LongThoracic N.

Medial Border of theScapula moves

Laterally &Posteriorly away from

the Thoracic Wall

Giving the Scapula theAppearance of a Wing

Winged Scapula

Especially when thePerson leans on a

Hand or Presses theUpper Limb against a

Wall

Inability to AbductArm above ,

Difficulty in Raisingthe Arm above Head


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WINGING OF

SCAPULA


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INJURY TO CORDS & TERMINAL

BRANCHES


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THORACODORSAL N. INJURY (C6-C8)

Paralysis of Latissimus

DorsiUnable to raisethe Trunk with

Upper Limb as inClimbing

Cannot useCrutches because

Shoulder isPushed Superiorly

Injury to

Thoracodorsal N.

Surgery in AxillaSurgery on

Scapular LymphNodes


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AXILLARY N. INJURY (C5,C6)

Mode of Injury:

FractureSurgical Neck

of Humerus

Incorrect use

of Crutches

Dislocation ofGlenohumeral

Joint

MisplacedInjection into

Deltoid


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Injury toAxillary Nerve

Round Contour

Disappears Impaired

Abduction

Atrophy ofDeltoid Area Supplied

by Sup. Lat.Cutaneous N. ofArm

Sensory Loss


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MUSCULOCUTANEOUS NERVE

Uncommon Injurydue to its

Protected Position

Injured by a

Weapon e.g., Knife


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Area of Loss:

Sensory: Area supplied

By Lat. Cut. N. of

Forearm

Motor: Paralysis of

Coracobrachialis, Biceps

& Brachialis

Weak Flexion of ElbowJoint

Weak Supination of

Forearm


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RADIAL NERVE MostCommonly

injured High up

Mode of Injury

Wrist Drop

Saturday Night Palsy;

Drunkard fallingasleep with one Armover the Back of a

Chair

Improper Use ofCrutches

Pressure on the Backof Arm on the Edge of

Operating Table

ProlongedApplication of

Tounique

Fracture &Dislocation of Shaft

of Humerus &Subsequent Callus

Formation

Transient


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3 in Axilla

4 in Spiral

Groove

4 in Ant.

Compartment of

Arm

2 in Cubital

Fossa


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RADIAL N. INJURY IN AXILLA

SENSORY

LOSS

Post. Surface ofArm

Post. Surface ofForearm

Lat. on theDorsum of Hand

except DistalPhalanges

MOTOR

LOSS

Triceps,Anconeus

Brachioradialis

Supinator

ExtensorMuscles of Wrist& Fingers (Wrist

Drop)

TROPHIC

CHANGES

Slight

WRIST

DROP

RADIAL N INJURY IN ARM (RADIAL


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RADIAL N. INJURY IN ARM (RADIAL

GROOVE)

TROPHICCHANGES

Slight / Absent

SENSORYLOSS

Post. Surface ofForearm

Lat. on theDorsum of Hand

except DistalPhalanges

MOTORLOSS

Triceps(Incompletely

Paralyzed)

Brachioradialis

Supinator

ExtensorMuscles of Wrist& Fingers (Wrist

Drop)


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RADIAL N. INJURY IN FOREARM

RADIAL N. INFOREARM

DEEPBRANCH

MuscularDistribution

ArticularDistribution

SUPERFICIALBRANCH

CutaneousNerve

INJURY TO SUPERFICIAL BRANCH OF


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INJURY TO SUPERFICIAL BRANCH OF

RADIAL N. Stab Wound

Minimal Sensory Loss

Coin Shaped Area ofAnaesthesia Distal to Bases of

2nd & 3rd Metacarpals

Less than expected

Considerable Overlap from

Cut. Br. of Median & Ulnar N.


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INJURY TO DEEP BRANCH OF RADIAL N.

Mode of Injury:

Deep Penetrating Wounds of Forearm

Fracture of the Proximal end of the Radius

Dislocation of the Radial Head

Area of Loss:

No loss of Sensation

No Wrist Drop as Brachioradialis & Ext. Carpi RadialisLongus will be undamaged & they keep the Wrist Joint

Extended

Inability to Extend Thumb & MP Joints of Other Digits

IP Joints can be extended weakly through action of

TESTING THE INTEGRITY OF DEEP


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TESTING THE INTEGRITY OF DEEP

BRANCH OF RADIAL N.

