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THEIR LESIONS
DR TATHEER ZAHRA
ASSISTANT PROFESSOR ANATOMY
Ascends along
Sympathetic Trunk
Through Brachial
Plexus & its Branches
MOTOR
SENSORY
AUTONOMIC
Vasomotor &
Secretomotor
DERMATOMES
(FOERSTER, 1933)
(KEEGAN &
GARRETT, 1948)
BRACHIAL PLEXUS
Between Scalene
Muscles
In Post.
Triangle
Behind
Clavicle
SURGICAL APPROACH
SUPRACLAVICULAR
APPROACH
INFRACLAVICULAR
APPROACH
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 Nerve
oElbow Extension ~ Radial N.
Multiple Nerves
oElbow Flexion ~ Musculocutaneous N., Median N.
Muscles
Mechanism of Injury:
Injury to C5-C6
Axillary N.
Suprascapular N.
N. to Subclavius
Musculocutaneous
N.
Supraspinatus &
Infraspinatus
Subclavius
Biceps, Brachialis,
Brachioradialis
Clinical Features:
o Upper Limb with Adducted Shoulder
o Medially rotated Arm
o Extended Elbow
o Loss of Sensation in Lateral Aspect of Upper Limb
o Waiters Tip Position
HYPERABDUCTION SYNDROME /
COMPRESSION OF CORDS OF BRACHIAL
PLEXUS & AXILLARY VESSELS
Mode of Injury:
Axilla Pathology
Painting a Ceiling
Clinical Features:
Pain ~ Radiating down the Arm
Numbness
Paraesthesia (Tingling)
Erythema (Redness of Skin due to Capillary Dilatation)
Weakness of Hands
Injury to Brachial Plexus Affects Nerve Roots
KLUMPKE PALSY
Much Less Common ~ C8-T1
Mode of Injury:
o Cervical Rib
o Malignant Metastasis from the Lungs in the Lower Deep
Cervical Lymph Nodes
o When Upper Limb is Suddenly Pulled Superiorly e.g.,
A Person grasps something to break a fall
Babys Upper Limb pulled extensively during
Delivery
Nerves Affected: Ulnar & Median N.
Clinical Features:
o Short Muscles of the Hand are affected ~ Claw Hand
o Loss of Sensation along the Medial Side of Arm, Forearm,
Hand & Medial 2 Fingers
Complete claw
hand
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)
Interrupts Conduction of
Impulses of Peripheral
Nerves
Produces Anaesthesia
Trauma
Clinical Feature:
Pain
Onset: Sudden
Intensity: Severe
Site: Around Shoulder
Begins: At Night
Muscle Weakness & Muscular Atrophy (Neurologic Amyotrophy)
Scapula on the
Affected Side is
Located Farther
from the Midline
Inability to Abduct
Arm above ,
Difficulty in Raising
the Arm above Head
WINGING OF
SCAPULA
Surgery on
Scapular Lymph
Nodes
Paralysis of Latissimus
Dorsi
Unable to raise
the Trunk with
Upper Limb as in
Climbing
Cannot use
Crutches because
Shoulder is
Pushed Superiorly
Fracture
Surgical Neck
of Humerus
Incorrect use
of Crutches
Dislocation of
Glenohumeral
Joint
Misplaced
Injection into
Deltoid
Anterior
Shoulder Dislocation
Dislocated Head
Normal Head
Atrophy of
Deltoid
Injury to
Axillary Nerve
Round Contour
Disappears
Impaired
Abduction
Area Supplied
by Sup. Lat.
Cutaneous N. of
Arm
Sensory Loss
Waisting of shoulder
Winging of the Scapula
Combined
Axillary and Long
Thoracic Nerve
Injuries
MUSCULOCUTANEOUS NERVE
Uncommon Injury
due to its
Protected Position
Injured by a
Area of Loss:
Sensory: Area supplied
By Lat. Cut. N. of
Forearm
Motor: Paralysis of
Coracobrachialis, Biceps
& Brachialis
Joint
Weak Supination of
Forearm
Most
Commonly
injured High up
Mode of Injury
RADIAL NERVE
Saturday Night Palsy;
Drunkard falling
asleep with one Arm
over the Back of a
Chair
Improper Use of
Crutches
Transient
Wrist Drop
Prolonged
Application of
Tounique
Fracture &
Dislocation of Shaft
of Humerus &
Subsequent Callus
Formation
3 in Axilla
4 in Spiral
Groove
4 in Ant.
