Injuries to the nerves of the upper limb can result from trauma, compression, lacerations, or certain medical conditions. Nerve injuries may lead to various symptoms, including pain, weakness, numbness, or loss of function in specific areas of the upper limb. Nerve injuries may range from mild to severe, and appropriate medical evaluation and treatment are essential. Physical therapy, splinting, medications, or in some cases, surgical intervention may be recommended based on the type and severity of the nerve injury. Early intervention is crucial for optimal recovery.
3. Injuries to the nerves of the upper limb can result from trauma, compression,
lacerations, or certain medical conditions. Nerve injuries may lead to various
symptoms, including pain, weakness, numbness, or loss of function in specific areas
of the upper limb. Nerve injuries may range from mild to severe, and appropriate
medical evaluation and treatment are essential. Physical therapy, splinting,
medications, or in some cases, surgical intervention may be recommended based on
the type and severity of the nerve injury. Early intervention is crucial for optimal
recovery.
7. NERVE ROOT
AXILLARY C 5,6
MUSCULSKELETAL C 5,6,7
RADIAL C 5,6,7,8 T1
MEDIAN C 5,6,7,8 T1
ULNAR C 7,8 T1
8.
9. ā¢ Divisions & cords
Each trunk divides into anterior or ventral division and posterior or dorsal division
ā¢ Cords:
A- The lateral cord
is formed by union of the anterior divisions of the upper and middle trunks.
B- The medial cord
is formed by the anterior division of the lower trunk only.
C- The posterior cord
is formed by union of the posterior divisions of the 3 trunks.
10. ā¢ Branches of Roots:
- n. to seRRatus anterior (long thoracic)
C5, 6, 7
- n. to Rhomboids (Dorsal Scapular
Nerve)
C5
11. N. to serratus anterior (long thoracic)
c5, 6, 7
serratus anterior
12. Scapula winging
Damage to the long thoracic [C5-7]
nerve may lead to āwingingā of the
scapula, most evident when a patient
pushes forward with the upper limb
against resistance.
This type of nerve injury may occur from
ā¢ Trauma to the lateral thoracic wall
ā¢ Lateral flexion of the neck to the
opposite side
ā¢ Radical mastectomy .
Clinical Insight
15. Clinical Insight
DSN damage
Damage to the dorsal scapular nerve can weaken
the rhomboid muscles, resulting in an ipsilateral
lateral shift of the scapula.
16. ā¢ Branches of upper trunk :
SUPRA-scapular nerve.
Nerve to SUB-clavius.
20. ā¢ Branches of Medial cord:
Medial pectoral nerve.
Medial root of median nerve.
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm.
Ulnar nerve
21. Medial cord
Medial pectoral nerve
Medial root of median nerve
Medial cutaneous nerve of forearm
Ulnar nerve
Medial cutaneous nerve of arm
22. ā¢ Branches of Posterior cord
Upper subscapulra
Lower subscapular nerves
N. to latissimus dorsi [Thoraco-dorsal
nerve ]
Axillary nerve
Radial n
24. Obstetric Brachial Plexus Palsy
(OBPP)
is defined as brachial plexus nerve injury
that occurs during early delivery.
OBBP commonly happen during delivery
process and resulting in overstretch of
the neck.
Erbās Palsy which involved the upper
brachial plexus (C5, C6 & C7)
Klumpkeās Palsy involves forearm and
hand . (C8 & T1)
Clinical Insight
27. ā¢ Course
In the arm:
The nerve descends lateral to the upper part of
the brachial artery then crosses in front of it to
run along its medial side to reach the cubital
fossa.
MEDIAN NERVE C 5,6,7,8 T1
median nerve
brachial artery
cubital fossa
29. It then runs exactly in the midline of
forearm deep to the flexor digitorum
superficialis
median nerve
brachial artery
cubital fossa
flexor digitorum superficialis
30. Median nerve + palmaris longus
By having the patient make a tight fist,
one can determine if the patient
possesses the palmaris longus muscle, as
its tendon will appear in the mid wrist.
The median nerve lies just lateral to the
tendon of this muscle before entering the
carpal tunnel.
