NERVES OF UPPER LIMB &

THEIR LESIONS

DR TATHEER ZAHRA
ASSISTANT PROFESSOR ANATOMY

NERVE SUPPLY OF UPPER LIMB

Sympathetic
Preganglionic Fibers
T2-T6

Ascends along
Sympathetic Trunk

Through Brachial
Plexus & its Branches

Middle & Inf.

Cervical Ganglion +
1st Thoracic
Sympathetic Ganglia

MOTOR

SENSORY

AUTONOMIC

Vasomotor &
Secretomotor

CUTANEUS NERVE SUPPLY

DERMATOMES

(FOERSTER, 1933)

(KEEGAN &
GARRETT, 1948)

BRACHIAL PLEXUS

Between Scalene
Muscles

In Post.
Triangle

Behind
Clavicle

Arranged Around 2nd Part

of Axillar Artery in Axilla

SURGICAL APPROACH
SUPRACLAVICULAR
APPROACH

INFRACLAVICULAR
APPROACH

In Angle Between SCM &

Clavicle

Deltopectoral Groove is opened

up

Inf. Belly of Omohyoid & Lateral

Branches of ThyrocervicalTrunk
are Divided

Pectoralis Minor is detached

from Coracoid Process

Roots of Brachial Plexus are

identified Behind Scalenus Ant.

Plexus Branches Around

Axillary Artery can be dissected
Around Axillary Sheath

Scalenus Ant. Retracted /

Severed to display Lower Trunk
of Brachial Plexus

Middle Part of Clavicle may be removed if a more Proximal Approach

is needed

TYPES OF NERVE LESIONS

COMPRESSION
STRETCH
SECTION
BRACHIAL PLEXOPATHY
Can refer to involvement of the Entire
Plexus, or Parts of the Plexus
Trunk Lesion
Cord Lesion
Distribution of Weakness & 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 Nerve
oElbow Extension ~ Radial N.
Multiple Nerves
oElbow Flexion ~ Musculocutaneous N., Median N.

A: VARIATIONS IN BRACHIAL PLEXUS:

Variations in Origin & or Combination of Branches
Prefixed Brachial Plexus (C4-C8) ~ 10%
Post Fixed Brachial Plexus (C6-T2) ~ 10% T2

compressed by First Rib Neurovascular Symptoms of

Upper Limb
Variations in Formation of Trunks, Divisions & Cords
Variations in relationship to Axillary Artery & Scalene

Muscles

B: BRACHIAL PLEXUS INJURIES:

Incomplete Paralysis (Weak Movement)
Complete Paralysis (No Movement + Horners Syndrome)

~ Rare Devastating Motorbike Accident

Erb-Duchenne Palsy/ Backpackers Palsy
Klumpke Paralysis

C: BRACHIAL PLEXUS BLOCK:

D: BRACHIAL PLEXUS NEURITIS:

ERB-DUCHENNE PALSY (WAITERS TIP)

Mode of Injury:
o Angle Between Neck & Shoulder (e.g., A

Person thrown from Motorcycle or Horse &

Lands on Shoulder)
o Person thrown Shoulder often hits

something e.g., Tree or the Ground & stops ,

but the Head & Trunk continue to move
Stretches or Ruptures Sup. Part of Brachial
Plexus or avulses the Roots of the Plexus
from Spinal Cord
o Newborns when Excessive Stretching of the

Neck occurs during Delivery

 Mechanism of Injury:
Injury to C5-C6
Axillary N.

Suprascapular N.

N. to Subclavius

Musculocutaneous
N.

Paralysis of Muscles of Shoulder & Arm supplied by C5-C6

Deltoid

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

BACK PACKERS PALSY

Superior Brachial Plexus Injury
In Hikers, who carry Heavy Backpacks
for Long Periods
Mechanism of Injury:
Chronic Micro-trauma to Upper Trunk

from Carrying Heavy Packs

Motor & Sensory Deficit in Areas supplied
by Radial & Musculocutaneous Nerves
Clinical Features:
Muscle Spasms
Sever Disability

HYPERABDUCTION SYNDROME /
COMPRESSION OF CORDS OF BRACHIAL
PLEXUS & AXILLARY VESSELS
Mode of Injury:
Axilla Pathology

Disease or Stretching Wounds in Lateral Cervical

Region (Post Triangle of Neck)

Mechanism of Injury:
Hyperabduction of Arm
Manual Tasks over Head

Painting a Ceiling

Cords impinged between Pectoralis Minor & Coracoid

Process

 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

(Paralysis of Muscles) & Cutaneous sensation

(Anaesthesia) in Upper Limb

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)

