University of Baghdad

Al-Kindy college of medicine

Fifth stage / Group A

Median, Ulnar and Radial Nerve

Injuries

By
‫نور الزهراء علي اسماعيل‬
Supervisor: Dr. Ghadeer Hikmat
Orthopedics Module
2019-2020
Topic Page
Introduction 2
Classification of nerve injuries 3
Pathophysiology of nerve injury and repair 3-4
Investigations 4
Median Nerve Injuries 5-7
Ulnar nerve injuries 7-9
Radial nerve injuries 9-11
Summary 11
References 12

[1]
Introduction
Peripheral nerve injuries (PNI) are a common presentation that can affect
patients at any age in the context of trauma. It is especially important in athletes
since it may preclude the safe return to sports. In elderly, it can occur due to
improper use of clutches or degenerative processes.
Nerve lesions may be due to acute injury (e.g. from a direct blow) or chronic
injury secondary to repetitive micro-trauma (nerve entrapment).
Early identification of PNI is important. Because if untreated, it may be sources of
serious disabilities in later life, given the highly productive age group of the trauma
population.
Diagnosis is based upon physical examination and a knowledge of the relative
anatomy. neurological testing and provocative manoeuvres are mainstays of
diagnosis. Diagnostic suspicion can be confirmed by electrophysiological testing,
including electromyography and nerve conduction studies. (1)
Seddon classified nerve injuries into three categories: neurapraxia, axonotmesis,
and neurotmesis. After complete axonal transection, the neuron undergoes a
number of degenerative processes, followed by attempts at regeneration. A distal
growth cone seeks out connections with the degenerated distal fiber.(2)
Peripheral Nerve injuries of the upper limb are one of the most common
causes of hand dysfunction caused by upper limb trauma. Median, ulnar and
radial nerves are liable for injury by various mechanisms, including orthopedic,
compressive or iatrogeic.
If the nerve is contused, Rest, anti-inflammatories, physical therapy and
appropriate splinting are the mainstays of treatment. However, if a nerve is cut or
crushed, surgical procedures may be needed. (1)
Unfortunately, current surgical management is still suboptimal. With results
showing only 50% of patients regaining useful function. However, There is
ongoing research regarding pharmacologic agents, immune system modulators,
and enhancing factors to improve the results of treatment of nerve injuries.(2)

[2]
Classification of nerve injuries:
Nerve injuries were classified by Seddon et
al. after his World War 2 experience of nerve
injuries in injured soldiers into: neuropraxia,
axonotmesis and neurotmesis.
Then Sunderland expanded on this
classification according to histological
(3)
diagnosis : Physio-pedia.com.com

Pathophysiology of nerve injury and repair:

-following an insult to the nerve
fiber, the process of “Wallerian
degeneration” starts immediately
at the distal stump.
-The axon breaks down, and
the axoplasm is enclosed within
ellipsoids of myelin formed as a
result of retraction of the myelin
sheath. Lysosomal enzymes cause Researchgate.com
hydrolysis within these ellipsoids. 

[3]
-During the first week, Schwann cells start multiplying and form a chain within
the endoneurium. macrophages continue to ingest debris for about two weeks.
-Regeneration may start as early as 6 hours after a clean cut but may be delayed
several weeks after a crush or tearing injur
-Each axon produces several regenerating sprouts. Some of these sprouts succeed
in making contact with the distal stump and begin growing distally at a rate of
about 5 mm/day in the larger nerve trunks and 1 to 2 mm/day in the smaller ones.
-Functional recovery depends on the integrity of the endoneurium. Outcome is
better
with crush injuries than after a clean cut. (4)

Investigations:
The diagnosis is mainly based on history, clinical examination and special tests.
However, diagnostic suspicion can be confirmed by tests like:

-Electromyography (EMG): thin-needle electrode inserted into muscle to record

its electrical activity at rest and in motion, Reduced activity can indicate nerve
injury. An EMG can be used to determine if there is pathology within the muscle
and to differentiate between nerve root injury and peripheral nerve lesion.

