NERVES OF UPPER LIMB AND THEIR INJURIES

LEARNING OBJECTIVES Revise the course and branches of nerves of upper limbs Understand Injuries associated with these nerves Know causes and motor and sensory loss associated with nerve injuries of upper limb Know deformities associated with these nerves

BRACHIAL PLEXUS
Present in neck and axilla Formed by ventral primary rami of C5-T1 ROOTS C5+C6=UPPERTRUNK C7---- MIDDLE TRUNK C8+T1 = LOWER TRUNK All trunk divides into anterior and posterior DIVISIONS Anterior divisions of upper and middle trunk unite to form LATERAL CORD Anterior division of middle trunk continues as MEDIAL CORD Posterior divisions of all 3 trunk form POSTERIOR CORD

BRANCHES FROM ROOTS & TRUNKS ROOTS: Dorsal scapular nerve C5, Long thoracic nerve C5,6,7 UPPER TRUNK C5 C6 Suprascapular nerve , Nerve to subclavius BRANCHES FROM LATERAL CORD Lateral pectoral nerve Musculocutaneous nerve Lateral root of median BRANCHES FROM MEDIAL CORD Medial pectoral nerve Medial cutaneous nerve of arm and forearm Ulnar nerve Medial root of median BRANCHES FROM POSTERIOR CORD Upper and lower subscapular nerves Thoracodorsal Axillary nerve Radial nerve

BRACHIAL PLEXUS INJURIES 1. Upper lesions of brachial plexus Erb duchenne palsy 2. Lower lesions of brachial plexus Klumpke palsy UPPER LESION OF BRACHIAL PLEXUS Traction or even tearing of C5 and C6 root Cause: Excessive displacement of head to opposite side and depression of shoulder on same side In infants during a difficult delivery In adults following a fall on or a blow to the shoulder Nerves involved: Supra scapular nerve, Nerve to Subclavius Musculocutaneous nerve ,Axillary nerve MUSCLES AND FUNCTIONS LOST Lateral rotation of arm: Teres minor Infraspinatus Abduction of shoulder Supraspinatus Deltoid Flexion of shoulder: corobrachialis Biceps brachii Flexion of elbow: Brachialis Biceps brachii Supination of forearm Biceps brachii ERBS PALSY (UPPER TRUNK INJURY) Loss of muscle function innervated by C5 and C6 Also known as waiters tip or policemans tip Arm medially rotated, adducted, hangs by side Forearm extended and pronated

LOWER LESIONS OF BRACHIAL PLEXUS Fibers of C8 and mostlyT1 root are torn Cause: Excessive abduction of arm a) Birth injury in breech delivery b) Person falling from a height clutching an object to save himself Compression of lower trunk a) Cervical rib b) Malignant mets in lower deep cervical lymph nodes Nerves involved T1 fibers run in ulnar and median nerve Muscles involved All small muscles of the hand( interossei and lumbricals) Sensory loss along the medial side of forearm KLUMPKE,S PALSY Clawed hand Hyperextension of metacarpophalangeal joint----- by unopposed extensor digitorum Flexion at interphalangeal joint by unopposed flexor digitorum superficialis and profundus LONG THORACIC NERVE Arise from roots c5 , c6 and c7 Muscles involved Serratus anterior Functions lost Abduction above 90 degrees Causes: Blows or pressure in posterior triangle of neck In radical mastectomy Deformity Winging of scapula vertebral border and inferior angle of scapula unduly prominent

AXILLARY NERVE From posterior cord Important landmarks Axilla quadrangular space scapular region In quadrangular space----close relation with shoulder joint and surgical neck of humerus Terminates by dividing into anterior and posterior branches

AXILLARY NERVE INJURY Arise from posterior cord of brachial plexus Causes a. Fracture of surgical neck of humerus b. Inferior dislocation of shoulder joint c. Pressure of badly adjusted crutch upward into armpit d. Misplaced injection into deltoid Muscles involved Deltoid Teres minor Sensory loss Upper lateral cutaneous nerve of arm Loss of skin sensation over the lower half of deltoid muscle

RADIAL NERVE

Largest branch of plexus From posterior cord Arise in axilla --- spiral groove - lateral intermuscular septum - front of lateral epicondyle - divides into superficial and deep Superficial -- lateral side of radial artery posterior surface of wrist Deep branch supinator neck of radius posterior surface of wrist

RADIAL NERVE Branches in axilla Posterior cutaneous nerve of ARM Nerve to long head of triceps Nerve to medial head of triceps Branches in spiral groove Lower lateral cutaneous nerve of arm Posterior cutaneous nerve of forearm Nerve to lateral head of triceps Nerve to medial head of triceps Branches in anterior compartment of arm: Nerve to small part of brachialis Nerve to brachioradialis Nerve to extensor carpi radialis longus Branches in cubital fossa: Deep branch of radial nerve to extensor carpi radialis brevis, supinator and all muscles in posterior compartment of forearm Superficial branch provides sensation to dorsum of hand and dorsum of Branches in distal fore arm Palmar cutaneous branch----skin on lateral side of palm Branches in palm Muscle of thenar eminence First 2 lumbricals Skin of palmar surface of lateral 3 fingers lateral 3 fingers RADIAL NERVE INJURIES IN AXILLA Causes Pressure of badly fitted crutch into armpit Falling asleep with arm over the back of chair-----Saturday night palsy Motor loss: Extension at elbow----- paralysis of triceps and anconeus Extension of wrist and fingers-----paralysis of extensors of wrist and all muscles of posterior compartment Supination----can still be performed by