BRACHIAL PLEXUS BLOCK

Injection of An
Anesthetic Solution into
or Immediately
Surrounding the
Axillary Sheath

Interrupts Conduction of
Impulses of Peripheral
Nerves

Produces Anaesthesia

Blocked Sensations in All

Deep Structures of the
Upper Limb & the Skin
Distal to the Middle of the
Arm

Combined with an Occlusive Tourniquet Technique

to retain the Anesthetic Agent, this Procedure
enables Surgeons to Operate on the Upper Limb
without using a General Anesthetic
Brachial Plexus Block By

using Other Approaches

e.g.,
Cervical Approach
Interscalene Approach
Supraclavicular Approach
Axillary Approach

ACUTE BRACHIAL PLEXUS NEURITIS

(BRACHIAL PLEXUS NEUROPATHY)
Neurological Disorder of Unknown Cause

Usually, Nerve Fibers of Upper Trunk are affected

Preceded by Some Event e.g., URTI, Vaccination, Non-specific

Trauma
Clinical Feature:
Pain

Onset: Sudden
Intensity: Severe
Site: Around Shoulder

Begins: At Night
Muscle Weakness & Muscular Atrophy (Neurologic Amyotrophy)

INJURY TO NERVE ROOTS &

BRANCHES

DORSAL SCAPULAR N. INJURY

Injury to the Dorsal
Scapular Nerve, the
N. to the
Rhomboids

Affects the Actions

of Rhomboids

Scapula on the
Affected Side is
Located Farther
from the Midline

LONG THORACIC N. INJURY

Blow/ Pressure on the
Post. of Neck, Injury
During Radical
Mastectomy

Injury to the Long

Thoracic N.

Medial Border of the

Scapula moves
Laterally &
Posteriorly away from
the Thoracic Wall

Giving the Scapula the

Appearance of a Wing
Winged Scapula

Especially when the

Person leans on a
Hand or Presses the
Upper Limb against a
Wall

Inability to Abduct
Arm above ,
Difficulty in Raising
the Arm above Head

WINGING OF
SCAPULA

INJURY TO CORDS & TERMINAL

BRANCHES

THORACODORSAL N. INJURY (C6-C8)

Injury to
Thoracodorsal N.
Surgery in Axilla

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

AXILLARY N. INJURY (C5,C6)

Mode of Injury:

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

Weapon e.g., Knife

 Area of Loss:
Sensory: Area supplied

By Lat. Cut. N. of
Forearm
Motor: Paralysis of
Coracobrachialis, Biceps
& Brachialis

Weak Flexion of Elbow

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

Pressure on the Back

of Arm on the Edge of
Operating Table

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

RADIAL N. INJURY IN AXILLA

SENSORY
LOSS

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

RADIAL N. INJURY IN ARM (RADIAL

GROOVE)
TROPHIC
CHANGES

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)

RADIAL N. INJURY IN FOREARM

RADIAL N. IN
FOREARM

DEEP
BRANCH

Muscular
Distribution

Articular
Distribution

SUPERFICIAL
BRANCH

Cutaneous
Nerve

INJURY TO SUPERFICIAL BRANCH OF

RADIAL N.
Stab Wound
Minimal Sensory Loss

Coin Shaped Area of

Anaesthesia Distal to Bases of

2nd & 3rd Metacarpals
Less than expected
Considerable Overlap from

Cut. Br. of Median & Ulnar N.

INJURY TO DEEP BRANCH OF RADIAL N.

Mode of Injury:
Deep Penetrating Wounds of Forearm
Fracture of the Proximal end of the Radius
Dislocation of the Radial Head
Area of Loss:
No loss of Sensation
No Wrist Drop as Brachioradialis & Ext. Carpi Radialis

Longus will be undamaged & they keep the Wrist Joint

Extended
Inability to Extend Thumb & MP Joints of Other Digits
IP Joints can be extended weakly through action of

TESTING THE INTEGRITY OF DEEP

BRANCH OF RADIAL N.
May be tested by asking the Person to extend the MP Joints while

the Examiner provides Resistance

If the Nerve is Intact the Long Extensor Tendons should appear
Prominently on the Dorsum of the Hand Confirming that the
Extension is occurring at the MP Joints rather than at the IP Joints
(Movements under the Control of other Nerves)

MEDIAN NERVE
Elbow Region ~
Supracondylar
Fracture of
Humerus
Broken Glass Just
Proximal to
Flexor
Retinaculum

Stab Wound

MEDIAN N. INJURY AT ELBOW

(HAND OF BENEDICTION)
Median N. is Severed in the Elbow Region

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

Lat. of the Palm

of Hand
Palmar Aspect of
3 Fingers
Distal Part of
Dorsal Surfaces of
Lateral 3 Fingers

