Upper limb nerve injuries

NERVE INJURIES OF
THE UPPER LIMB
Muhammad Ramzan Ul Rehman

Upper limb is supplied by the branches
of the brachial plexus, formed by the
ventral rami of the spinal nerves C5, 6, 7,
8, and T1
Since the spinal nerves are mixed nerves carrying
sensory, motor and autonomic fibers, their injuries result
in sensory, motor and autonomic disturbances

SYMPTOMS & SIGNS OF PERIPHERAL NERVE INJURY
Depend on the site and extent of the lesion
Motor changes: The innervated muscles become paralyzed.
The reflexes in which the muscles participate are lost
Sensory changes: Loss of cutaneous sensibility over the area
exclusively supplied by the nerve
Trophic 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

UPPER LIMB TENDON REFLEXES
Biceps 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)

 A spinal nerve may get injured:
1. at the level of its roots within
the vertebral canal
2. at the level of its passage
through the intervertebral
foramen
3. At any level in its peripheral
course
 Injuries 1 & 2 may result due to:
 Fracture of the vertebra
 Narrowing of intervertebral
foramina
 Herniation of the intervertebral
disc
 Degeneration of the
intervertebral disc

BRACHIAL PLEXUS INJURIES
 May involve the roots, trunks,
divisions, cords & branches
 Supraclavicular injuries involve the
roots and the trunks, infraclavicular
injuries will affect the divisions and
cords
 Result due to:
 Compression
 Traction
 Stab wounds
 Symptoms depend on the site of
injury & involvement of nerve fibers

BRACHIAL PLEXUS INJURIES
 Are of two types:
 Upper lesions usually involving C5 & C6
Lower lesions usually involving (C8), T1

UPPER LESIONS OF THE BRACHIAL PLEXUS
(ERB-DUCHENNE PALSY)
• These are usually the result of
traction & tearing of the 5th and
6th root of the brachial plexus
• This may occur:
• In infants during a difficult
delivery
• In adults following a fall on or a
blow to the shoulder.
• It involves the:
• Nerve to sublavius
• Suprascapular nerve
• Axillary nerve
• Musculocutaneous nerve

 The muscles affected are:
 Abductors (supraspinatus & deltoid)
and lateral rotators (Infraspinatus
&teres minor) of the shoulder
 Subclavius, biceps, brachialis &
coracobrachialis
 Thus:
 The limb hangs limply by the side,
and is medially rotated
 The forearm is pronated and
extended
 There is loss of sensation down the
lateral side of the arm & the forearm
 Another name for this lesion is 'porters
tip'

LOWER LESIONS OF THE BRACHIAL PLEXUS
(KLUMPKE PALSY)
 These are usually caused by
excessive abduction of the arm
as a result of:
 Someone clutching for an
object when falling from a
height
 Difficult delivery in which
baby’s upper limb is pulled
excessively.
 Result of malignant
metastases from the lungs in
the lower deep cervical lymph
nodes
 A cervical rib

 Usually the lowest root (T1) of the brachial plexus is
involved
 The fibers from this segment of the spinal cord
supply the small muscles of the hand (interossei
and lumbricals).
 Paralysis and wasting of small muscles of hand
occurs
 There is also sensory loss along the medial side of
the forearm, hand and medial 2 fingers
 Often associated with Horner’s syndrome (drooping
of upper eyelid & constricted pupil) due to traction
of sympathetic fibers

The hand has a clawed appearance
due to:
Hyperextension of the
metacarpophalangeal joints (the
extensor digitorum is unopposed
by the lumbricals and interossei
and extends the
metacarpophalangeal joints).
Flexion of the interphalangeal
joints (the flexor digitorum
superficialis and profundus are
unopposed by the lumbricals and
interossei, the middle and terminal
phalanges are flexed).

LONG THORACIC NERVE LESION
(NERVE TO SERRATUS ANTERIOR)
 This nerve may be injured by:
 Blows or pressure in the
posterior triangle of the neck
 During a radical mastectomy
surgical procedure.
 The serratus anterior muscle:
 Pulls the medial border of the
scapula to the posterior
thoracic wall and stabilizes it
there.
 Rotates scapula during the
abduction of arm above a right
angle

The patient shows difficulty
in raising the arm above the
head
If patient is asked to push
against a wall, the medial
border of the scapula will be
pushed away from the
thoracic wall and protrude
like a wing, on the side of the
lesion. 'winged scapula'.

AXILLARY NERVE LESION
 Axillary nerve may get injured:
 Due to downward dislocation of
humeral head in shoulder
dislocation
 Fracture of the surgical neck of
humerus
 Deltoid and teres minor muscles
become paralyzed
 Abduction of the shoulder is
impaired. The paralyzed deltoid
wastes rapidly (loss of rounded
contour of the shoulder)
 Loss of sensation over the lower
half of deltoid muscle

RADIAL NERVE
 The radial nerve is commonly damaged:
 in the axilla
 in the radial groove
 Injury to the deep branch (in the supinator tunnel)
 Injury to the superficial branch

RADIAL NERVE INJURY IN THE AXILLA
 In the axilla the nerve may be
injured by:
 Pressure of the upper end of
badly fitting crutch pressing up
in to the armpit (crutch palsy)
 The drunkard falling asleep
with his arm over the back of a
chair (saturday night palsy).
 Fractures or dislocations of the
upper end of the humerus

Motor:
Triceps, anconeus and long extensor of the
wrist are paralysed.
The patient is unable to extend the elbow
joint, wrist joint and fingers.
“Wrist drop” or flexion of the wrist occurs
as a result of the unopposed flexor muscles
of the wrist.
This is a very disabling injury, since a
person can't flex the fingers strongly for
gripping an object with the wrist fully
flexed.
The brachioradialis and supinator muscles
are paralyzed, but supination can still be
performed due to intact biceps brachii.