May be tested by asking the Person to extend the MP Joints while

the Examiner provides Resistance

If the Nerve is Intact the Long Extensor Tendons should appear

Prominently on the Dorsum of the Hand Confirming that the

Extension is occurring at the MP Joints rather than at the IP Joints

(Movements under the Control of other Nerves)

MEDIAN NERVE


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MEDIAN NERVE

Elbow Region ~SupracondylarFracture ofHumerus

Broken Glass JustProximal toFlexorRetinaculum

Stab Wound

MEDIAN N INJURY AT ELBOW


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MEDIAN N. INJURY AT ELBOW

(HAND OF BENEDICTION)

Median N. is Severed in the Elbow Region

VASOMOTOR

CHANGES Loss of Sympathetic

Control

ArteriolarDilatation

Absence ofSweating

In Area of Loss,Skin is Warmer &Drier than Normal

TROPHIC

CHANGES In long-standing

Cases

In Hands& Fingers

Dry & Scaly Skin

Nails Crack Easily

Atrophy of Pulp Of

Fingers

SENSORY LOSS

Lat. of the Palmof Hand

Palmar Aspect of3 Fingers

Distal Part ofDorsal Surfaces ofLateral 3 Fingers

MOTOR LOSS

Pronators Long Flexors of

Wrist & Fingers(except FCU &Ulnar of FDP)

Thenar Muscles

1st 2 Lumbricals

Ape Like Hand

Hand ofBenediction

Fl i f th P i l IP J i t f th 1 t 3 d Di it i l t


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Flexion of the Proximal IP Joints of the 1st-3rd Digits is lost

& Flexion of the 4th & 5th Digits is weakened

Flexion of the Distal IP Joints of the 2nd & 3rd Digits is also

lost Flexion of the Distal IP Joints of the 4th and 5th Digits is

not affected (Medial Part of the FDP~ Supplied by the

Ulnar Nerve)

Ability to Flex the Metacarpophalangeal Joints of the 2nd &3rd Digits is affected (Digital Branches of the Median N.

supply the 1st & 2nd Lumbricals)

When the person attempts to make a Fist, the 2nd & 3rd

fingers remain partially extended (Hand ofBenediction)

Thenar Muscle Function is Lost Waisted ThenarMuscles


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ANTERIOR INTEROSSEOUS N. INJURY

Thenar Muscles are Unaffected

Paresis of the Flexor Digitorum Profundus & Flexor Pollicis Longus When the Person attempts to make the Okay Sign, opposing the

Tip of the Thumb & Index Finger in a Circle a Pinch Posture of

the Hand results instead owing to the Absence of Flexion of the IP

Joint of the Thumb & Distal IP joint of the Index Finger (AnteriorInterosseous Syndrome)

MEDIAN N INJURY AT WRIST


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MEDIAN N. INJURY AT WRIST Most Serious Disability of all in Median N. injuries ~ Loss

of the Ability to Oppose the Thumb to the Other Fingers

& the Loss of Sensation over the Lateral Fingers. Ape like hand ~ Delicate Pincerlike Action of the

Hand is No Longer Possible

VASOMOTORCHANGES

Loss of SympatheticControl

Arteriolar Dilatation

Absence of Sweating

In Area of Loss, Skinis Warmer & Drierthan Normal

TROPHICCHANGES

In long-standingCases

In Hands& Fingers

Dry & Scaly Skin

Nails Crack Easily Atrophy of Pulp Of

Fingers

SENSORY LOSS

Lat. of the Palm ofHand

Palmar Aspect of 3Fingers

Distal Part of Dorsal

Surfaces of Lateral 3Fingers

MOTOR LOSS

Thenar Muscles

1st 2 Lumbricals

Ape Like Hand

PRONATOR SYNDROME


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PRONATOR SYNDROME

Nerve Entrapment Syndrome

Near the Elbow

Compressed between the Heads of the Pronator

Teres as a result of

Trauma

Muscular Hypertrophy

Fibrous Bands

Clinical Features:

Pain & Tenderness in the Proximal Aspect of the

Anterior ForearmHyperesthesia of Palmar Aspects of the Radial 3

Digits & Adjacent Palm

Symptoms often Follow Activities that involve

Repeated Pronation

CARPAL TUNNEL SYNDROME


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Most Common Site of Median N. Injury