Clinical Insight
32. ā¢ Branches
It supplies all flexor muscles of the front of forearm
except
1- Flexor polices + lateral Ā½ FDP
2- FCU+ medial Ā½ of FDP
Flexor polices
FDP
median n.
FCU
Ulnar n.
33. N.B: FCU+ medial Ā½ of FDP supplied by ulnar
Flexor polices
FDP
median n.
FCU
Ulnar n.
34. median n.
ant interosseous of median
Flexor polices
FDP
N.B: Flexor polices + lateral Ā½ FDP supplied by ant interosseous
of median
35. N.B: anterior interosseous nerve supplies 3 muscles
1. - Flexor pollicis longus
2. - Lateral 1/2 of the flexor digitorum profundus
3. - Pronator quadratus median n.
ant interosseous of median
Flexor polices
FDP
Pronator quadratus
36. In hand
a) Lateral division
ā¢ 3 muscles of the thenar eminence by
recurrent motor branch
ā¢ 1st lumbrical muscle
ā¢ 3 digital branches: To thumb and index
Recurrent motor branch to thenar eminence
3 digital branches
Branch to 1st lumbrical muscle
Lateral division
Medial division
37. Carpal Tunnel Syndrome
Entrapment of the median nerve and
other structures in the carpal tunnel due
to any condition that reduces the space
results in carpal tunnel syndrome.
Clinical Insight
38. Carpal Tunnel Syndrome
The median nerve is the only nerve affected in
Carpal Tunnel Syndrome
and the patient will present with:
ā¢ Atrophy and weakness of the thenar
compartment muscles (opposition of the
thumb-ape hand) .
ā¢ There is also sensory loss and numbness on
the palmar surfaces of the lateral 3 Ā½ digits.
Clinical Insight
Ape hand
39. Carpal Tunnel Syndrome
Note that the skin on the lateral side of
the palm (thenar eminence) is healthy in
Carpal Tunnel Syndrome because the
palmar cutaneous branch of the median
nerve which supplies the lateral palm
enters the hand superficial to the flexor
retinaculum and does not course through
the carpal tunnel.
Clinical Insight
40. Lacerations of thenar eminence
The recurrent branch of the median nerve lies
somewhat superficial in the palm.
Lacerations across the palm and thenar eminence
may cut.
Therefore, clinically, physician must carefully test
the integrity of these muscles in case of hand
lacerations.
Clinical Insight
41. Clinical Insight
Ape hand deformity
is a condition in which the thumb is
permanently rotated and adducted,
resulting in a loss of its opposable
function.
This deformity is caused by damage to
the median nerve, which supplies the
muscles that control the thumb
42. b) Medial division:
ā¢ 2nd lumbrical muscle
ā¢ 4 digital branches: to adjacent sides of
the index and middle fingers and to
adjacent sides of the middle and ring
fingers.
Lateral division
Branch to 2nd lumbrical muscle
4 digital branches
Medial division
43.
44. Median nerve entrapment
The median nerve is liable for entrapment at the carpal tunnel as part of carpal
tunnel syndrome.
Clinical Insight
carpal tunnel
45. In the axilla and arm:
It descends medial to the brachial artery and contiues
back of the medial epicondyle.
In the forearm
descends deep to flexor carpi ulnaris
ULNAR NERVE C 5,6,7,8 T1
brachial artery
ulnar nerve
flexor carpi ulnaris
46.
47. Cubital tunnel syndrome
As the ulnar nerve passes between the 2 heads
of the flexor carpi ulnaris, the nerve can
become compressed, leading to a cubital tunnel
syndrome.
Compression may be especially acute as the
elbow is flexed because this narrows the space
between the 2 muscle heads.
Clinical Insight
48.
49. Elbow ulnar neuropathy
Ulnar neuropathy at the elbow presents with
ā¢ Paresthesia over digits 4 and 5
ā¢ Weakness of the flexor muscles of the forearm (wrist
and finger flexion)
ā¢ Weakness of the intrinsic muscles of the hand (hand
grip).
Clinical Insight
50. In the hand:
divides into superficial and deep terminal branches
Ulnar nerve
Superficial terminal branches
Deep terminal branches
51. ā¢ Branches
1- Branch to flexor carpi ulnaris.
2- Branch to medial 1/2 of the flexor
digitorum profundus.