-Nerve conduction study: Electrodes placed at two different points to measure

conducting velocity at different levels of the nerve. Can also be used to
differentiate radiculopathy from neuropathy.
-Nerve blocking: local anesthesia injection to the injured nerve, if it’s followed by
sensory or motor loss then the injury is partial.(5)

Median Nerve Injuries:

-the median nerve innervates the flexor and
pronator muscles in the anterior

[4]
compartment of forearm (except flexor carpi ulnaris and part of flexor digitorum
profundus, innervated by the ulnar nerve). Also innervates the thenar muscles and
lateral two lumbricals in the hand.

-Sensory cutaneous innervation shown in the picture: (6)

TeachMeAnatomy.info

Median nerve injuries are rarely in isolation, and often associated

with radial or ulnar nerve neuropathies as well. Carpal tunnel
syndrome is the most frequently encountered entrapment neuropathy of the upper
extremity (3% of the general population). More in women.

Causes of Median Nerve palsy:

 Open wounds , lacerations

 Orthopedic injuries: e.g. gunshots and falls causing: anterior shoulder

dislocation, elbow dislocation, humerus fracture (especially supracondylar
fracture), midshaft radius fractures, wrist fractures, and repeated use of
crutches.
 Compressive: most important is Entrapment at the wrist under the flexor
retinaculum “carpal tunnel syndrome”, or at the elbow between two heads of
pronator teres “pronator teres syndrome”
 iatrogenic: Accidental during a surgical procedure, sometimes due to
prolonged use of a tourniquet
 Other causes: generalized degenerative and demyelinating disorders,
Neuropathy such as chemotherapy-induced neuropathy. (7)

It can be classified into 2 types—high (lesions at the elbow and forearm)

and low (lesions at the wrist).

High median nerve lesions:

 The forearm is constantly supinated, and wrist flexion is weak (and often
adducted).

[5]
  Impaired flexion of the thumb, impaired flexion at the MCP joints or extend
at IP joints of the index and middle fingers.
 Lack of sensation over the areas that the median
nerve innervates.
 The thenar eminence is wasted. If patient tries to
make a fist, only the little and ring fingers can flex
completely. This results in a characteristic shape
of the hand, known as hand of benediction.
Hand of benediction (StudyBlue.com)

Low median nerve lesions:

 Muscles function of forearm are preserved.

 other findings are similar to high lesions.
 -In cases of Carpal Tunnel Syndrome, the condition begins with
numbness, paresthesias as tingling or Burning pain. It’s worse at night and
awaken patients from sleep. Positive Tinel and Phalen tests are indicative.(8)

Management:
-Open wounds require surgical exploration, if the nerve is in continuity, it is
treated as a closed injury. If there is transection, but there is adequate nerve length,
then it should be repaired primarily. If length isn’t adequate Nerve Grafting might
be used.
- In closed injuries; Conservative treatment which may include:
Analgesia: oral or topical NSAIDs, Corticosteroid injections to decrease
inflammation, nerve blockers (e.g. gabapentin), Immobilization and Physiotherapy.
Patients typically recover 4 months as long as the nerve is not lacerated or torn. (5)

- If there’s no improvement, other surgical procedures may be suitable:

 Tendon transfer: a functioning tendon is moved from its original bone
attachment to a new one. This can help restore muscle function.
 Aim is to restore opposition to the thumb and provide thumb and
finger flexion.
[6]
  flexor digitorum superficialis of the long and ring fingers or the wrist
extensors is an ideal transfer. For high median nerve palsy,
brachioradialis or extensor carpi radialis longus transfer is more appropriate
(9)

 Carpal tunnel syndrome is treated by decompression surgery.(8)

The Ulnar nerve

-the ulnar nerve Innervates the intrinsic
muscles of the hand (apart from thenar
muscles and two lateral lumbricals), and two
muscles in the forearm; flexor carpi ulnaris
and medial half of flexor digitorum
profundus. (6)
TeachMeAnatomy.info
-Sensory innervation is shown in the figure:

