or “pns envy” zach london “you can’t make interesting without teres”
TRANSCRIPT
or
“PNS Envy”
Zach London
“You Can’t Make Interesting Without Teres”
ObjectiveUse the motor exam to distinguish focal
peripheral lesions that cause:
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
The rules
• Pick a symptom (foot drop, interosseous weakness, etc.)
• In the left column, write relevant localizations from distal to proximal.
• Localizations should be a nerve, part of the plexus, or root.
• Fill out the chart, checking off which muscles would be weak with lesions in each localization.
Radial nerve (Spiral Groove)
C7 root
Posterior Cord Plexus
Radial nerve (Axilla)
Posterior Interosseus n.
Shoulder Abduction
Elbow extension
Elbow flexion
Finger extension
DeltoidTricepsBrachioradialis
Extensor digitorum
Finger Drop
Deltoid (C5, C6)
Triceps (C6, C7, C8)
Brachioradialis (C5, C6)
Extensor Digitorum Communis (C6, C7)
Posterior Interosseus
Radial nerve (Spiral Groove)Radial Nerve
(Axilla)
Posterior Cord Plexopathy
Deltoid (C5, C6)
Triceps (C6, C7, C8)
Brachioradialis (C5, C6)
Extensor Digitorum Communis (C6, C7)
C7 Root
Q: What muscle can distinguish a posterior interosseus
mononeuropathy from a radial mononeuropathy at the
spiral groove?
A: Brachioradialis (elbow flexion with thumb up)
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
The rules, again
• Pick a symptom (foot drop, interosseous weakness, etc.)
• In the left column, write relevant localizations from distal to proximal.
• Localizations should be a nerve, part of the plexus, or root.
• Fill out the chart, checking off which muscles would be weak with lesions in each localization.
*
Ankle plantarflexion
Gastroc-nemius
Common peroneal n.
L5 root
Lumbosacral plexus
Sciatic nerve
Deep peroneal n.
Hip abduction
Ankle inversion
Ankle eversion
Ankle
dorsiflexion
Gluteus Medius
Tibialis Posterior
Peroneus longus
Tibialis Anterior
Foot Drop
* If S1 fibers are also involved
Tibialis Posterior (L5, S1)
Peroneus Longus (L5, S1)
Tibialis Anterior (L4, L5)
Deep Peroneal
Common Peroneal
Sciatic
Lumbosacral PlexusGluteus Medius
(L5, S1)
Gastrocnemius (S1, S2)
Peroneus Longus (L5, S1)Tibialis Posterior
(L5, S1)Tibialis Anterior (L4, L5)
Gluteus Medius (L5, S1)
Gastrocnemius (S1, S2)
L5 Root
Q: What muscles can be used to distinguish a common
peroneal neuropathy from an L5 radiculopathy?
A: Tibialis Posterior (inversion)Gluteus Medius (hip abduction)
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
Medial cord plexus
C8-T1 root
Lower trunk plexus
Ulnar nerve (elbow)
Index finger extension
Thumb abduction
Spreading out fingers
Extensor indicis
Abductor pollicis brevis
Interossei
Interosseous Weakness
Abductor Pollicis Brevis (C8, T1)
Extensor Indicis (C7, C8)
Interossei (C8, T1)
Ulnar (elbow)
Medial cord plexusLower trunk plexus
or C8 Root
Q: What muscle can be used to distinguish an ulnar
mononeuropathy at the elbow from a C8 radiculopathy?
A: Abductor pollicis brevis and extensor indicis
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
C8 Root
Median nerve (proximal)
Anterior Interosseous
nerve
Median nerve (carpal tunnel)
Spreading out Fingers
Thumb FlexionThumb
Abduction
InterosseiFlexor Pollicis
LongusAbductor
pollicis brevis
Thumb weakness
Abductor Pollicis Brevis (C8, T1)
Flexor Pollicis Longus (C7, C8)
Interossei (C8, T1)
Median (carpal tunnel)
Anterior Interosseus
Proximal Median
C8 root, medial cord
or lower trunk
Q: What muscle can be used to distinguish carpal tunnel syndrome from a
median mononeuropathy at the elbow?
A: Flexor pollicis longus (Thumb flexion)
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
Quadriceps Weakness
Femoral n. (above inguinal
ligament)
L4 root
L3 root
Lumbar Plexus
Femoral n. (below inguinal
ligament)
Hip adduction
Hip flexionKnee
extension
Adductor Longus
IliopsoasQuadriceps
Quadriceps (L3, L4)
Adductors (L2, L3, L4)
Iliopsoas (L2, L3)
Femoral (below inguinal ligament)
Femoral (above inguinal ligament)Obturator
Lumbar Plexus
or L3 Root
L4 Root
Q: What muscle can be used to distinguish a proximal femoral
mononeuroapathy from a lumbar plexopathy?
A: The adductor muscles
1. Finger drop
2. Foot drop
3. Interosseus weakness
4. Thumb weakness
5. Quadriceps weakness
Review
Shoulder abduction
Elbow extension
Elbow flexion
Finger extension
Which Muscles are Affected?
Radial mononeuropathy
at the axilla
Deltoid (C5, C6)
Triceps (C6, C7, C8)
Brachioradialis (C5, C6)
Extensor Digitorum Communis (C6, C7)
Radial Nerve (Axilla)
Ankle Eversion
Ankle Inversion
Ankle Plantarflexion
Ankle dorsiflexion
Which Muscles are Affected?
L5 Radiculopathy
Tibialis Posterior (L5, S1)
Peroneus Longus (L5, S1)
Tibialis Anterior (L4, L5)
Gluteus Medius (L5, S1)
Gastrocnemius (S1, S2)
L5 Root
Index finger
extension
Finger abduction
Thumb abduction
Which Muscles are Affected?
Medial cord plexopathy
Ulnar NerveMedial Cord
Lower Trunk
C8 Root
Interossei
Median Nerve
Medial CordLower Trunk
C8 Root
Abductor pollicis brevis
Radial Nerve Posterior Cord
Lower Trunk
C8 Root
Extensor indicis
Index finger
extension
Finger abduction
Thumb abduction
Which Muscles are Affected?
Medial cord plexopathy
Finger abduction
Thumb flexion
Thumb abduction
Which Muscles are Affected?
Anterior interosseus
mononeuropathy
Median nerve
Carpal Tunnel
Abductor pollicis brevis
Flexor pollicis longus
Elbow
Anterior Interosseus
Hip adduction
Hip flexion
Knee extension
Which Muscles are Affected?
L4 radiculopathy
Quadriceps (L3, L4)
Adductors (L2, L3, L4)
Iliopsoas (L2, L3)
L4 Root
Thank You