NERVE INJURIES OF UPPER LIMB
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Transcript NERVE INJURIES OF UPPER LIMB
NERVE INJURIES OF
UPPER LIMB
Dr. Mujahid Khan
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
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
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)
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
Brachial Plexus Injuries
(Lower lesions)
Are
usually a traction injuries caused by
excessive abduction of the arm
The
The
first thoracic nerve is usually torn
hand has a clawed appearance
caused by hyperextension of
metacarpophalangeal joints & flexion of
interphalangeal joints
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
The
of thenar eminence are paralyzed
hand looks flattened and ape like
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
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
Injury at Elbow
(Trophic changes)
In long standing cases:
Skin
Nails
is dry and scaly
crack easily
Atrophy
of the pulp of the fingers
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
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
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
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
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
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
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
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
occur
flexion of the terminal phalanges
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