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NERVE INJURIES OF UPPER LIMB

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NERVE INJURIES OF UPPER LIMB Dr. Mujahid Khan Injury to the Ulnar Nerve (motor at elbow) Flexor carpi ulnaris & medial half of flexor digitorum profundus are ... – PowerPoint PPT presentation

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Title: NERVE INJURIES OF UPPER LIMB


1
NERVE INJURIES OF UPPER LIMB
  • Dr. Mujahid Khan

2
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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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

5
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)

6
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

7
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

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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

10
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

11
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

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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

14
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

15
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

16
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

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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

19
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

20
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

21
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

22
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

23
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

24
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

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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

27
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

28
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

29
Injury at Elbow(Trophic changes)
  • In long standing cases
  • Skin is dry and scaly
  • Nails crack easily
  • Atrophy of the pulp of the fingers

30
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

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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

33
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

34
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

35
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

36
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

37
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

38
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

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40
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

41
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