Pronators
Long Flexors of
Wrist & Fingers
(except FCU &
Ulnar of FDP)
Thenar Muscles
1st 2 Lumbricals
Ape Like Hand
Hand of
Benediction

 Flexion of the Proximal IP Joints of the 1st-3rd Digits is lost

& Flexion of the 4th & 5th Digits is weakened

Flexion of the Distal IP Joints of the 2nd & 3rd Digits is also
lost
Flexion of the Distal IP Joints of the 4th and 5th Digits is
not affected (Medial Part of the FDP~ Supplied by the
Ulnar Nerve)
Ability to Flex the Metacarpophalangeal Joints of the 2nd &
3rd Digits is affected (Digital Branches of the Median N.
supply the 1st & 2nd Lumbricals)
When the person attempts to make a Fist, the 2nd & 3rd
fingers remain partially extended (Hand of
Benediction)

Thenar Muscle Function is Lost

Waisted Thenar
Muscles

ANTERIOR INTEROSSEOUS N. INJURY

Thenar Muscles are Unaffected
Paresis of the Flexor Digitorum Profundus & Flexor Pollicis Longus
When the Person attempts to make the Okay Sign, opposing the

Tip of the Thumb & Index Finger in a Circle a Pinch Posture of

the Hand results instead owing to the Absence of Flexion of the IP
Joint of the Thumb & Distal IP joint of the Index Finger (Anterior
Interosseous Syndrome)

MEDIAN N. INJURY AT WRIST

Most Serious Disability of all in Median N. injuries ~ Loss

of the Ability to Oppose the Thumb to the Other Fingers

& the Loss of Sensation over the Lateral Fingers.
Ape like hand ~ Delicate Pincerlike Action of the
Hand is No Longer Possible

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

Lat. of the Palm of

Hand
Palmar Aspect of 3
Fingers
Distal Part of Dorsal
Surfaces of Lateral 3
Fingers

Thenar Muscles
1st 2 Lumbricals
Ape Like Hand

PRONATOR SYNDROME
Nerve Entrapment Syndrome
Near the Elbow

Compressed between the Heads of the Pronator

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

CARPAL TUNNEL SYNDROME

Most Common Site of Median N. Injury

Any Lesion that Significantly the Size of the Carpal Tunnel or,

More Commonly, the Size of some of the 9 Structures or their

Coverings that Pass through it
Arthritic Changes in the Carpal Bones
Inflammation of Synovial Sheaths
Fluid Retention

Infection
Excessive Exercise

2 Terminal Sensory Branches that Supply the Skin of the Hand

Paresthesia (Tingling), Hypoesthesia (Diminished

Sensation), or Anesthesia (Absence of Sensation) in the Lateral 3

CARPAL TUNNEL
SYNDROME

 Palmar Cutaneous Branch of the Median N. arises Proximal to &

does not Pass through the Carpal Tunnel Sensation in the

Central Palm remains Unaffected.
Nerve also has 1 Terminal Motor Branch, the Recurrent

Branch, which serves the 3 Thenar Muscles Weakness of

Thenar Muscles
If the cause of Compression is not alleviated Progressive Loss

of Coordination & Strength in the Thumb (owing to Weakness

of the APB & Opponens Pollicis)
Unable to Oppose the Thumb & have Difficulty Buttoning a

Shirt or Blouse as well as Gripping Things such as a Comb

 As the Condition Progresses Sensory Changes Radiate into

the Forearm & Axilla

Symptoms of Compression can be Reproduced by Compression

of the Median N. with Your Finger at the Wrist for Approximately

30 Seconds
Treatment: Partial or Complete Surgical Division of the Flexor

Retinaculum, Carpal Tunnel Release, Longitudinal Incision

made toward the Medial Side of the Wrist & Flexor Retinaculum
to Avoid Possible Injury to the Recurrent Branch of the Median
N.

COMMUNICATIONS BETWEEN MEDIAN &

ULNAR NERVES
Occasionally
In the Forearm

Slender nerves
Clinically Important
Even with a Complete Lesion of the Median Nerve, Some

Muscles may not be Paralyzed ~ May lead to an Erroneous

Conclusion that the Median N. has not been Damaged

ULNAR NERVE
> 27% of Nerve Lesions of Upper Limb
Classical Sign Claw Hand (main en griffe) ~

Unopposed Action of the Extensors & of FDP

Loss of Interossei & Lumbricals Hyperextension
at MP Joints of the Ring & Little Fingers Cannot
Flex the MP Joints or Extend the IP Joints
With Ulnar N. Injuries, the Higher the Lesion, the
Less Obvious the Clawing Deformity of the Hand
Injuries At the Elbow or Above: Partial Claw Hand
Deformity, More Prominent Straight Fingers (Ulnar
Paradox) Ulnar of FDP is Out of Action
Unlike Median N. Injuries, Lesions of the Ulnar N.
leave a Relatively Efficient Hand ~ Pincerlike
Action of the Thumb & Index Finger is
Reasonably Good

Post. To Med.
Epicondyle of
Humerus
CubitalTunnel at
Elbow
Ulnar Canal
Syndrome at Wrist

Cuts & Stab Wounds

at Wrist
Handlebar
Neuropathy in the
Hand
Places of Injury to
Ulnar N.

