nerve injuries of upper limb
TRANSCRIPT
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DR TATHEER ZAHRA
ASSISTANT PROFESSOR ANATOMY
NERVES OF UPPER LIMB &
THEIR LESIONS
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NERVE SUPPLY OF UPPER LIMB
MOTOR
SENSORY
AUTONOMIC
SympatheticPreganglionic FibersT2-T6
Ascends alongSympathetic Trunk
Middle & Inf.Cervical Ganglion +
1stThoracicSympathetic Ganglia
Through BrachialPlexus & its Branches
Vasomotor &Secretomotor
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CUTANEUS NERVE SUPPLY
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DERMATOMES
(FOERSTER, 1933)
(KEEGAN &
GARRETT, 1948)
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BRACHIAL PLEXUS
Between Scalene
Muscles
Arranged Around 2nd Part
of Axillar Artery in Axilla
In Post.
Triangle
Behind
Clavicle
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SURGICAL APPROACH
SUPRACLAVICULAR
APPROACH
In Angle Between SCM &Clavicle
Inf. Belly of Omohyoid & LateralBranches of ThyrocervicalTrunk
are Divided
Roots of Brachial Plexus areidentified Behind Scalenus Ant.
Scalenus Ant. Retracted /Severed to display Lower Trunk
of Brachial Plexus
INFRACLAVICULAR
APPROACH
Deltopectoral Groove is openedup
Pectoralis Minor is detachedfrom Coracoid Process
Plexus Branches AroundAxillary Artery can be dissected
Around Axillary Sheath
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Middle Part of Clavicle may be removed if a more Proximal Approachis needed
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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
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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
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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 NerveoElbow Extension ~ Radial N.
Multiple Nerves
oElbow Flexion ~ Musculocutaneous N., Median N.
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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
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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:
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ERB-DUCHENNE PALSY (WAITERS TIP)
Mode of Injury:
o Angle Between Neck & Shoulder (e.g., APerson thrown from Motorcycle or Horse &
Lands on Shoulder)
o Person thrown Shoulder often hitssomething 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 Plexusfrom Spinal Cord
oNewborns when Excessive Stretching of the
Neck occurs during Delivery
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Mechanism of Injury:
Clinical Features:
o Upper Limb with Adducted Shouldero Medially rotated Arm
o Extended Elbow
o Loss of Sensation in Lateral Aspect of Upper Limb
o Waiters Tip Position
Paralysis of Muscles of Shoulder & Arm supplied by C5-C6
DeltoidSupraspinatus &
InfraspinatusSubclavius
Biceps, Brachialis,Brachioradialis
Injury to C5-C6
Axillary N. Suprascapular N. N. to Subclavius MusculocutaneousN.
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BACK PACKERS PALSY
Superior Brachial Plexus Injury
In Hikers, who carry Heavy Backpacksfor Long Periods
Mechanism of Injury:
Chronic Micro-trauma to Upper Trunkfrom Carrying Heavy Packs
Motor & Sensory Deficit in Areas supplied
by Radial & Musculocutaneous Nerves
Clinical Features:
Muscle Spasms
Sever Disability
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HYPERABDUCTION SYNDROME /
COMPRESSION OF CORDS OF BRACHIAL
PLEXUS & AXILLARY VESSELS Mode of Injury:
Axilla Pathology
Disease or Stretching Wounds in Lateral CervicalRegion (Post Triangle of Neck)
Mechanism of Injury:
Cords impinged between Pectoralis Minor & Coracoid
Process
Hyperabduction of ArmManual Tasks over Head Painting a Ceiling
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Clinical Features:
Pain ~ Radiating down the Arm
NumbnessParaesthesia (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
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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
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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)
Complete claw
hand
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BRACHIAL PLEXUS BLOCK
Injection of AnAnesthetic Solution into
or Immediately
Surrounding theAxillary Sheath
Interrupts Conduction ofImpulses of Peripheral
Nerves
Produces Anaesthesia
Blocked Sensations in AllDeep Structures of theUpper Limb & the Skin
Distal to the Middle of theArm
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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 Approachese.g.,
Cervical Approach
Interscalene ApproachSupraclavicular Approach
Axillary Approach
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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)
ACUTE BRACHIAL PLEXUS NEURITIS
(BRACHIAL PLEXUS NEUROPATHY)
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INJURY TO NERVE ROOTS &
BRANCHES
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DORSAL SCAPULAR N. INJURY
Injury to the Dorsal
Scapular Nerve, theN. to theRhomboids
Affects the Actionsof Rhomboids
Scapula on theAffected Side isLocated Farther
from the Midline
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LONG THORACIC N. INJURY
Blow/ Pressure on the
Post. of Neck, InjuryDuring Radical
Mastectomy
Injury to the LongThoracic N.
