NERVE INJURIES OF

UPPER LIMB

By: 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 of C5 and

C6 roots of the plexus

Muscles to be Paralyzed

Supraspinatus (Abductor of shoulder)

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

Axillary Sheath
A

brachial plexus nerve block can be

obtained by injecting a local anesthetic

The

position of the sheath can be verified

by feeling the pulsations of the 3rd part of
the axillary artery

Injuries of Long Thoracic Nerve

Can be injured by blows to or pressure on the

posterior triangle of the neck

Serratus anterior is paralyzed

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 recognized

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
Little

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 & 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 & 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 & fingers

Sensory

loss occurs on the skin of the

distal part of the dorsal surfaces of the
lateral 3 & 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

is dry and scaly

Nails

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 & 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 & 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 & 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