Ulnar nerve
flexor carpi ulnaris.
flexor digitorum profundus.
52. Medial 1/2 of the flexor digitorum profundus
Lateral 1/2 of the flexor digitorum profundus
Ulnar nerve
Ant. Interosseous nerve
Of
Median nerve
53. 3- Palmar cutaneous branch:
supply the medial 1/3 of the palm
4- Dorsal cutaneous branch:
supply the medial 1/3 of the back of the
hand
Ulnar nerve
Dorsal cutaneous branch
Palmar cutaneous branch
55. 5- Superficial terminal branch
ā¢ Two palmar digital branches:
medial 1.5 fingers.
ā¢ Branch to the palmaris brevis
muscle
6- Deep terminal branch;
ā¢ All muscles of the hand except
Ć¼ Thenar muscles
Ć¼ Lateral two lumbricals
Ulnar nerve
Deep terminal branch
Superficial terminal branch
2 palmar digital branches
palmaris brevis muscle
56.
57. Ulnar nerve + bone fracture
The ulnar nerve is vulnerable with a fracture of the medial epicondyle of the
humerus (at the elbow) or a wrist fracture on the hamate bone.
Clinical Insight
58. Claw hand
Ulnar nerve injury can present as a claw
hand and an inability to effectively use
the ring and little fingers, as well as a
loss of abduction and adduction of the
2nd to 5th digits.
Clinical Insight
claw hand
59. It enters the spiral groove at back of arm.
RADIAL NERVE C 5,6,7,8 T1
radial nerve in spiral groove
60. After leaving the spiral groove the nerve is divided into
Ć superficial division ( loop to back of forearm deep to
brachioradialis )
Ć deep division ( loop in mass of supinator and continue
in back of forearm) radial nerve
deep division
supinator
superficial division
brachioradialis
61. Fracture shaft humerus
As the radial nerve passes around the
shaft of the humerus, fractures of the
shaft of the humerus can place the radial
nerve in jeopardy of being stretched or
torn as it wraps around the humerus,
affecting wrist and finger extensors.
Clinical Insight
62. About 5 cm above the wrist, the superficial
division of the nerve winds round the lateral side
of the radius to reach the back of the hand
About 5 cm above the wrist, the superficial division of the nerve
winds round the lateral side of the radius to reach the back of
the hand
63. ā¢ Branches
Before spiral groove:
1- Long head of triceps
2- Medial head of triceps
radial nerve
Long head of triceps
Medial head of triceps
64. In the spiral groove:
3- Lateral head of triceps
4- Medial head of triceps
radial nerve
Lateral head of triceps
Medial head of triceps
65. On the lateral side of arm;
5- A branch to lateral part of brachialis.
6- A branch to brachioradialis.
7- A branch to extensor carpi radialis
longus.
8- A branch to anconeus
radial nerve
brachialis.
brachioradialis.
extensor carpi
radialis longus.
66. In the forearm and hand:
9- Posterior Interosseous Nerve (continuation of radial deep
division.
ā¢ PIN, supplies all extensor compartment, except:
ā¢
radial main trunk
ā¢
radial superficial division
ā¢
radial deep division
ā¢
Posterior interosseous nerve
ā¢
radial superficial division
Anconeus Radial nerve (main trunk)
Brachioradialis Radial nerve (main trunk)
ECRL Radial nerve (main trunk)
67. 10- Dorsal digital branches: skin of the lateral
2/3 of dorsum of the hand
Dorsal digital branches
68.
69. Posterior compartment neuropathy
The deep branch of the radial nerve (continues as PIN) can become
compressed as it passes through the supinator, leading to a
posterior compartment neuropathy, resulting in weakened
extension of the wrist and fingers.
Clinical Insight
supinator
PIN
weakened extension of the
wrist and fingers
Supinator compression
70. Spiral groove
As the radial nerve runs in the spiral groove in direct contact with bone, it is
vulnerable with a fracture of the shaft of the humerus.
Clinical Insight
71. Saturday night palsy
The term Saturday night palsy
has become synonymous with
radial nerve compression in the
arm resulting from direct
pressure against a firm object.
It typically follows deep sleep
on the arm, often after alcohol
intoxication.
