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MOB TCD

Anatomy of Nerve Injuries
Upper Limb
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity Coll...
MOB TCD

Anatomy of Nerve Injuries
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•
•

Dermatomes
Myotomes
Nerves entrapped
Pierce muscle
Pierce fascia
Repetitiv...
MOB TCD

Dermatomes
•
•
•
•
•

Skin
Bones
Muscles, tendons
Nerves
Blood vessels
MOB TCD

Cutaneous Supply
MOB TCD

Extrinsic Factors
• External forces
• Fibro-osseous tunnels tether
the nerve
• Oedema
• Callus formation as a res...
MOB TCD

Extrinsic Factors
•
•
•
•
•

Fibrous bands
Accessory muscles
Spurs
Narrow notches
Anatomical variations of the ne...
MOB TCD

Extrinsic Factors
Congenital and structural
anomalies include:
• Cervical ribs
• Scalenus anterior syndrome
• Fib...
MOB TCD

Extrinsic Factors
• Costoclavicular, where it may also be

•
•
•
•

due to anatomical anomalies or
structural cha...
MOB TCD

Costoclavicular Compression
• Costoclavicular compression is
usually dynamic
• If you elevate the arm, the clavic...
MOB TCD

Brachial Plexus
• Roots arise from Anterior
Primary Rami
• C5
• C6
• C7
• C8
• T1
• Contribution from C4
MOB TCD

Brachial Plexus
• Roots unite to form trunks;
posterior triangle of neck
• C5, C6 form upper trunk
• C7 middle tr...
MOB TCD

Brachial Plexus
• Roots between scalenus
anterior and scalenus
medius
• Trunks in the posterior
triangle
• Divisi...
MOB TCD

Brachial Plexus
MOB TCD

Branches From Roots
• Branch to phrenic nerve C5
• Nerve to rhomboids or
dorsal scapular C5
• Nerve to subclavius...
MOB TCD

Brachial Plexus Entrapment
• Compression of
thoracic inlet
• Cervical rib
• Scalenus anterior or
fibrous band
• B...
MOB TCD

Suprascapular Nerve
• Upper trunk of brachial plexus
• C5, C6 in the posterior triangle
• Passes through suprasca...
MOB TCD

Blood and Nerve Supply
• At spinoglenoid notch
only infraspinatus affected

√
MOB TCD

Cords of Brachial Plexus
• Outer border of first rib
• Divisions unite to form
cords
• Lateral, medial and
poster...
MOB TCD

Lateral Cord of Brachial Plexus
Lateral cord gives off:
• Musculocutaneous
• Lateral pectoral
• Lateral root of m...
MOB TCD

Medial Cord of Brachial Plexus
•
•
•
•
•

Medial cutaneous of arm
Medial pectoral
Medial cutaneous of forearm
Med...
MOB TCD

Posterior Cord of Brachial Plexus
• Axillary nerve
• Upper subscapular nerve
• Lower subscapular nerve,
subscapul...
MOB TCD

Musculocutaneous Nerve
• Supplies and pierces
coracobrachialis
• Passes between
brachialis and
biceps supplying t...
MOB TCD

Lateral Cord of Brachial Plexus
• Lateral pectoral pierces the
clavipectoral fascia and
• Supplies pectoralis maj...
MOB TCD

Axillary Nerve
• Posterior cord lower border of
pectoralis minor
• Quadrilateral space
• Upper lateral cutaneous ...
MOB TCD

Shoulder Relations
Anterior
• subscapularis
Posterior
• infraspinatus, teres minor
Superior
• long head of biceps...
MOB TCD

Shoulder Anterior Relations
MOB TCD

Axillary Nerve
MOB TCD

Axillary Nerve Compression
• Dislocated shoulder
• Quadrilateral space
MOB TCD

Radial Nerve
• In axilla
• Posterior cord: lower
border of pectoralis minor,
posterior to axillary artery
• Gives...
MOB TCD

