NERVE INJURIES OF NERVE INJURIES OF UPPER LIMBUPPER LIMB

Brachial Plexus InjuriesBrachial Plexus Injuries(upper lesions)(upper lesions)

These are caused by the excessive These are caused by the excessive displacement of the head to the opposite displacement of the head to the opposite sideside

Depression of the shoulder on the same Depression of the shoulder on the same sideside

This causes excessive traction or tearing This causes excessive traction or tearing of C5 and C6 roots of the plexusof C5 and C6 roots of the plexus

Nerves To be AffectedNerves To be Affected

The suprascapular nerveThe suprascapular nerve

The nerve to the subclaviusThe nerve to the subclavius

The musculocutaneous nerveThe musculocutaneous nerve

Axillary nerveAxillary nerve

All possess nerve fibers derived from C5 and 6 roots All possess nerve fibers derived from C5 and 6 roots and will therefore be functionlessand will therefore be functionless

Muscles to be ParalyzedMuscles to be Paralyzed Supraspinatus (Abductor of shoulder)Supraspinatus (Abductor of shoulder)

Subclavius (depresses the clavicle)Subclavius (depresses the clavicle)

Infraspinatus (lateral rotator of shoulder)Infraspinatus (lateral rotator of shoulder)

Biceps brachii (flexor of elbow)Biceps brachii (flexor of elbow)

Coracobrachialis (flexor of shoulder)Coracobrachialis (flexor of shoulder)

Deltoid (Abductor of shoulder)Deltoid (Abductor of shoulder)

Teres minor (lateral rotator of shoulder)Teres minor (lateral rotator of shoulder)

Erb-Duchenne PalsyErb-Duchenne Palsy

The limb hangs limply The limb hangs limply by the side likenedby the side likenedto a waiter or porter to a waiter or porter hinting for a tiphinting for a tip

There will be a loss ofThere will be a loss ofsensation down the sensation down the lateral side of armlateral side of arm

Brachial Plexus InjuriesBrachial Plexus Injuries(Lower lesions)(Lower lesions)

Are usually a traction injuries caused by Are usually a traction injuries caused by excessive abduction of the armexcessive abduction of the arm

The first thoracic nerve is usually tornThe first thoracic nerve is usually torn

The hand has a clawed appearance The hand has a clawed appearance caused by hyperextension of caused by hyperextension of metacarpophalangeal joints & flexion of metacarpophalangeal joints & flexion of interphalangeal jointsinterphalangeal joints

Brachial Plexus InjuriesBrachial Plexus Injuries(Lower lesions)(Lower lesions)

Loss of sensation will occur along the Loss of sensation will occur along the medial side of the armmedial side of the arm

Lower lesions can also be produced by a Lower lesions can also be produced by a presence of a cervical rib or malignant presence of a cervical rib or malignant metastases from the lungs in the lower metastases from the lungs in the lower deep cervical lymph nodesdeep cervical lymph nodes

Injuries of Long Thoracic NerveInjuries of Long Thoracic Nerve

Can be injured by blows to or pressure on the Can be injured by blows to or pressure on the posterior triangle of the neckposterior triangle of the neck

During the surgical procedure of radical During the surgical procedure of radical mastectomymastectomy

Paralysis of the serratus anterior results in the Paralysis of the serratus anterior results in the inability to rotate the scapula during the inability to rotate the scapula during the movement of abduction of the arm above a right movement of abduction of the arm above a right angleangle

Injuries of Long Thoracic NerveInjuries of Long Thoracic Nerve

The patient feels difficulty in raising the The patient feels difficulty in raising the armarm

The vertebral border & inferior angle of The vertebral border & inferior angle of scapula protrude posteriorlyscapula protrude posteriorly

Known as winged scapulaKnown as winged scapula

Injuries of Axillary NerveInjuries of Axillary Nerve

Can be injured by the pressure of a badly Can be injured by the pressure of a badly adjusted crutch pressing upward into the armpitadjusted crutch pressing upward into the armpit

It is vulnerable during the downward It is vulnerable during the downward displacement of the humeral head in shoulder displacement of the humeral head in shoulder dislocations or fractures of the surgical neck of dislocations or fractures of the surgical neck of the humerusthe humerus

Paralysis of deltoid and teres minor muscles Paralysis of deltoid and teres minor muscles resultsresults

Axillary NerveAxillary Nerve

Loss of skin sensation over the lower half of the Loss of skin sensation over the lower half of the deltoid muscle deltoid muscle

Paralyzed deltoid wastes rapidlyParalyzed deltoid wastes rapidly

Underlying greater tuberosity can be palpatedUnderlying greater tuberosity can be palpated

Abduction of the shoulder is impairedAbduction of the shoulder is impaired

Paralysis of teres minor is not recognizable Paralysis of teres minor is not recognizable clinicallyclinically

Injuries of Radial NerveInjuries of Radial Nerve

Can be injured by:Can be injured by:

Pressure of badly fitting crutchesPressure of badly fitting crutches

Drunkard falling asleep with one arm over Drunkard falling asleep with one arm over the back of a chairthe back of a chair