Clinical Insight
72. Saturday night palsy
The radial nerve is vulnerable to stretching or
tearing in fractures of the shaft of the humerus
and can be compressed by tourniquets that are too
tight or by direct compression (Saturday night
palsy) leading to weakened elbow, wrist and
finger extension, and supination.
Wristdrop is a common clinical sign if the
forearm extensor muscles are affected.
Clinical Insight
73. Porter (Policeman) tip hand
The posterior cord of the brachial
plexus gives rise to the axillary and radial
nerves.
An injury to this structure will manifest as:
ā¢ Inability to perform shoulder abduction
[axillary n.]
ā¢ Wrist extension [radial n.]
Clinical Insight
74. MUSCULOCUTANEOUS NERVE C 5,6,7
ā¢ Course:
It pierce the corachobrachialis muscle from the
back , Lie between biceps and brachialis
Continue in forearm as lateral cutaneous n. of
forearm
musculocutaneous n.
corachobrachialis
brachialis
biceps
lat cut n of forearm
75. ā¢ Branches
Ć¼ Muscular: to all the ant compartment of arm
Ć¼ Cutaneous: lat cut n of forearm
musculocutaneous n.
corachobrachialis
brachialis
biceps
lat cut n of forearm
76.
77. Musculocutaneous compression
Since the musculocutaneous nerve runs
through the coracobrachialis muscle, it is
vulnerable to nerve compression within the
muscle and this can lead to weakness of elbow
flexion (loss of some brachialis and biceps
function) and hypesthesia of the lateral
forearm.
Clinical Insight
78. ā¢ Course
It curves backwards to enter the quadrangular
space and come in contact with the surgical
neck of the humerus where it divides into
anterior and posterior divisions
AXILLARY NERVE C 5,6
ā¢
axillary nerve posterior division
ā¢
quadrangular space
ā¢
surgical neck of the humerus
79.
80. ā¢ Branches
1. Articular branch to supply the shoulder joint.
2. Posterior division:
- Branches to the deltoid and teres minor.
- Upper lateral cutaneous nerve of the arm
3. Anterior division: ends in the deltoid.
ā¢
axillary nerve posterior division
ā¢
quadrangular space
ā¢
surgical neck of the humerus
ā¢
Upper lateral cutaneous nerve of the arm
TER. MIN.
D
E
LT
D
.
81. Hand sensation
Testing of radial sensation can only be
done reliably over the dorsal web space
between the thumb and index finger.
Median sensation is tested reliably on the
palmar (volar) aspect of the tip of the
index finger.
Ulnar sensation is tested reliably on the
palmar aspect of the tip of the little
finger.
Clinical Insight
86. Q1 A 45-year-old woman presents to the clinic with discomfort in her left shoulder.
She recently underwent a left mastectomy and axillary dissection for breast cancer.
Physical examination shows a notable protrusion of the posterior left shoulder blade
when she is asked to push up against the wall. Which of the following spinal nerve
roots give rise to the most likely affected nerve branch?
ā¢ C3-C5
ā¢ C5-C6
ā¢ C5-C7
ā¢ C8-T1
87. Q2 A 27-year-old man is brought to the emergency department
after falling off a ladder from the height of the roof. An x-ray
of the patientās right arm is shown.
Which of the following neurologic deficits is most likely to
occur as a result of his fracture?
A protruding scapula
Inability to abduct the arm fully
Inability to hold a piece of paper between the fingers
Pain over the palmar aspects of the first three and a half digits
Weakness in wrist extension
88. Q3 A 16-year-old boy is brought to the emergency department for severe arm pain
after he fell out of a tree. Physical examination reveals tenderness to palpation over
the left shoulder. There is limited range of motion at the shoulder including loss of
abduction and decreased flexion. His arm dangles at his side, with the forearm
pronated and extended. Sensation is absent along his left lateral forearm.
Which of the following structures is most likely injured in this patient?