ULNAR N. INJURY AT ELBOW

Site:
Posterior to the Medial
Epicondyle of the
Humerus

Mode of Injury:
Results when the
Medial Part of the
Elbow hits a Hard
Surface, Fracturing the
Medial Epicondyle
(Funny Bone)

 FCU, FDP (Ulnar )

Hypothenar Muscles
3rd & 4th Lumbricals
Adductor Pollicis
Palmaris Brevis, Interossei
Claw Hand
Inability to Adduct Thumb

Loss of Sensation over

the Ant. & Post. Surfaces
of the Medial of the
Hand & the Medial
Fingers
Numbness & Tingling

MOTOR
LOSS

SENSORY
LOSS

Warmer & Drier Skin

Arteriolar Dilatation &
Absence of Sweating ~
Loss of Sympathetic
Control

VASOMOTOR
CHANGES

 Loss of FCU, FDP (Ulnar )

Week Flexion
Loss of Adduction
Flexion of the Wrist Joint will Result in Abduction
Medial Border of the Front of the Forearm will show Flattening
All Small Muscles of the Hand will be Paralyzed, Except the Muscles of the
Thenar Eminence & the First 2 Lumbricals
Inability to Put the Hand in Writing Position
Inability to Adduct Thumb ~ (Froment's Sign ~ If the Patient is asked
to Grip a Piece of Paper Between the Thumb & the Index Finger, One does
so by Strongly Contracting the FPL & Flexing the Terminal Phalanx)
Unable to Adduct & Abduct the Fingers
Guttering Between Metacarpals
Hyperextended MP Joints & Flexed IP Joints ~Claw Deformity (main
en griffe)
Flattening of the Hypothenar Eminence & Loss of the Convex Curve to
the Medial Border of the Hand

CUBITAL TUNNEL SYNDROME

Ulnar Nerve Entrapment

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)

ULNAR N. INJURY AT WRIST (ULNAR

CANAL SYNDROME/ GUYON TUNNEL
SYNDROME)
Site of Nerve Entrapment: Osseofibrous Tunnel/ Ulnar Canal

(Pisiform Bone, Hook of Hemate & Pisiohemate Ligament)

Clinical Features:
Hypoesthesia in Medial 1 Fingers
Weakness of Intrinsic Muscles of Hand
Clawing of 4th & 5th Fingers ~ Much more Obvious as FDP

is not Paralyzed, & Marked Flexion of the Terminal

Phalanges Occurs
Ability to Flex at Wrist Joint is Unaffected
No Radial Deviation when trying to make a Fist

Hypothenar Muscles
3rd & 4th Lumbricals
Adductor Pollicis
Palmaris Brevis, Interossei
Claw Hand ~ More
Obvious
Inability to Adduct Thumb

Loss of Sensation over the

Palmar Surface of the
Medial of the Hand &
Medial 1 Fingers & to the
Dorsal Aspects of the
Middle & Distal Phalanges
of the Same Fingers

MOTOR LOSS

SENSORY
LOSS

Warmer & Drier Skin

Arteriolar Dilatation &
Absence of Sweating ~
Loss of Sympathetic
Control

VASOMOTOR
CHANGES

ULNAR N. INJURY IN THE HAND

(HANDLEBAR NEUROPATHY)
Mode of Injury
People who Ride Long Distances on Bicycles Compress

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

 An Inability to Oppose the Thumb to the

Little Finger can result from Damage to the

________ Nerve.
a) Axillary
b) Musculocutaneous
c) Radial
d) Ulnar
e) Median

 Hyperextension of the Proximal Phalanges of

the Little & Ring Fingers can result from

damage to the ________ Nerve.
a) Ulnar
b) Axillary
c) Radial
d) Median
e) Musculocutaneous

 Wrist Drop can result from Damage to the

________ 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 &

ARTHUR F. DALLEY, 5th Edition

LASTS Anatomy, By CHUMMY S SINNATAMBY,

Churchill Livingstone, 11th Edition

GRAYs Anatomy, 40th Edition