UPPER LIMB NERVE INJURIES

Deborah Falla

CENTER FOR SENSORY-MOTOR INTERACTION AALBORG UNIVERSITY, DENMARK

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Brachial Plexus (plexus brachialis)

Roots of spinal nerves C5-8 and T1 form the brachial plexus Divided into Roots Divisions Cords Trunks Branches

Trunk: superior, middle, inferior Divisions: anterior, posterior Cords/ Fasciculi: lateral, medial, posterior Principle nerves branch from the cords

Brachial Plexus
PARS SUPRACLAVICULARIS Dorsalis scapulae Thoracicus longus Suprascapularis Subclavius PARS INFRACLAVICULARIS Short Branches: Subscapularis Thoracodorsalis Pectorales medialis and lateralis Cutaneus brachii medialis Cutaneus antebrachii medialis Long Branches: Musculocutaneus Axillaris Radialis Medianus Ulnaris

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Nerve Musculocutaneus (C5-7)

The musculocutaneus nerve leaves the Fasciculus lateralis as a mixed nerve at the level of the lateral boarder of the pectoralis minor muscle and runs a short course before piercing the coracobrachialis It then runs between the biceps brachii and brachialis to the elbow, where its terminal sensory branch supplies the skin on the radial side of the forearm

Nerve Musculocutaneus (C5-7)

Motor Branches: Coracobrachialis, Biceps brachii, Brachialis Sensory Branches: Cutaneus antebrachii lateralis skin on the radial side of the forearm

Nerve Axillaris (C5 & 6)

The axillary nerve leaves the Fasciculus posterior as a mixed nerve and runs backward through the deep part of the axilla, passing directly below the shoulder joint It courses through the quadrangular space of the axilla and to the posterior side of the proximal humerus Its terminal sensory branch supplies the skin over the deltoid muscle

Nerve Axillaris (C5 & 6)

Motor Branches: Deltoideus, Teres minor Sensory Branch: Cutaneus brachii lateralis superior skin over the muscle deltoideus

Nerve Radialis (C5-T1)

The radial nerve is the direct continuation of the Fasciculus posterior It winds around the back of the humerus in the Sulcus n. Radialis After piercing the septum intermusculare laterale approximately 10cm proximal to the lateral epicondyle, the nerve runs distally between the brachioradialis and brachialis (radial tunnel) to the elbow where it divides into a superficial and deep branch The R. Profundus passes between the superficial and deep parts of the supinator and continues to the wrist as the N. Interosseus posterior

Nerve Radialis (C5-T1)

Motor Branches: Brachialis (contribution), triceps brachii, anconeus, brachioradialis, extensor carpi radialis longus and brevis; R. Profundus: supinator, extensor digitorum, extensor digiti minimi, ext. Carpi ulnaris, ext. Pollicis longus and brevis, ext. Indicis, abductor pollicis longus Sensory Branches: several branches: Radial region of postero-lateral arm, radial dorsum of the hand and the dorsal margins of the radial 2 digits

Nerve Ulnaris (C8 + T1)

The ulnar nerve leaves the axilla as the continuation of the Fasciculus medialis It initially descends in the sulcus bicipitalis medialis Halfway down the arm it crosses to the extensor side It reaches the elbow joint between the septum and the medial head of the triceps and crosses over the joint on the medial side of the medial epicondyle, embedded in the sulcus nervi ulnaris

Nerve Ulnaris (C8 + T1)

The nerve then passes to the flexor side of the forearm between the two heads of the flexor carpi ulnaris and runs beneath that muscle to the wrist In the hand, the ulnar nerve runs on the retinaculum musculorum flexorum radial to the Os pisiforme, passing through the ulnar tunnel to the palmer surface where it divides into a superficial and deep branch

Nerve Ulnaris (C8 + T1)

Motor Branches: flexor carpi ulnaris, flexor digitorum profundus; palmaris brevis; abductor digiti minimi, flexor digiti minimi, opponens digiti minimi, lumbicales III and IV, interossei palmares and dorsales, adductor pollicis, flexor pollicis brevis Sensory Branches: several branches: Ulnar region of the lower forearm and hand

Nerve Medianis (C6-T1)

The median nerve runs in the sulcus bicipitalis medialis above the brachial artery to the elbow and passes under the aponeurosis bicipitalis and between the 2 heads of the pronator teres to the forearm Then runs between the flexor digitorum superficialis and profundus to the wrist and passes beneath the Retinaculum musculorum flexorum in the carpal tunnel to the palm of the hand Divides into terminal branches

Nerve Medianis (C6-T1)

Motor Branches: several branches: Pronator teres, Flexor carpi radialis, palmaris longus, flexor digitorum superficialis, pronator quadratus, flexor pollicis longus, flexor digitorum profundus, abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, lumbricales I and II Sensory Branches: skin on the palmer side of the radial 3 digits

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Radial Nerve
Approximately halfway down the lateral side of the arm, below the insertion of the deltoid, a groove can be palpated running downwards and forwards.
Radial nerve in radial groove

With careful palpation, particularly just behind the groove, the radial nerve can be rolled against the humerus just anterior to the lateral head of the triceps

Superficial terminal branch

Ulnar Nerve
Press pads of fingers against the lateral wall of the axilla - cord like structures can be palpated extending down the medial aspect of the arm Ulnar nerve can be palpated posterior to the medial supracondylar ridge as it passes from the medial aspect of the arm, over the medial collateral ligament of the elbow joint 2 superficial terminal branches can be rolled against the hook of the hammate just distal to the pisiform, deep in the hypothenar muscle

Ulnar nerve in Sulcus n. ulnaris

Superficial terminal branches

N Ulnaris

Median Nerve
The median nerve can be palpated in the arm on the medial side of the biceps just before it forms its tendon

