nerve injuries of the upper limb dr. zeenat zaidi

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Page 1: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi
Page 2: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Nerve Injuries of Nerve Injuries of the Upper Limbthe Upper Limb

Dr. Zeenat ZaidiDr. Zeenat Zaidi

Page 3: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Upper limb is supplied by Upper limb is supplied by the branches of the the branches of the brachial brachial plexusplexus, formed by the , formed by the ventral rami of the spinal ventral rami of the spinal nerves C5, 6, 7, 8, and T1nerves C5, 6, 7, 8, and T1

Since the spinal nerves are mixed nerves carrying Since the spinal nerves are mixed nerves carrying sensorysensory, , motormotor and and autonomicautonomic fibers, their injuries result in sensory, motor and fibers, their injuries result in sensory, motor and autonomic disturbances autonomic disturbances

Page 4: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Symptoms & Signs of Peripheral Nerve Injury

Depend on the site and extent of the lesionMotor changes: The innervated muscles become paralyzed. The reflexes in which the muscles participate are lostSensory changes: Loss of cutaneous sensibility over the area exclusively supplied by the nerveTrophic changes: Due to interruption of postganglionic sympathetic fibers:

There is loss of vascular control: the skin at first becomes red & hot. Later becomes blue and colder than normal. The nail growth becomes retarded

The sweat glands cease to produce sweat and the skin becomes dry and scaly

Page 5: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Upper Limb Tendon ReflexesBiceps brachii reflex: C5, 6 (flexion of elbow joint by tapping the tendon of biceps muscle)Triceps brachii reflex: C6, 7, 8 (extension of elbow joint by tapping the tendon of triceps muscle)Supinator (brachioradialis) reflex: C5, 6, 7 (supination of radioulnar joint by tapping the tendon of brachioradialis muscle)

Page 6: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi
Page 7: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

A spinal nerve may get injured:A spinal nerve may get injured:

1.1. at the level of its at the level of its rootsroots within within the vertebral canalthe vertebral canal

2.2. at the level of its passage at the level of its passage through the through the intervertebral intervertebral foramenforamen

3.3. At any level in its At any level in its peripheral peripheral coursecourse

Injuries 1 & 2 may result due to:Injuries 1 & 2 may result due to: Fracture of the vertebraFracture of the vertebra Narrowing of intervertebral Narrowing of intervertebral

foraminaforamina Herniation of the Herniation of the

intervertebral discintervertebral disc Degeneration of the Degeneration of the

intervertebral discintervertebral disc

Page 8: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Brachial plexus injuriesBrachial plexus injuriesMay involve the roots, trunks, May involve the roots, trunks, divisions, cords & branches divisions, cords & branches

Supraclavicular injuries involve Supraclavicular injuries involve the roots and the trunks, the roots and the trunks, infraclavicular injuries will affect infraclavicular injuries will affect the divisions and cordsthe divisions and cords

Result due to:Result due to: CompressionCompression TractionTraction Stab woundsStab wounds

Symptoms depend on the site of Symptoms depend on the site of injury & involvement of nerve injury & involvement of nerve fibersfibers

Page 9: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Brachial plexus injuriesBrachial plexus injuries

Are of two types:Are of two types: Upper lesions Upper lesions usually involving usually involving C5 & C6C5 & C6 Lower lesions Lower lesions usually involving usually involving (C8), T1 (C8), T1

Page 10: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Upper Lesions of the Brachial PlexusUpper Lesions of the Brachial Plexus(Erb-Duchenne Palsy)(Erb-Duchenne Palsy)

• These are usually the result of These are usually the result of traction & tearing of the traction & tearing of the 5th and 5th and 6th root 6th root of the brachial plexus of the brachial plexus

• This may occur:This may occur:• In infants during a difficult In infants during a difficult

delivery delivery • In adults following a fall on or In adults following a fall on or

a blow to the shoulder.a blow to the shoulder.• It involves the:It involves the:

• Nerve to sublaviusNerve to sublavius• Suprascapular nerveSuprascapular nerve• Axillary nerveAxillary nerve• MusculocutaneousMusculocutaneous nervenerve

Page 11: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

The muscles affected are: AbductorsAbductors (s (supraspinatus &

deltoid) and and lateral rotators lateral rotators ((Infraspinatus &teres minor) of &teres minor) of the shoulderthe shoulder

Subclavius, biceps, brachialis & Subclavius, biceps, brachialis & coracobrachialiscoracobrachialis

