Perpheral Nerves (Normal and Pathological) Flashcards
1
Q
Which is the posterior root?
A
2
Q
Which is is the anterior root?
A
3
Q
Which is the posterior ramus? And what does the posterior ramus do? Can you give any other names for the post. ramus?
A
The posterior ramus = the posterior division of a spinal nerve
It carries information that supplies muscles and sensation to the human back.
- other names for posterior ramus =
- dorsal ramus of spinal nerve
- posterior ramus of spinal nerve
- posterior primary division
- The dorsal ramus carries
4
Q
Which is the posterior root ganglion?
A
5
Q
Which is the spinal cord?
A
6
Q
Which is the anterior rami?
What is it? and what does it do? Can you give any other names for this structure?
A
the anterior ramus = the anterior division of a spinal nerve.
The anterior rami supply the antero-lateral parts of the trunk and the limbs. They are mainly larger than the dorsal rami.
aka. ventral rami
7
Q
Which are the communicating rami?
what are these? and what do they do?
are there any other names for this structure?
A
communicating rami = any of the bundles of nerve fibers connecting a sympathetic ganglion with a spinal nerve and being divided into two kinds:
a: one consisting of myelinated preganglionic fibers — called also white ramus, white ramus communicans
b : one consisting of unmyelinated postganglionic fibers — called also gray ramus, gray ramus communicans
aka. rami communicantes
8
Q
________ = any of the bundles of nerve fibers connecting a sympathetic ganglion with a spinal nerve
A
rami communicantes; communicating rami
9
Q
A
rami communicantes; communicating rami
10
Q
_______**_carries information that **supplies muscles and sensation to the human back.
A
posterior ramus
aka. dorsal ramus
11
Q
Rami = latin for ____
A
branch
12
Q
There are two types of rami communicantes
white ramus communicans = consisting of _______ fibers - called also white ramus
gray ramus communicans = consisting of ________ fibers - called also gray ramus
A
myelinated preganglionic
unmyelinated postganglionic
13
Q
rami communicantes are any of the bundles of nerve fibers connecting a ______ with a _____ and being divided into two kinds:
white ramus - consisting of myelinated preganglionic fibers
gray ramus - consisting of unmyelinated postganglionic fibers
A
sympathetic ganglion; spinal nerve
14
Q
The brachial plexus contains ventral rami from spinal nerves _____. This plexus innervates the _____ and _____.
The lumbar plexus contains ventral rami from spinal nerves ______.
The sacral plexus contains ventral rami from spinal nerves _____.
The lumbar and sacral plexuses innervate the _____ and lower limbs.
A
C5-T1
pectoral girdle; upper limb
L1-L4
L4-S4
pelvic girdle & lower limbs
15
Q
The brachial plexus contains ____rami from spinal nerves C5-T1.
______ innervates the pectoral girdle and upper limb.
The lumbar plexus contains _____ rami from spinal nerves L1-L4.
The sacral plexus contains _____ rami from spinal nerves L4-S4.
The ____ and ____ plexuses innervate the pelvic girdle and lower limbs.
A
16
Q
After the spinal nerve exits the intervertebral foramen it branches into the ____, ____, & ____.
Each of these structures carries sensory and motor information.
A
dorsal ramsus, ventral ramus and ramus communicans
17
Q
After the spinal nerve exits the intervertebral foramen it branches into the dorsal ramsus, ventral ramus and ramus communicans.
Each of these structures carries ______ information.
A
sensory and motor
18
Q
the brachial plexus formed by nerve roots arising from the ___________
A
cervical enlargement at C5 - T1
19
Q
The Lumbosacral plexus formed by nerve roots arising from the _________
A
lumbosacral enlargement at L1 – S4
20
Q
what is #1
what does it innervate?
A
dorsal scapular nerve.
rhomboid major; rhomboid minor, levator scapula?
21
Q
What is #2? What does it innervate?
A
Nerve to subclavius
subclavius mm; which acts to depress the clavicle
22
Q
What is #3? What does it innervate?
A
Suprascapular nerve. (mixed nerve)
motor sensation to inn. supraspinatus mm. + infraspinatus mm.
supraspinatus = shoulder abductor
infraspinatus = shoulder ER
23
Q
What is #4?
Where does it come from? And where is it going?
