This document discusses radial, median, and ulnar nerve injuries. It describes the anatomy and course of each nerve, typical injury locations and mechanisms, clinical features of injuries, and classifications of nerve injuries. Treatment options are also summarized, including nerve mobilization, grafting, and surgical techniques like neurolysis and neurorrhaphy.

1. Radial,Median and Ulnar nerve
injuries
Dr. Debesh Shrestha
Resident of Orthopaedics
GMC

3. Radial nerve
• C5,C6, C7, C8, T1
• It is the terminal branch of the posterior cord
of the brachial plexus

4. Course
oIn the axilla
• It lies anterior to the
subscapularis, teres major
and lattismus dorsi
muscle
• Motor supply to the long
head of triceps
• Posterior cutaneous nerve
of arm

5. In the arm
• Lies in the spiral groove of humerus
• Re-enters anterior compartment by
piercing lateral intermuscular
septum
• Motor supply to triceps (medial
and lateral head), anconeus,
brachialis, brachioradialis, extensor
carpi radialis longus
• Sensory : lower lateral cutaneous
nerve of arm
posterior cutaneous nerve
of forearm

6. In the elbow
• Anterior to the lateral
epicondyle, radial nerve
divides into the terminal
branches :
1. Posterior interosseus
nerve
2. Superficial radial sensory
nerve

7. In the forearm
• PIN reaches the back of the forearm
by passing round lateral aspect of the
radius between the two heads of
supinator
• As it emerges from the supinator
posteriorly, the nerve at first lies
between the superficial and deep
extensor muscles.
• At the distal border of extensor
pollicis brevis, it passes deep to
extensor pollicis longus and
diminished to a fine thread, descends
on the interosseus membrane to the
dorsum of the carpus- supply carpal
ligaments and articulations

8. • PIN supplies
1. Extension carpi radialis brevis
2. Supinator
3. Extensor digitorum
4. Extensor digiti minimi
5. Extensor carpi ulnaris
6. Abductor pollicis longus
7. Extensor pollicis longus
8. Extensor pollicis brevis
9. Extensor indicis

10. Radial nerve injury
1. Very high– above the spiral
groove
• crutch palsy
• Saturday night palsy
• Trauma/operations around the
shoulder
2. High – at or below the spiral
groove
• Fracture shaft of humerus
• Prolonged torniquet pressure

11. 3. Low– at or below the elbow
• PIN injury– radial tunnel syndrome
fractures (monteggia fracture)
iatrogenic
• superficial radial nerve injury
o fracture
o iatrogenic (venous canulation)
o Laceration
o Blunt trauma

12. Clinical features
• Very high radial injury–
o weak elbow extension
o loss of wrist, finger and thumb extension (wrist drop)
o Sensory loss over the posterior arm, forearm and
posterolateral hand
• High radial injury
o Normal elbow extension
o Loss of wrist, finger and finger extension
o Normal sensation over posterior arm and forearm
o Sensory loss over posterolateral hand

13. • Low radial injury
Posterior interosseus nerve injury
o Normal elbow and wrist extensors
o Weak finger and thumb extensors
o Normal sensation over posterior arm, forearm and
posterolateral hand
 Superficial radial nerve injury
o Normal extensors
o Sensory loss over posterolateral hand
o Normal sensation over posterior arm and forearm

14. Wartenberg syndrome
• Compression of
superficial branch of
radial nerve between
ECRL and
brachioradialis
• Numbness over
posterior aspect of
thumb

15. Radial tunnel syndrome
• About 5 cm space
• Dorsally– capsule of the
radiocapitellar joint
• Volarly– brachioradialis
• Laterally– ECRB and ECRL
• Medially– biceps tendon and
brachialis
• PIN nerve compressed
• C/F– loss of finger and thumb
extension, weak wrist
extension

16. Median nerve
• Roots from the lateral ( C5, C6,
C7) and medial ( C8, T1) cords
unite to form the median nerve
• In the axilla– no branches
• In the arm– descends along the
lateral side of the 3rd part of the
axillary artery and brachial
artery
• Near the insertion of the
coracobrachialis, it crosses in
front of the brachial artery from
lateral to medial side

17. In the cubital fossa
• Lies medial to the
brachial artery
• Covered by bicipital
aponeurosis

18. In the forearm
• Enters forearm between
the two heads of
pronator teres
• Passes beneath the arch
of flexor digitorum
superficialis
• Runs between flexor
digitorum superficialis
and flexor digitorum
profundus

19. Branches in the forearm
1. Anterior interosseus nerve
• Arises between the two heads of pronator teres
• Descends between and deep to FPL and FDP
along with anterior interosseus artery
• Supplies
i. Flexor policis longus
ii. FDP (lateral half i.e. Index and middle finger)
iii. Pronator quadratus

20. 2. Muscular braches
• Pronator teres
• Flexor carpi radialis
• Palmaris longus
• Flexor digitorum superficialis
3. Other branches
• Articular branch to elbow and wrist joint
• Palmar cutaneous branch

