Nerves of upper limb

injuries

MJ MEDICOS
• Axillary nerve
• Median nerve
• Radial nerve
• Ulnar nerve
Axillary nerve
Origin
• Posterior cord of
brachial plexus

Root value
• C5,6
Course
• Passes through
quadrangular space
• Below shoulder joint
• Passes behind the
surgical neck of
humerus
• Divides into anterior
and posterior branches
 Branches
• Anterior branch
• Deltoid muscle
• Cutaneous- skin of
lower half of deltoid
• Posterior branch
• Teres minor
• Upper lateral
cutaneous nerve of arm
• Articular branch-
shoulder joint
Injury to axillary nerve
• shoulder dislocations
• fractures of the
surgical neck of the
humerus
Clinical findings
• Motor
• Paralysis of the deltoid-
abduction of shoulder lost
• teres minor muscles – not
recognizable clinically.
• Sensory
• loss of skin sensation over
the lower half of the
deltoid muscle.
• The paralyzed deltoid
wastes rapidly, and the
greater tuberosity can be
readily palpated.
 Median nerve
Origin
• two roots- from the lateral
(C5, 6, 7) and medial (C8, T1)
cords,

• which embrace the third part

of the axillary artery, and
unite anterior or lateral to it.
Arm
• The median nerve enters the
arm lateral to the brachial
artery.
• Near the insertion of
coracobrachialis it crosses in
front of the artery, descending
medial to it to the cubital fossa
Cubital fossa
• it is posterior to the bicipital
aponeurosis
• anterior to brachialis,
separating it from the elbow
joint.
Forearm
• leaves the cubital fossa by
passing between the two
heads of the pronator teres
• continues downward behind
the flexor digitorum
superficialis and rests
posteriorly on the flexor
digitorum profundus.
Wrist
• emerges from the lateral
border of the flexor digitorum
superficialis muscle and lies
behind the tendon of the
palmaris longus –
• It enters the palm by passing
behind the flexor retinaculum
• Anterior interosseus
branch of median
nerve
• Passes deep to
pronator quadratus
Palm
• enters the palm by passing
behind the flexor
retinaculum and through
the carpal tunnel.
• It immediately divides into
lateral and medial
branches.
 Branches
• Articular branches-
Forearm
Muscular
• Pronators-teres.quadratus
• all the flexor muscles of the
forearm
• except the flexor carpi ulnaris and
the medial half of the flexor
digitorum profundus
Cutaneous
• a palmar cutaneous branch
• crosses in front of the flexor
retinaculum
• supplies the skin on the lateral
half of the palm-thenar eminence
Palm
• the muscles of the thenar eminence
• the first two lumbricals
• Cutaneous
• sensory innervation to the skin of the palmar
aspect of the lateral 3 ½ fingers, including the nail
beds on the dorsum.
Injury of median nerve

• Labourers nerve
Elbow
• supracondylar
fractures of the
humerus.
Wrist
• commonly injured by
stab wounds or broken
glass just proximal to
the flexor retinaculum
 Clinical findings
Motor
• Loss of pronation- The pronator muscles
of the forearm paralyzed
• the forearm is kept in the supine
• Weak flexion of wrist- long flexor muscles
of the wrist and fingers-paralyzed.
• accompanied by adduction of wrist
• No flexion - at the interphalangeal joints
of the index and middle fingers
• When the patient tries to make a fist, the
index and to a lesser extent the middle
fingers tend to remain straight, whereas
the ring and little fingers flex – ape like
hand
• Thumb
• Flexion of the terminal
phalanx lost - paralysis of
the flexor pollicis longus.
• Oppostion lost- Loss of
pincerlike action
• The thumb is laterally
rotated and adducted.
• The muscles of the thenar
eminence are paralyzed
and wasted so that the
eminence is flattened.

