NERVES OF UPPER

EXTREMITY

MAJ DR POONAM SINGH

DEPT OF ANATOMY
NAIHS
 OBJECTIVES

ORIGIN, ROOT VALUE, COURSE, BRANCHES

AND APPLIED OF MAJOR NERVES OF UPPER
EXTREMITY
BRACHIAL PLEXUS- imp nerves
 BRACHIAL PLEXUS: NERVES

DISTRIBUTION OF MAIN NERVES

– AXILLARY –
• Deltoid & Teres minor

– MUSCULOCUTANEOUS –
• Muscles of Anterior Compartment of arm
(flexors)

– MEDIAN –
• Most of the Flexor muscles of forearm &
Intrinsic muscles in hand- labourer

– ULNAR –
• FCU & part of FDP (forearm) and Intrinsic
muscles in hand- musician

– RADIAL –
• Innervates all Extensor muscles of arm &
forearm
MUSCULOCUTANEOUS NERVE
 MUSCULOCUTANEOUS NERVE
– Arise opposite lower border of Pectoralis Minor.
– Derived from C5-C7 cervical ventral rami

Course :
 Supplies Coracobrachialis and then
pierces it.
 Descends laterally between Biceps and
Brachialis to lateral side of arm.
 Just below elbow it pierces deep fascia.
 Continues as lateral cutaneous nerve of
forearm..
– Supplies –

Coracobrachialis,
Biceps and
most of Brachialis.
Branch to Brachialis
supplies Elbow joint.
Br to humerus via
nutrient art
 LESIONS OF MUSCULOCUTANEOUS NERVE

Commonest causes

– Isolated lesion is rare.

– injuries to
• upper arm and
• shoulder including
fracture of humerus.
 LESIONS OF MUSCULOCUTANEOUS NERVE

Symptom and sign

– Marked weakness of elbow flexion
• because of paralysis of
– biceps brachii and much of
– brachialis

– Sensory impairment
• on the extensor aspect of the forearm in the distribution of
lateral cutaneous nerve of the forearm.
AXILLARY NERVE
 AXILLARY (CIRCUMFLEX) NERVE
– From posterior cord (C5 - C6) .

– Posterior to Axillary artery (3rd

part) and anterior to
Subscapularis,

– Above posterior circumflex

humeral vessels, traverses
quadrangular space.

– Axillary trunk supplies a branch

to shoulder joint.
 BRACHIAL PLEXUS- POST CORD Axillary N cont’d
Divides into
• anterior and
• posterior branches.

Anterior branch
along posterior circumflex
humeral vessels,
curves behind the humeral neck,

Supplies
– Deltoid (deep to).
– skin over its middle part.(cutaneous branches which pierce the
muscle)
 Anterior br of Axillary
Nerve

Posterior branch
Posterior branch
supplies

– Teres minor
» Branch to Teres minor has a pseudoganglion
– posterior and lower part of Deltoid.
– upper part of long head of Triceps
– upper lateral cutaneous nerve of arm
 LESIONS OF AXILLARY NERVE

• Commonest causes
• Dislocations of shoulder
• Fractures of upper end humerus
• Misplaced injections into deltoid

• Symptom and sign

• Wasting and weakness of Deltoid-

• abduction of shoulder affected.
• sensory loss on outer aspect of upper arm below
acromion.
MEDIAN NERVE
FORMATION MEDIAN NERVE

• Formed by two roots:

– Medial & Lateral roots

• Contribution from both cords

– Medial Root -
• derived from Medial cord, C8 &
T1
– Crosses downward and
laterally infront of 3rd part of
Axillary and join Lateral root)
– Lateral root –
• continuation of lateral cord, C5
to C7

• Supplies flexors of forearm

• Labourer’s Nerve
• Thickest nerve of Brachial
Plexus 17
 MEDIAN NERVE: COURSE

• Formed in Axilla
• lateral to 3rd part of Axillary artery

18
In arm-
Nerve descends
lateral to Brachial
artery

In middle of arm

 crosses in front of
artery
 runs on its medial side
to Cubital fossa

19
At elbow-

 lies deep to
Bicipital
aponeurosis

 in front of
Brachialis

 Medial to
Brachial art

20
 MEDIAN NERVE: COURSE
Forearm
─ Enters forearm
─ Bt two heads of Pronator Teres

─ Then passes deep to

tendinous bridge
─ (formed by humero-ulnar &
radial heads of FDS)

