Nerve injuries in the

upper limb

By:-
Bushra ahmed
Ibtihal adnan
Thekryat AD ali
 Median nerve injury
• The median nerve is most commonly injured
near the wrist or high up in the forearm.
 Clinical features

Low lesions may be caused by cuts in front of

the wrist or by carpal dislocations. The patient is
unable to abduct the thumb, and sensation is
lost over the radial three and a half digits. In
longstanding cases the thenar eminence is
wasted and trophic changes may be seen.
High lesions are generally due to forearm fractures
or elbow dislocation, but stabs and gunshot
wounds may damage the nerve at any level.

The signs are the same as those of low lesions but,

in addition, the long flexors to the thumb, index and
middle fingers, the radial wrist flexors and the
forearm pronator muscles are all paralysed.
Typically the hand is held with the ulnar fingers
flexed and the index straight (the ‘pointing index
sign’).

Also, because the thumb and index flexors are

deficient, there is a characteristic pinch
defect: instead of pinching with the thumb and
index fingertips flexed, the patient pinches with the
distal joints in full extension.
Wasting of the thenar Typical area of sensory loss.
eminence
thumb and index fingers are
also paralysed and the patient
shows the pointing index sign’.
Median nerve – testing for abductor
power

The hand must remain flat,

palm upwards.
(b) The patient is told to point
the thumb towards
the ceiling against the
examiner’s resistance.
 Treatment

If the nerve is divided, suture or nerve grafting

should always be attempted. Postoperatively the
wrist is splinted in flexion to avoid tension; when
movements are commenced, wrist extension
should be prevented.
Late lesions are sometimes seen. If there has been
no recovery, the disability is severe because of sensory
loss and deficient opposition.

If sensation recovers but opposition does not, extensor

indicis proprius or, less suitably, abductor digiti minimi can
be rerouted to the insertion of abductor pollicis brevis.

Extensor carpi radialis longus is available as a transfer for

flexor digitorum profundus, brachioradialis for flexor
pollicis longus and extensor indicis for abductor pollicis
brevis.
Nerve transfers from the radial nerve in its
branches to extensor carpi radialis brevis and
the supinator have been proposed to restore
pronation and anterior interosseous nerve
function in high median nerve injuries.
ULNAR NERVE
 Ulnar nerve injury
Injuries of the ulnar nerve are usually either
near the wrist or near the elbow, although open
wounds may damage it at any level.
 Clinical features
Low lesions are often caused by cuts on shattered
glass. There is numbness of the ulnar one and a
half fingers.

The hand assumes a typical posture in repose –

the claw-hand deformity – with hyperextension of
the metacarpophalangeal joints of the ring and
little fingers, due to weakness of the intrinsic
muscles.
Hypothenar and interosseous wasting may be obvious by
comparison with the normal hand. Finger abduction is weak
and this, together with the loss of thumb adduction, makes
pinch difficult.

The patient is asked to grip a sheet of paper forcefully

between thumbs and index fingers while the examiner tries
to pull it away; powerful flexion of the thumb
interphalangeal joint signals weakness of adductor pollicis
and first dorsal interosseous with overcompensation by the
flexor pollicis longus (Froment’s sign).
Entrapment of the ulnar nerve in the
pisohamate tunnel (Guyon’s canal) is often seen
in long-distance cyclists who lean with the
pisiform pressing on the handlebars.

Unexplained lesions of the distal (motor) branch

of the nerve may be due to compression by a
deep carpal ganglion or ulnar artery aneurysm.
High lesions occur with elbow fractures or
dislocations. The hand is not markedly deformed
because the ulnar half of flexor digitorum
profundus is paralysed and the fingers are
therefore less ‘clawed’ (the ‘high ulnar paradox’).

Otherwise, motor loss and sensory loss are the

same as in low lesions.
‘Ulnar neuritis’ may be caused by compression or
entrapment of the nerve in the medial epicondylar
(cubital) tunnel, especially where there is severe valgus
deformity of the elbow or prolonged pressure on
the elbows in anaesthetized or bedridden patients.

It is important to be aware of this condition in patients

who start complaining of ulnar nerve symptoms some
weeks after an upper limb injury; one can easily be
misled into thinking that the nerve lesion is due to
the original injury!
 A good test for interosseous muscle
Clawing of the ring and weakness. Ask the patient to spread his
little fingers fingers (abduct) as strongly as possible
and wasting of the and then force his hands together with
the little fingers apposed; the weaker
intrinsic muscles.
side will collapse (the left hand in this
case).
Froment’s sign: the patient
is asked to grip a card firmly between
thumbs and index fingers; normally
this is done using the thumb adductors
while the interphalangeal joint is held
extended. In the right hand, because
the adductor pollicis is weak, the
patient grips the card only by acutely
flexing the interphalangeal joint of the
thumb (flexor pollicis longus is supplied
by the median nerve).
Typical area of sensory loss.
 Treatment
Exploration and suture of a divided nerve are well
worthwhile, and anterior transposition at the elbow
permits closure of gaps up to 5 cm. While recovery
is awaited, the skin should be protected from burns.
Hand physiotherapy keeps the hand supple and
useful.
If there is no recovery after nerve division, hand
function is significantly impaired. Grip strength is
diminished because the primary
metacarpophalangeal flexors are lost, and pinch is
poor because of the weakened thumb adduction
and index finger abduction.