Fractures or dislocation of the proximal Fractures or dislocation of the proximal end of the humerusend of the humerus

Findings in Radial N. InjuryFindings in Radial N. Injury

Triceps, anconeus and long extensors of the Triceps, anconeus and long extensors of the wrist are paralyzedwrist are paralyzed

Unable to extend the elbow joint, wrist joint and Unable to extend the elbow joint, wrist joint and fingersfingers

Wrist drop or flexion of wrist occurs Wrist drop or flexion of wrist occurs

Unable to flex the fingers firmly for grippingUnable to flex the fingers firmly for gripping

Brachioradialis & supinator are paralyzedBrachioradialis & supinator are paralyzed

Sensory FindingsSensory Findings

Small loss of skin sensation over posterior Small loss of skin sensation over posterior surface of lower part of the armsurface of lower part of the arm

Sensory loss on the lateral part of dorsum Sensory loss on the lateral part of dorsum of the handof the hand

Sensory loss on the dorsal surface of the Sensory loss on the dorsal surface of the roots of the lateral 3 & ½ fingers roots of the lateral 3 & ½ fingers

In the Spiral GrooveIn the Spiral Groove

Radial nerve can be injured in the spiral Radial nerve can be injured in the spiral groove at the time of fracture of shaft of groove at the time of fracture of shaft of the humerusthe humerus

Wrist drop occursWrist drop occurs

Sensory loss on the dorsal surface of the Sensory loss on the dorsal surface of the roots of the lateral 3 & ½ fingers roots of the lateral 3 & ½ fingers

Deep Branch of Radial NerveDeep Branch of Radial Nerve

Can be damaged in the fracture of the Can be damaged in the fracture of the proximal end of radius or during dislocation proximal end of radius or during dislocation of the radial headof the radial head

No wrist drop as extensor carpi radialis No wrist drop as extensor carpi radialis longus is undamagedlongus is undamaged

No sensory loss as this is a motor nerveNo sensory loss as this is a motor nerve

Injuries of Musculocutaneous Injuries of Musculocutaneous NerveNerve

Rarely injured due to its protected position Rarely injured due to its protected position beneath the biceps brachii musclebeneath the biceps brachii muscle

If injured high up in the arm, the biceps & If injured high up in the arm, the biceps & coracobrachialis are paralyzed & coracobrachialis are paralyzed & brachialis is weakenedbrachialis is weakened

Sensory loss along the lateral side of the Sensory loss along the lateral side of the forearm occursforearm occurs

Injuries of Median NerveInjuries of Median Nerve

Can be injured:Can be injured:

Occasionally in the elbow region in Occasionally in the elbow region in supracondylar fractures of the humerussupracondylar fractures of the humerus

Commonly injured by stab wounds or broken Commonly injured by stab wounds or broken glass just proximal to the flexor retinaculumglass just proximal to the flexor retinaculum

Here it lies between the tendons of flexor carpi Here it lies between the tendons of flexor carpi radialis and flexor digitorum superficialisradialis and flexor digitorum superficialis

Injury at ElbowInjury at Elbow(motor)(motor)

Pronator muscles of forearm, long flexor Pronator muscles of forearm, long flexor muscles of the wrist & fingers will be paralyzedmuscles of the wrist & fingers will be paralyzed

Forearm is kept in supine positionForearm is kept in supine position

Wrist flexion is weak & accompanied by Wrist flexion is weak & accompanied by adductionadduction

No flexion at interphalangeal joints of index & No flexion at interphalangeal joints of index & middle fingersmiddle fingers

Injury at ElbowInjury at Elbow(motor)(motor)

When the patient tries to make a fist, the When the patient tries to make a fist, the index & middle fingers tend to remain index & middle fingers tend to remain straightstraight

Only ring & little fingers flexOnly ring & little fingers flex

Flexion in these fingers is weakened by Flexion in these fingers is weakened by the loss of the flexor digitorum superficialisthe loss of the flexor digitorum superficialis

Injury at ElbowInjury at Elbow(motor)(motor)

Flexion of terminal phalanx of thumb is lost Flexion of terminal phalanx of thumb is lost because of paralysis of flexor policis because of paralysis of flexor policis longuslongus

The thumb is laterally rotated and The thumb is laterally rotated and adductedadducted

Muscles of thenar eminence are paralyzedMuscles of thenar eminence are paralyzed

The hand looks flattened and ape likeThe hand looks flattened and ape like

Injury at ElbowInjury at Elbow(sensory)(sensory)

Skin sensation is lost on the palmar aspect Skin sensation is lost on the palmar aspect of the lateral 3 & ½ fingersof the lateral 3 & ½ fingers

Sensory loss occurs on the skin of the Sensory loss occurs on the skin of the distal part of the dorsal surfaces of the distal part of the dorsal surfaces of the lateral 3 & ½ fingerslateral 3 & ½ fingers

Total area of anesthesia is lessTotal area of anesthesia is less

Injury at ElbowInjury at Elbow(vasomotor changes)(vasomotor changes)