Deformity known as WRIST DROP -----flexion of wrist as a result of action of unopposed flexors of wrist and fingers Sensory loss posterior surface of arm and fore arm Dorsum of hand and dorsal surface of lateral 3 fingers RADIAL NERVE INJURY IN SPIRAL GROOVE Most commonly in distal part of groove beyond the origin of nerves to triceps and anconeus and cutaneous nerves Causes: Fracture of shaft of humerus Prolonged pressure on the back of arm as in Unconscious patient by edge of operating table Prolonged application of tourniquet in thin lean person Motor loss: Extension of wrist, fingers and thumb Elbow extension is spared Sensory loss: Dorsum of hand and dorsum of lateral 3 fingers Sensations on posterior arm and forearm are spared

MEDIAN NERVE Formed in axilla by lateral and medial roots from respective cords Anterior compartment of arm ---- crosses brachial artery from lateral to medial At elbow crossed by bicipital aponeurosis Passes between 2 heads of pronator teres to enter forearm At wrist at lateral border of flexor digitorum profundus Enter palm beneath flexor retinaculum Branches in axilla and arm no branches Branches in proximal forearm To all anterior compartment muscles except flexor carpi ulnaris and medial half of flexor digitorum profundus

Branches in distal fore arm Palmar cutaneous branch----skin on lateral side of palm Branches in palm Muscle of thenar eminence First 2 lumbricals Skin of palmar surface of lateral 3 fingers INJURY TO MEDIAN NERVE AT ELBOW Cause: Supracondylar fracture of humerus Motor loss Loss of pronator of forearm Loss of long flexors of wrist and fingers except medial half of flexor digitorum profundus and flexor carpi ulnaris Loss of flexion of terminal phalanx of thumb Loss of thenar muscles (wasted) Deformity: Forearm ----supinated Wrist----flexion is weak accompanied by adduction Fingers----no flexion of interphalangeal joint of index and middle Thumb---flexion, abduction and opposition is lost APES HAND----thumb laterally rotated adducted and thenar eminence flattened Sensory loss Lateral side of palm Palmar surface of lateral 3 fingers Distal part of dorsal surface of lateral 3 fingers

INJURY TO MEDIAN NERVE AT WRIST Most common injury of median nerve Causes Due to penetrating injuries or stab wound at the wrist Motor loss Muscle of thenar eminence First two lumbricals Deformity APES HAND Sensory loss Same as in elbow lesion

INJURY TO MEDIAN NERVE IN CARPAL TUNNEL Carpal tunnel---Osseo fibrous space formed by anterior concave surface of carpus and flexor retinaculum Passage of long flexor tendon and median nerve Syndrome is caused by compression of median nerve due reduced size of canal Causes Inflammation of retinaculum Arthritis of carpal bones Inflammation of synovial sheaths of flexor tendons Sensory and motor Loss: Pain and paraesthesia of lateral one and half finger Weakness of thenar muscle ULNAR NERVE Arise from medial cord in axilla Descends between axillary artery and vein In anterior compartment of arm on medial side of brachial artery Pierces medial intermuscular septum to enter in posterior compartment At elbow lies behind medial epicondyle Enter forearm between 2 heads of flexor carpi ulnaris At wrist between tendons of flexor carpi ulnaris and digitorum profundus Enter palm superficial to flexor retinaculum Branches in axilla or arm No branches Branches in proximal forearm Nerve to flexor carpii ulnaris Medial half of flexor digitorum profundus Branches in distal forearm Palmar cutaneous branch -----skin of hypothenar eminence to

Posterior cutaneous branch----skin of medial third of dorsum of hand and dorsal side of medial one and half finger

Branches in palm Superficial branch of ulnar---- skin of palmar surface of medial one and half finger Deep branch of ulnar All small muscles of hand except of thenar muscles and first 2 lumbricals

ULNAR NERVE INJURY AT THE ELBOW Most commonly injured at this site Cause Fracture of medial epicondyle Motor loss Flexor carpi ulnaris and medial half of flexor digitorum profundus Small muscle of hand are paralyzed except thenar muscles and first 2 lumbricals Deformity Wasting of ulnar border of forearm Terminal phalanges of little and ring finger can not be flexed Inability to abduct and adduct fingers Loss of adduction of thumb Forments sign flexion of terminal phalanx of thumb while attempting adduct the thumb in ulnar nerve palsy CLAW HAND a. Metacarpophalangeal joints of fourth and fifth finger are hyper extended b. Interphlangeal joint of fourth and fifth fingers are flexed Flattening of hypothenar eminence Hollowing between metacarpals on dorsum of hand due to paralysis of dorsal interossei

Sensory loss Anterior and posterior surfaces of medial half of hand and medial one and half fingers

ULNAR NERVE INJURY AT WRIST Due to superficial position Causes Penetrating wounds Motor loss Small muscles of hand except those of thenar eminence and first 2 lumbricals Deformity Claw hand more prominent Sensory loss On the medial side of palm and palmar and dorsal surface of 1 fingers Sensation on posterior medial surface of hand is intact

summary
Erbs palsy------upper trunk Klumpkes palsy---- lower trunk Winging of scapula---- long thoracic nerve Ape s hand---- median nerve---- supracondylar fracture Wrist drop------ Radial nerve---fracture of spiral groove Claw hand-----ulnar nerve----- fracture of medial epicondyle