Palpable median nerve

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Brachial Plexopathy Can refer to involvement of the entire plexus, or parts of the plexus Trunk lesion (Upper: Erb-Duchenne Palsy; waiters tip hand; Lower: Klumpke palsy: intrinsic muscles of hand; claw hand) Cord lesion Distribution of weakness and numbness depends upon the part of the plexus affected Mononeuropathy Dysfunction of a single peripheral nerve Weakness in muscles supplied by the nerve Sensory loss in the area of the skin supplied by the cutaneous branches of the nerve Radiculopathy Process affecting the nerve root, most commonly by a herniated disc Weakness in muscles supplied by the nerve root (myotome) Sensory loss in the area of the skin supplied by the nerve root (dermatome) Nerve root exits above the corresponding vertebra in the cervical region

Principles of Localization
Certain sites are prone to nerve entrapments/injuries Nerve opposing bone Ulnar nerve at the elbow Closed spaces Carpal tunnel Adjacent structures Median nerve at the elbow, adjacent to the brachial artery

Radialis nerve lesion

Proximal lesion Chronic pressure in the axilla e.g. Crutch use Typical dropped wrist with loss of triceps + sensory disturbances Chronic compression against the sulcus N. Radialis e.g. Sleep or general anesthetic Dropped wrist without triceps involvement + sensory disturbances Distal lesion Compression of the R. Profundus of the N. Radialis at its entry into the supinator canal by a tendon of the supinator muscle Supinator syndrome No wrist drop, no sensory disturbances Palsies involving ext. pollicis longus and brevis, abductor pollicis longus, extensor digitorum, extensor indicis, extensor carpi ulnaris

Ulnaris nerve lesion

Characteristic feature is a claw hand - loss of the M. Interossei causes the fingers to be hyperextended at the MCP joints. Plus thumb is hyperextended due to the loss of M. Adductor pollicis Proximal N. Ulnaris lesion Traumatic lesions usually occurring at the elbow joint due to the exposed position of the nerve in the Sulcus n. Ulnaris, or articular injuries due to fractures Claw hand and sensory disturbances Distal N. Ulnaris lesion Compression of the deep branch of the N. Ulnaris in the palm due to chronic pressure (e.g. tools) Claw hand with no sensory disturbances

Froment sign: indicates palsy of the M. Adductor pollicis

Medianis Nerve Lesions

Proximal N. Lesion Fracture or dislocation of the elbow joint Hand of Benediction when fist closure is attempted, with incomplete pronation, loss of thumb opposition, impaired grasping ability, atrophy of the thenar muscles + sensory disturbances Positive Bottle Sign fingers and thumb cannot close fully around a cylindrical object due to weakness of the M. Abductor Pollicis Brevis Distal N. Lesion Superficial location makes it venerable to cuts and lacerations Chronic compression in the Canalis Carpi (Carpal Tunnel Syndrome). Hand of Benediction is not present. Initial signs consist of sensory disturbances (parasthesia and dysasthesia) chiefly affecting the tips of the index and middle fingers and thumb Chronic or severe damage leads to motor deficits involving the thenar muscles and positive bottle sign

Case 1
A 38 yo woman was the restrained passenger in a car struck head on She braced her hands on the dashboard immediately prior to impact She suffered bilateral fractures of the humerus She complains of diffuse aches in her arms and neck and weakness in her arms

Case 1, cont
On examination she has: Profound weakness of wrist and finger extension at the MCPs bilaterally Weakness of supination Weakness of elbow flexion with forearm held so that thumb is toward shoulder, but not with hand held in supination Remainder of strength exam is normal She has numbness in the posterior forearm extending into dorsum of hand into thumb and proximal index finger

Sensory Loss

Final Diagnosis

Bilateral radial nerve palsies at the spiral (radial) groove related to fractures

Case 2
15 yo football player is hit by another player striking him in the axilla On getting up, he is aware of shoulder weakness and pain and is taken to the emergency room On exam he has: Normal elbow flexion Normal elbow extension Normal shoulder adduction Ability to initiate shoulder abduction, but he cannot raise his arm more than 15 degrees Mild weakness of external (lateral) rotation of the arm A patch of sensory loss over his upper arm

Sensory Loss

Final Diagnosis

Axillary Neuropathy in the Axilla

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Motor disturbances with nerve injury

Radialis Ulnaris

Medianus Ulnaris Medianus

Sensory distribution

Sensory Disturbances

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.

Injury to the roots of the brachial plexus

Process affecting the nerve root, most commonly by a herniated disc Weakness in muscles supplied by the nerve root (myotome) Sensory loss in the area of the skin supplied by the nerve root (dermatome) A lesion to a single nerve root is usually associated with incomplete paralysis of the muscle - Radiculopathy Nb: Nerve root exits above the corresponding vertebra in the cervical region e.g. C6 - C7 (C7 nerve root)

Dermatomes

Myotomes
Group of muscles supplied by a single nerve root A lesion to a single nerve root is usually associated with incomplete paralysis of the muscle A lesion to the peripheral nerve leads to complete paralysis of the muscle

Nerve Root C5

Myotomes Shoulder Abduction, Elbow flexion Elbow flexion and wrist extension Elbow extension, wrist flexion /finger extension Finger flexion and thumb abduction Finger adduction and finger abduction

Reflex Biceps

C6

Brachioradialis

C7

Triceps

C8

Triceps

T1

Learning Objectives Review the brachial plexus and its major branches. Describe the origin, course and distribution of the axillary, radial, musculocutaneous, median and ulnar nerves. Describe the surface markings of these principal nerves of the upper limb. Describe where these nerves are commonly injured. Outline the testing of these nerves for motor and sensory functions. Describe and explain the significance of the dermatomes and myotomes of the upper limb.