Nerves of upper limb and their

injuries
Learning objectives
1. Revise the course and branches of nerves of
upper limbs.
2. Understand injuries and the causes associated
with these nerves.
3. Identify motor and sensory loss associated
with nerve injuries of upper limb.
4. Describe the deformities associated with these
nerves.
Functions of the nerves of the upper limb:

 Sensory innervation to the skin and joints.

 Motor innervation to the muscles.

 Vasomotor (control B.Vs diameter).

 Secretomotor to sweat glands.

 Brachial plexus:

 Network of nerves which supply the upper limb.

 Except:

1. Trapezius.
2. Skin over upper 1\2 of deltoid.
• Present in neck and axilla.

• Formed by ventral primary rami of C5-T1

roots.
Brachial plexus:
• C5+C6=upper (Superior) trunk.
• C7---- middle trunk.
• C8+T1 = lower (Inferior) trunk.
• All trunk divides into anterior and posterior divisions.
• Anterior divisions of upper and middle trunk unite to
form lateral cord.
• Anterior division of middle trunk continues as medial
cord.
• Posterior divisions of all 3 trunk form posterior cord.
 Dorsal scapular nerve

Suprascapular nerve

Nerve to subclavius
Long thoracic
Branches from roots & trunks roots:

1. Dorsal scapular nerve C5.

2. Long thoracic nerve C5,6,7
• Upper trunk C5 C6:

1. Suprascapular nerve.

2. Nerve to subclavius.
 Upper &
lower
Subscapular
nerves Thoracodorsal

Axillary

Radial

Lateral pectoral
Musculocutaneous

Median Medial pectoral nerve

Medial cutaneous nerve of arm and
Ulnar
forearm
5 Branches from posterior cord:

• Upper and lower subscapular nerves.

• Thoracodorsal.

• Axillary nerve.

• Radial nerve.
• 3 Branches from lateral cord:
1. Lateral pectoral nerve
2. Musculocutaneous nerve.
3. Lateral root of median nerve.

5 Branches from medial cord:

1. Medial pectoral nerve.

2. Medial cutaneous nerve of arm and forearm.
3. Ulnar nerve.
4. Medial root of median.
Cutaneous nerves of upper limb
The area of skin supplied by a single spinal nerve
is .dermatomes
 Injury of brachial plexus

• Injury of all roots of brachial plexus:

• Paralysis of all muscles of upper limb except
• Trapezius muscle which innervated by accessory
(11th cranial nerve).
• Loss of sensation except
• Upper lateral & medial parts of arm.
  Upper trunk (C5-6) lesions of brachial
plexus
 Erb’s duchenne palsy
  
 Lower lesions of brachial plexus

 Klumpke’s palsy
 Upper lesion of brachial plexus

• Traction or even tearing of C5 and C6 root.

 Causes:

• Excessive displacement between

head and the shoulder.
• In infants during a difficult
delivery.
• In adults following a fall on or a
blow to the shoulder.
Nerves involved:

 Supra scapular nerve, Nerve to Subclavius

Musculocutaneous nerve ,Axillary nerve.
 Results of injury:
 Muscles and functions lost:
 (1) Motor loss:
 Lateral rotation of arm:
• Teres minor
• Infraspinatus
 Abduction of shoulder
• Supraspinatus
• Deltoid
 Flexion of shoulder:
• corobrachialis
• Biceps brachii
 Flexion of elbow:
• Brachialis
• Biceps brachii
 Supination of forearm
• Biceps brachii
 (2) Sensory loss:
 Loss of sensation of lateral side of upper limb
except
 Upper half of deltoid.
 (3) Disability:
 Loss of abduction.
 Loss of lateral rotation.
 Weak flexion.
 Weak supination.
 (4) Deformity:
Erb’s palsy (upper trunk injury)

• Also known as waiter’s tip or policeman’s tip

• Arm medially rotated, adducted, hangs by side.
• Forearm extended and pronated
(5) Wasting changes:

Atrophy of muscles.
Klumpke’s palsy
 Lower lesions of brachial plexus:

 Fibers of C8 and mostlyT1 root are torn.

 Causes:

:Excessive abduction of arm )1(

 Birth injury in breech delivery.
 Person falling from a height clutching an object
to save himself.
 (2) Compression of lower trunk

Cervical rib: Connects C7 with first rib.

 Malignancy in lower deep cervical lymph nodes.

 Nerves involved:

• T1 fibers run in ulnar and median nerve.

• Muscles involved:
• All small muscles of the hand( interossei and
lumbricals).
• Sensory loss:

• along the medial side of forearm.

 Klumpke's palsy:

• Clawed hand.

• Hyperextension of metacarpophalangeal joint.

• Flexion at interphalangeal joint.
Late muscular wasting:

• Wasting of lumbricals & interossi muscles.

• Dorsal hollow between metacarpal bones.
 Ulnar nerve damage

Claw hand

Paralysis of little and ring finger(1st & 2nd )

What's ulnar paradox?

Ulnar nerve injury at the level of elbow

Ulnar nerve injury at the level of the wrist

 Ulnar nerve
Superficial
branch In the hand
Deep branch
Long thoracic nerve:

• Arise from roots C5 , 6 and 7.