─ Descends bt
─ FDS & FDP in forearm

─ 5 cm above Flexor
retinaculum
─ emerges from behind lateral
edge of FDS
21
passes deep to tendinous
bridge of FDS
─formed by humero-ulnar &
radial heads of FDS
22
Descends between
─ FDS & FDP in forearm

23
5 cm above Flexor
retinaculum
─ emerges from behind
lateral edge of FDS

24
 MEDIAN NERVE: COURSE
wrist
– becomes
superficial
– bt FDS & FCR
tendons)

– Passes deep to
flexor retinaculum
to enter palm

25
IN ARM
BRANCHES
1. Vascular brs (symp twigs ) to brachial artery
2. Branch to pronator teres above elbow

IN FOREARM
1. Muscular brs
a). Trunk of median nv Flexors of forearm except FCU &
medial half of FDP
b). Ant Interrosseous nv arise from median nv as it passess
between 2 heads of PT
- Runs infront of Interrosseous membrane
- supplies Deep flexors:- Lat ½ of FDP, FPL & PQ
- Supplies joints
Distal Radio- Ulnar joint
Radio- Carpal joint
Carpal joints
26
 Forearm cont’d MEDIAN NERVE:
BRANCHES

2. ARTICULAR
- Elbow joint
- Proximal R- U joint

3. PALMAR CUTANEOUS
– Given proximal to flexor
retinaculum
– Passes over retinaculum.
Supplies
– central palm,
– Skin thenar eminence,

4. COMMUNICATING
Frequently present.
To ulnar nerve.

27
IN HAND
MEDIAN NERVE: BRANCHES
1. Recurrent branch
• recurrent branch – supplies
Thenar muscles

2. Lateral branch / Main Nerve

– Lateral branch divides into
• 3 proper palmar digital
branches.
Supply:
1. skin of thumb
2. Lat side of index finger.
3. Supplies msls:
• 1st lumbrical.

28
2. Medial branch
MEDIAN NERVE:
– Divides into
BRANCHES
• two common palmer digital
nerves.
• These further divide into
Proper palmer digital nerves
Supply:
1. Sides of index, middle & half
of ring fingers.
2. 2nd lumbrical

summary
• All proper palmar digital nerves reach
on dorsum of Hand to supply nail
beds and palmar aspect of lateral 3 ½
fingers
• Lateral two lumbricals supplied by
29
Median
MEDIAN NERVE: BRANCHES

30
MEDIAN NERVE: CUTANEOUS INNERVATION

PALM

31
MEDIAN NERVE: CUTANEOUS INNERVATION
DORSUM OF HAND- short of nailbeds

32
 MEDIAN NERVE - APPLIED

• Median Nerve Injury At Elbow

• Carpal Tunnel Syndrome

• Pronator Syndrome

33
 MEDIAN NERVE INJURY AT ELBOW
• All muscles paralyzed except FCU & FDP (medial half)

• MOTOR LOSS
1. FDS & FDP ( LAT. HALF) –
• Loss of flexion at MP & IP Jts
(OCHSNER’S CLASPING TEST – When patient asked to clasp the hands, index finger of
affected side fails to flex – remains as Pointing Index Finger)

2. FCR -
• Loss of flexion of wrist
• Ulnar deviation on attempts of flexion of wrist.

3. FPL -
• Inability to flex terminal phalanx of thumb.

4. PQ and PT – pronation lost

5. Thenar eminence : muscles of thenar region affected –

• Flattening of eminence.
• Ape like hand
• Abductor Pollicis Brevis and Opponens Pollicis– Paralysis.
(PEN TEST : Hand laid flat on table. Patient asked to touch a pen kept at slightly higher level
than palm with the thumb)

