NERVE INJURIES OF

UPPER LIMB

Brachial Plexus Injuries

(upper lesions)
These are caused by the excessive

displacement of the head to the opposite

side

Depression of the shoulder on the same

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

The first thoracic nerve is usually torn
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

Lower 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

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

Known as winged scapula

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 of badly fitting crutches
Drunkard falling asleep with one arm

the back of a chair

over

Fractures or dislocation of the proximal

end of the humerus

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

Sensory loss on the lateral part of dorsum

of the hand
Sensory loss on the dorsal surface of the

roots of the lateral 3 & fingers

In the Spiral Groove

Radial nerve can be injured in the spiral

groove at the time of fracture of shaft of

the humerus
Wrist drop occurs
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

No wrist drop as extensor carpi radialis

longus is undamaged

No sensory loss as this is a motor nerve

Injuries of Musculocutaneous
Nerve
Rarely injured due to its protected position

beneath the biceps brachii muscle

If injured high up in the arm, the biceps &

coracobrachialis are paralyzed &

brachialis is weakened

Sensory loss along the lateral side of the

forearm occurs

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
Only ring & little fingers flex
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

because of paralysis of flexor policis

longus

The thumb is

adducted

lost

laterally rotated and

Muscles of thenar eminence are paralyzed

The hand looks flattened and ape like

Injury at Elbow
(sensory)
Skin sensation is lost on the palmar

aspect of the lateral 3 & fingers

Sensory loss occurs on the skin of the

distal part of the dorsal surfaces of the

lateral 3 & fingers
Total area of anesthesia is less

Injury at Elbow
(vasomotor changes)
The skin areas involved in sensory loss

are warmer and drier than normal

Arteriolar dilatation and absence of

sweating resulting from loss of

sympathetic control

Injury at Elbow
(Trophic changes)
In long standing cases:
Skin is dry and scaly
Nails crack easily
Atrophy of the pulp of the fingers

Injury at Wrist
Almost all the clinical findings are same as

injury of the median nerve at elbow

In addition a delicate pincer like

movement is not possible

Carpal Tunnel Syndrome

The carpal tunnel is formed by the

concave anterior surface of carpal bones

and closed by flexor retinaculum

Clinically, the syndrome consists

of a
burning pain or pins & needles along the
distribution of the median nerve

Lateral 3 & fingers

are involved

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

Small muscles of hand will be paralyzed

except the muscles of thenar eminence

and first 2 lumbricals
Adductor pollicis

longus is paralyzed so
the adduction of thumb is not possible

Injury to the Ulnar Nerve

(motor at elbow)
Metacarpophalangeal joints become

hyperextended due to the paralysis of

lumbrical and interosseous muscles

Interphalangeal joints are flexed due to the

same reason as mentioned above

Dorsum

of hand will show hollowing due to

the wasting of dorsal interosseous muscles

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

The skin areas

involved in sensory loss

are warmer and drier than normal

Arteriolar dilatation and absence of

sweating resulting from loss of sympathetic

control

Injury to the Ulnar Nerve

(motor at wrist)
Small muscles of the hand will be

paralyzed

Claw hand is more obvious as flexor

digitorum profundus is not paralyzed

Marked flexion of the terminal phalanges

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