21. In the wrist
• 5 cm proximal to the
flexor retinaculum it
emerges from behind the
lateral edge of FDS
• Lies between the tendons
of FDS and FCR
• Passes laterally from
beneath the tendon of
Palmaris Longus deep to
the retinaculum

22. Branches in the hand
1. Lateral terminal branch
• Supplies thenar muscles
• 1st lumbrical
• 3 proper palmer digital
nerves
2. Medial terminal branch
• Supplies 2nd lumbrical
• 2 common palmer digital
nerves

24. Median nerve injury

25. Median nerve can be injured in
• In the course of arm
• At Elbow
• In the forearm
• At wrist
• At hand

26. Effects
• Paralysis of muscle supplied by it
• Deformity of hand
• Loss of sensation

27. Classification
• High: above the origin of Anterior
interosseous nerve (proximal to elbow)
• Low: injury in distal 3rd of forearm
• Carpel tunnel syndrome

28. High median nerve injury
• Injury proximal to elbow
• Due to forearm fractures or elbow dislocations
• Stab and gun shot wounds
• Paralysis of all the muscles supplied by it in
forearm and hand

29. Low median nerve injury
• Injury in distal 3rd of forearm
• Cuts in front of wrist and carpel bone
dislocations
• Spare forearm muscle
• paralysis of muscles of hand, thenar intrinsic
muscle paralysis
• Thumb abduction and opposition weak
• Sensation lost over radial 3 and half fingers

30. • Anesthesia over median nerve distribution in
hand
• Thenar eminence wasted, thumb abduction
and oppositions of fingers are weak
• Sensations lost over three and half of radial
fingers

31. Examinations
• Flexor pollicis longus:
patient is asked to flex
the terminal phalynx of
the thumb while his/her
base of thumb is held

32. • Flexor digitorium
superficialis and
profundus: (oscher’s
clasping test) patienr is
asked to clasp both the
hands where index
finger of affected side
fails to flex.

33. • Flexor carpi radialis: hand deviates to ulnar
side when flexed against resistance
• Muscles of thenar eminance: abductor pollicis
brevis (pen test): pen is kept level higher than
thumb and pts is asked to touch tip of pen

34. • Opponens pollicis:
patient is asked to
touch tip of other finger
with tip of thumb

36. Pointing index sign

37. Wasting of thenar eminance

38. Typical area of sensory loss in median
nerve palsy

39. Ape thumb deformity

40. Ulnar nerve
• Composed of fibers from C8
and T1 coming from medial
cord of brachial plexus
• Above the axilla: It courses
with the axillary artery and
vein and lies deep to
pectoralis minor
• In the axilla, it crosses
medial to brachial artery and
lies deep to the pectoralis
major

41. In the arm
• At the level of distal attachment
of coracobrachialis to the
humerus (about 10 cm proximal
to the medial epicondyle), ulnar
nerve pierces the medial
intermuscular septum to enter
the posterior compartment of
the arm.
• Here it lies on the anterior
border of the medial head of the
triceps
• Then it passes through the
ligament of Struthers and then
behind the medial epicondyle
through cubital tunnel

43. In the forearm
• As the nerve exits the cubital tunnel, it courses
between the two heads of flexor carpi ulnaris
and enters the anterior compartment of the
forearm.
• Shortly after exiting the cubital tunnel, ulnar
nerve gives off motor branches to the flexor
carpi ulnaris
• It then lies on the anterior surface of the flexor
digitorum profundus
• At about 5 cm distal to the medial epicondyle,
ulnar nerve gives off branches to the ulnar
aspect of FDP (providing innervation to long
flexors of ring and small fingers)
• In the middle of the forearm, at about 12 cm
distal to the medial epicondyle, ulnar nerve
becomes superficial and meets with the ulnar
artery as it travels towards the wrist

44. In the wrist
• Ulnar nerve and artery lie in a canal
formed by the pisiform bone
medially and the hook of hamate
laterally (guyon’s canal)
• In this region the nerve divides into
1. The superficial sensory branch–
distal palm, 5th and half of 4th digit
2. The deep motor branch–
hypothenar muscles, adductor
pollicis,3rd and 4th lumbricals,
palmar digital branches to medial
one and half fingers

46. Ulnar nerve injury
 At the level of elbow
 Motor loss
• FCU and medial half of FDP paralyzed
• Profundus tendon to the ring and little fingers will be
functionless
• Terminal phalanges to these fingers fail to flex properly
• Flexion of wrist will result in abduction due to paralysis of
FCU
• Small muscles of hand will be paralyzed except the muscles
of thenar eminence and first two lumbricals
• Adductor pollicis longus is paralyzed-- adduction of thumb
not possible

47. • Metacarpophalyngeal joints
become hyperextended due
to paralysis of lumbrical and
interosseus muscles
• IP joints are flexed (claw
hand)
• Dorsum of hand shows
hollowing due to wasting of
the dorsal interosseus
muscles

48. Sensory loss
• Loss of skin sensation over anterior and
posterior surfaces of medial 3rd of the hand
and medial one and half fingers