34
 MEDIAN NERVE INJURY AT ELBOW

INJURY RESULTS IN
1. Loss of pronation :
• PT & PQ
2. Loss of powerful flexion at wrist :
• FCR & FDS (wrist deviates to ulnar side)
3. Loss of flexion of PIP of all digits :
• FDS is paralyzed
4. Loss of flexion of DIP & MCP Joints of index and
middle fingers
• FDP – lat. ½ &
• Lumbricals 1st , 2nd paralyzed)
5. Loss of flexion, abduction & opposition of thumb :
• Thenar muscles paralyzed
Thumb in adducted & extended position : APE LIKE HAND

35
Most common entrapment CARPAL TUNNEL SYNDROME
mononeuropathy

Incidence -
• females over 50 years.
• 50% cases B/L. Mostly in dominant
hand.

Cause -

• Compression of Median nerve in fibro-

osseous tunnel beneath flexor
retinaculum.

Tunnel may be narrowed by

a) Arthritic changes in wrist joint (RA)

b) Anterior dislocation of Lunate /
complication of Colle’s fracture
c) Soft tissue thickening in
Myxoedema & Acromegaly
d) Oedema, Obesity, Pregnancy
36
 CARPAL TUNNEL SYNDROME

Symptoms

1. impairment of finer movements

• (sewing, knitting, picking a pin)

2. paresthesia -
• attacks of pain, tingling & numbness of radial 3
½ digits of affected hand.
• wakes patient at night.

37
 CARPAL TUNNEL SYNDROME cont’d

On examination Tinel’s

– Wasting Of Thenar Eminence –

• Muscle affected: AbPB & OP

– Hypo aesthesia –
• palmar aspect of radial 3 ½ digits.
• skin over thenar eminence and palm not affected
– as it is supplied by palmar cutaneous br of median N which
arise proximal to carpal tunnel.

– Tinel’s Sign –
• Percussion of Median nerve gently at wrist
– causing tingling sensation radiating into hand.
38
 CARPAL TUNNEL SYNDROME cont’d

• Wrist Flexion Test (Phalen’s Sign) –

• Exacerbation of symptoms when patient is asked to flex
wrist. Symptoms disappear as wrist straightened.

surgical treatment –
– Carpal tunnel release.
– Partial or complete division of flexor retinaculum

39
Thenar atrophy

40
 PRONATOR SYNDROME
• Uncommon entrapment neuropathy of Median Nerve

• Anatomical basis
– Deep to Biceps aponeurosis
– Between two heads of Pronator Teres
– Through a fibrous arch of Flexor Digitorum Superficialis

• Clinical Features:
1. Pain & tenderness
• in proximal aspect of anterior forearm.

2. Weakness of all muscles innervated by Median nerve.

• Including Abductor Pollicis Brevis & long finger flexors.

3. Sensory impairment on palm of hand.

41
ULNAR NERVE
FORMATION ULNAR NERVE

- Branch of Medial cord.

- One of the terminal branch.

- Supplies small muscles in

hand that are involved in fine
intricate hand movements

- Called MUSICIAN’S Nerve.

ROOT VALUE:- (C7) C8-T1

- C7- contribution from median N (lat
cord)

43
 ULNAR NERVE : COURSE
Axilla

• Forms in Axilla.

• Runs on medial side

of axillary artery

44
 ULNAR NERVE : COURSE

arm

• runs medial to Brachial Artery till middle.

• Pierces IM septum &
• enters posterior compartment.
• Descends in front of medial head of Triceps along
superior ulnar collateral artery (br of Brachial
Art)

45
Ulnar nerve medial to
artery

Enters posterior
compt by piercing
medial IM septum

46
Ulnar nerve lies
infront of medial head
of triceps
and then behind the
medial epicondyle

47
 ULNAR NERVE : COURSE

elbow
• lies in a groove on
dorsal aspect of
medial epicondyle
• interval bt medial
epicondyle and
olecranon process.

48
 ULNAR NERVE : COURSE

forearm
• Enters forearm
• bt humeral & ulnar heads of FCU (Cubital Tunnel)
• Runs downwards
• in medial side of forearm.

49
Ulnar N rest on COURSE
FDP undercover of
FCU which has
been removed
here
• Rest on
• FDP and under cover of FCU.
• Ulnar artery is radial to nerve.

