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Upper Limb: Nerves

Upper Limb: Nerves. Clinical Anatomy. Brachial Plexus. Ventral rami of C5‐T1 Formed in the posterior triangle of the neck Organization Roots C5‐T1 Trunks Upper C5‐C6 Middle C7 Lower C8‐T1 Divisions Anterior and posterior divisions Cords Lateral

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Upper Limb: Nerves

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  1. Upper Limb:Nerves ClinicalAnatomy

  2. Brachial Plexus • Ventral rami ofC5‐T1 • Formed in the posterior triangle of theneck • Organization • Roots • C5‐T1 • Trunks • UpperC5‐C6 • MiddleC7 • LowerC8‐T1 • Divisions • Anterior and posteriordivisions • Cords • Lateral • Anterior divisions of middle & upper trunks • Medial • Anterior division of lowertrunk • Posterior • All the posteriordivisions

  3. BrachialPlexus: Relations • Scalenus anterior and medius • Axillaryartery • Axillarysheath

  4. Brachial Plexus:Branches • Roots • Dorsal scapularn. • Long thoracicn. • Uppertrunk • Suprascapularn. • Nerve to subclavius • Lateralcord • Lateral pectoraln. • Musculocutaneousn. • Lateral root of mediann. • Posteriorcord • Upper subscapularn. • Thoracodorsaln. • Lower supscapularn. • Axillary n. & radialn. • Medialcord • Medial pectoral n. • Medial cutaneous n. ofarm • Medial cotaneous n. of forearm • Ulnarn. • Medial root of mediann.

  5. Upper lesions of the brachial plexus (ErboDuchenne Palsy) • Increase the angle between the head andshoulder • Injury to C5 & C6roots • Affectedmm. • Supraspinatus, infraspinatus, subclavius, biceps brachii, coracobrachialis, deltoid, and teres minor • Waiter’s tipposition • Limb hang byside • Medially rotated • Pronatedforearm • Loss of sensationdown lateralside

  6. Lower lesions of the brachial plexus (KlumpkePalsy) • Injury to C8 &T1 • Excessive abduction of thearm • Affectedmm. • Small handmuscles • Claw hand • Hyperextension of metacarpophalangealjoints • Flexion of interphalangealjoints • Loss of sensation down medialside

  7. Long thoracic nerve injury • Resultsfrom • Injury to posterior triangle of the neck • Injury in the chestwall • Radicalmastictomy • Paralysis of serratus anteriorm. • Winged scapula • Difficult to raise hand abovehead • Medial border and inferiorangle moves laterally andposteriorly

  8. MusculocutaneousNerve • Relations • Pierces coracobrachialism. • Deep tobiceps • Branches • Muscularnn. • Innervate the anterior compartment of armmm. • Lateral cutaneous nerve of theforearm

  9. Musculocutaneous NerveBlock • Area: lateral side of the forearm(cutaneous) • Lateral cutaneous n. block • Lateral to the tendonof the bicepsm. • On a line betweenthe humeralepicondyles

  10. MedianNerve • Relations • Inarm • Brachiala. • Inhand • Flexorretinaculum

  11. Median Nerve:branches • Branches inforearm • Muscularbranches • Anterior compartment of forearm • Palmar cutaneousbranch • Branches in palm • Muscularbranches • Thenarmuscles • Cutaneous branches

  12. Median nerveinjury • Injury at theelbow • Forearm kept in supineposition • Wrist flexion is weak and accompanied byadduction • No flexion at interphalangeal joints of 2nd and 3rd fingers and weak flexion at the metacarpophalangeal joints of thesefingers • Sensory loss at lateral half of the palm

  13. Median nerveinjury • Injury at wrist • Paralysis and atrophy of the thenarmm. • Loss of oppositionmovement • Carpal tunnelsyndrome • Compression of the median n. by the content of the carpal tunnel • Pain (pins and needles) along the distribution of the median n. to the lateral 3 & ½ fingers

  14. Median NerveBlock • Area: lateral side of the palm and palmer 3½ digits and their nail beds • Block atelbow • Brachial a. palpated to the medial side of the biceps tendon on an extendedelbow • Medial to the palpated brachiala. • Block atwrist • Between tendons of the palmaris longus and flexor carpi radialismm. • Proximal to the flexor retinaculum (proximal to distal transverse crease ofwrist)

  15. UlnarNerve • Relations • Inarm • Medialepicondyle • Inhand • Flexorretinaculum • Pisiform

  16. Ulnar Nerve:branches • Inforearm • Muscularbranches • Cutaneousbranches • Posterior cutaneousbranch • Palmar cutaneousbranch • Inhand • Superficial terminalbranch • Muscular branches (palmaris previs m.) • Cutaneousbranches • Deep terminalbranch • Muscularbranches

