This document provides information on the median nerve including its course, branches, and clinical significance. It begins with the median nerve's origin from the brachial plexus and course through the arm. It then describes branches and distribution in the forearm, hand, and injuries such as carpal tunnel syndrome. Clinical tests for median nerve function and management options are also summarized.

1. MEDIAN NERVE
Dr.HARSHA NANDINI TALASILA
M.S Ortho

2. • Branch of lateral and
medial cord of the
brachial plexus.
• In the arm it lies lateral
to the brachial artery.
• In the middle of the arm
it crosses the artery
from lateral to medial
side and remains on the
medial side upto the
elbow.

3. • In the arm: branch to the elbow joint and
vascular branch to the brachial artery.
• In the cubital fossa it lies medial to the
brachial artery.
• It enters the forearm by passing between the
2 heads of the pronator teres.
• In the forearm it passes beneath the fibrous
arch of flexor digitorum superficialis and on
the surface of flexor digitorum profundus.

5. • About 5cm above the flexor retinaculum it
becomes superficial and lies between the
tendons of flexor carpi radialis and FDS.
• It is overlapped by the tendon of palmaris
longus.
• Median nerve enters the hand by passing
deep to flexor retinaculum through the carpal
tunnel.

6. • Muscular branches to all the superficial flexors
of forearm except FCU
• Anterior interosseous nerve is given off in the
upper part of the forearm,it supplies the
flexor pollicis longus,the lateral half of FDP
and pronator quadratus
• DRUJ and wrist joints

7. Branches in the hand
MOTOR BRANCHES
• Abductor pollicis brevis
• Flexor pollicis brevis
• Opponens pollicis
• 1st and 2nd lumbricals
SENSORY SUPPLY
• Lateral 3½ digits on
palmar side and distal
half of dorsal surface

8. INJURY TO MEDIAN NERVE
• Median nerve is injured near the wrist or high up in
the fore arm.
1. High median nerve palsy
2. Low median nerve palsy

9. HIGH MEDIAN NERVE PALSY
• Injury proximal to the elbow.
• Stabs and gunshot wounds may damage the nerve at any level
• This will cause paralysis of all the muscles supplied by the
median nerve in the forearm and hand

10. LOW MEDIAN NERVE PALSY
• Injury in the distal third of the forearm
• Cuts in front of wrist or by carpal dislocation
• There will be sparing of the forearm muscles , but the muscles
of the hand will be paralysed
• There will be anaesthesia over the median nerve distribution in
the hand

11. • Thenar eminence is wasted and thumb
abduction and opposition are weak.
• Sensation is lost over the radial three and half
digits.

12. TESTS
• FPL: the patient is asked
to flex the terminal
phalanx of the thumb
against resistance while
the proximal phalanx is
kept steady by the
examiner.

13. OSCHNER’S CLASPING TEST
• FDS and lateral half of the
FDP: if the patient is
asked to clasp his
hand,the index finger will
remain straight,the so
called pointing index.
• This occurs because both
the finger flexors (FDS
and FDP)are paralysed
but the medial half of the
FDP makes flexion of the
others fingers possible.

14. • FCR: normally the
palmar flexion at the
wrist occurs at in the
long axis of the
forearm.
• In the patient with
paralysed flexor carpi
radialis,the wrist
deviates to the ulnar
side while the palmar
flexion occurs.

15. • ABDUCTOR POLLICIS
BREVIS: the patient is
asked to lay his hand
flat on the table with
palm facing the ceiling.
• A pen is held above the
thumb and the patient
is asked to touch the
pen with tip of his
thumb-PEN TEST

16. COMPRESSIVE NEUROPATHY

17. CARPAL TUNNEL SYNDROME
• Boundaries of carpal tunnel:
1. Medial: hook of hamate and pisiform
2. Lateral: scaphoid and trapezium
3. Roof : flexor retinaculum
• The most palmar structure in the carpal
tunnel is median nerve.
• Deep to the median nerve are present the
long flexor tendons of thumb and fingers.

18. • Entrapment of the median nerve at the wrist.
• CAUSES:
 Decrease in the size of the tunnel
1. Bony abnormalities of the carpal bones
2. Acromegaly .