A
Upper trunk of the brachial plexus
comes from C5/6 n. roots
gives rise to anterior and poster division
24
Q
What is #5?
Where does it come from? And where is it going?
A
middle trunk
comes from C7 n. root
helps to forms anterior and posterior divisions of brachial plexus
25
What is #6?
Where does it come from? And where is it going?
lower trunk
C8/T1 nerve roots
helps form the anterior and posteior divisions of the brachial plexus
26
What is #7?
Where does it come from? And where is it going?
**Divisions** → of the brachial plexus
forms anterior and posterior divisions that **will become** anterior, posterior, and medial **cords** of brachial plexus
27
What is #8?
Where does it come from? And where is it going?
Anterior division of the brachial plexus
forms the **lateral** **cord** + **medial cord**
28
What is #9?
Where does it come from? And where is it going?
**posterior division**
helps form posterior cords
29
What is #10?
Where does it come from? And where is it going?
**Cords** of the brachial plexus
Roots → Trunks → Division → **Cords** → Branches
(randy travis drink cold beer)
30
What is #11?
Where does it come from? And where is it going?
**Lateral Cord** (C5-6-7)
Formss the _anterior_ divisions of upper trunk + middle trunk (C5-6-7)
31
What is #12?
Where does it come from? And where is it going?
**Posterior Cord (C5-T1)**
comes from the upper, middle, and lower trunk
32
What is #13?
Where does it come from? And where is it going?
**Medial Cord (C8-T1)**
comes from the anterior division of the lower trunk
33
What is #14?
Where does it come from? And where is it going?
**Branches** of brachial plexus
34
What is #15?
Where does it come from? And where is it going?
**_Branch of brachial plexus_**
**Musculocutaneous n.**
**(C5-C7)**
innervates **the three muscles of the _anterior compartment of the arm_: the coracobrachialis, biceps brachii, and brachialis**. It is also responsible for cutaneous innervation of the lateral forearm
35
What is #17?
Where does it come from? And where is it going?
Axillary nerve
comes from the **Posterior Cord**
**C5-C6**
**inn. Deltoid mm + Teres minor**
Deltoid muscle = shoulder abductor, flexor, extensor
Teres minor = Sh ER
36
What is #18?
Where does it come from? And where is it going?
radial nerve
(C5-C8)
comes from posterior cord
* Inn. the posterior portion of the arm + forearm
* innervates medial + lateral heads of the triceps brachii
37
What is #19?
Where does it come from? And where is it going?
**_Median nerve_**
comes from Median + Lateral cords **(C5-C8)**
* **inn = anterior forearm and hand**
* flexor digitorum superficialis + pronator quadratus get sole innervation by the median nerve
38
What is #20?
Where does it come from? And where is it going?
**Ulnar Nerve**
comes from **medial cord (C8-T1)**
* **the flexor muscles of the forearm**
* flexor carpi ulnaris + flexor digitorum profundus.
* **Intrinsic muscles of the hand**
* palmaris brevis
* lumbricals
* hypothenar
* interossei muscles
39
What is #21?
Where does it come from? And where is it going?
Medial cutaneous nerve of **_FOREARM_**
aka. (medial antebrachial cutaneous nerve)
**C8-T1**
median cord → Medial cutaneous nerve of **_FOREARM_**
**supplies = anterior + medial aspects of forearm + wrist**
40
What is #22?
Where does it come from? And where is it going?
**medial cutaneous n. of the arm**
aka. medial brachial cutaneous nerve
**(C8-T1)**
* **provides _sensation_** to the medial cutaneous aspect of the arm.
* It is the smallest and most medial branch of the brachial plexus
41
What is #23?
Where does it come from? And where is it going?
**thoracodorsal n.**
**comes from the posterior cord**
**(C6-C8)**
innervates latissimus dorsi muscle.
42
What is #24?
Where does it come from? And where is it going?
**subscapular nerve**
**(C4-C6)**
**upper trunk → posterior cord →** subscapularis muscle (IRs +adducts the humerus)
43
What is #25?
Where does it come from? And where is it going?
**medial pectoral nerve**
**(C7-C8)** → lower trunk → medial cord → sternal head of pec major + Pec minor
* Pec major action = flexion, adduction, and IR of the humerus
* pec minor = stabilization, depression, abduction/ protraction, IR and downward rotation of the scapula
44
What is #26?