Causes of ulnar nerve injury:

 open wounds at any level
 at the elbow: Medial epicondylar fractures, lateral epicondylar fractures
(causing cubitus valgus with tardy nerve palsy), Olecranon fractures,
Distal humerus fractures,, Childhood supracondylar fracture, cubital tunnel
syndrome.

 at the wrist: Lacerations to anterior wrist, ulnar (Guyon’s) tunnel syndrome

 Bilateral ulnar nerves: Leprosy.(10)

Injury at different levels causes specific

motor and sensory deficits:

Damage at the Wrist

[7]
  wrist movement is normal –only intrinsic muscles of the hand are affected
 Presence of a claw hand deformity when the hand is at rest, due to
hyperextension of the 4th and 5th digits at the MCP joints, and flexion at
the IP joints.
 Impaired Abduction and adduction of the fingers, impaired Movement of the
4th and 5th digits and impaired adduction Claw Hand (StudyBlue.com)
of thumb (positive Froment’s sign.)
 Loss of sensation or paresthesiae over area supplied by ulnar nerve only the
palmar side as the dorsal branch is unaffected.

Damage at the Elbow

 All the muscles innervated by ulnar nerve are affected and there is loss of
sensation over all areas that the ulnar nerve innervates.
 Weak Flexion of the wrist, accompanied by abduction
 other hand findings are similar to the ones with wrist injuries (10)
 However, the claw hand deformity is milder, as the ulnar half of the flexor
digitorum profundus is affected, flexion of the IP joints is weakened, which
reduces the claw-like appearance of the hand. This is known as the ulnar
paradox (11)

Management
--Approach to open injuries is similar to the median nerve, as well as conservative
management. If nerve damage is extensive, extremely painful, or not improving
surgery is recommended, surgical procedures involve:

 Tendon transfer: Sublimis-to-extensor

 Cubital tunnel release if compression is at that level
 Ulnar nerve anterior transposition: move the nerve from behind the muscle
to in front of it, so there is less tension on the nerve when the elbow is bent.
 Medial epicondylectomy: to prevent the nerve from
rubbing on this area. (12)

[8]
  Zancolli Lasso Procedure (Metacarpophalangeal volar plate
capsulorrhaphy): One tendon of Flexor digitorum superficialis split into two
or four tails and each tail looped around one affected finger. (13)
Zancolli Lasso operation
(Researchgate.net)

Radial Nerve injury

Motor function: The radial nerve
innervates the muscles located in the
posterior arm and posterior forearm.
Their action is to extend forearm, extend at
the wrist and finger joints, and supinate the
forearm.(6)
-sensory innervation is shown in the figure:
TeachMeAnatomy.info
Causes:
 Open wounds: lacerations
 Orthopedic injury: most important is humeral shaft fractures (e.g. spiral
fractures of the distal shaft of the humerus “Holstein-Lewis fracture”),
dislocation at the shoulder dislocation of the radial head, Improper use of
crutches
 Anatomic compression: as in “Radial Tunnel syndrome”, by tumors
(Lipomas, neuromas, schwannomas, neurofibromas, metastatic tumors)
 Iatrogenic: use of a tourniquet, injuries with injection, operative
complications.(5)

Radial nerve Injury can be categorized into four groups – depending on

where the damage is and thus which components of the nerve is affected:

[9]
In the Axilla
 In shoulder dislocation, fracture of
the proximal humerus. Occasionally, it
is injured via excessive pressure on the
nerve within the axilla (e.g. a badly
fitting crutch).

 Loss of ability to extend forearm, wrist

and fingers.  unopposed flexion of wrist
occurs “wrist-drop” (shown in
picture)
 loss of sensation over all area supplied by branches of radial nerve
Wrist Drop (TeachMeAnatomy.info)
In the Radial Groove
 Possible weakness of forearm extension but there’s no loss of movement
 Loss of extension at the wrist and fingers with wrist-drop.
 sensory loss to the dorsal surface of the lateral three and half digits and the
associated area on the dorsum of the hand.

