Upper limb nerve lesions.

Revise the brachial plexus formation before going through the

lesions.
Brachial plexus injuries.
Superior plexus injury.
Waiters tip position, also known as Erb-Duchenne palsy, is
superior plexus injury. It occurs due to severing of the upper trunk
C5 and C6 nerves. It causes paralysis of the arm. Since the
muscles are paralysed, the patients hand is adducted close to the
body, pronated and the hand if flexed (since the ulnar nerve is
flexed). When it is caused by cord compression, it is
hyperabduction syndrome.
Erb-Duchenne palsy is common caused during childbirth when the
babys head and neck is pulled toward the side at the same time
as the shoulders pass through the canal, which stretches the
cords of the brachial plexus.
Inferior plexus injury.
Inferior plexus injuries include Klumpkes paralysis. It is a form of
paralysis involving the muscles of the forearm and hand, resulting
from a brachial plexus injury where C8 and T1 nerves before or
after they have joined to form the lower trunk. This paralyses the
intrinsic muscles of the hand (notably the interossei, thenar and
hypothenar muscles), as well as flexors of wrists and fingers
(notably flexor carpi ulnaris and ulnar half of the flexor digitorum
profundus).
Patients having Klumpkes paralysis will have a claw hand.
Radial nerve.
The radial nerve is formed by the fusion of all posterior divisions
of the trunk. It passes through the axilla deeply and then winds
around the radial groove of the humerus and ends up in the
posterior compartment, passing between the medial and lateral
heads of the triceps. From the posterior compartment, the radial
nerve in the arm supplies the three heads of triceps brachii.
The radial nerve travels down near the lateral epicondyle and
passes underneath the brachioradialis muscle into the posterior
compartment of the forearm, where it supplies muscles there. The
radial nerve in the arm divides into a superficial and deep branch
(the deep branch is the posterior interosseous nerve). The
superficial branch passes through the anatomical snuff box.
The superficial branch of the radial nerve divides after it passes
the anatomical snuff box to supply the lateral 3.5 fingers on the
dorsal aspect of the hand, but the nail beds are not supplied.
In the forearm, the radial nerve supplies the extensors, the skin
over the extensors and the skin of 3.5 dorsal surface of the hand,
excluding the nail beds.
It is at risk when the humerus is fractured mid-shaft. It is also at
risk in Saturday night palsy where the posterior cord has been
stretched, due to the person falling asleep with ones arm hanging

over the arm rest of a chair, compressing the radial nerve at the
spiral groove. It is also at risk due to crutch palsy, where it is
caused by poorly fitted axillary crutches.
Damage to the radial nerve at the arm means there is loss of
innervation to muscles of posterior arm and posterior forearm.
Compression syndrome can also occur. This is when an injury to
the upper or lower part causes perforation of the vessels, so fluid
leaks out into the compartment. The fluid accumulates and like in
the carpal tunnel, compresses the softest structure such as the
nerves so the radial nerve can be compressed.
The wrist drop can test the deep branch of integrity; the patient is
asked to extend the metacarpophalangeal joints while the
examiner provides resistance. The examiner watches for the
prominent long extensor tendons.

Axillary nerve.
Meanwhile, the axillary nerve is a branch of the posterior cord
that comes out of the quadrangular space, and winds around the
surgical neck of the humerus. It lies underneath the deltoid and
because of that, it supplies the deltoid and teres minor. In a large
percentage of the population, it may supply the long head of
triceps as well.
The axillary nerve is at risk when there is fracture at the surgical
neck. This would result to loss of function of the deltoid (so there
is limited abduction of only 15 degrees), and as well as loss of
function of the teres minor.

Axillary & Radial nerves

ORIGIN

COURSE

DISTRIBUTION (SUPPLIES)

Axillary'n.:''
deltoid'm.,''
teres'minor'm'
skin'over'deltoid'

FROM : POSTERIOR CORD

Axillary#
nerve#

Radial#
nerve#

Radial'n.:'
extensors'of'arm,'
forearm'''
skin'over'
extensors'&'
dorsum'of'hand'
(as'in'diag.)'
Axillary'n':'C5,6''
Radial'n.':'C5>
T1'
Posterior#

Median nerve.
The median nerve have contributions from all of the ventral rami.
When the median nerve passes through the arm, it does not
innervate any muscles. In the arm, it lies in the anterior
compartment midline. It then passes into the cubital fossa into
the forearm. From then onwards, the innervation of the median
nerve can be considered as partners with the ulnar nerve.
The median nerve supplies most of the muscles of the forearm,
except for half of flexor digitorum profundus (the ulnar part) and
also, it does not supply the flexor carpi ulnaris. In the forearm, the
median nerve is between FDS and FDP but eventually goes down
towards the carpal tunnel. It is usually attached to the FDS if you
lift FDS up. The median nerve also gives off a superficial branch
called the superficial (palmar) branch that passes over the flexor
retinaculum and supplies the skin, so there is still sensation when
a patient has carpal tunnel syndrome.
It also supplies the 2 radial lumbricals and supplies the 3 muscles
of the thenar eminence. The mnemonic is 2LOAF.
The median nerve supplies 3.5 digits of the fingers on the palmar
surface, as well as the nail beds. In carpal tunnel syndrome, there
is compression and the patient is tested by having their 3.5
fingers stroke to see which ones have sensations.

