NERVE INJURIES OF UPPER LIMB

Dr. Mujahid Khan

Brachial Plexus Injuries

(upper lesions)
These

are caused by the excessive displacement of the head to the opposite side
of the shoulder on the same

Depression

side
This

causes excessive traction or tearing of C5 and C6 roots of the plexus

Nerves To be Affected

The suprascapular nerve The nerve to the subclavius The musculocutaneous nerve Axillary nerve All possess nerve fibers derived from C5 and 6 roots and will therefore be functionless

Muscles to be Paralyzed

Supraspinatus (Abductor of shoulder) Subclavius (depresses the clavicle) Infraspinatus (lateral rotator of shoulder) Biceps brachii (flexor of elbow) Coracobrachialis (flexor of shoulder) Deltoid (Abductor of shoulder)

Teres minor (lateral rotator of shoulder)

Erb-Duchenne Palsy
The

limb hangs limply by the side likened to a waiter or porter hinting for a tip
There

will be a loss of sensation down the lateral side of arm

Brachial Plexus Injuries

(Lower lesions)
Are

usually a traction injuries caused by excessive abduction of the arm first thoracic nerve is usually torn

The
The

hand has a clawed appearance caused by hyperextension of metacarpophalangeal joints & flexion of interphalangeal joints

Brachial Plexus Injuries

(Lower lesions)
Loss

of sensation will occur along the medial side of the arm

lesions can also be produced by a presence of a cervical rib or malignant metastases from the lungs in the lower deep cervical lymph nodes

Lower

Injuries of Long Thoracic Nerve

Can be injured by blows to or pressure on the posterior triangle of the neck

During the surgical procedure of radical mastectomy Paralysis of the serratus anterior results in the inability to rotate the scapula during the movement of abduction of the arm above a right angle

Injuries of Long Thoracic Nerve

The

patient feels difficulty in raising the

arm
The

vertebral border & inferior angle of scapula protrude posteriorly as winged scapula

Known

Injuries of Axillary Nerve

Can be injured by the pressure of a badly adjusted crutch pressing upward into the armpit
It is vulnerable during the downward displacement of the humeral head in shoulder dislocations or fractures of the surgical neck of the humerus Paralysis of deltoid and teres minor muscles results

Axillary Nerve

Loss of skin sensation over the lower half of the deltoid muscle Paralyzed deltoid wastes rapidly Underlying greater tuberosity can be palpated Abduction of the shoulder is impaired Paralysis of teres minor is not recognizable clinically

Injuries of Radial Nerve

Can be injured by:
Pressure Drunkard

of badly fitting crutches

falling asleep with one arm over the back of a chair or dislocation of the proximal end of the humerus

Fractures

Findings in Radial N. Injury

Triceps, anconeus and long extensors of the wrist are paralyzed Unable to extend the elbow joint, wrist joint and fingers Wrist drop or flexion of wrist occurs Unable to flex the fingers firmly for gripping Brachioradialis & supinator are paralyzed

Sensory Findings
Small

loss of skin sensation over posterior surface of lower part of the arm loss on the lateral part of dorsum of the hand
loss on the dorsal surface of the roots of the lateral 3 & fingers

Sensory

Sensory

In the Spiral Groove

Radial

nerve can be injured in the spiral groove at the time of fracture of shaft of the humerus
drop occurs

Wrist

Sensory

loss on the dorsal surface of the roots of the lateral 3 & fingers

Deep Branch of Radial Nerve

Can

be damaged in the fracture of the proximal end of radius or during dislocation of the radial head
wrist drop as extensor carpi radialis longus is undamaged sensory loss as this is a motor nerve

No

No

Injuries of Musculocutaneous Nerve

Rarely

injured due to its protected position beneath the biceps brachii muscle injured high up in the arm, the biceps & coracobrachialis are paralyzed & brachialis is weakened loss along the lateral side of the forearm occurs

If

Sensory

Injuries of Median Nerve

Can be injured:

Occasionally in the elbow region in supracondylar fractures of the humerus Commonly injured by stab wounds or broken glass just proximal to the flexor retinaculum Here it lies between the tendons of flexor carpi radialis and flexor digitorum superficialis

Injury at Elbow
(motor)

Pronator muscles of forearm, long flexor muscles of the wrist & fingers will be paralyzed
Forearm is kept in supine position Wrist flexion is weak & accompanied by adduction No flexion at interphalangeal joints of index & middle fingers

Injury at Elbow
(motor)
When

the patient tries to make a fist, the index & middle fingers tend to remain straight
ring & little fingers flex

Only

Flexion

in these fingers is weakened by the loss of the flexor digitorum superficialis

Injury at Elbow
(motor)
Flexion

of terminal phalanx of thumb is lost because of paralysis of flexor policis longus

thumb is laterally rotated and adducted of thenar eminence are paralyzed

The

Muscles

The

hand looks flattened and ape like

Injury at Elbow
(sensory)
Skin

sensation is lost on the palmar aspect of the lateral 3 & fingers loss occurs on the skin of the distal part of the dorsal surfaces of the lateral 3 & fingers
area of anesthesia is less

Sensory

Total

Injury at Elbow
(vasomotor changes)
The

skin areas involved in sensory loss are warmer and drier than normal
dilatation and absence of sweating resulting from loss of sympathetic control

Arteriolar

Injury at Elbow
(Trophic changes) In long standing cases:
Skin

is dry and scaly

crack easily of the pulp of the fingers

Nails

Atrophy

Injury at Wrist
Almost

all the clinical findings are same as injury of the median nerve at elbow addition a delicate pincer like movement is not possible

In

Carpal Tunnel Syndrome

The

carpal tunnel is formed by the concave anterior surface of carpal bones and closed by flexor retinaculum
the syndrome consists of a burning pain or pins & needles along the distribution of the median nerve 3 & fingers are involved

Clinically,

Lateral

Carpal Tunnel Syndrome

The

exact cause is difficult to determine

Condition

is relieved by decompressing the tunnel by making a longitudinal incision through the flexor retinaculum

Injury to the Ulnar Nerve

(motor at elbow)

Flexor carpi ulnaris & medial half of flexor digitorum profundus are paralyzed
In a tightly clenched fist the tightening of the tendon of profundus is absent Profundus tendon to the ring & little fingers will be functionless Terminal phalanges of these fingers fail to flex properly

Injury to the Ulnar Nerve

(motor at elbow)
Flexion

of wrist joint will result in abduction due to paralysis of flexor carpi ulnaris muscles of hand will be paralyzed except the muscles of thenar eminence and first 2 lumbricals
pollicis longus is paralyzed so the adduction of thumb is not possible

Small

Adductor

Injury to the Ulnar Nerve

(motor at elbow)
Metacarpophalangeal

joints become hyperextended due to the paralysis of lumbrical and interosseous muscles
joints are flexed due to the same reason as mentioned above of hand will show hollowing due to the wasting of dorsal interosseous muscles

Interphalangeal

Dorsum

Injury to the Ulnar Nerve

(sensory at elbow)
Loss

of skin sensation of anterior & posterior surfaces of the medial 3rd of the hand and medial 1 & fingers
skin areas involved in sensory loss are warmer and drier than normal dilatation and absence of sweating resulting from loss of sympathetic control

The

Arteriolar

Injury to the Ulnar Nerve

(motor at wrist)
Small

muscles of the hand will be paralyzed hand is more obvious as flexor digitorum profundus is not paralyzed flexion of the terminal phalanges

Claw

Marked

occur

Injury to the Ulnar Nerve

(sensory at wrist)

The sensory loss is usually confined to the palmar surface of medial 3rd of the hand and the medial 1 & finger Trophic changes are same as that injuries of ulnar nerve at elbow Unlike median nerve injuries, lesions of ulnar nerve leave a relatively efficient hand
Pincer like action is good