Radial Nerve
• In spiral groove
• Nerve to lateral and medial
head of triceps
• Posterior cutaneous nerve of
fore...
MOB TCD

Radial Nerve - Spiral Groove
• Lies between brachioradialis
and brachialis and the extensor
carpi radialis longus...
MOB TCD

Posterolateral
• Lies below head of radius
• Below lateral epicondyle
• Deep or posterior interosseous
supplies a...
MOB TCD

Posterior Relations
• Superficial lies lateral to radial
artery in upper two thirds of
forearm
• Passes posterior...
MOB TCD

Radial Nerve in Forearm
• Deep or posterior
interosseus nerve supplies
and then pierces supinator
• Muscles of po...
MOB TCD

Radial Nerve
• Extensor digitorum communis,
extensor digiti minimi extensor
carpi ulnaris
• Abductor pollicis lon...
MOB TCD

Elbow Nerve Compression
• Radial tunnel syndrome
• Posterior interosseous
nerve syndrome
• Cubital tunnel syndrom...
MOB TCD

Tennis Elbow Extensor Muscles
• Extensor carpi radialis brevis
in most cases
• Anterior edge of extensor
digitoru...
MOB TCD

Posterior Relations of Elbow
•
•
•
•

Triceps
Anconeus
Olecranon bursa
Ulnar nerve posterior to
medial epicondyle...
MOB TCD

Posterior Interosseous
MOB TCD

Deep Branch of Radial Nerve
Posterior Interosseus
• Supplies and then enters forearm
between the two heads of
sup...
MOB TCD

Radial Nerve in Forearm and Hand
MOB TCD

Radial Nerve in Forearm and Hand
MOB TCD

Anatomical Snuffbox
Medial
• Abductor pollicis longus
• Extensor pollicis brevis
• Both involved in De Quervain’s...
MOB TCD

Nerves in Forearm
•
•
•
•
•
•

Posterior interosseus nerve
Supinator
Median nerve
Pronator teres
Ulnar nerve
Flex...
MOB TCD

Median Nerve
Median nerve
• Lower border of pectoralis minor
• Union of the two roots of median
• Anterior to axi...
MOB TCD

Median Nerve in Forearm
• Median gives off branches to
flexor tendons
• Pronator teres, flexor carpi
radialis
• P...
MOB TCD

Median Nerve
MOB TCD

Median Nerve
• Passes deep to flexor digitorum
superficialis
• Gives off
• Anterior interosseous, supplies
flexor...
MOB TCD

Median Nerve
• Median passes deep to flexor
digitorum superficialis
• At wrist, posterolateral to
palmaris longus...
MOB TCD

Carpal Tunnel
• No loss of sensation over skin of
palmar aspect of thenar eminence
• Loss over palmar aspect radi...
MOB TCD

Wrist and Carpal Tunnel
MOB TCD

Wrist and Carpal Tunnel
• Median distal border gives off
motor branch to abductor pollicis
brevis
• Flexor pollic...
MOB TCD

Injury at Elbow
• Loss of sensation over skin
of palmar aspect of thenar
eminence
• Palmar aspect of radial
three...
MOB TCD

Median Nerve Lesion
MOB TCD

Compartment Syndrome
• Forearm is the most
common site of
compartment syndrome
• Anterior compartment of
the fore...
MOB TCD

Compartment Syndrome
• Windsurfing may cause
compartment syndrome in
flexor compartment
• Compression of median
n...
MOB TCD

Blood and Nerve Supply
MOB TCD

Ulnar Nerve
• Lower border of pectoralis minor
from medial cord
• Medial to brachial artery
• Midway down
• Pierc...
MOB TCD

Ulnar Nerve
MOB TCD

Ulnar Nerve
• Supplies and then runs between
flexor carpi ulnaris and flexor
digitorum profundus
• Supplying medi...
MOB TCD