In the Forearm
There are two terminal branches of the radial nerve located within the forearm. The
typical mechanism of injury and effect of their injury differs: (14)

MANAGEMENT:

[10]
-management of open wounds and conservative management are similar to median
and ulnar nerves.
-special splints are shown to produce improvement
-Further surgical intervention to allow independent wrist, finger, and thumb
extension with thumb abduction includes Tendon transfer (flexor-to-extensor).
Donor muscles include the pronator teres (PT), flexor carpi ulnaris (FCU), flexor
carpi radialis (FCR), flexor digitorum superficialis (FDS) 3 and 4, and palmaris
longus (PL). (15)

Summary
This report has studied Peripheral nerve injuries of the upper limb. Starting with an
overview of the classification of nerve lesions, pathophysiological mechanism by
which nerve injury and repair occur (Wallerian regeneration), and general notes
about investigation methods used to study nerve function. The Median, ulnar and
radial nerve injuries, each was discussed separately in details, starting a general
review of function of nerve, followed by different causes and mechanisms by
which nerve injury can occur, and the clinical findings and type of deformities that
are to occur. Wrist drop, Claw hand, and Hand of benediction deformities were
highlighted. Finally, short notes about the management are given including
approach to open wounds, conservative management options, and surgical
procedures for refractory cases (e.g. tendon transfers).

[11]
References:
1-Lorei M, Hershman E. Peripheral Nerve Injuries in Athletes. Sports Medicine. 1993;16(2):130-147.

2-Lee S, Wolfe S. Peripheral Nerve Injury and Repair. Journal of the American Academy of Orthopaedic
Surgeons. 2000;8(4):243-252.

3-Classification of Peripheral Nerve Injury [Internet]. Physiopedia. 2019 [cited 14 July 2020]. Available
from: https://www.physio-pedia.com/Classification_of_Peripheral_Nerve_Injury

4-Jain S, Gupta R. Neural Blockade with Neurolytic Agents. Pain Management. 2007:343-348.

5- Gragossian A, Varacallo M. Radial Nerve Injury. [Updated 2020 Apr 14]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK537304/

6-Snell R. Clinical Anatomy by Regions. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2019. p.
326-369.

7- Davis D, Kane S. Median Nerve Palsy [Internet]. Ncbi.nlm.nih.gov. 2020 [cited 14 July 2020].
Available from: https://www.ncbi.nlm.nih.gov/books/NBK557890/

8-Patel N. Median Nerve Injuries [Internet]. Mobile Physiotherapy Clinic Ahmedabad Gujarat. 2019
[cited 14 July 2020]. Available from: https://mobilephysiotherapyclinic.in/median-nerve/

9-Sridhar K. Tendon transfer for median nerve palsy. Indian Journal of Plastic Surgery. 2011;44(2):357.

10- Jones O. The Ulnar Nerve - Course - Motor - Sensory [Internet]. Teachmeanatomy.info. 2018 [cited
13 July 2020]. Available from: https://teachmeanatomy.info/upper-limb/nerves/ulnar-nerve/

11- Neal S. Peripheral Nerve Injury of the Upper Extremity. Nerves and Nerve Injuries. 2015;:505-524.

12- Ding W, et al. Repair Method for Complete High Ulnar Nerve Injury Based on Nerve Magnified
Regeneration. Therapeutics and Clinical Risk Management. 2020;16:155-168.

13-Gupta V, Consul A, Swamy M. Zancolli Lasso Procedure for Correction of Paralytic Claw Hands.
Journal of Orthopaedic Surgery. 2015;23(1):15-18.

14- Jones O. The Radial Nerve - Course - Motor – Sensory [Internet]. Teachmeanatomy.info. 2020 [cited
14 July 2020]. Available from: https://teachmeanatomy.info/upper-limb/nerves/radial-nerve/

15- Hoyen H. Tendon Transfers for Radial Nerve Palsy [Internet]. Musculoskeletal Key. 2016 [cited 14
July 2020]. Available from: https://musculoskeletalkey.com/tendon-transfers-for-radial-nerve-palsy/

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