Nerve injury of upper limb by Dr. Bipul Borthakur

1. NERVE INJURY OF UPPER
LIMB
DR. BIPUL BORTHAKUR
PROF OF ORTHOPAEDICS ,
SILCHAR MEDICAL COLLEGE

2. ANATOMY
• Functions of the nerves in the upper limb
• The nerves entering the upper limb provide the following
important functions:
1. Sensory innervation to the skin and deep structures, such as
the joints;
2. Motor innervation to the muscles;
3. Influence over the diameters of the blood vessels by the
sympathetic vasomotor nerves;
4. Sympathetic secretomotor supply to the sweat glands

3. ANATOMY

4. BRACHIAL PLEXUS

5. Formation of the brachial plexus
• The roots of the brachial plexus is formed by the union of the anterior rami of the
5th , 6th , 7th , and 8th cervical and the 1st thoracic spinal nerves,
The roots of C5 and 6 unite to form the upper trunk.
The root of C7 continues as the middle trunk.
The roots of C8 and T1 unite to form the lower trunk.
Each trunk then divides into anterior and posterior divisions.
The anterior divisions of the upper and middle trunks unite to form the lateral cord.
The anterior division of the lower trunk continues as the medial cord. The posterior
divisions of all three trunks join to form the posterior cord

6. Branches of the cords
• From the lateral cord
• Musculocutaneous nerve (C5,6).
• Lateral pectoral nerve (C5,6).
• Lateral root of median nerve (C5,6,7).
• From the medial cord
• Medial pectoral nerve (C8 ,T1)
• Medial cutaneous nerves of arm (C8 ,T1).
• Medial cutaneous nerves of forearm(C8 ,T1).
• Ulnar nerve(C7, 8 ,T1)
• Medial root of median nerve (C8 ,T1).
• From the posterior cord
• Upper subscapular nerves (C5,6).
• lower subscapular nerves (C5,6).
• Nerve to latissimus dorsi (thoracodorsal nerve) (C 6, 7,8).
• Axillary nerve(C5,6).
• Radial nerve (C5,6,7,8,T1).

7. BRACHIAL PLEXUS
• : NERVES DISTRIBUTION OF MAIN NERVES –
• AXILLARY –
• Deltoid & Teres minor –
• MUSCULOCUTANEOUS –
• Muscles of Anterior Compartment of arm (flexors) –
• MEDIAN –
• Most of the Flexor muscles of forearm & Intrinsic muscles in hand- labourer –
• ULNAR –
• FCU & part of FDP (forearm) and Intrinsic muscles in hand- musician –
• RADIAL –
• Innervates all Extensor muscles of arm & forearm

8. ANATOMY- brachial plexus
BRACHIAL PLEXUS INJURIES
1. INJURIES OF THE TRUNKS:
• Upper trunk lesion of brachial plexus
• Lower trunk lesions of brachial plexus
2. INJURIES OF INDIVIDUAL NERVES
• Long thoracic nerve
• Axillary nerve
• Radial nerve
• Median nerve
• Ulnar nerve

9. BRACHIAL PLEXUS
• Erb’s palsy------upper trunk
• Klumpke’s palsy---- lower trunk
• Winging of scapula---- long thoracic nerve
• Axillary nerve injury
• Ape’ s hand---- median nerve
• Wrist drop------ Radial nerve
• Claw hand-----ulnar nerve

10. BRACHIAL PLEXUS
Upper trunk lesion of brachial plexus
• Traction or even tearing of C5 and C6 root
• Cause:
• Excessive displacement of head to opposite
side and depression of shoulder on same side
• In infants during a difficult delivery
• In adults following a fall on or a blow to the
shoulder
• Nerves involved:
Suprascapular nerve
Nerve to Subclavius Musculocutaneous nerve
Axillary nerve

11. BRACHIAL PLEXUS
Manifestations of upper trunk injury (Erb’s Palsy)
• Loss of muscle function innervated by
C5 and C6 known as Erb’s Palsy or
waiter’s tip.
Manifestations
• Arm medially rotated, adducted, hangs by side
• Forearm extended and pronated

12. BRACHIAL PLEXUS
Lower trunk lesions of brachial plexus
• Fibers of C8 and mostly T1 root are torn
Causes:
• Excessive abduction of arm as in:
1. Birth injury
2. Person falling from a height holding an object to
save himself
• Compression of lower trunk as in case of:
1. Cervical rib
2. Malignant lower deep cervical lymph nodes
Nerves involved
• Ulnar and median nerves

13. BRACHIAL PLEXUS
• Lower trunk lesions of brachial plexus (klumpke’s palsy)
• Muscles involved
• All small muscles of the hand (interossei and lumbricals)
Note: The lumbricals are intrinsic muscles of the hand that flex the
metacarpophalangeal joints and extend the interphalangeal joints
Manifestations of klumpke’s palsy
• Hyperextension of metacarpophalangeal joint----- by unopposed
extensor digitorum
• Flexion at interphalangeal joint by unopposed flexor digitorum
superficialis and profundus
This deformity known as clawed hand
Sensory loss:
Along the medial side of forearm

