Peripheral Nerve Injuries of the Upper Limb

Dermatomes of the Posterior Arm

Dermatomes of the Anterior Arm

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

Principles of localization, cont

Order in which branches arise Movements at specific joints Single nerve Elbow extension Radial Multiple nerves Elbow flexion Musculocutaneous Radial

Case 1
A 38 yr woman was the restrained passenger in a car struck head on She braced her hands on the dashboard immediately prior to impact She suffered bilateral fractures of the humerus at the spiral (radial) groove She complains of diffuse aches in her arms and neck and weakness in her arms

Case 1, cont
On exam she has:
Bilateral wrist and finger drop (ie profound weakness of wrist and finger extension at the MCPs) Weakness of supination Weakness of elbow flexion with forearm held so that thumb is toward shoulder, but not with hand held in supination Remainder of strength exam is normal She has numbness in the posterior forearm extending into dorsum of hand into thumb and proximal index finger

Case 1, cont
FINDING MUSCLE
WR DROP ECR, ECU

ROOT
C7, C8

PLEXUS
POST C

PN
RADIAL

MT, LT
FING DRP EDC,EI C7, C8 POST C MT, LT POST C UT LAT C UT RADIAL

ELB FLX

BR

C5,C6

RADIAL

SENS

----

C6

RADIAL

Triceps, long head Triceps, lateral head Brachioradialis ECRL ECRB Supinator Ext Digit Abd Pol Longus Ext Pol Longus Ext Pol Br Ext Indicies

Triceps, med hd

Superficial Radial sens Post Interosseous

Sensory loss in a high radial nerve lesion (Signficant variability b/w patients)

Final Diagnosis

????????????

Bilateral radial nerve palsies at the spiral (radial) groove related to fractures

Case 2
A 25 year old man gets involved in a fist fight and the police arrest him When he is released on bail, he goes to see his doctor because he has numbness in the hand On exam he had a number of scratches and bruises on both arms normal strength sensory loss on the dorsum of the hand

Patients sensory loss

Case 2, cont
FINDING SENS LOSS ROOT < C6 PLEXUS < LAT CORD PN SUP RAD SENS

Triceps, long head Triceps, lateral head Brachioradialis ECRL ECRB Supinator Ext Digit Abd Pol Longus Ext Pol Longus Ext Pol Br Ext Indicies

Triceps, med hd

Superficial Radial sens Post Interosseous

Final Diagnosis
??????????????????

Superficial radial neuropathy secondary to handcuffs

Case 3
15 yo football player is hit be another player, with the helmet striking him in the axilla On getting up, he is aware of shoulder weakness and pain and is taken to the ER

Case 3, cont
On exam he has: Normal elbow flexion Normal elbow extension Normal shoulder adduction Ability to initiate shoulder abduction, but he cannot raise his arm more than 15 degrees Mild weakness of external (lateral) rotation of the arm A patch of sensory loss over his upper arm

Case 3, sensory loss

Case 3, cont
FINDING Abd>15 Ext Rot Sens MUSCLE Deltoid T. Minor Infrasp ------ROOT C5,6 C5,6 C5,6 <C5 PLEXUS Post C UT Post C UT <POST C <UT PN Axillary Axillary Suprascap Axillary

C5
C6 C7

C8
T1

Case 3, cont
If its at the posterior cord Radial innervated muscles should be affected But elbow extension is spared If its at the upper trunk Musculocutaneous innervated muscles should be affected But elbow flexion is spared

Pattern of sensory loss

Case 3, Final diagnosis

???????? Axillary Neuropathy in the Axilla

Case 4
A 55 yo hospital worker comes to see you with a 2 week history of pain in her neck, shoulder, and upper arm Symptoms began when she tried to help restrain a combative patient

Case 4, cont
On exam she she: Weakness of shoulder abduction Weakness of elbow flexion Mild weakness of pronation Sensory loss in her lateral forearm and thumb both posteriorly and anteriorly

Case 4, cont
FINDING MUSCLE ARM ABD DELTOID Suprasp ROOT PLEXUS C5,6 PN

POST C, UT AXIL SUPRASC MED C, UT MUSC POST C, UT RAD LAT C MED

ELB FLX BC, BRACH C5,6 BR PRON PT C6,7

SENS

------

C6

LAT C, UT

MULT

Case 4, Final Diagnosis

???????? C6 Radiculopathy secondary to a herniated disc

Case 5
40 yo woman comes to see you because she has noticed weakness and numbness in her right hand This started 2 months ago and is slowly worsening She is otherwise healthy, and rides her bike at lease 40 miles per week

Case 5, cont
On exam she has: Atrophy of the interosseous muscles of the right hand Mild weakness of abducting and adducting the fingers Normal thumb abduction, opposition and extension Normal wrist flexion, abduction and adduction

Case 5, sensory loss

CASE 5, cont
FINDING MUSCLE ROOT PLEXUS FING AD PALM INT FING ABD Sens loss C8T1 MED C, LT MED C, LT LT/Med Cd PN ULNAR ULNAR Uln

DORSAL C8T1 INT ---<C8

Case 5, cont
If its the lower trunk, C8/T1, or medial cord other muscles affected should include: APB and Opponens pollicus (median) EPL and EPB (radial)

Can it be localized further to a specific site of the ulnar nerve?

Ulnar sensory loss in an ulnar lesion proximal to the midforearm

Ulnar nerve
Elbow Flexor carpi ulnaris

Flex Dig Prof III/IV Dorsal uln cut Wrist Abductor Opponens Digiti Minimi Flexor

Adductor Pollicus Flex Pollicus Br Dorsal/palmar Interosseous

3rd/4th lumbricals

Case 5, final diagnosis

?????????

Ulnar neuropathy at the wrist