Axillary nerve
C5-C6 nerve roots
C8-T1 roots
Long thoracic nerve
Lower trunk
Radial nerve
89. Q4. A patient presents with weakness in wrist extension and finger abduction,
commonly known as "wrist drop." This condition is most likely due to damage to
which nerve?
a) Median nerve
b) Ulnar nerve
c) Radial nerve
d) Axillary nerve
90. Q5. The musculocutaneous nerve innervates muscles in the anterior compartment of
the arm. Which muscle primarily relies on the musculocutaneous nerve for motor
innervation?
a) Biceps brachii
b) Brachialis
c) Coracobrachialis
d) Pronator teres
91. Q6. Damage to the median nerve can result in a characteristic "ape hand" deformity,
with weakness in thumb opposition and flexion of the wrist. Which anatomical
landmark is a common site for compression of the median nerve, leading to
conditions like carpal tunnel syndrome?
a) Guyon's canal
b) Cubital fossa
c) Carpal tunnel
d) Supracondylar ridge
92. Q7. The ulnar nerve innervates several intrinsic muscles of the hand and plays a
crucial role in fine motor control. Damage to the ulnar nerve can lead to weakness
in intrinsic muscles and the development of which hand deformity?
a) Claw hand
b) Pope's blessing
c) Ape hand
d) Wrist drop
93. Q8. The axillary nerve, a branch of the brachial plexus, innervates the deltoid
muscle and the teres minor muscle. Damage to the axillary nerve can lead to
weakness in shoulder abduction and is often associated with traumatic injuries or
surgical procedures in which region of the body?
a) Axilla
b) Elbow
c) Wrist
d) Forearm
94. Q9 A 74-year-old man is brought to the emergency department with left shoulder
pain after being involved in a motor vehicle accident. Physical examination reveals
difficulty abducting the left shoulder. Passive movement of the shoulder elicits
severe pain. There are mild sensory deficits over the inferior aspect of the deltoid
muscle. The patient has good hand grip with active motion. X-ray of the left
shoulder discloses a fracture of the surgical neck of the humerus.
An injury to which of the labeled locations in the image would most likely explain
this patientās physical findings?
A
B
C
D
E
95. Q10 A 10-year-old boy is brought to the pediatrician with a 4-day history of fever,
fatigue, and right shoulder pain. His temperature is 38.6Ā°C (101.5Ā°F). On physical
examination, he has right shoulder tenderness, worse at the right axillary region, and
painful and weak abduction. On palpation, a swollen mass in the axillary region is
noted. He also has wrist-extension weakness and triceps hyporeflexia in the same
limb. Sensory examination reveals absent sensation to light touch over the right
shoulder and lateral and posterior arm. Imaging identifies an abscess in the right
axillary region. The most likely diagnosis is an abscess.
Which of the following structures is most likely being compressed by the abscess?
Axillary nerve
Lateral cord of the brachial plexus
Medial cord of the brachial plexus
Posterior cord of brachial plexus
Radial nerve
96. Q11 A 34-year-old woman comes to the physician with right hand weakness for the
last 3 months. She has had progressive difficulty opening jars with her right hand.
She does not recall any trauma. She has no significant medical history and is not on
medication. On physical examination there is diminished sensation to light touch
over digits 4 and 5 on the right hand. Strength is 3/5 in the right hand involving the
following muscle groups: attempted abduction of the index finger, wrist flexion, and
flexion of the fourth and fifth digits.
Damage or compression of which of the following nerves is most likely in this
patient?
Axillary
Median
Musculocutaneous
Radial
Ulnar
97. Q12 A 17-year-old boy is brought to the clinic with shooting pain in his right hand
following a snowboarding accident, in which he directly struck a tree with his arms
raised. On physical examination, the right fingers are held in flexion at the proximal
and distal interphalangeal joints. The patient also has decreased sensation over the
medial aspect of his right palm, atrophy of the hypothenar eminence, and inability
to maintain finger abduction against resistance.
Which of the following parts of the brachial plexus is most likely injured in this
patient?
Lateral cord
Lower trunk
Middle trunk
Posterior cord
Upper trunk
98. Q13 A 24-year-old man comes to the emergency department because of a laceration
over the palmar surface of the middle section of his left index finger. A
subcutaneous local block is used to numb the area with lidocaine so that it can be
sutured.
The nerve that the physician is most likely targeting also provides cutaneous
innervation to which of the following areas?