• Gives
 palmar cutaneous
(hypothenar eminence)and
 dorsal branch

• Enters palm by passing over

flexor retinaculum 50
 ULNAR NERVE : COURSE

wrist
• enter palm by passing over
flexor retinaculum.
• Ulnar N lies lateral to
pisiform and
• medial to hook of
hamate.
• Ulnar art is lateral to
Nerve

51
COURSE

• Both are bridged over

• by a slender band of fibrous
tissue (superficial part of
retinaculum)volar carpal lig
• forming a canal – GUYON’S
CANAL.

Palm
• In palm it passes deep to
Palmaris brevis
• and divides into
• superficial &
• deep branches. 52
53
Right palm

In palm it
passes deep to
Palmaris brevis

54
Right palm

Ulnar N lies lateral

to pisiform and
medial to hook of
hamate.

55
Right palm

56
Superficial branch –
• supplies ULNAR NERVE : COURSE
• Palmaris Brevis & IN PALM

• skin on medial 11/2 side of hand.

• Divides into
• 2 palmar digital nerves
• can be compressed against hook of
hamate
• 1st palmar digital branch –
• medial side of little finger
• 2nd palmar digital branch –
• adjacent sides of little & ring
fingers 57
58
 ULNAR NERVE : COURSE IN PALM

Deep branch –
• Passes bt
• Abductor & Flexor digiti minimi and

• then bt
• Opponens Digiti Minimi & 5TH Metacarpal.

• Follows course of deep palmar arch deep to

flexor tendons.

59
Supplies :
1. Hypothenars ,
2. Interossei – dorsal and
palmar
3. Lumbricals 3rd & 4th
4. Adductor Pollicis (at
times Flex Poll Brevis)

• Ends by supplying
Adductor Pollicis –
Grave yard

60
 Ulnar N

Deep branch
entering bt
abductor digiti
minimi and
flexor digiti
minimi

61
Right palm

Passes bt
Abductor &
Flexor digiti
minimi

and

then bt
Opponens
Digiti Minimi
& 5TH
Metacarpal.

62
 ULNAR NERVE : Branches
1. ARTICULAR
a) Elbow joint
b) Wrist joint
c) Small joints of hand-
– intercarpal and
– carpometacarpal joints

2. CUTANEOUS
a) Palmar cutaneous branch :
• Skin of hypothenar eminence
b) Dorsal branch :
• Dorsal 1 ½ digits (medial) on dorsum of hand

3. MUSCULAR AT FOREARM
a) FCU
b) FDP (med. Half) 63
4. TERMINAL
a) Superficial branch :
• Supplies Palmaris Brevis & medial 1 ½ digits
b) Deep branch : (muscular)
Supplies
a. Hypothenars :
• Ab Digiti Minimi,
• Flex Digiti Minimi,
• Opponens Digiti Minimi
b. Interossei :
• All 4 Dorsal & 4 Palmar
c. Lumbricals :
• 3rd & 4th (medial two)
d. Thenar :
• Adductor Pollicis & Flex. Poll. Brevis (sometimes)

5. VASCULAR
Vascular twigs to Axillary, Brachial, Ulnar and Deep palmar arch.
64
 MUSCLES SUPPLIED IN FOREARM

These muscles are

primarily flexors of the
wrist and fingers
FCU
FDP (Med.half)

65
 MUSCLES SUPPLIED IN FOREARM

FCU
FDP (Med. half)

66
MUSCLES SUPPLIED IN HAND

Palmar Dorsal
aspect aspect
67
ULNAR NERVE: CUTANEOUS INNERVATION OF HAND

PALM DORSUM

MEDIAN
ULNAR
ULNAR

SUPERFICIAL BRANCH OF RADIAL

68
 LESIONS OF ULNAR NERVE

1. AT THE WRIST

• Ulnar nerve may be compressed in

• Guyon's canal or
• deeply thro msl of hypothenar eminence
• trough formed by pisiform medially and hook of
hamate laterally
• Tight pisohamate lig