The skin areas involved in sensory loss The skin areas involved in sensory loss are warmer and drier than normalare warmer and drier than normal

Arteriolar dilatation and absence of Arteriolar dilatation and absence of sweating resulting from loss of sweating resulting from loss of sympathetic controlsympathetic control

Injury at ElbowInjury at Elbow(Trophic changes)(Trophic changes)

In long standing cases:In long standing cases:

Skin is dry and scaly Skin is dry and scaly

Nails crack easily Nails crack easily

Atrophy of the pulp of the fingers Atrophy of the pulp of the fingers

Injury at WristInjury at Wrist

Almost all the clinical findings are same as Almost all the clinical findings are same as injury of the median nerve at elbowinjury of the median nerve at elbow

In addition a delicate pincer like movement In addition a delicate pincer like movement is not possibleis not possible

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

The carpal tunnel is formed by the The carpal tunnel is formed by the concave anterior surface of carpal bones concave anterior surface of carpal bones and closed by flexor retinaculumand closed by flexor retinaculum

Clinically, the syndrome consists of a Clinically, the syndrome consists of a burning pain or pins & needles along the burning pain or pins & needles along the distribution of the median nervedistribution of the median nerve

Lateral 3 & ½ fingers are involved Lateral 3 & ½ fingers are involved

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

The exact cause is difficult to determineThe exact cause is difficult to determine

Condition is relieved by decompressing Condition is relieved by decompressing the tunnel by making a longitudinal the tunnel by making a longitudinal incision through the flexor retinaculumincision through the flexor retinaculum

Injury to the Ulnar NerveInjury to the Ulnar Nerve(motor at elbow)(motor at elbow)

Flexor carpi ulnaris & medial half of flexor Flexor carpi ulnaris & medial half of flexor digitorum profundus are paralyzeddigitorum profundus are paralyzed

In a tightly clenched fist the tightening of the In a tightly clenched fist the tightening of the tendon of profundus is absenttendon of profundus is absent

Profundus tendon to the ring & little fingers will Profundus tendon to the ring & little fingers will be functionlessbe functionless

Terminal phalanges of these fingers fail to flex Terminal phalanges of these fingers fail to flex properlyproperly

Injury to the Ulnar NerveInjury to the Ulnar Nerve(motor at elbow)(motor at elbow)

Flexion of wrist joint will result in abduction Flexion of wrist joint will result in abduction due to paralysis of flexor carpi ulnarisdue to paralysis of flexor carpi ulnaris

Small muscles of hand will be paralyzed Small muscles of hand will be paralyzed except the muscles of thenar eminence except the muscles of thenar eminence and first 2 lumbricalsand first 2 lumbricals

Adductor pollicis longus is paralyzed so Adductor pollicis longus is paralyzed so the adduction of thumb is not possiblethe adduction of thumb is not possible

Injury to the Ulnar NerveInjury to the Ulnar Nerve(motor at elbow)(motor at elbow)

Metacarpophalangeal joints become Metacarpophalangeal joints become hyperextended due to the paralysis of hyperextended due to the paralysis of lumbrical and interosseous muscleslumbrical and interosseous muscles

Interphalangeal joints are flexed due to the Interphalangeal joints are flexed due to the same reason as mentioned abovesame reason as mentioned above

Dorsum of hand will show hollowing due to Dorsum of hand will show hollowing due to the wasting of dorsal interosseous the wasting of dorsal interosseous musclesmuscles

Injury to the Ulnar NerveInjury to the Ulnar Nerve(sensory at elbow)(sensory at elbow)

Loss of skin sensation of anterior & Loss of skin sensation of anterior & posterior surfaces of the medial 3posterior surfaces of the medial 3rdrd of the of the hand and medial 1 & ½ fingershand and medial 1 & ½ fingers

The skin areas involved in sensory loss The skin areas involved in sensory loss are warmer and drier than normalare warmer and drier than normal

Arteriolar dilatation and absence of Arteriolar dilatation and absence of sweating resulting from loss of sweating resulting from loss of sympathetic controlsympathetic control

Injury to the Ulnar NerveInjury to the Ulnar Nerve(motor at wrist)(motor at wrist)

Small muscles of the hand will be Small muscles of the hand will be paralyzedparalyzed

Claw hand is more obvious as flexor Claw hand is more obvious as flexor digitorum profundus is not paralyzeddigitorum profundus is not paralyzed

Marked flexion of the terminal phalanges Marked flexion of the terminal phalanges occur occur

Injury to the Ulnar NerveInjury to the Ulnar Nerve(sensory at wrist)(sensory at wrist)

The sensory loss is usually confined to the The sensory loss is usually confined to the palmar surface of medial 3palmar surface of medial 3rdrd of the hand and the of the hand and the medial 1 & ½ fingermedial 1 & ½ finger

Trophic changes are same as that injuries of Trophic changes are same as that injuries of ulnar nerve at elbowulnar nerve at elbow

Unlike median nerve injuries, lesions of ulnar Unlike median nerve injuries, lesions of ulnar nerve leave a relatively efficient handnerve leave a relatively efficient hand

Pincer like action is goodPincer like action is good