14. BRACHIAL PLEXUS
LONG THORACIC NERVE INJURY
• Arise from roots C5 , C6 and C7
• Causes:
• Blows or pressure in posterior triangle of neck
• In radical mastectomy
Muscles involved:
Serratus anterior
Functions lost:
• Abduction above 90 degrees
• Protraction
Deformity
Winging of scapula: medial border and inferior angle of scapula prominent

15. Axillary nerve lesion
• Causes
a. Fracture of surgical neck of humerus
b. Inferior dislocation of shoulder joint
c. Misplaced injection into deltoid
Muscles involved : Deltoid and Teres minor
Manifestations
• Loss of abduction from 18° to 90°
• Shoulder weakness
• As the deltoid atrophies, the rounded contour
of the shoulder is lost and becomes flattened
compared to the uninjured side.
• Sensory loss
Injury of the upper lateral cutaneous nerve of arm
leads to loss of skin sensation over the lower half of deltoid muscle

16. Radial nerve injury in axilla
• Causes
• Pressure of badly fitted crutch into armpit
• Falling a sleep with arm over the back of chair (Saturday night palsy)
• Motor loss:
• loss of extension of elbow due to paralysis of triceps and anconeus
• Loss of extension of wrist and fingers due to paralysis of extensors of wrist
and all muscles of posterior compartment
• Supination can still be performed by biceps muscle
• Deformity
known as WRIST DROP: flexion of wrist as a result of action of unopposed flexors of wrist
and fingers
• Sensory loss
• posterior surface of arm and forearm
• Dorsum of hand and dorsal surface of lateral 3 ½ fingers

17. Radial nerve injury in spiral groove
• Most commonly in distal part of groove beyond the origin of nerves to
triceps and anconeus and cutaneous nerves
• Causes:
• Fracture of shaft of humerus
• Prolonged pressure on the back of arm as in unconscious
patient by edge of operating table
• Prolonged application of tourniquet in thin lean person
• Motor loss:
loss of extension of wrist, fingers and thumb (wrist drop)
Sensory loss:
Dorsum of hand and dorsum of lateral 3 ½ fingers

18. Injury of median nerve at elbow
• Cause: Supracondylar fracture of humerus
• Motor loss
• Paralysis of pronators of forearm
• Paralysis of long flexors of wrist and fingers except medial half of
flexor digitorum profundus and flexor carpi ulnaris
• paralysis of the flexor pollicis longus
• Paralysis of thenar muscles (wasted)
• Deformity:
• Forearm: loss of pronation (supinated)
• Wrist: flexion is weak accompanied by adduction
• Fingers: no flexion of interphalangeal joint of index and middle fingers
• Thumb: loss of flexion, abduction and opposition
• APE’S HAND: thumb laterally rotated, adducted and thenar eminence flattened
• Sensory loss
Lateral side of palm, Palmar surface of lateral 3 ½ fingers and distal part of dorsal surface of lateral 3 ½ fingers

19. Injury to median nerve at wrist
• Most common injury of median nerve
• Causes
• Due to penetrating injuries or stab wound at the wrist
• Motor loss
• Muscle of thenar eminence
• First two lumbricals
• Deformity APE’S HAND
• Sensory loss
• Same as in elbow lesion

20. ULNAR NERVE INJURY AT THE
ELBOW
• Most commonly injured at this site
• Cause:
Fracture of medial epicondyle
• Motor loss
• Flexor carpi ulnaris and medial half of flexor digitorum profundus
• Small muscle of hand are paralyzed except thenar muscles and first 2 lumbricals
• Deformity
• Wasting of ulnar border of forearm
• Loss of flexion of terminal phalanges of little and ring finger
• Inability to abduct and adduct fingers
• Loss of adduction of thumb
• CLAW HAND: Metacarpophalangeal joints of fourth and fifth finger are hyper extended and the
interphlangeal joint s are flexed
• Flattening of hypothenar eminence
• Hollowing between metacarpals on dorsum of hand due to paralysis of dorsal interossei
• Sensory loss
• Anterior and posterior surfaces of medial half of hand and medial one and half fingers

21. NERVE INJURY -DIAGNOSIS
CLINICAL TEST-
1.Loss of sensation of along the sensory distribution of that particular
nerve.

22. NERVE INJURY -DIAGNOSIS

23. NERVE INJURY -DIAGNOSIS
•Electromyography (EMG). In an EMG, a thin-needle electrode
inserted into your muscle records your muscle's electrical activity
at rest and in motion. Reduced muscle activity can indicate nerve
injury.
•Nerve conduction study. Electrodes placed at two different
points in your body measure how well electrical signals pass
through the nerves.
•Magnetic resonance imaging (MRI). MRI uses a magnetic field
and radio waves to produce detailed images of the area affected
by nerve damage.

24. TREATMENT-NON OPERATIVE

25. TREATMENT-OPERATIVE
• Surgical treatment is decided on a case-by-case basis, and depends on
the location, duration, and type of nerve injury.
• Surgery. The goal of surgery is to improve function of the affected area in
the upper extremity.
• If the nerve is thought to be repairable, surgical treatment may consist of:
• Nerve decompression
• Nerve repair
• Nerve graft
• If nerve repair is not an option, a tendon transfer may be
recommended. Tendon transfers borrow extra tendons from other parts of
the hand or forearm to perform a function that is lost due to the nerve
injury. The tendon chosen so the patient does not have loss of function
with use of the donor tendon

26. THANK YOU