69
• Preservation of
• FDP to ring and little fingers.
• Dorsal cutaneous branch and palmar branch of Ulnar
nerve are spared –
• lesion is distal to their origin from main trunk of
Ulnar nerve in forearm

• Lesion of
• Superficial (to digits) and deep branches (intrin msls)

• Presentation

• Ulnar claw hand (medial two fingers are extended at

MCP jt and flexed at the IP jt.
• Hypo aesthesia medial 1 ½ fingers 70
 LESIONS OF ULNAR NERVE

2. AT THE ELBOW
Ulnar nerve lesion due to :
1. vulnerable position –
• lies between medial epicondyle & olecranon:
• lies on bone covered only by a thin layer of skin.
• Easily damaged if ulnar groove is shallow.

2. Cubital tunnel syn

• Entrapment neuropathy bt two heads of FCU

71
 LESIONS OF ULNAR NERVE

Presentation

• Weakness of FDP
• affect ring & little fingers.
• Produce ulnar claw hand with straighter fingers
• Called “ulnar paradox” – lower lesion has more claw feature

• All intrinsic msls of hand and sensations lost

• Radial deviation of wrist on flexion

72
 LESIONS OF ULNAR NERVE

3. HAND

• Deep motor branch of Ulnar nerve compressed against

pisiform & hamate
• - When hand is used as a mallet, or if a vibrating tool or motorcycle handlebar
is held in such a way that Hypothenar eminence is off the edge of the handle.

• Sensory branches are always spared.

• involvement of hypothenar muscles is variable. (depends on

the level at which branches to these muscles arise)

73
Ulnar claw hand with
lesion at wrist

FDP spared

74
 Ulnar claw hand
FDP affected – lesion
higher level

75
True claw hand – due to
lesion of ulnar and
median N

76
RADIAL NERVE
 RADIAL NERVE

FORMATION:-
Nerve of Extensors of
•continuation of Posterior Cord - arm
• Root value: C5-C8 & T1
• Largest branch of Brachial Plexus - forearm

Sensory to
- backof arm
- back of forearm
- dorsum of hand

78
 RADIAL NERVE: COURSE

Descends
–behind 3rd part
of Axillary artery
&
–later behind
brachial art.

79
In axilla

anterior to
Subscapularis &
tendons of LD
& T Major

80
Leaves axilla

thru triangular
space along with
Profunda brachii

81
arm

At first Lies bt long &

medial heads of Triceps.

Passes obliquely and

enters spiral groove
across post surf of
humerus bt lateral &
medial heads of Triceps.
Here it covered by lat
head.

Enter anterior
compartment

82
Showing relation of
radial nerve to
humerus and vessels

83
 RADIAL NERVE: COURSE con’td

Descends
– bt Brachialis & Brachioradialis
(proximally)
– and ECRL (distally)

Anterior to lateral Epicondyle-

– Divides into terminal branches:
a) Superficial branch
b) Posterior Interosseous
nerve (Deep br) 84
85
Ant. to lat. Epicondyle –

Divides into terminal

branches :
•
Post. Interosseous nerve
(Deep branch)
•
Superficial branch

86
 Superficial branch

– descends along radial

border of forearm.
– Crosses anatomical
snuff box
– Reach back of hand

Flexor aspect – Sensory to

• dorsum of hand (lat.
2/3rd)
• small area over palm.
• Lateral 3 1/2 fingers
short of nail beds

87
Anatomical snuff box

88
 Deep branch

– Pierces Supinator

– enters extensor Compt of

forearm.

Flexor aspect

89
 Deep branch

Supplies extensors of
forearm.
Supinator
ECRB, (BR, ECRL??)
ED,
EDM,
ECU,

AbPL, EPB, EPL,

EI

90
91
 RADIAL NERVE: REGION WISE BRANCHES
IN AXILLA ( 2 muscular & 1 cut)
1. Post Cutaneous N of arm
2. A br to long head of triceps
3. A br to medial head of triceps

92
IN SPIRAL GROOVE (muscular,
cut & articular)

1. Lower lat cut N of arm

2. Post cut N of forearm
3. Lateral & medial head of
triceps ANCONEUS,
articular twigs to the
elbow jt.

93
Branches to triceps

Triceps supplied by 4
branches from radial N.
• Medial head : 2 br,
• long head : 1 br,
• lateral head : 1 br

