2. NERVE INJURIES OF
THE UPPER LIMB
Muhammad Ramzan Ul Rehman
Muhammad Ramzan Ul Rehman
3. Upper limb is supplied by the branches
of the brachial plexus, formed by the
ventral rami of the spinal nerves C5, 6, 7,
8, and T1
Since the spinal nerves are mixed nerves carrying
sensory, motor and autonomic fibers, their injuries result
in sensory, motor and autonomic disturbances
Muhammad Ramzan Ul Rehman
4. SYMPTOMS & SIGNS OF PERIPHERAL NERVE INJURY
Depend on the site and extent of the lesion
Motor changes: The innervated muscles become paralyzed.
The reflexes in which the muscles participate are lost
Sensory changes: Loss of cutaneous sensibility over the area
exclusively supplied by the nerve
Trophic changes: Due to interruption of postganglionic
sympathetic fibers:
There is loss of vascular control: the skin at first becomes red & hot.
Later becomes blue and colder than normal. The nail growth
becomes retarded
The sweat glands cease to produce sweat and the skin becomes dry
and scaly
Muhammad Ramzan Ul Rehman
5. UPPER LIMB TENDON REFLEXES
Biceps brachii reflex: C5, 6
(flexion of elbow joint by
tapping the tendon of biceps
muscle)
Triceps brachii reflex: C6, 7, 8
(extension of elbow joint by
tapping the tendon of triceps
muscle)
Supinator (brachioradialis)
reflex: C5, 6, 7 (supination of
radioulnar joint by tapping the
tendon of brachioradialis
muscle)
Muhammad Ramzan Ul Rehman
7. A spinal nerve may get injured:
1. at the level of its roots within
the vertebral canal
2. at the level of its passage
through the intervertebral
foramen
3. At any level in its peripheral
course
Injuries 1 & 2 may result due to:
Fracture of the vertebra
Narrowing of intervertebral
foramina
Herniation of the intervertebral
disc
Degeneration of the
intervertebral disc
Muhammad Ramzan Ul Rehman
8. BRACHIAL PLEXUS INJURIES
May involve the roots, trunks,
divisions, cords & branches
Supraclavicular injuries involve the
roots and the trunks, infraclavicular
injuries will affect the divisions and
cords
Result due to:
Compression
Traction
Stab wounds
Symptoms depend on the site of
injury & involvement of nerve fibers
Muhammad Ramzan Ul Rehman
9. BRACHIAL PLEXUS INJURIES
Are of two types:
Upper lesions usually involving C5 & C6
Lower lesions usually involving (C8), T1
Muhammad Ramzan Ul Rehman
10. UPPER LESIONS OF THE BRACHIAL PLEXUS
(ERB-DUCHENNE PALSY)
• These are usually the result of
traction & tearing of the 5th and
6th root of the brachial plexus
• This may occur:
• In infants during a difficult
delivery
• In adults following a fall on or a
blow to the shoulder.
• It involves the:
• Nerve to sublavius
• Suprascapular nerve
• Axillary nerve
• Musculocutaneous nerve
Muhammad Ramzan Ul Rehman
11. The muscles affected are:
Abductors (supraspinatus & deltoid)
and lateral rotators (Infraspinatus
&teres minor) of the shoulder
Subclavius, biceps, brachialis &
coracobrachialis
Thus:
The limb hangs limply by the side,
and is medially rotated
The forearm is pronated and
extended
There is loss of sensation down the
lateral side of the arm & the forearm
Another name for this lesion is 'porters
tip'
Muhammad Ramzan Ul Rehman
12. LOWER LESIONS OF THE BRACHIAL PLEXUS
(KLUMPKE PALSY)
These are usually caused by
excessive abduction of the arm
as a result of:
Someone clutching for an
object when falling from a
height
Difficult delivery in which
baby’s upper limb is pulled
excessively.
Result of malignant
metastases from the lungs in
the lower deep cervical lymph
nodes
A cervical rib
Muhammad Ramzan Ul Rehman
13. Usually the lowest root (T1) of the brachial plexus is
involved
The fibers from this segment of the spinal cord
supply the small muscles of the hand (interossei
and lumbricals).
Paralysis and wasting of small muscles of hand
occurs
There is also sensory loss along the medial side of
the forearm, hand and medial 2 fingers
Often associated with Horner’s syndrome (drooping
of upper eyelid & constricted pupil) due to traction
of sympathetic fibers
Muhammad Ramzan Ul Rehman
14. The hand has a clawed appearance
due to:
Hyperextension of the
metacarpophalangeal joints (the
extensor digitorum is unopposed
by the lumbricals and interossei
and extends the
metacarpophalangeal joints).