Any Lesion that Significantly the Size of the Carpal Tunnel or,

More Commonly, the Size of some of the 9 Structures or their

Coverings that Pass through it

Arthritic Changes in the Carpal Bones

Inflammation of Synovial Sheaths

Fluid Retention

Infection

Excessive Exercise

2 Terminal Sensory Branches that Supply the Skin of the Hand

Paresthesia (Tingling), Hypoesthesia (Diminished

Sensation), or Anesthesia (Absence of Sensation) in the Lateral 3

CARPAL TUNNEL SYNDROME


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CARPAL TUNNEL

SYNDROME

Palmar Cutaneous Branch of the Median N arises Proximal to &


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Palmar Cutaneous Branch of the Median N. arises Proximal to &

does not Pass through the Carpal Tunnel Sensation in the

Central Palm remains Unaffected.

Nerve also has 1 Terminal Motor Branch, the Recurrent

Branch, which serves the 3 Thenar Muscles Weakness of

Thenar Muscles

If the cause of Compression is not alleviated Progressive Lossof Coordination & Strength in the Thumb (owing to Weakness

of the APB & Opponens Pollicis)

Unable to Oppose the Thumb & have Difficulty Buttoning a

Shirt or Blouse as well as Gripping Things such as a Comb

As the Condition Progresses Sensory Changes Radiate into


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As the Condition Progresses Sensory Changes Radiate into

the Forearm & Axilla

Symptoms of Compression can be Reproduced by Compression

of the Median N. with Your Finger at the Wrist for Approximately30 Seconds

Treatment: Partial or Complete Surgical Division of the Flexor

Retinaculum, Carpal Tunnel Release, Longitudinal Incision

made toward the Medial Side of the Wrist & Flexor Retinaculum

to Avoid Possible Injury to the Recurrent Branch of the Median

N.

CO CA O S A &


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COMMUNICATIONS BETWEEN MEDIAN &

ULNAR NERVES

Occasionally In the Forearm

Slender nerves

Clinically Important

Even with a Complete Lesion of the Median Nerve, Some

Muscles may not be Paralyzed ~ May lead to an Erroneous

Conclusion that the Median N. has not been Damaged

ULNAR NERVEP t T M d


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> 27% of Nerve Lesions of Upper Limb

Classical Sign Claw Hand (main en griffe) ~

Unopposed Action of the Extensors & of FDP Loss of Interossei & Lumbricals Hyperextension

at MP Joints of the Ring & Little Fingers Cannot

Flex the MP Joints or Extend the IP Joints

With Ulnar N. Injuries, the Higher the Lesion, the

Less Obvious the Clawing Deformity of the Hand

Injuries At the Elbow or Above: Partial Claw Hand

Deformity, More Prominent Straight Fingers (UlnarParadox) Ulnar of FDP is Out of Action

Unlike Median N. Injuries, Lesions of the Ulnar N.

leave a Relatively Efficient Hand ~ Pincerlike

Action of the Thumb & Index Finger is

Reasonabl Good

Post. To Med.Epicondyle of

Humerus

CubitalTunnel atElbow

Ulnar Canal

Syndrome at Wrist

Cuts & Stab Woundsat Wrist

HandlebarNeuropathy in the

Hand

Places of Injury to

Ulnar N.

ULNAR N INJURY AT ELBOW


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ULNAR N. INJURY AT ELBOW

Site:Posterior to the Medial

Epicondyle of theHumerus

Mode of Injury:Results when the

Medial Part of the

Elbow hits a Hard

Surface, Fracturing theMedial Epicondyle

(Funny Bone)

FCU FDP (Ulnar ) Loss of Sensation over


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FCU, FDP (Ulnar )

Hypothenar Muscles

3rd & 4th Lumbricals

Adductor Pollicis

Palmaris Brevis, Interossei

Claw Hand Inability to Adduct Thumb

MOTORLOSS

Loss of Sensation overthe Ant. & Post. Surfacesof the Medial of theHand & the Medial Fingers

Numbness & Tingling

SENSORYLOSS

Warmer & Drier Skin

Arteriolar Dilatation &Absence of Sweating ~Loss of SympatheticControl

VASOMOTORCHANGES

Loss of FCU, FDP (Ulnar )