Axillary n (C5,6):
supplies deltoid m., tere
minor m. & skin over de

Radial n. (C5-T1):
Supplies extensors of a
& skin over extensors &
hand (as shown in diag

Median nerve in the arm

ORIGIN'
'
'
FROM':' 'LATERAL'&'MEDIAL'CORDS'

COURSE'

DISTRIBUTION'(SUPPLIES)'

Muscles:(
forearm#
flexor#
muscles#
(except#
FCU#
&#
#
FDP)#
thenar#
muscles#
lateral#
2#
lumbricals#
Skin:(((
palmar#
surface#
of#
lateral#
3#
digits,#
including#
finger#
Bp#
&#
nail#
beds

Median n. :
C5, 6, 7, 8, T1
2LOAF
Anterior#

The median nerve is at risk due to entrapment, or through median

nerve palsy.
In carpal tunnel syndrome, there is loss of function of thenar
muscles, causing the hand to be in an ape hand position.

Median nerve injury above elbow.

Injury of the median nerve above the elbow causes loss of
function of all forearm muscles (except for half of FDP and FCU),
thenar muscles and the 2 lumbricals. As a result, there is a loss of
precision grip and thumb opposition.
The ape hand position occurs due to the loss of function to the
lumbricals. Additionally, there is weakness in flexion of the wrist
as well as loss of function at IP of the middle and index fingers.

 However, when you ask the person to make a fist, their hands will
be in a position called the hand of benediction.
The hand of benediction is when the index and middle fingers do
not flex (although flexion of metacarpophalangeal joints as
interossei are working), the FDP is paralysed and so is the FPL so
there is no flexion of the thumb. There is also no pronation.
Although there is weak flexion and abduction of the hand at wrist
as a result of hand of benediction, it is not fully lost due to
innervation of muscles innervated by the ulnar nerve.

Ulnar nerve.
In the arm, the ulnar nerve passes medially behind the medial
epicondyle. It is at risk in the arm when there is medial epicondyle
fracture, as well as dislocations at the elbow.
After it passes behind the medial epicondyle, the ulanr nerve lies
on the ulnar side directly underneath FCU. It passes superficially
to the carpal tunnel into the Guyons canal.
The ulnar nerve is at risk due to wrist lacerations as well as
entrapment. Wrist laceration at the hand may cause loss of
innervation of the lumbricals, but not for muscle long tendons.
There is also loss of innervation of the interossei, so there is no
abduction/adduction of the fingers as well.
As the ulnar nerve complements the function of the median
nerve, it supplies FCU and the ulnar half of FDP. It also supplies
small muscles of the hand except for the thenar muscles and
lateral 2 lumbricals. The ulnar nerve also supplies both surfaces of
the medial 1.5 digits of the skin.
When there is lesion of the ulnar nerve at the elbow region, there
is loss of the 2 lumbricals that supplies digit 4 and 5. It will also
impact the FCU and half of FDP. As a result, the hand will be in an
ulna claw position that looks similar to the hand of benediction
because of the unopposed flexion of digits 4 and 5. The clawing is
of the other digits. The ulna claw looks like the hand of
benediction even though the person may not be asked to make a
fist.
The ulnar nerve can also be compromised in bikers palsy where a
biker compresses the ulnar nerve when holding the handles of a
bike.

 The ulna paradox describes that when there is a lesion of the

ulnar nerve higher up, there is a lesser effect than a lesion of the
ulnar nerve lower down. Injury of the ulnar nerve at the elbow
joint causes the denervation of the medial half of FDP, so flexion
of the interphalangeal joints is weakened and reduces the clawlike appearance of the hand.

Musculocutaneous nerve.
The musculocutaneous nerve pierces the coracobrachialis muscle
in the anterior compartment of the arm. It supplies muscles of the
anterior compartment of the arm (biceps brachii, brachialis and
coracobrachialis).
It also supplies
Musculocutaneous
Nerve the lateral aspect of the anterior
forearm (the lateral cutaneous nerve of forearm).
ORIGIN'
'
FROM':' 'LATERAL'CORD'

COURSE'

DISTRIBUTION'(SUPPLIES)'

Muscles:
Anterior compartment of
arm
(biceps brachii, brachialis,
coracobrachialis)

Skin
Lateral aspect of anterior
forearm (lateral
cutaneous nerve of
forearm)

Anterior#

Summary#
of#
cutaneous#
nerve#
supply#
of#
upper#
limb#
Peripheral nerve distribution

Axillary#
n.#

Radial#
n.#

Axillary#
n.#

Medial'cutaneous'
nn'of'arm'&'
forearm''

Radial#
n.#

Musculocutaneous#
n.#
Musculocutaneous#
n.#
Median#
n.#
Anterior'view'

Ulnar#
n.#

Median#
n.#

Posterior'View'
Dr Nalini Pather
School of Medical Sciences