Flexion of the interphalangeal
joints (the flexor digitorum
superficialis and profundus are
unopposed by the lumbricals and
interossei, the middle and terminal
phalanges are flexed).
Muhammad Ramzan Ul Rehman
15. LONG THORACIC NERVE LESION
(NERVE TO SERRATUS ANTERIOR)
This nerve may be injured by:
Blows or pressure in the
posterior triangle of the neck
During a radical mastectomy
surgical procedure.
The serratus anterior muscle:
Pulls the medial border of the
scapula to the posterior
thoracic wall and stabilizes it
there.
Rotates scapula during the
abduction of arm above a right
angle
Muhammad Ramzan Ul Rehman
16. The patient shows difficulty
in raising the arm above the
head
If patient is asked to push
against a wall, the medial
border of the scapula will be
pushed away from the
thoracic wall and protrude
like a wing, on the side of the
lesion. 'winged scapula'.
Muhammad Ramzan Ul Rehman
17. AXILLARY NERVE LESION
Axillary nerve may get injured:
Due to downward dislocation of
humeral head in shoulder
dislocation
Fracture of the surgical neck of
humerus
Deltoid and teres minor muscles
become paralyzed
Abduction of the shoulder is
impaired. The paralyzed deltoid
wastes rapidly (loss of rounded
contour of the shoulder)
Loss of sensation over the lower
half of deltoid muscle
Muhammad Ramzan Ul Rehman
18. RADIAL NERVE
The radial nerve is commonly damaged:
in the axilla
in the radial groove
Injury to the deep branch (in the supinator tunnel)
Injury to the superficial branch
Muhammad Ramzan Ul Rehman
19. RADIAL NERVE INJURY IN THE AXILLA
In the axilla the nerve may be
injured by:
Pressure of the upper end of
badly fitting crutch pressing up
in to the armpit (crutch palsy)
The drunkard falling asleep
with his arm over the back of a
chair (saturday night palsy).
Fractures or dislocations of the
upper end of the humerus
Muhammad Ramzan Ul Rehman
20. Motor:
Triceps, anconeus and long extensor of the
wrist are paralysed.
The patient is unable to extend the elbow
joint, wrist joint and fingers.
“Wrist drop” or flexion of the wrist occurs
as a result of the unopposed flexor muscles
of the wrist.
This is a very disabling injury, since a
person can't flex the fingers strongly for
gripping an object with the wrist fully
flexed.
The brachioradialis and supinator muscles
are paralyzed, but supination can still be
performed due to intact biceps brachii.
Muhammad Ramzan Ul Rehman
21. Sensory: Due to the overlap of
sensory innervation by adjacent
median & ulnar nerves, the area
of total anaesthesia is relatively
small, overlying the first dorsal
interosseous muscle (between
the 1st and 2nd metacarpal bones)
Muhammad Ramzan Ul Rehman
22. RADIAL NERVE INJURY IN THE RADIAL
GROOVE
The most common lesion of the
radial nerve resulting because of
the:
Fracture of the shaft of
humerus
Callus formation
Pressure on the back of the arm
on the edge of the operating
table in an unconscious patient
Prolonged application of
tourniquet.
Muhammad Ramzan Ul Rehman
23. The injury to radial nerve occurs most
commonly in the distal part of the
groove beyond the origin of the nerve
to the triceps & anconeus (so that
extension of the elbow is possible), and
beyond the origin of the cutaneous
nerves
Motor :The long extensors of the
forearm are paralyzed and this will
result in a "wrist drop".
Sensory: Loss of sensation from small
area overlying the first dorsal
interosseous muscle
Muhammad Ramzan Ul Rehman
24. INJURY TO THE DEEP BRANCH OF THE RADIAL
NERVE
It may be damaged in fractures of the proximal end of
the radius or during dislocation of the radial head.
Motor:.
Intact forearm extension and flexion with intact hand extension.
Only weakness of finger extensors.
Nerve supply to the supinator and extensor carpi radialis longus
will be undamaged and because the later muscle is powerful it
will keep the wrist joint extended and wrist drop will not occur.
Sensory: There will be no sensory loss since this is a
motor nerve.
Muhammad Ramzan Ul Rehman
25. INJURY TO THE SUPERFICIAL BRANCH OF THE
RADIAL NERVE
It may be damaged as a result of stab injury, or
pressure from handcuffs & tight bangles
Motor: There will be no motor loss since this is a
sensory nerve.
Sensory: There is a small loss of sensation over the
dorsal surface of the hand and the dorsal surfaces of
the roots of the lateral three fingers
Muhammad Ramzan Ul Rehman
26. MEDIAN NERVE LESIONS
Injury of median nerve at
different levels cause different
syndromes.