2/3 of the outer palmar side of the hand, including 3 and one-half fingers
The lateral aspect of the forearm
The medial surface of the forearm
The radial aspect of the wrist
The ulnar aspect of the wrist
99. Q14 A 39-year-old man has suffered for many years from pains in his right arm.
Recently, after moving to a new job that requires carrying heavy parcels, the pain
has worsened, and occasional tingling and numbness is felt in the little finger and
ring finger of the right hand. The area of pain in the limb is localized to the medial
side of the arm and forearm and the ulnar side of the hand. General muscle strength
in the right extremity is less than in the left, and there is particular weakness of
opposition and adduction of the right thumb. Wasting of the right hypothenar and
thenar eminence is evident, and the patient cannot hold a piece of paper between his
index and middle fingers. The most likely site of the injury is
(A) lower trunk of the brachial plexus
(B) upper trunk of the brachial plexus
(C) posterior cord of the brachial plexus
(D) ulnar nerve
(E) median nerve
100. Q15 A 20-year-old man stated that he was unable to raise his right arm. Questioning
revealed that he had been involved in a motorcycle accident, at which time he had
been thrown from the motorcycle and had hit his shoulder against a tree. The patient
held his upper limb limply at his side, with the arm medially rotated and the hand
pronated. Muscles covering the shoulder joint showed significant wasting. The most
likely site of the injury is the
(A) lower trunk of the brachial plexus
(B) upper trunk of the brachial plexus
(C) posterior cord of the brachial plexus
(D) axillarynerve
(E) radial nerve
101. Q16 Your patient has fallen on his outstretched hand and has dislocated a carpal
bone. The patient does not seek treatment, and several weeks later he begins to
exhibit signs of nerve compression. The patient is most likely to present with which
of the following conditions?
(A) Wrist drop
(B) Clawing of ring and index fingers
(C) Inability to spread and oppose the fingers
(D) Weakness in the ability to oppose the thumb
(E) Pain on the palmar aspects of the ring and little fingers
102. Q17 A 7-year-old boy is brought to the emergency department after falling off his
grandparentsā deck; an x-ray film shows that he has a mid- shaft fracture of the
humerus. Which of the following defects is most likely to occur with this type of
fracture?
(A) A protruding scapula
(B) Inability to fully abduct the arm
(C) Inability to hold a piece of paper between fingers
(D) Pain over the palmar aspects of the first three and a half digits
(E) Weakness in wrist extension
103. Q1 C5-C7
Q2 Weakness in wrist extension
Q3 C5-C6 nerve roots
Q4 Radial nerve
Q5 Coracobrachialis
Q6 Carpal tunnel
Q7 Claw hand
Q8 Axilla
Q9 A
Q10 Posterior cord of brachial plexus
Q11 Ulnar
Q12 Lower trunk
Q13 2/3 of the outer palmar side of the hand, including 3 and one-half fingers
Q14 lower trunk of the brachial plexus
Q15 upper trunk of the brachial plexus
Q16 Weakness in the ability to oppose the thumb
Q17 Weakness in wrist extension
104. List of Texts and Recommended Readings
ā¢ Last's Anatomy, Regional and Applied. Chummy S. Sinnatamby. 12th edition 2011, ISBN:13 - 978 0 7020 3394 0
(Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3-s2.0- C2009060533X)
ā¢ Estomih Mtui, Gregory Gruener and Peter Dockery. Fitzgerald's Clinical Neuroanatomy and Neuroscience. 7th
edition; 2016, ISBN: 13 - 978-0-7020- 6727-3 (Available in ClinicalKey:
https://www.clinicalkey.com/#!/browse/book/3-s2.0- C20130134113
ā¢ Drake, Richard L. Gray's Anatomy for Students, Third Edition, Elsevier Saunders 2015. ISBN-13: 978-0702051319
(Available in ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20110061707).
ā¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.1, 15th Edition; 2013, ISBN: 9780702052514 (Available in
ClinicalKey: https://www.clinicalkey.com/#!/content/book/3- s2.0-B9780702052514500067)
ā¢ Sobotta Atlas of Human Anatomy. F. Paulsen. Vol.2, 15th Edition; 2013, ISBN:13 - 978-0-7020-5252-1 (Available in
ClinicalKey: https://www.clinicalkey.com/#!/browse/book/3- s2.0-C20130046919)