W k Fl


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Week Flexion

Loss of Adduction

Flexion of the Wrist Joint will Result in Abduction

Medial Border of the Front of the Forearm will show Flattening

All Small Muscles of the Hand will be Paralyzed, Except the Muscles of the

Thenar Eminence & the First 2 Lumbricals

Inability to Put the Hand in Writing Position

Inability to Adduct Thumb ~ (Froment's Sign ~ If the Patient is asked

to Grip a Piece of Paper Between the Thumb & the Index Finger, One does

so by Strongly Contracting the FPL & Flexing the Terminal Phalanx)

Unable to Adduct & Abduct the Fingers

Guttering Between MetacarpalsHyperextended MP Joints & Flexed IP Joints ~Claw Deformity (main

en griffe)

Flattening of the Hypothenar Eminence & Loss of the Convex Curve to

the Medial Border of the Hand

CUBITAL TUNNEL SYNDROME


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CUBITAL TUNNEL SYNDROME

Ulnar Nerve Entrapment

Cubital Tunnel

(The Tendinous Arch Joining the

Humeral & Ulnar Heads of

Attachment of the FCU)

Clinical Features:

Same as an Ulnar N. Lesion in the

Ulnar Groove on the Posterior

Aspect of the Medial Epicondyle

of the Humerus ~ Claw

Hand (main en griffe)

ULNAR N INJURY AT WRIST (ULNAR


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ULNAR N. INJURY AT WRIST (ULNAR

CANAL SYNDROME/ GUYON TUNNEL

SYNDROME) Site of Nerve Entrapment: Osseofibrous Tunnel/ Ulnar Canal

(Pisiform Bone, Hook of Hemate & Pisiohemate Ligament)

Clinical Features:Hypoesthesia in Medial 1 Fingers

Weakness of Intrinsic Muscles of Hand

Clawing of 4th & 5th Fingers ~ Much more Obvious as FDP

is not Paralyzed, & Marked Flexion of the Terminal

Phalanges Occurs

Ability to Flex at Wrist Joint is Unaffected

No Radial Deviation when trying to make a Fist


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Hypothenar Muscles Loss of Sensation over the


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Hypothenar Muscles

3rd & 4th Lumbricals

Adductor Pollicis

Palmaris Brevis, Interossei

Claw Hand ~ More

Obvious Inability to Adduct Thumb

MOTOR LOSS

Loss of Sensation over thePalmar Surface of theMedial of the Hand &Medial 1 Fingers & to theDorsal Aspects of theMiddle & Distal Phalangesof the Same Fingers

SENSORYLOSS

Warmer & Drier Skin

Arteriolar Dilatation &Absence of Sweating ~Loss of Sympathetic

Control

VASOMOTORCHANGES

ULNAR N. INJURY IN THE HAND


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Mode of Injury

People who Ride Long Distances on Bicycles CompressUlnar N.

Symptoms

Tingling & Numbness

Pain on the Outside or Middle of the Forearm; this Sensation

of Discomfort may run all the Way to the Little Finger

Weakness of Intrinsic Muscles of Hand

Treatment Anti-inflammatory Medications

Wrist Splints

Therapeutic Exercises

(HANDLEBAR NEUROPATHY)


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An Inability to Oppose the Thumb to the

Little Finger can result from Damage to the

________ Nerve.

a) Axillary

b) Musculocutaneous

c) Radial

d) Ulnar

e) Median


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Hyperextension of the Proximal Phalanges of

the Little & Ring Fingers can result from

damage to the ________ Nerve.

a) Ulnar

b) Axillary

c) Radial

d) Median

e) Musculocutaneous

W i t D lt f D t th


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Wrist Drop can result from Damage to the

________ Nerve.

a) Medianb) Ulnar

c) Radial

d) Anterior interosseous

e) Axillary

REFERENCES


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REFERENCES

Cinical Anatomy By Regions, By RICHARD S. SNELL,8th Edition

Clinical Oriented Anatomy, By KEITH L. MOORE &

ARTHUR F. DALLEY, 5th Edition

LASTS Anatomy, By CHUMMY S SINNATAMBY,

Churchill Livingstone, 11th

Edition

GRAYs Anatomy, 40th Edition


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nerve injuries of upper limb

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