19.  Increase in the contents of the tunnel.
1. Scaphoid or distal radius fractures
2. Scaphoid subluxation or lunate dislocation
3. Local tumors like ganglion,neuroma,lipoma
4. Hematoma

20.  Neuropathic conditions
1. Diabetes mellitus
2. Alcoholism
 Inflammatory conditions
1. Rheumatoid arthritis
2. Gout
3. Infections

21.  Alterations of fluid balance.
1. Pregnancy
2. Thyroid disease
3. Renal failure
4. Obesity
5. Amyloidosis
External forces.
1. Vibration
2. Direct pressure

22. TESTS
• DURKAN’S TEST:
 Compression is applied
to the median nerve by
the examiner for 30
seconds.
 Patients will have
symptoms of
numbness,pain,parasth
esia in the region of
median nerve
distribution.

23. • PHALEN’S TEST:
 Patient is asked to keep
the wrist flexed
continuously for 1
minute.
 Patient will have
tingling and numbness
in the lateral 3 and a
half fingers.

24. • GILIAC TEST:
Arm torniquet is inflated above systolic pressure
for 60seconds.
Tingling and numbness in the median nerve
distribution.

25. MANAGEMENT
1. Splinting of the wrist in neutral position
2. Corticosteroid injection into the carpal tunnel

26. 1. SURGERY
a) Constant parasthesias
not relieving after
conservative
management
b) Thenar atrophy
c) Delayed median nerve
conduction velocity on
NCV

27. PRONATOR SYNDROME
• ETIOLOGY:
 Supracondylar process:
• On the anteromedial surface of the
humerus,about 5cm above the medial
epicondyle ,an aberrant spur of bone
• A ligament of struthers runs from spur to the
medial epicondyle.
• Median nerve,brachial artery and vein run
beneath this ligament.

28. • CLINICAL FEATURES:
Vague anterior forearm pain
Sensory disturbances over the palmar
cutaneous branch of the median nerve.
Tenderness over the course of the median
nerve in the forearm

29. • Tests:
PROXIMAL FOREARM COMPRESSION TEST
Firm direct pressure is applied to the forearm at
the elbow for 30 seconds.
Pain in the forearm and sensory disturbance
along the median nerve course.

30. TREATMENT
• NSAIDS
• ELBOW SPLINTING in 90 degree flexion and
neutral forearm rotation

31. ANTERIOR INTEROSSEOUS SYNDROME
• Seen in athletes resulting from a violent
muscle contracture from aggressive forearm
exercises
• This syndrome involves motor loss without
sensory involvement.
• AIN innervates: FDP,FPL,Pronator quadratus

32. CLINICAL FEATURES
• Inability to flex the
thumb
• No complaint of
parasthesias or sensory
disturbances
• OK Sign/ Klien Nioh Sign
TREATMENT : Surgical
decompression

33. TENDON TRANSFERS
• BRANDS TECHNIQUE and BUNNELL
PROCEDURE: FDS of ring finger to OPPONENS
POLLICIS
• CAMITZ PROCEDURE :PALMARIS LONGUS to
APB
• BURKHALTER TECHNIQUE: EXTENSOR INDICES
PROPRIUS to OPPONENS POLLICIS

34. MUSCULOCUTANEOUS NERVE

35. • Musculocutaneous nerve is a branch of lateral
cord of the brachial plexus.
• COURSE :
In the axilla it is present lateral to the axillary
artery.
It pierces the coracobrachialis and enters the
anterior aspect of the arm.
It runs downwards and laterally between the
biceps brachii and brachialis muscles.
It terminates as the lateral cutaneous nerve of
the forearm.

36. • Motor supply:
1. Biceps brachii.
2. Brachialis
3. Coracobrachialis
• Sensory supply
 Lateral cutaneous nerve of the forearm: Skin
over the lateral aspect of the forearm

37. • Causes of injury:
Penetrating injury
Rarely by anterior dislocation of
shoulder,fracture of humerus

38. • Musculocutaneous neuropathy is rare
• Possible cause due to lifting heavy weights on
the shoulder with the arm curled around the
object: CARPET CARRIER’S PALSY.
• More common entrapment is the distal
sensory nerve at the elbow between the
biceps tendon and brachialis muscle.

39. • Clinical features:
Decreased sensation over the lateral aspect of
the forearm.
Wasting of biceps and brachialis.
Motor loss is not significant as flexion of the
elbow is also performed by brachioradialis

40. TREATMENT
• REST
• Corticosteroid injection
• Massages and manual exercises to release the
fascial adhesions and any scar tissue in the
muscle which are entrapping the nerve.
• Surgical decompression if symptoms persist
more than 6months and donot respond to
conservative management.

41. • CAMPBELL’S OPERATIVE ORTHOPAEDICS
• NETTAR’S ATLAS OF HUMAN ANATOMY
• CHAURASIA TEXTBOOK OF ANATOMY

42. THANK YOU