49. At the level of wrist
Motor loss
• Small muscles of the hand paralyzed
• Claw hand more obvious (as FDP not
paralyzed)
• Marked flexion of terminal phalanges occur

50. Sensory loss
• Sensory loss over the palmer surface of medial
3rd of the hand and medial one and half finger

51. Froment’s sign
• Weakness of adductor
pollicis: pts asked to grip
sheet of paper forcefully
between thumb and index
finger while examiner try
to pull it away, powerful
flexion of thumb
interphalyngeal joint of
affected side signal
weakness in adductor
pollicis.
• FPL flexes thumb

52. Card test and Egawa test
• Inability to hold a card or paper
between the fingers due to loss
of adduction by the palmer
interossei
Egawa test
• With the palm placed flat on the
table, the patient is asked to
move the middle finger sideways
• This is a test for the dorsal
interossei of middle finger

53. Guyons tunnel syndrome
• Entrapment of ulnar
nerve in pisohammate
tunnel(guyon’s canal)
• Seen in long distance
cyclist, lean with
pisiform pressing on
handlebars

54. Cubital tunnel syndrome(ulnar
neuronitis)
• Compression or
entrapment of nerve in
medial epicondylar
tunnel(cubital tunnel)
• Esp in severe valgus
deformity of elbow or
prolong pressure of
elbow on anesthetised
patient

55. Autonomous sensory zones
• These are the regions where single nerve supply distinct
and non-overlapping areas of skin
• Radial nerve: 1st dorsal web space of hand (Anatomical
snuff box)
• Median nerve: Distal phalanx (tip) of index finger (2nd
finger)
– Other: Tip of thumb
• Ulnar nerve: Distal phalanx (tip) of little finger (5th finger)

56. Peripheral nerve injury

57. Classifications
• Seddon’s classifications:
1. Neurapraxia:
• reversible physiological nerve conduction block
• Spontaneous recovery after few days
2. Axonotmesis:
• loss of conduction but the nerve is in continuity and nerve
tubes are intact
• Recovery may occur but may take several months
3. Neurotmesis:
• Severe damage to the nerve
• May occur without actually dividing the nerve
• Spontaneous recovery unlikely

58. • Sunderland classifications:
1. 1st degree: Transient ischemia and
neuroprexia, Reversible
2. 2nd degree: Seddon’s axonotmesis,
regeneration can lead to complete or near
complete recovery without intervention.
3. 3rd degree: worse, endoneurium disrupted
but perineural sheath intact, fibrosis limit the
recovery

59. • 4th degree: only epineurium is intact, nerve
trunk still in continuity but internal damage is
severe , recovery unlikely
• 5th degree: nerve divided and will have to be
repaired

60. Diagnosis
Clinical examination
• Tinel sign– gentle percussion by finger or
hammer over the course of injured nerve
produces tingling sensation in the distribution
of the injured nerve
• A positive sign is presumptive evidence that
regenerating axonal sprouts that have not
obtained complete myelinization are
progressing along the endoneural tube

61. Imaging
• High resolution USG
• MRI
Electo-diagnostic studies
• Nerve conduction velocity
• Electromyography

62. Treatment of nerve injuries
.General considerations
• Maintain ABC
• Evalutate nerve injury
• Open wound should be cleansed and debrided
• Immediate primary repair of nerve done if
o Wound is clean and sharply incised
o Patient is stable
o Adequate personnel and equipments
• Delayed primary repair– 7-18 days
• >18 mths—loss of motor end plates and muscle fibrosis
• Release of compression

63. • When closed fractures are complicated by peripheral
nerve injuries, reinnervation awaited and early surgical
exploration avoided.
• If nerve deficit follows manipulation or casting of a
closed fracture, early exploration of nerve done.

64. Techniques
• Neurolysis
o External neurolysis– nerve is freed from enveloping scar
o Internal neurolysis– nerve sheath dissected longitudinally to
relieve the pressure from the fibrous tissue within the nerve
• Epineural neurorrhaphy
• Perineural (fascicular ) neurorraphy
individual fasciculi sutured within the nerve trunk
Suture used– 8-0 or 9-0 monofilament nylon for epineural
suturing and 9-0 or 10-0 for perineural suturing

67. Closing nerve gaps
• Mobilization of nerve
• Positioning of joint—to relax the nerve
• Transposition
• Bone resection
• Nerve grafts

68. Interfascicular nerve graft
If nerve gap is more than 10 cm
Donor nerves
• Sural
• Saphenous
• Lateral cutaneous nerve of thigh
• Lateral and medial cutaneous nerve of the forearm
• Posterior cutaneous nerve of the forearm
• Superficial nerve of the radial nerve
• Dorsal branch of the ulnar
• Intercostal nerves

69. Post- operative care
• Upper limb immobilised in plaster slab (minimum of 4
wks)
• Wound dressed after 7-10 days

70. Prognosis
• Age
• Size of gap
• Type of injury
• Level of injury
• Delay in repair