• The hand looks flattened

and ape- like hand
• Sensory

• Vasomotor Changes
• The skin areas involved in
sensory loss are warmer and
drier than normal because of
the arteriolar dilatation and
absence of sweating resulting
from loss of sympathetic
control.
• Trophic Changes
• The skin is dry and scaly, the
nails crack easily, and atrophy
of the pulp of the fingers is
present.
Injury at the Wrist
• Motor:
• The muscles of the
thenar eminence are
paralyzed and wasted
• Sensory, vasomotor,
and trophic changes-
same
 Carpal Tunnel Syndrome
• concave anterior surface of the carpal
bones the flexor retinaculum,
• is tightly packed with the long flexor
tendons of the fingers, with their
surrounding synovial sheaths,
• has the median nerve.
Clinical features-
• burning pain or pins and needles along
the distribution of the median nerve to
the lateral three and a half fingers
• weakness of the thenar muscles
• no paresthesia occurs over the thenar
eminence
Reason
• compression of the
median nerve within the
tunnel.
Cause -?
• thickening of the
synovial sheaths of the
flexor tendons
• arthritic changes in the
carpal bones would
expect.
 Ulnar nerve
Origin
• Medial cord of brachial
plexus
• C8,T1
Axilla
• Medial to axillary artery
Arm
• Medial to brachial artery
• Pierces medial intermuscular septum, turns medialy, Anterior to triceps
medial head, behind medial epicondyle
Forearm
• Between two heads of flexor carpi ulnaris, Proximally covered by it
• On flexor digitorum profundus
Branches in forearm
In the distal third of
the forearm
• palmar cutaneous
branch
• posterior
cutaneous branch
Wrist
• Crosses flexor
retinaculum
• Enters palm
Palm
• Lies between pisiform
and ulnar vessels
• Passes through
Guyon's canal
• Terminates into
superficial and deep
branch
 Branches
• Articular- elbow joint,wrist
joint, joints of hands
• Forearm
• Muscular branches
• Flexor carpi ulnaris
• Flexor digitorum profundus-
medial half
• Palmar cutaneous
• Skin over hypothenar
eminence
• Dorsal branch
• Proximal part of ulnar 1 1/2
fingers
• Hand
• Superficial terminal
branch
• Palmaris brevis- muscular
• 2 Palmar digital nerve
• Medial side of minimus
• Adjoining minimus and
annularis
• Deep terminal branch
• All hypothenar muscles
• All interossei
• 3rd 4th lumbricals
• Adductor pollicus
 Injuries to the Ulnar Nerve