Ulnar Nerve
• Passes superficial to flexor
retinaculum with artery on
lateral side, Guyons’ tunnel
• Supplies pal...
MOB TCD

Ulnar Nerve
MOB TCD

Ulnar Nerve
MOB TCD

Ulnar Nerve
Compression at wrist affects
skin over palmar small
finger, half of the ring finger
and hypothenar mu...
MOB TCD

Ulnar Nerve Injury
• Rounded elbow in throwing
sports
• Javelin
• Discus puts tension on ulnar
nerve at elbow
• E...
MOB TCD

Hamate
• Hook of hamate may fracture if
palm hits a wall
• Damage deep branch of ulnar
• Wasting of adductor poll...
MOB TCD

Ulnar Nerve Paradox
• More deformity with an injury at
wrist than elbow
• Wasting of first web and guttering
due ...
MOB TCD

Grips
MOB TCD

Test for Ulnar Neuritis
• Tap ulnar nerve on
posteromedial aspect of
medial epicondyle
• Completely flex elbow an...
MOB TCD

Test for Medial Epicondylitis
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•
•
•

Stabilise flexed elbow
Palpate medial epicondyle
Slowly supinate the forea...
MOB TCD

Elbow
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•
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•
•

Biceps brachii
Brachialis
Triceps
Pronator teres
Supinator

Anderson & Hall, 1995

Musculocutane...
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
Anatomy of nerve injuries upper limb
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Anatomy of nerve injuries upper limb