• Muscles involved:
• Serratus anterior.
• Functions lost:
• Abduction above 90 degrees.
• Cannot pushing or reaching objects.
• Causes:
• In radical mastectomy.
Chest tube insertion or stab wound
Deformity:
 Winging of scapula.
 vertebral border and inferior angle of
scapula unduly prominent.
 Axillary nerve:
• From posterior
cord.

• Important
landmarks:

• Axilla –- scapular region .

• in quadrangular space close relation with shoulder joint
and surgical neck of humerus
• Terminates by dividing into anterior and posterior
branches
 Causes of axillary N. injury:

1. Fracture of surgical neck of humerus.

2. Inferior dislocation of shoulder joint.
3. Pressure of badly adjusted crutch upward into
armpit.
4. Misplaced injection into deltoid.

Muscles involved
 Deltoid.
 Teres minor.
 Sensory loss

 Upper lateral
cutaneous nerve of
arm.
 Loss of skin sensation
over the lower half of
deltoid muscle.
Radial nerve:

• Largest branch of plexus.

• From posterior cord.
• Arise in axilla  spiral groove  lateral
intermuscular septum  front of lateral
epicondyle  divides into superficial and deep
• Superficial  lateral side of radial artery
posterior surface of wrist
• Deep branch supinator neck of radius posterior
surface of wrist.
 • Branches in axilla:
• Posterior cutaneous nerve of ARM.
• Nerve to long head of triceps.
• Nerve to medial head of triceps.

• Branches in spiral groove:

• Lower lateral cutaneous nerve of arm.
• Posterior cutaneous nerve of forearm.
• Nerve to lateral head of triceps.
• Nerve to medial head of triceps.
• Anconeus.
• Branches in anterior compartment of arm:
• Nerve to small part of brachialis.

• Nerve to brachioradialis.
• Nerve to extensor carpi radialis longus.
Radial nerve
• Branches in cubital fossa:
• Deep branch of radial nerve to extensor carpi
radialis brevis, supinator and all muscles in
posterior compartment of forearm.
• Superficial branch provides sensation to dorsum
of hand and
• Lateral 3 and half fingers .
• Branches in distal fore arm
• Palmar cutaneous branch---skin on lateral side of palm
• Branches in palm
• Muscle of thenar eminence.
• First 2 lumbricals.
• Skin of palmar surface of lateral 3 ½ fingers
• lateral 3 ½ fingers
Radial nerve injuries
 Injuries in axilla:

• Causes
• Pressure of badly fitted crutch into armpit.
• Falling asleep with arm over the back of chair------
Saturday night palsy.
• Motor loss:
• Extension at elbow----- paralysis of triceps and
anconeus
• paralysis of extensors of wrist and all muscles of
posterior compartment
• Supination----can still be performed.
• Deformity known as WRIST DROP -----flexion of
wrist as a result of action of unopposed flexors of
wrist and fingers
• Sensory loss
• posterior surface of arm and fore arm
• Dorsum of hand and dorsal surface of lateral 3 ½
fingers
 Radial nerve injury in spiral groove

Most commonly in distal part of groove beyond the

origin of nerves to triceps .
 Causes:

• Fracture of shaft of humerus

• Prolonged pressure on the back of arm as in
 Unconscious patient by edge of operating table
 Prolonged application of tourniquet in thin lean
person
• Motor loss:
• Extension of wrist, fingers and thumb
• Elbow extension is spared

• Sensory loss:
• Dorsum of hand and dorsum of lateral 3 ½ fingers

• Sensations on posterior arm and forearm are

spared
Median nerve

 Formed in axilla by lateral and medial roots from

respective cords.
 Anterior compartment of arm ---- crosses
brachial artery from lateral to medial
 At elbow crossed by bicipital aponeurosis
 Passes between 2 heads of pronator teres to enter
forearm
 At wrist at lateral border of flexor digitorum
profundus
 Enter palm beneath flexor retinaculum
Branches:

 no branches in axilla.

 in proximal forearm
 To all anterior compartment muscles except:
 flexor carpi ulnaris .
 medial half of flexor digitorum profundus.
 Branches in distal forearm

 Palmar cutaneous branch----skin on

lateral side of palm
 Branches in palm
 Muscle of thenar eminence
 First 2 lumbricals
 Skin of palmar surface of lateral 3 ½
fingers
Injury to median nerve at elbow

Cause:
• Supracondylar fracture of humerus
Deformity:

• Forearm ----supinated
• Wrist----flexion is weak accompanied by
adduction
• Fingers----no flexion of interphalangeal joint of
index and middle
• Thumb---flexion, abduction and opposition is lost
Ape’s hand:

thumb laterally rotated adducted and thenar

eminence flattened.
Sensory loss

• Lateral side of palm

• Palmar surface of lateral 3 ½ fingers
• Distal part of dorsal surface of lateral 3 ½ fingers
Median nerve
Injury to median nerve in carpal tunnel:

• Carpal tunnel---Osseo fibrous space formed by

anterior concave surface of carpus and flexor
retinaculum
• Passage of long flexor tendon and median nerve.

• Syndrome is caused by compression of median

nerve due to reduced size of canal.
Causes

• Inflammation of retinaculum
• Arthritis of carpal bones
• Inflammation of synovial sheaths of flexor tendons

• Sensory and motor Loss:

• Pain and paraesthesia of lateral one and half finger

• Weakness of thenar muscle

Cutaneous Innervation to the Hand