Thus:Thus: TThe limb hangs limply by the he limb hangs limply by the

side, and is side, and is medially rotatedmedially rotated The forearm is The forearm is pronatedpronated and and

extendedextended There is loss of sensation down There is loss of sensation down

the lateral side of the arm & the the lateral side of the arm & the forearmforearm

Another name for this lesion is Another name for this lesion is 'porters tip' 'porters tip'

Page 12: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Lower Lesions of the Brachial Plexus Lower Lesions of the Brachial Plexus (Klumpke Palsy)(Klumpke Palsy)

These are usually caused These are usually caused by by excessive abduction of excessive abduction of the arm the arm as a result of:as a result of: Someone clutching for Someone clutching for

an object when falling an object when falling from a heightfrom a height

Difficult delivery in which Difficult delivery in which baby’s upper limb is baby’s upper limb is pulled excessively. pulled excessively.

Result of Result of malignant malignant metastases metastases from the from the lungs in the lower deep lungs in the lower deep cervical lymph nodescervical lymph nodes

AA cervical rib cervical rib

Page 13: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Usually the lowest root Usually the lowest root (T1) (T1) of the brachial of the brachial plexus is involvedplexus is involved

The fibers from this segment of the spinal cord The fibers from this segment of the spinal cord supply the small muscles of the hand supply the small muscles of the hand ((interossei and lumbricalsinterossei and lumbricals).).

Paralysis and wasting of small muscles of Paralysis and wasting of small muscles of hand occurshand occurs

There is also There is also sensory loss sensory loss along the medial along the medial side of the forearm, hand and medial 2 fingersside of the forearm, hand and medial 2 fingers

Often associated with Often associated with Horner’s syndromeHorner’s syndrome (drooping of upper eyelid & constricted pupil) (drooping of upper eyelid & constricted pupil) due to traction of sympathetic fibers due to traction of sympathetic fibers

Page 14: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

The hand has a The hand has a clawedclawed appearance due to:appearance due to: Hyperextension of the Hyperextension of the

metacarpophalangeal jointsmetacarpophalangeal joints (the extensor digitorum is (the extensor digitorum is unopposed by the lumbricals unopposed by the lumbricals and interossei and extends and interossei and extends the metacarpophalangeal the metacarpophalangeal joints).joints).

Flexion of the interphalangeal Flexion of the interphalangeal jointsjoints (the flexor digitorum (the flexor digitorum superficialis and profundus superficialis and profundus are unopposed by the are unopposed by the lumbricals and interossei, the lumbricals and interossei, the middle and terminal middle and terminal phalanges are flexed).phalanges are flexed).

Page 15: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Long Thoracic Nerve LesionLong Thoracic Nerve Lesion(Nerve to Serratus Anterior)(Nerve to Serratus Anterior)

This nerve may be injured by:This nerve may be injured by: Blows or pressure in the Blows or pressure in the

posterior triangle of the posterior triangle of the neckneck

During a radical During a radical mastectomy surgical mastectomy surgical procedure.procedure.

The serratus anterior muscle:The serratus anterior muscle: Pulls the medial border of Pulls the medial border of

the scapulathe scapula to the to the posterior thoracic wall and posterior thoracic wall and stabilizes it there.stabilizes it there.

Rotates scapulaRotates scapula during the during the abduction of arm above a abduction of arm above a right angleright angle

Page 16: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

The patient shows The patient shows difficulty in raising the difficulty in raising the arm above the headarm above the head

If patient is asked to If patient is asked to push against a wall, the push against a wall, the medial border of the medial border of the scapula will be pushed scapula will be pushed away from the thoracic away from the thoracic wall and protrude like a wall and protrude like a wing, on the side of the wing, on the side of the lesion. lesion. 'winged scapula'. 'winged scapula'.