Fine, coordinated finger movements are also

affected.
Metacarpophalangeal flexion can be improved by extensor
carpi radialis longus to intrinsic tendon transfers (Brand),
or by looping a slip of flexor digitorum superficialis around
the opening of the flexor sheath (Zancolli procedure).

Index abduction is improved by transferring extensor

pollicis brevis or extensor indicis to the interosseous
insertion on the radial side of the finger.

Distal nerve transfer from the anterior interosseous

nerve may be considered in high lesions of the ulnar
nerve.
RADIAL NERVE
a continuation of the posterior cord of the brachial
.plexus
.Contains fibers from all nerve roots C5 – T1
Mixed nerve
 : In the axilla 
it lies posterior to the axillary 
artery
: Branches 3 
Branch to long head of triceps-1

Branch to medial head of-2

triceps
Posterior cutaneous nerve of-3
the arm
exit through the triangular 
interval with the profunda
.brachii artery posteriorly
: In the arm 
enters the upper arm between the long head and the medial •
head of the triceps and then it runs towards the spiral
.groove of the humerus
:branches 4 
Branch to lateral head of triceps-1
Branch to medial head of triceps-2
Lower lateral cutaneous nerve of the arm-3
Posterior cutaneous nerve of the forearm-4
Laterally , between the brachialis and •
brachioradialis muscle , anterior to the lateral
epicondyle
branches to : brachialis , brachioradialis 4 
,extensor carpi radials longus , extensor carpi
.radialis brevis muscle
:In the forearm
At about the level of the lateral epicondyle, it 
: divide into
deep motor branch (posterior interosseous ).1
superficial sensory branch.2
 Radial nerve injury
The radial nerve may be injured at the elbow, in
the upper arm or in the axilla.
 Clinical features
Low lesions are usually due to fractures or
dislocations at the elbow, or to a local wound.

Iatrogenic lesions of the posterior interosseous

nerve where it winds through the supinator
muscle are sometimes seen after operations on
the proximal end of the radius.
The patient complains of clumsiness and, on testing,
cannot extend the metacarpophalangeal joints of the
hand. In the thumb there is also weakness of extension
and retroposition.

Wrist extension is preserved because the branch to the

extensor carpi radialis longus arises proximal to the
elbow. The wrist is seen to extend into radial deviation
without the balance of the extensor carpi radialis brevis.
High lesions occur with fractures of the humerus
or after prolonged tourniquet pressure. There is an
obvious wrist drop, due to weakness of the radial
extensors of the wrist, as well as inability to extend
the metacarpophalangeal joints or elevate the
thumb.

Sensory loss is limited to a small patch on the dorsum

around the anatomical snuffbox.
Very high lesions may be caused by trauma or operations
around the shoulder.

More often, though, they are due to chronic compression in

the axilla; this is seen in drink and drug addicts who fall into a
stupor with the arm dangling over the back of a chair
(‘Saturday night palsy’) or in thin elderly patients using
crutches (‘crutch palsy’).

In addition to weakness of the wrist and hand, the triceps is

paralysed and the triceps reflex is absent.
(a) This man developed a complete
(b) The typical area of sensory
drop-wrist palsy following a severe
loss
open fracture of the humerus and
division of the
radial nerve. (
Radial nerve Function with Tendon transfers for radial nerve
palsy (a) FCU to EDC and EPL;
(b) Palmaris Longus to APL (c) Pronator Teres to ECRB
 Treatment
Open injuries should be explored and the nerve
repaired or grafted as soon as possible.
Closed injuries are usually neurapraxia or conduction
block lesions, and function eventually returns.

In patients with fractures of the humerus it is important

to examine for a radial nerve injury on admission, before
treatment and again after manipulation or internal fixation.
If the palsy is present on admission, one can afford to wait
for 12 weeks to see if it starts to recover.
If it does not, then EMG should be performed; if
this shows denervation potentials and no active
potentials, a neurapraxia is excluded and the
nerve should be explored.

The results, even with delayed surgery and quite

long grafts, can be gratifying as the radial nerve
has a straightforward motor function.
If it is certain that there was no nerve injury on
admission, and the signs appear only after
manipulation or internal fixation, then the
chances of an iatropathic injury are high and the
nerve should be explored and – if necessary –
repaired or grafted without delay.
While recovery is awaited, the small joints of
the hand must be put through a full range of
passive movements.

The wrist is splinted in extension. ‘Lively’ hand

splints are avoided as they tend to hold the
metacarpophalangeal joints in extension with the
proximal interphalangeal (IP) joints flexed and this
will lead to fixed contractures.
If recovery does not occur, the disability can be
largely overcome by tendon transfers: pronator
teres to the short radial extensor of the wrist,
flexor carpi radialis or ulnaris to the long finger
extensors and palmaris longus (where present)
to the long thumb abductor
Thank for