Medial Border of theScapula moves
Laterally &Posteriorly away from
the Thoracic Wall
Giving the Scapula theAppearance of a Wing
Winged Scapula
Especially when thePerson leans on a
Hand or Presses theUpper Limb against a
Wall
Inability to AbductArm above ,
Difficulty in Raisingthe Arm above Head
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WINGING OF
SCAPULA
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INJURY TO CORDS & TERMINAL
BRANCHES
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THORACODORSAL N. INJURY (C6-C8)
Paralysis of Latissimus
DorsiUnable to raisethe Trunk with
Upper Limb as inClimbing
Cannot useCrutches because
Shoulder isPushed Superiorly
Injury to
Thoracodorsal N.
Surgery in AxillaSurgery on
Scapular LymphNodes
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AXILLARY N. INJURY (C5,C6)
Mode of Injury:
FractureSurgical Neck
of Humerus
Incorrect use
of Crutches
Dislocation ofGlenohumeral
Joint
MisplacedInjection into
Deltoid
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Injury toAxillary Nerve
Round Contour
Disappears Impaired
Abduction
Atrophy ofDeltoid Area Supplied
by Sup. Lat.Cutaneous N. ofArm
Sensory Loss
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MUSCULOCUTANEOUS NERVE
Uncommon Injurydue to its
Protected Position
Injured by a
Weapon e.g., Knife
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Area of Loss:
Sensory: Area supplied
By Lat. Cut. N. of
Forearm
Motor: Paralysis of
Coracobrachialis, Biceps
& Brachialis
Weak Flexion of ElbowJoint
Weak Supination of
Forearm
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RADIAL NERVE MostCommonly
injured High up
Mode of Injury
Wrist Drop
Saturday Night Palsy;
Drunkard fallingasleep with one Armover the Back of a
Chair
Improper Use ofCrutches
Pressure on the Backof Arm on the Edge of
Operating Table
ProlongedApplication of
Tounique
Fracture &Dislocation of Shaft
of Humerus &Subsequent Callus
Formation
Transient
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3 in Axilla
4 in Spiral
Groove
4 in Ant.
Compartment of
Arm
2 in Cubital
Fossa
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RADIAL N. INJURY IN AXILLA
SENSORY
LOSS
Post. Surface ofArm
Post. Surface ofForearm
Lat. on theDorsum of Hand
except DistalPhalanges
MOTOR
LOSS
Triceps,Anconeus
Brachioradialis
Supinator
ExtensorMuscles of Wrist& Fingers (Wrist
Drop)
TROPHIC
CHANGES
Slight
WRIST
DROP
RADIAL N INJURY IN ARM (RADIAL
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RADIAL N. INJURY IN ARM (RADIAL
GROOVE)
TROPHICCHANGES
Slight / Absent
SENSORYLOSS
Post. Surface ofForearm
Lat. on theDorsum of Hand
except DistalPhalanges
MOTORLOSS
Triceps(Incompletely
Paralyzed)
Brachioradialis
Supinator
ExtensorMuscles of Wrist& Fingers (Wrist
Drop)
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RADIAL N. INJURY IN FOREARM
RADIAL N. INFOREARM
DEEPBRANCH
MuscularDistribution
ArticularDistribution
SUPERFICIALBRANCH
CutaneousNerve
INJURY TO SUPERFICIAL BRANCH OF
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INJURY TO SUPERFICIAL BRANCH OF
RADIAL N. Stab Wound
Minimal Sensory Loss
Coin Shaped Area ofAnaesthesia Distal to Bases of
2nd & 3rd Metacarpals
Less than expected
Considerable Overlap from
Cut. Br. of Median & Ulnar N.
