Nerve injuries of upper limb
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NERVE INJURIES OF UPPER LIMB. Dr. Mujahid Khan. 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.

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NERVE INJURIES OF UPPER LIMB

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Nerve injuries of upper limb

NERVE INJURIES OF UPPER LIMB

Dr. Mujahid Khan


Brachial plexus injuries upper lesions

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

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

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

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

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 lesions1

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

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 nerve1

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

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

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

Injuries of Radial Nerve

Can be injured by:

  • Pressure of badly fitting crutches

  • Drunkard falling asleep with one arm over the back of a chair

  • Fractures or dislocation of the proximal end of the humerus


Findings in radial n injury

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

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 & ½ fingers


In the spiral groove

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 & ½ fingers


Deep branch of radial nerve

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

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

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

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 motor1

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 motor2

Injury at Elbow(motor)

  • Flexion of terminal phalanx of thumb is lost because of paralysis of flexor policis longus

  • The thumb is laterally rotated and adducted

  • Muscles of thenar eminence are paralyzed

  • The hand looks flattened and ape like


Injury at elbow sensory

Injury at Elbow(sensory)

  • Skin sensation is lost on the palmar aspect of the lateral 3 & ½ fingers

  • Sensory loss occurs on the skin of the distal part of the dorsal surfaces of the lateral 3 & ½ fingers

  • Total area of anesthesia is less


Injury at elbow vasomotor changes

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

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

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

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 & ½ fingers are involved


Carpal tunnel syndrome1

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

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 elbow1

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 elbow2

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

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 & ½ 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

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

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 & ½ 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


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