• Elbow
• behind the medial
epicondyle in its
fractures
• Wrist
• where it lies with the
ulnar artery in front of
the flexor retinaculum-
cuts, stab wounds
At elbow
Motor
• FCU- flat
• FDP-thterminal
th
phalanges
of 4 5 fingers - no
flexion
• Flexion of the wrist joint
will result in abduction,
due to paralysis of the
flexor carpi ulnaris.
• The medial border of
the front of the forearm
will show flattening due
to the wasting of the
underlying ulnaris and
profundus muscles.
adductor pollicis muscle is
paralyzed
• impossible to adduct the
thumb
• If the patient is asked to
grip a piece of paper
between the thumb and
the index finger,
• he does so by contracting
the flexor pollicis longus
and flexing the terminal
phalanx (Froment's sign).
Paralysis of the lumbrical and
interosseous muscles
• The metacarpophalangeal
joints become hyperextended
• The interphalangeal joints are
flexed
• most prominent in the fourth
and fifth fingers.
• because the first and second
lumbrical muscles of the index
and middle fingers are not
paralyzed.
• In long-standing cases the
hand assumes the claw
deformity
• Wasting of the paralyzed
muscles results in
flattening of the
hypothenar eminence
• Examination of the
dorsum of the hand will
show hollowing between
the metacarpal bones
caused by wasting of the
dorsal interosseous
muscles
• Sensory
• Loss of skin sensation
will be observed over
the anterior and
posterior surfaces of
the medial third of the
hand and the medial
one and a half fingers.
• Vasomotor Changes
At the Wrist
• Motor:
• The small muscles of the hand
will be paralyzed and show
wasting,
• The clawhand is much more
obvious in wrist lesions because
the flexor digitorum profundus
muscle is not paralyzed, and
marked flexion of the terminal
phalanges occurs.
• Sensory:
• the posterior cutaneous branch,
is usually unaffected.
 Radial nerve
• Largest branch
Origin
• Posterior cord of brachial
plexus
• C5,6,7,8T1
Axilla
• Descends behind the
third part of axillary
artery
• In lower triangular space
Arm
• The nerve winds around
the back of the arm in
the in triangular space
• Lies in the spiral groove,
with the profunda
vessels, and directly in
contact with the shaft of
the humerus
• It pierces the lateral
fascial septum above the
elbow between the
heads of the triceps
Forearm
• continues downward
into the cubital fossa
• between the brachialis
and the brachioradialis
muscles & extensor carpi
radialis longus
• passes downward in
front of the lateral
epicondyle of the
humerus,
• & divides into superficial
and deep branches
• Superficial Branch of the
Radial Nerve
• is the direct continuation
of the nerve
• It runs down under cover
of the brachioradialis
muscle on the lateral side
of the radial artery.
• In the distal part of the
forearm, it leaves the
artery and passes
backward under the
tendon of the
brachioradialis
• It reaches the posterior
surface of the wrist
Wrist
• it divides into terminal
branches that supply
• the skin on the lateral
two thirds of the
posterior surface of the
hand
• the posterior surface of
the proximal phalanges
-lateral three and a half
fingers.
• Deep Branch of the Radial
Nerve( posterior interosseous
nerve)-
• Muscular branch
• It pierces the supinator
• winds around the lateral aspect
of the neck of the radius
• to reach the posterior
compartment of the forearm.
• descends in the interval
between the superficial and
deep groups of muscles
• reaches the posterior surface of
the wrist joint.
 Branches

Axilla
• Cutaneous
• the posterior cutaneous
nerve of the arm-
• Muscular
• the nerve to the long head
of the triceps
• nerve to the medial head
of the triceps
Arm- In the spiral groove
• Cutaneous
• the lower lateral
cutaneous nerve of the
arm-
• the posterior cutaneous
nerve of the forearm-
• Muscular branches:
• Triceps medial,lateral
head of the triceps,
anconeus,
brachialis(small part),
brachioradialis, extensor
carpi radialis longus.
Forearm
• Muscular
• the deep branch of the
radial nerve
• All extensors
• Cutaneous
• superficial branch
radial nerve-
Injuries to the Radial Nerve
Axilla
• by the pressure of a
badly fitting crutch
pressing up into the
armpit- crutch palsy
• drunkard falling asleep
with one arm over the
back of a chair- Saturday
night palsy
• by fractures and
dislocations of the
proximal end of the
humerus.
In the spiral groove of the
humerus
• Fracture of the shaft of the
humerus
• Or in formation of the
callus
• The pressure of the back of
the arm on the edge of the
operating table in an
unconscious patient
• The prolonged application
of a tourniquet to the arm
in a person with a slender
triceps
Clinical findings- Injury in axilla
Motor
• The triceps, the anconeus, and
the long extensors of the wrist
are paralyzed.
• The patient is unable to extend
the elbow joint,
• no extension at the wrist joint,
and the fingers.
• Wristdrop, or flexion of the wrist
• Weak grip- because one is unable
to flex the fingers strongly with
the wrist fully flexed.
• The brachioradialis and supinator
muscles are also paralyzed, but
supination is still performed well
by the biceps brachii.
• Sensory loss
• Clinical findings- Injury in arm
• Motor:
• wristdrop
• Sensory:
• anesthesia over the dorsal surface of the hand and the
dorsal surface of the roots of the lateral three and a
half fingers.
Dermatome
s
THIS
IS
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