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    1. 1. MOB TCD Anatomy of Nerve Injuries Upper Limb Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. MOB TCD Anatomy of Nerve Injuries • • • • • • Dermatomes Myotomes Nerves entrapped Pierce muscle Pierce fascia Repetitive movements
    3. 3. MOB TCD Dermatomes • • • • • Skin Bones Muscles, tendons Nerves Blood vessels
    4. 4. MOB TCD Cutaneous Supply
    5. 5. MOB TCD Extrinsic Factors • External forces • Fibro-osseous tunnels tether the nerve • Oedema • Callus formation as a result of a fracture • External compression due to specific movements • Mechanical compression • The nerve is tender at the site of compression
    6. 6. MOB TCD Extrinsic Factors • • • • • Fibrous bands Accessory muscles Spurs Narrow notches Anatomical variations of the nerve itself • The most common symptom complex involves the lower trunk of the brachial plexus C8,T1 • With pain and paresthesia along the medial border of the limb
    7. 7. MOB TCD Extrinsic Factors Congenital and structural anomalies include: • Cervical ribs • Scalenus anterior syndrome • Fibrous or fibro-muscular bands
    8. 8. MOB TCD Extrinsic Factors • Costoclavicular, where it may also be • • • • due to anatomical anomalies or structural changes, e.g. shoulder girdle depression Between the pectoralis minor and the coracoid process The shoulder is very mobile and the neurovascular structures may change direction by a full 180° The coracoid process and the pectoralis minor act as a fulcrum for the change in direction This is a potential site of compression
    9. 9. MOB TCD Costoclavicular Compression • Costoclavicular compression is usually dynamic • If you elevate the arm, the clavicle rotates at the sternoclavicular and acromioclavicular joints, narrowing the costoclavicular space • This space will be further narrowed by retraction of the shoulders, particularly if you are carrying a heavy weight • Deep inspiration elevates the first rib; this narrows the space even further
    10. 10. MOB TCD Brachial Plexus • Roots arise from Anterior Primary Rami • C5 • C6 • C7 • C8 • T1 • Contribution from C4
    11. 11. MOB TCD Brachial Plexus • Roots unite to form trunks; posterior triangle of neck • C5, C6 form upper trunk • C7 middle trunk • C8,T1 form lowest trunk • Branches arise mainly from roots and cords • Only 1 from upper trunk
    12. 12. MOB TCD Brachial Plexus • Roots between scalenus anterior and scalenus medius • Trunks in the posterior triangle • Divisions behind clavicle • Cords in axilla to lower border of pectoralis minor
    13. 13. MOB TCD Brachial Plexus
    14. 14. MOB TCD Branches From Roots • Branch to phrenic nerve C5 • Nerve to rhomboids or dorsal scapular C5 • Nerve to subclavius C5,C6, accessory phrenic • Long thoracic nerve to serratus anterior C5, C6, C7 along the side wall of thorax • Kick or blow may affect rotation of scapula and winging of scapula
    15. 15. MOB TCD Brachial Plexus Entrapment • Compression of thoracic inlet • Cervical rib • Scalenus anterior or fibrous band • Back pack narrow costoclavicular
    16. 16. MOB TCD Suprascapular Nerve • Upper trunk of brachial plexus • C5, C6 in the posterior triangle • Passes through suprascapular foramen into the • Supraspinous fossa supplies suprascapular muscle • Passes through the spinoglenoid notch supplies infraspinatus muscle • Articular to shoulder joint
    17. 17. MOB TCD Blood and Nerve Supply • At spinoglenoid notch only infraspinatus affected √
    18. 18. MOB TCD Cords of Brachial Plexus • Outer border of first rib • Divisions unite to form cords • Lateral, medial and posterior cords, related to first and second parts of axillary artery • End at lower border of pectoralis minor
    19. 19. MOB TCD Lateral Cord of Brachial Plexus Lateral cord gives off: • Musculocutaneous • Lateral pectoral • Lateral root of median nerve
    20. 20. MOB TCD Medial Cord of Brachial Plexus • • • • • Medial cutaneous of arm Medial pectoral Medial cutaneous of forearm Medial root of median Ulnar
    21. 21. MOB TCD Posterior Cord of Brachial Plexus • Axillary nerve • Upper subscapular nerve • Lower subscapular nerve, subscapularis and teres major • Nerve to latissimus dorsi • Radial nerve
    22. 22. MOB TCD Musculocutaneous Nerve • Supplies and pierces coracobrachialis • Passes between brachialis and biceps supplying them • Continues as lateral cutaneous of forearm