Page 17: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Axillary Nerve LesionAxillary Nerve LesionAxillary nerve may get injured:Axillary nerve may get injured: Due to downward Due to downward

dislocation of humeral head dislocation of humeral head in shoulder dislocationin shoulder dislocation

Fracture of the surgical Fracture of the surgical neck of humerusneck of humerus

Deltoid and teres minorDeltoid and teres minor muscles become paralyzedmuscles become paralyzedAbduction of the shoulder is Abduction of the shoulder is impairedimpaired. The paralyzed . The paralyzed deltoid wastes rapidly (loss of deltoid wastes rapidly (loss of rounded contour of the rounded contour of the shoulder)shoulder)Loss of sensation Loss of sensation over the over the lower half of deltoid musclelower half of deltoid muscle

Page 18: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Radial NerveRadial Nerve

The radial nerve is commonly damaged:The radial nerve is commonly damaged: in the axillain the axilla in the radial groove in the radial groove Injury to the deep branch (in the Injury to the deep branch (in the

supinator tunnel)supinator tunnel) Injury to the superficial branch Injury to the superficial branch

Page 19: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Radial Nerve Injury in the AxillaRadial Nerve Injury in the AxillaIn the axilla the nerve may In the axilla the nerve may be injured by:be injured by: Pressure of the upper end Pressure of the upper end

of badly fitting crutch of badly fitting crutch pressing up in to the pressing up in to the armpit (crutch palsy) armpit (crutch palsy)

The drunkard falling The drunkard falling asleep with his arm over asleep with his arm over the back of a chair the back of a chair (saturday night palsy).(saturday night palsy).

Fractures or dislocations Fractures or dislocations of the upper end of the of the upper end of the humerushumerus

Page 20: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

MotorMotor:: TricepsTriceps, , anconeusanconeus and and long extensor long extensor of the wrist are paralysed. of the wrist are paralysed.

The patient is The patient is unable tounable to extend the extend the elbow joint, wrist joint and fingerselbow joint, wrist joint and fingers. .

““Wrist drop” Wrist drop” or flexion of the wrist or flexion of the wrist occurs as a result of the unopposed occurs as a result of the unopposed flexor muscles of the wrist.flexor muscles of the wrist.

This is a very disabling injury, since a This is a very disabling injury, since a person can't flex the fingers strongly person can't flex the fingers strongly for gripping an object with the wrist for gripping an object with the wrist fully flexed. fully flexed.

The The brachioradialisbrachioradialis and and supinatorsupinator muscles are paralyzed, but supination muscles are paralyzed, but supination can still be performed due to intact can still be performed due to intact biceps brachii. biceps brachii.

Page 21: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

SensorySensory: Due to the overlap : Due to the overlap of sensory innervation by of sensory innervation by adjacent median & ulnar adjacent median & ulnar nerves, the area of total nerves, the area of total anaesthesia is relatively anaesthesia is relatively small, overlying the small, overlying the firstfirst dorsal interosseous muscle dorsal interosseous muscle (between the 1(between the 1stst and 2 and 2ndnd metacarpal bones)metacarpal bones)

Page 22: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Radial Nerve Injury in the Radial Radial Nerve Injury in the Radial GrooveGroove

The most common lesion of The most common lesion of the radial nerve resulting the radial nerve resulting because of the:because of the: Fracture of the shaft of Fracture of the shaft of

humerushumerus Callus formationCallus formation Pressure on the back of the Pressure on the back of the

arm on the edge of the arm on the edge of the operating table in an operating table in an unconscious patientunconscious patient

Prolonged application of Prolonged application of tourniquettourniquet. .

Page 23: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

The injury to radial nerve occurs The injury to radial nerve occurs most commonly in the most commonly in the distal part distal part of the groove of the groove beyond the origin of beyond the origin of the nerve to the triceps & the nerve to the triceps & anconeus (so that anconeus (so that extension of extension of the elbow is possiblethe elbow is possible), and ), and beyond the origin of the beyond the origin of the cutaneous nervescutaneous nerves

Motor :Motor :The long extensors of the The long extensors of the forearm are paralyzed and this forearm are paralyzed and this will result in a "will result in a "wrist dropwrist drop". ".

Sensory: Sensory: Loss of sensation from Loss of sensation from small area overlying the first small area overlying the first dorsal interosseous muscle dorsal interosseous muscle

Page 24: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Injury to the Deep Branch of the Radial Injury to the Deep Branch of the Radial NerveNerve

It may be damaged in fractures of the proximal end It may be damaged in fractures of the proximal end of the radius or during dislocation of the radial of the radius or during dislocation of the radial head. head.

Motor:Motor:. . Intact forearm extension and flexion with intact hand Intact forearm extension and flexion with intact hand

extension. Only extension. Only weakness of finger extensorsweakness of finger extensors. . Nerve supply to the supinator and extensor carpi radialis Nerve supply to the supinator and extensor carpi radialis

longus will be undamaged and because the later muscle longus will be undamaged and because the later muscle is powerful it will keep the wrist joint extended and is powerful it will keep the wrist joint extended and wrist wrist drop will not occurdrop will not occur. .