94
BEYOND RADIAL GROOVE ( in the
lower part of arm)
(Above lateral Epicondyle)

– Brachialis Lateral part

– Brachioradialis
– Extensor Carpi Radialis
Longus (ECRL)
– Elbow joint

– Then it divides into two

branches

95
 RADIAL NERVE: REGION WISE BRANCHES

IN CUBITAL FOSSA
1. Posterior interosseous
nerve (Deep branch)
2. Branch to Supinator
3. Superficial br-
• supply
• skin of lat side of dorsum of
hand and
• dorsum of lat 3 ½ fingers
proximal to nail beds.

96
 RADIAL NERVE: BRANCHES

Branches
1. Muscular
2. Cutaneous
3. Articular

1. Muscular
• Long, medial and lateral head of triceps
• Anconeus
• Extensor muscles
2. Cutaneous branch
• Posterior cut N of arm
• Lower lateral cut N of arm
• Posterior cut N of forearm
• Superficial br of radial (terminal)
3. Articular br
• Elbow jt
• Wrist and intercarpal
97
 RADIAL NERVE : APPLIED

studied under

1. Injury to N in axilla

2. Injury of N in spiral groove

3. Injury of Deep branch – Post interosseous N

4. Injury to superficial br

98
 RADIAL NERVE : APPLIED

1. Injury at axilla
• Causes
1. Extra long crutches (CRUTCH PALSY)
2. Fracture dislocation of upper humerus
3. During reduction of shoulder dislocation
• Symptoms
a) Motor:
– All extensors of wrist, elbow, finger paralyzed. Unopposed
action of flexors
– WRIST DROP
– Fingers can be extended (extension of IP jts) –
• done by lumbricals and interosseous (supplied by median/ulnar N)
– Inability to grip objects firmly.
• (flexors working with decreased mechanical advantage, b’coz extension at wrist
is essential for stretching prior to flexion of digits) 99
WRIST DROP
unopposed
action of flexors
at wrist and
elbow.

100
WRIST DROP
unopposed
action of
flexors at
wrist and
elbow.

101
 RADIAL NERVE : APPLIED

b) Sensory
– Loss of sensation over
• posterior surface of arm, forearm and
• lower lateral surface of arm
– Hand – dorsum lateral part
– Digits – lateral 31/2 digits upto nail beds, dorsal
surface

102
Sensory loss in radial nerve injury

103
 RADIAL NERVE : APPLIED
2. Injury of N in Spiral groove

• Causes
– Fracture of middle shaft of humerus
– Pressure on Nerve – Saturday Night palsy
– Operating table edge
– Prolonged use of tourniquet
a) Motor
– Triceps not affected, WHY ???
• Extension of elbow not impaired
– WRIST DROP
b) Sensory
– Back of forearm,
– dorsum of hand- lateral part
– Digits – lateral 31/2 upto nailbed 104
 RADIAL NERVE : APPLIED

3. Injury to Deep br – Posterior interosseous N

• Causes
– Fracture of upper radius
– Dislocation of head of radius
– Penetrating wound of upper forearm
• Motor
– Brachioradialis, ECRL escapes injury.
– Other extensors paralyzed
– Effect at wrist :
• Extension possible but with radial deviation
• ( be’coz ECRL escapes injury, ECU, ECRB paralyzed)
• No sensory loss
– (Deep br purely motor)
105
 RADIAL NERVE : APPLIED
4. Injury at Superficial br
• Superficial br superficially present on wrist

• Causes
– Compression by
• Tight bracelets, watch straps, plaster casts, hand cuffs etc

a) No motor loss
b) Sensory loss
– Hand – dorsum lateral ½
– Digits – dorsum lateral 31/2 up to nail beds
– Sensory loss may be minimal and may present only on dorsum of knuckle
of index finger

Summary
– If triceps paralyzed – injury at axilla
– BR paralyzed with normal triceps – injury at radial groove
– If BR and triceps both normal – injury beyond lateral epicondyle 106
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