DR TATHEER ZAHRAASSISTANT PROFESSOR ANATOMY

NERVES OF UPPER LIMB & THEIR LESIONS

NERVE SUPPLY OF UPPER LIMB

DERMATOMES

(FOERSTER, 1933)

(GARRETT, 1948)

BRACHIAL PLEXUS

SURGICAL APPROACH

TYPES OF NERVE LESIONS

BRACHIAL PLEXOPATHY Can refer to involvement

of the entire plexus, or parts of the plexus– Trunk lesion– Cord lesion

Distribution of weakness and numbness depends upon the part of the plexus affected

PATTERN OF INJURY

Pattern of root contribution to the plexus:

– Upper trunk lesion: Sensory loss in C5 & C6

– Middle trunk lesion: Sensory loss in C7

– Lower trunk lesion: Sensory loss in the combined C8 & T1 dermatomes

PRINCIPLES OF LOCALIZATION Certain sites are prone to nerve entrapments/injuries

– Nerve opposing bone ~ Ulnar nerve at the elbow– Closed spaces ~ Carpal tunnel– Adjacent structures ~ Median nerve at the elbow, adjacent

to the brachial artery Order in which branches arise Movements at specific joints

– Single nerveoElbow extension ~ Radial

– Multiple nervesoElbow flexion ~ Musculocutaneous, Median

A: VARIATIONS IN BRACHIAL PLEXUS:

Prefixed brachial plexus Post fixed brachial plexus

B: BRACHIAL PLEXUS INJURIES:

Incomplete paralysis Complete paralysis Erb-Duchenne palsy Backpacker’s palsy Klumpke paralysis

C: BRACHIAL PLEXUS BLOCK:

ERB-DUCHENNE PALSY (WAITER’S TIP)

BACK PACKER’S PALSY

KLUMPKE PALSY

Affection of:1 -Most of the small muscles of the hand (T1)

2 -Ulnar flexors of the flexor compartment of forearm are partially affected (C8)

Complete claw hand

BRACHIAL PLEXUS BLOCK

INJURY TO NERVE ROOTS & BRANCHES

INJURY TO DORSAL SCAPULAR NERVE

LONG THORACIC NERVE INJURY

WINGING OF SCAPULA

INJURY TO CORDS & TERMINAL BRANCHES

THORACODORSAL NERVE INJURY

INJURY TO AXILLARY NERVE

Anterior Shoulder Dislocation

Dislocated Head

Normal Head

Combined Axillary and Long Thoracic Nerve Injuries

Winging of the ScapulaWaisting of shoulder

MUSCULOCUTANEOUS NERVE

RADIAL NERVE

RADIAL NERVE INJURY IN ARM

WRIST DROP

MEDIAN NERVE

Waisted Thenar Muscles

MEDIAN NERVE INJURY AT ELBOW(HAND OF BENEDICTION)

PRONATOR SYNDROME

MEDIAN NERVE INJURYA- Above Elbow:1- Loss of pronation2-Week flexion3-Ulnar deviation4-Inability to flex thumb5-Inability to oppose fingers6-Inability to flex middle digits7-Inability to flex Index middle fingers

-Sensory loss-Ape hand deformity

B- Above Wrist:1- No Loss of pronation2- No Week flexion3- No Ulnar deviation4- No Inability to flex thumb5- Inability to oppose fingers6- No Inability to flex middle digits7- No Inability to flex index and middle fingers

-Sensory loss -Ape hand deformity

Flexed little and ring

Extended index and

middle

Adducted and extended

thumbFlat thenareminence

CARPAL TUNNEL SYNDROME

ULNAR NERVE

(CUBITAL TUNNEL SYNDROME)

ULNAR NERVE INJURYA - Above Elbow:

1- Week flexion2- Loss of adduction3- Inability to adduct thumb4- Inability to put the hand in writing position

- Sensory loss- Partial claw hand deformity

B - Above Wrist:

1- No Week flexion2- No Loss of adduction3- Inability to adduct thumb4- Inability to put the hand in writing position

- Sensory loss to fingers only- Partial claw hand deformity is moreprominent (Ulnar paradox)

ULNAR CANAL SYNDROME/ GUYON TUNNEL SYNDROME

Symptoms Tingling Numbness Pain on the outside or middle of the forearm; this sensation

of discomfort may run all the way to the little finger.

Treatment Anti-inflammatory medications Wrist splints Therapeutic exercises

HANDLEBAR NEUROPATHY

An inability to oppose the thumb to the little finger can result from damage to the ________ nerve.

a)Axillaryb)Musculocutaneous c)Radiald)Ulnare)Median

Hyperextension of the proximal phalanges of the little and ring fingers can result from damage to the ________ nerve.

a)Ulnarb)Axillaryc)Radiald)Mediane)Musculocutaneous

Wrist drop can result from damage to the ________ nerve.

a)Medianb)Ulnarc)Radiald)Anterior interosseouse)Axillary

REFERENCESCinical Anatomy By Regions, By RICHARD S.

SNELL, 8th edition

Clinical Oriented Anatomy, By KEITH L. MOORE & ARTHUR F. DALLEY, 5th edition

LAST’S Anatomy, By CHUMMY S SINNATAMBY, Churchill Livingstone, 11th edition

GRAY’s Anatomy, 40th edition