Sensory:Sensory: There will be There will be no sensory loss no sensory loss since this since this is a motor nerve. is a motor nerve.

Page 25: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Injury to the Superficial Branch of the Radial Injury to the Superficial Branch of the Radial NerveNerve

It may be damaged as a result of stab injury, or It may be damaged as a result of stab injury, or pressure from handcuffs & tight bangles pressure from handcuffs & tight bangles

Motor:Motor: There will be There will be no motor loss no motor loss since this is a since this is a sensory nerve. sensory nerve.

Sensory:Sensory: There is a small loss of sensation There is a small loss of sensation over the dorsal surface of the hand and the over the dorsal surface of the hand and the dorsal surfaces of the roots of the lateral three dorsal surfaces of the roots of the lateral three fingersfingers

Page 26: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Median Nerve LesionsMedian Nerve LesionsInjury of median nerve at Injury of median nerve at different levels cause different different levels cause different syndromes.syndromes.The most serious disability of The most serious disability of median nerve injuries is the:median nerve injuries is the: Loss of opposition of the Loss of opposition of the

thumbthumb. The delicate pincer-. The delicate pincer-like action is not possiblelike action is not possible

Loss of sensation Loss of sensation from the from the thumb and lateral 2½ thumb and lateral 2½ fingers & lateral ⅔ of the fingers & lateral ⅔ of the palmpalm

Page 27: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Median Nerve LesionsMedian Nerve Lesions

Median nerve can be damaged:Median nerve can be damaged: In the elbow regionIn the elbow region At the wrist above the flexor retinaculumAt the wrist above the flexor retinaculum In the carpal tunnelIn the carpal tunnel

Page 28: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Median Nerve Lesion in the Elbow RegionMedian Nerve Lesion in the Elbow Region

Damaged in Damaged in supracondylar fracture of supracondylar fracture of humerushumerus

Muscles affected are: Muscles affected are: Pronator muscles of the Pronator muscles of the

forearmforearm All long flexors of the All long flexors of the

wrist and fingers except wrist and fingers except flexor carpi ulnaris and flexor carpi ulnaris and medial half of flexor medial half of flexor digitorum profundusdigitorum profundus

Page 29: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Motor: Motor: Loss of pronation. Hand is kept in Loss of pronation. Hand is kept in supine positionsupine positionWrist shows weak flexion, and ulnar Wrist shows weak flexion, and ulnar deviationdeviationNo flexion possible on the No flexion possible on the interphalangeal joints of the index interphalangeal joints of the index and middle fingersand middle fingersWeak flexion of ring and little fingerWeak flexion of ring and little fingerThumb is adducted and laterally Thumb is adducted and laterally rotated, with loss of flexion of rotated, with loss of flexion of terminal phalanx and loss of terminal phalanx and loss of oppositionoppositionWasting of thenar eminenceWasting of thenar eminenceHand looks flattened and Hand looks flattened and “apelike”“apelike”, , and presents an inability to flex the and presents an inability to flex the three most radial digits when asked three most radial digits when asked to make a fist. to make a fist.

Page 30: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Sensory:Sensory: Loss of sensation Loss of sensation from:from: The radial side of the palmThe radial side of the palm Palmer aspect of the lateral Palmer aspect of the lateral

3½ fingers3½ fingers Distal part of the dorsal Distal part of the dorsal

surface of the lateral 3½ surface of the lateral 3½ fingers fingers

Trophic Changes:Trophic Changes: Dry and scaly skinDry and scaly skin Easily cracking nailsEasily cracking nails Atrophy of the pulp of the Atrophy of the pulp of the

fingersfingers

Page 31: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Median Nerve Lesion at the WristMedian Nerve Lesion at the Wrist

Often injured by penetrating wounds (stab Often injured by penetrating wounds (stab wounds or broken glass) of the forearmwounds or broken glass) of the forearm

Motor:Motor: Thenar muscles are paralyzed and Thenar muscles are paralyzed and atrophy in time so that the thenar eminence atrophy in time so that the thenar eminence becomes flattened. Opposition and abduction of becomes flattened. Opposition and abduction of thumb are lost, and thumb and lateral two thumb are lost, and thumb and lateral two fingers are arrested in adduction and fingers are arrested in adduction and hyperextension position. “hyperextension position. “Apelike handApelike hand””