  17. Ulnar nerveinjury • Injury atelbow • Common site for ulnar injury is posterior to the medialepicondyle • Flexion of wrist will accompanied by abduction • Inability to adduct and abduct the fingers • Clawdeformity • Loss of sensation on the medial ⅓ of the hand • Injury atwrist • Claw hand • Loss of sensation on ⅓ of palmarside

  18. Ulnar NerveBlock • Block atelbow • Area: medial side of thehand • – Between olecranon process and medial epicondyle ofhumerus • Block at wrist • Area: palmer side of the medial side of thehand • – Lateral to the tendon of the flexor carpi ulnaris m. at level of transverse crease ofwrist

  19. RadialNerve • Relations • inarm • Spiralgroove • Profunda a. • Lateralepicondyle

  20. Radial Nerve:branches • Muscularbranches • Posterior compartments ofarm and forearm • Cutaneous branch • Posterior cutaneous n. ofarm • Lower lateral cutaneous n. ofarm • Posterior cutaneous n. offorearm • Superficial branchof radialn.

  21. Radial nerveinjury • Injury in theaxilla • Wrist‐drop • Injury in the spiralgroove • Wrist‐drop • Injury to the deepbranch • No wrist‐drop • Inability to extend the thumb and the metacarpophalangeal joints (test against resistance) • No loss ofsensation • Injury to the superficial branch • Limitedanasthesia

  22. Radial NerveBlock • Area: lateral dorsal side of the hand proximal to the lateral 1½ lateral nailbeds • Block atelbow • Halfway between the tendon of the biceps m. and the tip of the lateral epicondyle of humerusin extendedelbow • Block atwrist • Lateral to the radial a.at the level of the proximal wrist transversecrease

  23. AxillaryNerve • Relations • Quadrangularspace • Posterior circumflex humeral vessels • Branches • Anterior terminalbranch • Posteriorterminal branch • Upper lateralcutaneous • n. of the arm

  24. Axillary NerveInjury • Results from injury inthe quadrangular space • Downward humeral dislocation • Humeral fracture at surgical neck • Deltoid m.paralysis • Deltoid atrophy • Loss of sensation over the lower half of deltoidmuscle

  25. Cutaneous Innervation of the UpperLimb Musculoskeletal Axillary Radial Ulnar Median Medialcord

  26. Dermatomes of the UpperLimb

  27. Dermatomes & Cutaneous Nerves of theHand

  28. Dermatome Tests for the UpperLimb

  29. Tendon Reflexes & Segmental Innervation of the Upper LimbMuscles • Biceps brachii tendonreflex • – C5&C6 • Flexion of the elbowjoint • Tapping on the bicepstendon • Triceps tendonreflex • – C6‐C8 • Extension of the elbowjoint • Tapping on the tricepstendon • Brachioradialistendon reflex • – C5‐C7 • Supination of the radioulnar joint • Tapping the brachioradialis tendon

  30. The specific neurovascular manifestations of acute cervical discherniation

  31. Myotome Tests for the UpperLimb • Abduction of Arm(C5) • Supraspinatus –Supraspinatus Nerve • Deltoid‐AxillaryNerve • Arm Adduction(C7) • Pectoralis Major‐ Pectoral Nerves • Latissimus Dorsi‐ ThoracodorsalNerve • Forearm Flexion (C5‐6) • Brachialis‐Musculocutaneous • Biceps Brachii‐ Musculocutaneous

  32. Myotome Tests for the UpperLimb • Forearm Extension(C7) • Triceps Brachii‐Radialnerve • Wrist Flexion (C7,8T1) • Flexor CarpiRadialis‐ MedianNerve • Flexor Carpi Ulnaris‐Ulnar Nerve • Wrist Extension(C7,8) • Extensor Carpi Radialis (Longus andBrevis)‐Radial Nerve • Extensor CarpiUlnaris‐ Posterior Interosseous Nerve

  33. Myotome Tests for the UpperLimb • Finger Flexion(C7,8T1) • Flexor Digitorum Superficialis‐ MedianNerve • Flexor Digitorum Profudus‐Ulnar & Anterior Interosseous branch ofMedian • Finger Extension(C7) • Extensor Digitorum‐Posterior Interosseous branch ofRadial • Thumb Abduction (C7,8T1) • Abductor Pollicis Longus‐Radial Nerve • Abductor Pollicis Brevis‐Median Nerve

  34. Myotome Tests for the UpperLimb • Thumb Opposition (T1) • Opponens Pollicis:Median Nerve • Finger Abduction(C8,T1) • Dorsal Interossei & Abductor Digiti Minimi‐UlnarNerve • Finger Adduction(C8,T1) • Palmarinterossei‐Ulnar Nerve • http://www.youtube.com/w atch?v=rKiTwagLYck

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