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

RADIAL NERVE INJURY IN THE RADIAL
GROOVE
 The most common lesion of the
radial nerve resulting because of
the:
 Fracture of the shaft of
humerus
 Callus formation
 Pressure on the back of the arm
on the edge of the operating
table in an unconscious patient
 Prolonged application of
tourniquet.


The injury to radial nerve occurs most
commonly in the distal part of the
groove beyond the origin of the nerve
to the triceps & anconeus (so that
extension of the elbow is possible), and
beyond the origin of the cutaneous
nerves
Motor :The long extensors of the
forearm are paralyzed and this will
result in a "wrist drop".
Sensory: Loss of sensation from small
area overlying the first dorsal
interosseous muscle

INJURY TO THE DEEP BRANCH OF THE RADIAL
NERVE
 It may be damaged in fractures of the proximal end of
the radius or during dislocation of the radial head.
 Motor:.
 Intact forearm extension and flexion with intact hand extension.
Only weakness of finger extensors.
 Nerve supply to the supinator and extensor carpi radialis longus
will be undamaged and because the later muscle is powerful it
will keep the wrist joint extended and wrist drop will not occur.
 Sensory: There will be no sensory loss since this is a
motor nerve.

INJURY TO THE SUPERFICIAL BRANCH OF THE
RADIAL NERVE
 It may be damaged as a result of stab injury, or
pressure from handcuffs & tight bangles
Motor: There will be no motor loss since this is a
sensory nerve.
 Sensory: There is a small loss of sensation over the
dorsal surface of the hand and the dorsal surfaces of
the roots of the lateral three fingers

MEDIAN NERVE LESIONS
 Injury of median nerve at
different levels cause different
syndromes.
 The most serious disability of
median nerve injuries is the:
 Loss of opposition of the thumb. The
delicate pincer-like action is not possible
 Loss of sensation from the thumb and lateral
2½ fingers & lateral ⅔ of the palm

MEDIAN NERVE LESIONS
 Median nerve can be damaged:
 In the elbow region
 At the wrist above the flexor retinaculum
 In the carpal tunnel

MEDIAN NERVE LESION IN THE ELBOW REGION
 Damaged in supracondylar
fracture of humerus
 Muscles affected are:
 Pronator muscles of the forearm
 All long flexors of the wrist and fingers
except flexor carpi ulnaris and medial
half of flexor digitorum profundus

Motor:
Loss of pronation. Hand is kept in supine
position
Wrist shows weak flexion, and ulnar
deviation
No flexion possible on the interphalangeal
joints of the index and middle fingers
Weak flexion of ring and little finger
Thumb is adducted and laterally rotated,
with loss of flexion of terminal phalanx and
loss of opposition
Wasting of thenar eminence
Hand looks flattened and “apelike”, and
presents an inability to flex the three most
radial digits when asked to make a fist.

Sensory: Loss of sensation from:
The radial side of the palm
Palmer aspect of the lateral 3½
fingers
Distal part of the dorsal surface of
the lateral 3½ fingers
Trophic Changes:
Dry and scaly skin
Easily cracking nails
Atrophy of the pulp of the fingers

MEDIAN NERVE LESION AT THE WRIST
 Often injured by penetrating wounds (stab wounds or
broken glass) of the forearm
 Motor: Thenar muscles are paralyzed and atrophy in
time so that the thenar eminence becomes flattened.
Opposition and abduction of thumb are lost, and
thumb and lateral two fingers are arrested in
adduction and hyperextension position. “Apelike
hand”
 Sensory & trophic changes are the same as in the
elbow region injuries

CARPAL TUNNEL SYNDROME
 Compression of median nerve in
the carpal tunnel
 Motor:Weak motor function of
thumb, index & middle finger
 Sensory: Burning pain or ‘pins
and needles’ along the
distribution of median nerve to
lateral 3½ fingers
 No sensory changes over the
palm as the palmer cutaneous
branch is given before the
median nerve enters the carpal
tunnel

ULNAR NERVE LESION
 Ulnar nerve can be damaged:
 At the elbow, where it lies behind the medial
epicondyle
 At the wrist, where it lies with the ulnar artery
superficial to the flexor retinaculum

ULNAR NERVE LESION AT THE ELBOW
 Often injured with fractures of the
medial epicondyle
 Motor paralysis involves:
 Flexor carpi ulnaris
 Medial half of flexor digitorum
profundus
 Small muscles of the hands, except
the muscles of thenar eminence and
first two lumbricals.
 Adductor pollicis
 Sensory loss over the anterior &
posterior surfaces of the palm &
medial one and half finger
 Trophic changes: because of loss of
sympathetic control

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

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

ULNAR NERVE LESION AT THE WRIST
 Commonly occur due to cuts and stab wounds
 Motor: The small muscles of the hands are paralyzed,
except the muscles of thenar eminence and first two
lumbricals. The claw hand is more obvious as the flexor
digitorum profundus is intact
 Sensory loss over the anterior surfaces of the palm and
the anterior & posterior surfaces of the medial one and
half finger. (The posterior surface of the hand is spared as
the posterior cutaneous branch arises above the level of
wrist)

Upper limb nerve injuries

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