SensorySensory & & trophictrophic changes are the same as in changes are the same as in the elbow region injuriesthe elbow region injuries

Page 32: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Compression of median Compression of median nerve in the carpal tunnelnerve in the carpal tunnel

Motor:Motor: Weak motor function Weak motor function of thumb, index & middle of thumb, index & middle fingerfinger

Sensory:Sensory: Burning pain or Burning pain or ‘pins and needles’ along the ‘pins and needles’ along the distribution of median nerve distribution of median nerve to lateral 3½ fingersto lateral 3½ fingers

No sensory changes over the No sensory changes over the palm as the palmer palm as the palmer cutaneous branch is given cutaneous branch is given before the median nerve before the median nerve enters the carpal tunnelenters the carpal tunnel

Page 33: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Ulnar Nerve LesionUlnar Nerve Lesion

Ulnar nerve can be damaged:Ulnar nerve can be damaged: At the elbow, where it lies behind the At the elbow, where it lies behind the

medial epicondylemedial epicondyle At the wrist, where it lies with the ulnar At the wrist, where it lies with the ulnar

artery superficial to the flexor artery superficial to the flexor retinaculumretinaculum

Page 34: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Ulnar Nerve Lesion at the ElbowUlnar Nerve Lesion at the ElbowOften injured with fractures of the Often injured with fractures of the medial epicondylemedial epicondyleMotorMotor paralysis involves: paralysis involves: Flexor carpi ulnarisFlexor carpi ulnaris Medial half of flexor digitorum Medial half of flexor digitorum

profundusprofundus Small muscles of the hands, Small muscles of the hands,

except the muscles of thenar except the muscles of thenar eminence and first two eminence and first two lumbricals. lumbricals.

Adductor pollicis Adductor pollicis SensorySensory loss over the anterior & loss over the anterior & posterior surfaces of the palm & posterior surfaces of the palm & medial one and half fingermedial one and half fingerTrophic changesTrophic changes: because of loss : because of loss of sympathetic control of sympathetic control

Page 35: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Flexion of the wrist will result in Flexion of the wrist will result in abductionabductionThe The thumbthumb is abducted and extended is abducted and extended with the distal phalanx flexed with the distal phalanx flexed (difficulty in holding a piece of paper (difficulty in holding a piece of paper between thumb and index finger).between thumb and index finger).The adduction and abduction of The adduction and abduction of fingers is lost (difficulty in holding a fingers is lost (difficulty in holding a piece of paper between fingers).piece of paper between fingers).The The lateral two fingers lateral two fingers are fully are fully extended with a slight flexion of the extended with a slight flexion of the distal phalanges. distal phalanges. The The medial two fingers medial two fingers are are hyperextended at the hyperextended at the metacarpophalangeal joints but metacarpophalangeal joints but flexed at the distal phalangeal jointsflexed at the distal phalangeal joints . .

Page 36: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Wasting of the Wasting of the hypothenar hypothenar eminenceeminenceThe dorsum of the hand The dorsum of the hand shows hollowing between shows hollowing between the metacarpal bonesthe metacarpal bonesThe hand resembles a The hand resembles a "claw" and is called a "claw" and is called a claw claw handhand. . The clawing becomes The clawing becomes most obvious when the most obvious when the person is asked to person is asked to straighten their fingers.straighten their fingers.

Page 37: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi

Ulnar Nerve Lesion at the WristUlnar Nerve Lesion at the Wrist

Commonly occur due to cuts and stab woundsCommonly occur due to cuts and stab wounds

Motor:Motor: The small muscles of the hands are The small muscles of the hands are paralyzed, except the muscles of thenar eminence paralyzed, except the muscles of thenar eminence and first two lumbricals. and first two lumbricals. The claw hand is more The claw hand is more obvious as the flexor digitorum profundus is intactobvious as the flexor digitorum profundus is intact

SensorySensory loss over the anterior surfaces of the palm loss over the anterior surfaces of the palm and the anterior & posterior surfaces of the medial and the anterior & posterior surfaces of the medial one and half finger. (The posterior surface of the one and half finger. (The posterior surface of the hand is spared as the posterior cutaneous branch hand is spared as the posterior cutaneous branch arises above the level of wrist) arises above the level of wrist)

Page 38: Nerve Injuries of the Upper Limb Dr. Zeenat Zaidi