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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 RadialisLongus 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
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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
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MEDIAN NERVE
Elbow Region ~SupracondylarFracture ofHumerus
Broken Glass JustProximal toFlexorRetinaculum
Stab Wound
MEDIAN N INJURY AT ELBOW
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MEDIAN N. INJURY AT ELBOW
(HAND OF BENEDICTION)
Median N. is Severed in the Elbow Region
VASOMOTOR
CHANGES Loss of Sympathetic
Control
ArteriolarDilatation
Absence ofSweating
In Area of Loss,Skin is Warmer &Drier than Normal
TROPHIC
CHANGES In long-standing
Cases
In Hands& Fingers
Dry & Scaly Skin
Nails Crack Easily
Atrophy of Pulp Of
Fingers
SENSORY LOSS
Lat. of the Palmof Hand
Palmar Aspect of3 Fingers
Distal Part ofDorsal Surfaces ofLateral 3 Fingers
MOTOR LOSS
Pronators Long Flexors of
Wrist & Fingers(except FCU &Ulnar of FDP)
Thenar Muscles
1st 2 Lumbricals
Ape Like Hand
Hand ofBenediction
Fl i f th P i l IP J i t f th 1 t 3 d Di it i l t
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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 ofBenediction)
Thenar Muscle Function is Lost Waisted ThenarMuscles
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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 (AnteriorInterosseous Syndrome)
MEDIAN N INJURY AT WRIST
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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
VASOMOTORCHANGES
Loss of SympatheticControl
Arteriolar Dilatation
Absence of Sweating
In Area of Loss, Skinis Warmer & Drierthan Normal
TROPHICCHANGES
In long-standingCases
In Hands& Fingers
Dry & Scaly Skin
Nails Crack Easily Atrophy of Pulp Of
Fingers
SENSORY LOSS
Lat. of the Palm ofHand
Palmar Aspect of 3Fingers
Distal Part of Dorsal
Surfaces of Lateral 3Fingers
MOTOR LOSS
Thenar Muscles
1st 2 Lumbricals
Ape Like Hand
PRONATOR SYNDROME
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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 ForearmHyperesthesia of Palmar Aspects of the Radial 3
Digits & Adjacent Palm
Symptoms often Follow Activities that involve
Repeated Pronation
CARPAL TUNNEL SYNDROME
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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
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CARPAL TUNNEL
SYNDROME
Palmar Cutaneous Branch of the Median N arises Proximal to &
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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 Lossof 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
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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 Approximately30 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.
CO CA O S A &
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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 NERVEP t T M d
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> 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 (UlnarParadox) 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
Reasonabl Good
Post. To Med.Epicondyle of
Humerus
CubitalTunnel atElbow
Ulnar Canal
Syndrome at Wrist
Cuts & Stab Woundsat Wrist
HandlebarNeuropathy in the
Hand
Places of Injury to
Ulnar N.
ULNAR N INJURY AT ELBOW
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ULNAR N. INJURY AT ELBOW
Site:Posterior to the Medial
Epicondyle of theHumerus
Mode of Injury:Results when the
Medial Part of the
Elbow hits a Hard
Surface, Fracturing theMedial Epicondyle
(Funny Bone)
FCU FDP (Ulnar ) Loss of Sensation over
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FCU, FDP (Ulnar )
Hypothenar Muscles
3rd & 4th Lumbricals
Adductor Pollicis
Palmaris Brevis, Interossei
Claw Hand Inability to Adduct Thumb
MOTORLOSS
Loss of Sensation overthe Ant. & Post. Surfacesof the Medial of theHand & the Medial Fingers
Numbness & Tingling
SENSORYLOSS
Warmer & Drier Skin
Arteriolar Dilatation &Absence of Sweating ~Loss of SympatheticControl
VASOMOTORCHANGES
Loss of FCU, FDP (Ulnar )
W k Fl
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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 MetacarpalsHyperextended 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
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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
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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
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Hypothenar Muscles Loss of Sensation over the
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Hypothenar Muscles
3rd & 4th Lumbricals
Adductor Pollicis
Palmaris Brevis, Interossei
Claw Hand ~ More
Obvious Inability to Adduct Thumb
MOTOR LOSS
Loss of Sensation over thePalmar Surface of theMedial of the Hand &Medial 1 Fingers & to theDorsal Aspects of theMiddle & Distal Phalangesof the Same Fingers
SENSORYLOSS
Warmer & Drier Skin
Arteriolar Dilatation &Absence of Sweating ~Loss of Sympathetic
Control
VASOMOTORCHANGES
ULNAR N. INJURY IN THE HAND
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Mode of Injury
People who Ride Long Distances on Bicycles CompressUlnar 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
(HANDLEBAR NEUROPATHY)
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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
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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
W i t D lt f D t th
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Wrist Drop can result from Damage to the
________ Nerve.
a) Medianb) Ulnar
c) Radial
d) Anterior interosseous
e) Axillary
REFERENCES
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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
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