    23. 23. MOB TCD Lateral Cord of Brachial Plexus • Lateral pectoral pierces the clavipectoral fascia and • Supplies pectoralis major • Gives off the lateral root of median nerve
    24. 24. MOB TCD Axillary Nerve • Posterior cord lower border of pectoralis minor • Quadrilateral space • Upper lateral cutaneous nerve of arm supplies skin over lower half of deltoid • Nerve to deltoid • Nerve to teres minor • Injury results in loss of sensation over the lower half of the deltoid • Weakness of the deltoid and the teres minor
    25. 25. MOB TCD Shoulder Relations Anterior • subscapularis Posterior • infraspinatus, teres minor Superior • long head of biceps • supraspinatus Inferior • axillary nerve In abduction • long head triceps
    26. 26. MOB TCD Shoulder Anterior Relations
    27. 27. MOB TCD Axillary Nerve
    28. 28. MOB TCD Axillary Nerve Compression • Dislocated shoulder • Quadrilateral space
    29. 29. MOB TCD Radial Nerve • In axilla • Posterior cord: lower border of pectoralis minor, posterior to axillary artery • Gives off posterior cutaneous nerve of arm • Supplies and then passes between long and medial head of triceps • Injury in axilla e.g. crutches, Saturday night paralysis
    30. 30. MOB TCD Radial Nerve • In spiral groove • Nerve to lateral and medial head of triceps • Posterior cutaneous nerve of forearm • Nerve to anconeus
    31. 31. MOB TCD Radial Nerve - Spiral Groove • Lies between brachioradialis and brachialis and the extensor carpi radialis longus • Pierces lateral intermuscular septum • Brachioradialis and lateral border of brachialis supplies them • Extensor carpi radialis longus • Divides into superficial branch • Posterior interosseus nerve
    32. 32. MOB TCD Posterolateral • Lies below head of radius • Below lateral epicondyle • Deep or posterior interosseous supplies and then passes between two heads of supinator • Supplies the extensor carpi radialis brevis • Extensors from the lateral epicondyle and all the deep extensors of forearm
    33. 33. MOB TCD Posterior Relations • Superficial lies lateral to radial artery in upper two thirds of forearm • Passes posterior to dorsum • Pierces deep fascia • Supplies posterior aspect of forearm • Skin of dorsum posterior aspect of radial three and half fingers
    34. 34. MOB TCD Radial Nerve in Forearm • Deep or posterior interosseus nerve supplies and then pierces supinator • Muscles of posterior compartment of forearm
    35. 35. MOB TCD Radial Nerve • Extensor digitorum communis, extensor digiti minimi extensor carpi ulnaris • Abductor pollicis longus • Extensor pollicis brevis • Extensor pollicis longus • Extensor indicis
    36. 36. MOB TCD Elbow Nerve Compression • Radial tunnel syndrome • Posterior interosseous nerve syndrome • Cubital tunnel syndrome • Pronator syndrome • Anterior interosseous nerve syndrome Behr & Altchek, 1997
    37. 37. MOB TCD Tennis Elbow Extensor Muscles • Extensor carpi radialis brevis in most cases • Anterior edge of extensor digitorum communis 30% less frequently • Extensor carpi radialis longus • Extensor carpi ulnaris Nirschl, 1993
    38. 38. MOB TCD Posterior Relations of Elbow • • • • Triceps Anconeus Olecranon bursa Ulnar nerve posterior to medial epicondyle • Common extensor origin
    39. 39. MOB TCD Posterior Interosseous
    40. 40. MOB TCD Deep Branch of Radial Nerve Posterior Interosseus • Supplies and then enters forearm between the two heads of supinator • Extensor carpi radialis brevis • Extensor digitorum communis • Extensor indicis • Extensor digiti minimus • Extensor carpi ulnaris • Extensor pollicis longus and brevis • Abductor pollicis longus
    41. 41. MOB TCD Radial Nerve in Forearm and Hand
    42. 42. MOB TCD Radial Nerve in Forearm and Hand
    43. 43. MOB TCD Anatomical Snuffbox Medial • Abductor pollicis longus • Extensor pollicis brevis • Both involved in De Quervain’s syndrome Posterior • Extensor pollicis longus Floor • Distal end of radius and scaphoid • Radial artery Superficial • Radial nerve
    44. 44. MOB TCD Nerves in Forearm • • • • • • Posterior interosseus nerve Supinator Median nerve Pronator teres Ulnar nerve Flexor carpi ulnaris
    45. 45. MOB TCD Median Nerve Median nerve • Lower border of pectoralis minor • Union of the two roots of median • Anterior to axillary artery at first • Then lateral and medial to brachial artery • Passes behind bicipital aponeurosis • No branches in arm • Pronator teres
