NERVE INJURIES OF UPPER LIMB

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NERVE INJURIES OF UPPER LIMB

• By Dr. Mujahid Khan

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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 of C5 and C6 roots
  of the plexus

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Muscles to be Paralyzed

• Supraspinatus (Abductor of shoulder)
• Infraspinatus (lateral rotator of shoulder)
• Biceps brachii (flexor of elbow)
• Coracobrachialis (flexor of shoulder)
• Deltoid (Abductor of shoulder)
• Teres minor (lateral rotator of shoulder)

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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

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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

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Axillary Sheath

• A brachial plexus nerve block can be obtained by
  injecting a local anesthetic
• The position of the sheath can be verified by
  feeling the pulsations of the 3rd part of the
  axillary artery

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Injuries of Long Thoracic Nerve

• Can be injured by blows to or pressure on the
  posterior triangle of the neck
• Serratus anterior is paralyzed
• 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

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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 recognized
  clinically

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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

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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

• Little 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

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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

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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

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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

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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

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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

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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

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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

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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

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Injury at Elbow(Trophic changes)

• In long standing cases
• Skin is dry and scaly
• Nails crack easily
• Atrophy of the pulp of the fingers

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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

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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

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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

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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

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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

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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

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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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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