The most serious disability of
median nerve injuries is the:
Loss of opposition of the thumb. The
delicate pincer-like action is not possible
Loss of sensation from the thumb and lateral
2½ fingers & lateral ⅔ of the palm
Muhammad Ramzan Ul Rehman
27. MEDIAN NERVE LESIONS
Median nerve can be damaged:
In the elbow region
At the wrist above the flexor retinaculum
In the carpal tunnel
Muhammad Ramzan Ul Rehman
28. MEDIAN NERVE LESION IN THE ELBOW REGION
Damaged in supracondylar
fracture of humerus
Muscles affected are:
Pronator muscles of the forearm
All long flexors of the wrist and fingers
except flexor carpi ulnaris and medial
half of flexor digitorum profundus
Muhammad Ramzan Ul Rehman
29. Motor:
Loss of pronation. Hand is kept in supine
position
Wrist shows weak flexion, and ulnar
deviation
No flexion possible on the interphalangeal
joints of the index and middle fingers
Weak flexion of ring and little finger
Thumb is adducted and laterally rotated,
with loss of flexion of terminal phalanx and
loss of opposition
Wasting of thenar eminence
Hand looks flattened and “apelike”, and
presents an inability to flex the three most
radial digits when asked to make a fist.
Muhammad Ramzan Ul Rehman
30. Sensory: Loss of sensation from:
The radial side of the palm
Palmer aspect of the lateral 3½
fingers
Distal part of the dorsal surface of
the lateral 3½ fingers
Trophic Changes:
Dry and scaly skin
Easily cracking nails
Atrophy of the pulp of the fingers
Muhammad Ramzan Ul Rehman
31. MEDIAN NERVE LESION AT THE WRIST
Often injured by penetrating wounds (stab wounds or
broken glass) of the forearm
Motor: Thenar muscles are paralyzed and atrophy in
time so that the thenar eminence becomes flattened.
Opposition and abduction of thumb are lost, and
thumb and lateral two fingers are arrested in
adduction and hyperextension position. “Apelike
hand”
Sensory & trophic changes are the same as in the
elbow region injuries
Muhammad Ramzan Ul Rehman
32. CARPAL TUNNEL SYNDROME
Compression of median nerve in
the carpal tunnel
Motor:Weak motor function of
thumb, index & middle finger
Sensory: Burning pain or ‘pins
and needles’ along the
distribution of median nerve to
lateral 3½ fingers
No sensory changes over the
palm as the palmer cutaneous
branch is given before the
median nerve enters the carpal
tunnel
Muhammad Ramzan Ul Rehman
33. ULNAR NERVE LESION
Ulnar nerve can be damaged:
At the elbow, where it lies behind the medial
epicondyle
At the wrist, where it lies with the ulnar artery
superficial to the flexor retinaculum
Muhammad Ramzan Ul Rehman
34. ULNAR NERVE LESION AT THE ELBOW
Often injured with fractures of the
medial epicondyle
Motor paralysis involves:
Flexor carpi ulnaris
Medial half of flexor digitorum
profundus
Small muscles of the hands, except
the muscles of thenar eminence and
first two lumbricals.
Adductor pollicis
Sensory loss over the anterior &
posterior surfaces of the palm &
medial one and half finger
Trophic changes: because of loss of
sympathetic control
Muhammad Ramzan Ul Rehman
35. Flexion of the wrist will result in
abduction
The thumb is abducted and extended
with the distal phalanx flexed (difficulty in
holding a piece of paper between thumb
and index finger).
The adduction and abduction of fingers is
lost (difficulty in holding a piece of paper
between fingers).
The lateral two fingers are fully extended
with a slight flexion of the distal
phalanges.
The medial two fingers are
hyperextended at the
metacarpophalangeal joints but flexed at
the distal phalangeal joints.
Muhammad Ramzan Ul Rehman
36. Wasting of the hypothenar
eminence
The dorsum of the hand
shows hollowing between
the metacarpal bones
The hand resembles a "claw"
and is called a claw hand.
The clawing becomes most
obvious when the person is
asked to straighten their
fingers.
Muhammad Ramzan Ul Rehman
37. ULNAR NERVE LESION AT THE WRIST
Commonly occur due to cuts and stab wounds
Motor: The small muscles of the hands are paralyzed,
except the muscles of thenar eminence and first two
lumbricals. The claw hand is more obvious as the flexor
digitorum profundus is intact
Sensory loss over the anterior surfaces of the palm and
the anterior & posterior surfaces of the medial one and
half finger. (The posterior surface of the hand is spared as
the posterior cutaneous branch arises above the level of
wrist)
Muhammad Ramzan Ul Rehman