Compartment of
Arm
2 in Cubital
Fossa
MOTOR
LOSS
Post. Surface of
Arm
Triceps,
Anconeus
Post. Surface of
Forearm
Brachioradialis
Lat. on the
Dorsum of Hand
except Distal
Phalanges
Supinator
Extensor
Muscles of Wrist
& Fingers (Wrist
Drop)
TROPHIC
CHANGES
Slight
WRIST
DROP
SENSORY
LOSS
MOTOR
LOSS
Slight / Absent
Post. Surface of
Forearm
Triceps
(Incompletely
Paralyzed)
Lat. on the
Dorsum of Hand
except Distal
Phalanges
Brachioradialis
Supinator
Extensor
Muscles of Wrist
& Fingers (Wrist
Drop)
DEEP
BRANCH
Muscular
Distribution
Articular
Distribution
SUPERFICIAL
BRANCH
Cutaneous
Nerve
MEDIAN NERVE
Elbow Region ~
Supracondylar
Fracture of
Humerus
Broken Glass Just
Proximal to
Flexor
Retinaculum
Stab Wound
VASOMOTOR
CHANGES
TROPHIC
CHANGES
Loss of Sympathetic
Control
Arteriolar
Dilatation
Absence of
Sweating
In Area of Loss,
Skin is Warmer &
Drier than Normal
In long-standing
Cases
In Hands& Fingers
Dry & Scaly Skin
Nails Crack Easily
Atrophy of Pulp Of
Fingers
SENSORY LOSS
MOTOR LOSS
Pronators
Long Flexors of
Wrist & Fingers
(except FCU &
Ulnar of FDP)
Thenar Muscles
1st 2 Lumbricals
Ape Like Hand
Hand of
Benediction
Waisted Thenar
Muscles
VASOMOTOR
CHANGES
TROPHIC
CHANGES
Loss of Sympathetic
Control
Arteriolar Dilatation
Absence of Sweating
In Area of Loss, Skin
is Warmer & Drier
than Normal
In long-standing
Cases
In Hands& Fingers
Dry & Scaly Skin
Nails Crack Easily
Atrophy of Pulp Of
Fingers
SENSORY LOSS
MOTOR LOSS
Thenar Muscles
1st 2 Lumbricals
Ape Like Hand
PRONATOR SYNDROME
Nerve Entrapment Syndrome
Near the Elbow
Teres as a result of
Trauma
Muscular Hypertrophy
Fibrous Bands
Clinical Features:
Pain & Tenderness in the Proximal Aspect of the
Anterior Forearm
Hyperesthesia of Palmar Aspects of the Radial 3
Digits & Adjacent Palm
Symptoms often Follow Activities that involve
Repeated Pronation
Any Lesion that Significantly the Size of the Carpal Tunnel or,
Infection
Excessive Exercise
CARPAL TUNNEL
SYNDROME
Slender nerves
Clinically Important
Even with a Complete Lesion of the Median Nerve, Some
ULNAR NERVE
> 27% of Nerve Lesions of Upper Limb
Classical Sign Claw Hand (main en griffe) ~
Post. To Med.
Epicondyle of
Humerus
CubitalTunnel at
Elbow
Ulnar Canal
Syndrome at Wrist
Mode of Injury:
Results when the
Medial Part of the
Elbow hits a Hard
Surface, Fracturing the
Medial Epicondyle
(Funny Bone)
MOTOR
LOSS
SENSORY
LOSS
VASOMOTOR
CHANGES
Cubital Tunnel
(The Tendinous Arch Joining the
Humeral & Ulnar Heads of
Attachment of the FCU)
Clinical Features:
Same as an Ulnar N. Lesion in the
Ulnar Groove on the Posterior
Aspect of the Medial Epicondyle
of the Humerus ~ Claw
Hand (main en griffe)
Hypothenar Muscles
3rd & 4th Lumbricals
Adductor Pollicis
Palmaris Brevis, Interossei
Claw Hand ~ More
Obvious
Inability to Adduct Thumb
MOTOR LOSS
SENSORY
LOSS
VASOMOTOR
CHANGES
Ulnar N.
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
Weakness of Intrinsic Muscles of Hand
Treatment
Anti-inflammatory Medications
Wrist Splints
Therapeutic Exercises
________ Nerve.
a) Median
b) Ulnar
c) Radial
d) Anterior interosseous
e) Axillary
REFERENCES
Cinical Anatomy By Regions, By RICHARD S. SNELL,
8th Edition
Clinical Oriented Anatomy, By KEITH L. MOORE &