    46. 46. MOB TCD Median Nerve in Forearm • Median gives off branches to flexor tendons • Pronator teres, flexor carpi radialis • Pronator teres • Flexor digitorium superficialis • Passes between two heads of pronator teres
    47. 47. MOB TCD Median Nerve
    48. 48. MOB TCD Median Nerve • Passes deep to flexor digitorum superficialis • Gives off • Anterior interosseous, supplies flexor pollicis longus • Radial one or two tendons of flexor digitorum profundus • Pronator quadratus
    49. 49. MOB TCD Median Nerve • Median passes deep to flexor digitorum superficialis • At wrist, posterolateral to palmaris longus • Gives off the superficial palmar branch • Passes superficial to flexor retinaculum • Main nerve goes deep to retinaculum
    50. 50. MOB TCD Carpal Tunnel • No loss of sensation over skin of palmar aspect of thenar eminence • Loss over palmar aspect radial 3.5 fingers • Wasting of thenar eminence particularly abductor pollicis brevis
    51. 51. MOB TCD Wrist and Carpal Tunnel
    52. 52. MOB TCD Wrist and Carpal Tunnel • Median distal border gives off motor branch to abductor pollicis brevis • Flexor pollicis brevis • Opponens pollicis • Unipennate lumbricals • Cutaneous branches to radial three and half and skin over the dorsum of corresponding fingers
    53. 53. MOB TCD Injury at Elbow • Loss of sensation over skin of palmar aspect of thenar eminence • Palmar aspect of radial three and half fingers • Wasting of thenar eminence • Weakness of superficialis and one or two of profundus tendons
    54. 54. MOB TCD Median Nerve Lesion
    55. 55. MOB TCD Compartment Syndrome • Forearm is the most common site of compartment syndrome • Anterior compartment of the forearm may compress median nerve • Posterior compartment • Mobile wad may be altered sensation over the dorsum
    56. 56. MOB TCD Compartment Syndrome • Windsurfing may cause compartment syndrome in flexor compartment • Compression of median nerve
    57. 57. MOB TCD Blood and Nerve Supply
    58. 58. MOB TCD Ulnar Nerve • Lower border of pectoralis minor from medial cord • Medial to brachial artery • Midway down • Pierces medial intermuscular septum, into posterior compartment • Passes between two heads of flexor carpi ulnaris • Behind medial epicondyle to enter anterior compartment of forearm • No branches in the arm
    59. 59. MOB TCD Ulnar Nerve
    60. 60. MOB TCD Ulnar Nerve • Supplies and then runs between flexor carpi ulnaris and flexor digitorum profundus • Supplying medial two or three tendons of flexor digitorum profundus • 5 cm above wrist gives off the dorsal cutaneous branch skin of medial one and half fingers
    61. 61. MOB TCD Ulnar Nerve • Passes superficial to flexor retinaculum with artery on lateral side, Guyons’ tunnel • Supplies palmaris brevis • Muscles of hypothenar eminence • Bipennate lumbricals • Palmar and dorsal interossei • Ends in adductor pollicis
    62. 62. MOB TCD Ulnar Nerve
    63. 63. MOB TCD Ulnar Nerve
    64. 64. MOB TCD Ulnar Nerve Compression at wrist affects skin over palmar small finger, half of the ring finger and hypothenar muscles, not skin over the dorsal aspect.
    65. 65. MOB TCD Ulnar Nerve Injury • Rounded elbow in throwing sports • Javelin • Discus puts tension on ulnar nerve at elbow • Electric shock along course of nerve • Late result of supracondylar fracture
    66. 66. MOB TCD Hamate • Hook of hamate may fracture if palm hits a wall • Damage deep branch of ulnar • Wasting of adductor pollicis • 1st dorsal interossei
    67. 67. MOB TCD Ulnar Nerve Paradox • More deformity with an injury at wrist than elbow • Wasting of first web and guttering due to wasting of interossei and bilateral lumbricals • Hyperextension of metacarpophalangeal joints • Flexion of proximal and distal interphalangeal joints
    68. 68. MOB TCD Grips
    69. 69. MOB TCD Test for Ulnar Neuritis • Tap ulnar nerve on posteromedial aspect of medial epicondyle • Completely flex elbow and hold for five minutes • Positive is tingling along nerve Anderson & Hall, 1995
    70. 70. MOB TCD Test for Medial Epicondylitis • • • • Stabilise flexed elbow Palpate medial epicondyle Slowly supinate the forearm Extend wrist and elbow, while patient resists Anderson & Hall, 1995
    71. 71. MOB TCD Elbow • • • • • Biceps brachii Brachialis Triceps Pronator teres Supinator Anderson & Hall, 1995 Musculocutaneous C5,C6 Musculocutaneous C5,C6 Radial C6, C7, C8 Median C6,C7 Posterior interosseous C5,C6
    72. 72. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
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