Where does it come from? And where is it going?
**Long Thoracic Nerve**
C5-C7 → superior trunk → passes _posterior_ to the brachial plexus → Serratus Anterior muscle
(some people have C8 inn. of SA)
* SA action
* shoulder protraction (during punching)
* upward rotation of scapula during lifting
* assists with breathing
45
What is #27?
Where does it come from? And where is it going?
**Lateral Pectoral Nerve**
innervates clavicular head of pec major, which
C5-C6 → upper trunk → lateral cord → (clavicular) pec major mm
46
The Musculocutaneous N. comes from which cord? and which nerve roots?
Lateral cord
C5-C7
47
The Axillary N. comes from which cord? and which nerve roots?
posterior cord C5-C6
48
The Radial N. comes from which cord? and which nerve roots?
Posterior cord, C5-8
49
The Median N. comes from which cord? and which nerve roots?
Median and Lateral cords, C5-8
50
The Ulnar N. comes from which cord? and which nerve roots?
Medial cord, C8-T1
51
The Medial Cutaneous nerve of _forearm_ comes from which cord? and which nerve roots?
Medial cord, C8-T1
52
The Thoracodorsal nerve comes from which cord? and which nerve roots?
Posterior cord, C6-8
53
The Subscapular nerve comes from which cord? and which nerve roots?
Posterior cord, C5-C6
54
The Dorsal Subscapular nerve comes from which cord? and which nerve roots?
Plexus root, C(3-4)5
55
The Lateral Pectoral Nerve comes from which cord? and which nerve roots?
Lateral cord, C5-7
56
The Medial Pectoral nerve comes from which cord? and which nerve roots?
Medial cord, **_C7-8_**
**Snyder = C8-T1**
57
The Nerve to Subclavius comes from which cord? and which nerve roots?
plexus root
C5-C6
58
The Suprascapular nerve comes from which cord? and which nerve roots?
Upper Trunk, C4-C6
59
Posterior cord nerve branches are:
(hint: STAR or ARTS)
axillary n
radial n.
thoracodorsal n.
subscapular n.
60
61
What are the 5 important nerves in the arm?
(hint: 3 musc. men assassinate 5 rats, 4 mice, & 3 OK uncles)
Radial n.
median n.
ulnar n.
musculocutanous n
axillary n.
62
Motor functions of the ulnar nerve = \_\_\_\_
finger adduction & abduction (BUT NO THUMB ABD)
thumb add.
flexion of digits 4+ 5
wrist flexion + adduction
63
region of sensory loss with neuropathy of the ulnar n =\_\_\_\_
loss of sensation in digits 4+ % on dorsal and palmar side
64
Motor functions of the axillary nerve = \_\_\_\_
abd of arm at shoulder beyond 15 degrees
so loss of axillary n. = can't abd shoulder past 15 degrees; supraspinatus would abd arm in the first 15 degrees
65
region of sensory loss with neuropathy of the axillary n =\_\_\_\_
mid arm sensation loss (around deltoid insertion)
66
Motor functions of the musculocutaneous nerve = \_\_\_\_
flexion of arm at elbow + supination of forarm
67
region of sensory loss with neuropathy of the musculocutaneous n =\_\_\_\_
front and back of forearm
68
Motor functions of the radial nerve = \_\_\_\_
extension of all arm, wrist, & finger joints
BELOW the shoulder: forearm supination; thumb abd (in plane of palm)
69
region of sensory loss with neuropathy of the radial n =\_\_\_\_
loss of sensation on the back of the arm (central area)
elbow
down the forarm along C5? dermatome?
dorsal aspects of metacarpals 2,3 + **thumb**
70
Motor functions of the median nerve = \_\_\_\_
thumb flexion + opposition
flexion of digits 2+ 3
wrist flexion + abduction
forearm pronation
71
region of sensory loss with neuropathy of the median n =\_\_\_\_
palmar side = loss of sensation along hand of benediction (thumbs + digits 2 &3)
dorsal side = digits 2,3, half of 4 (DIP- metacarpal area)
72
Radial nerve _____ the thumb in the plane of \_\_\_\_\_
abducts; the palm
73
Ulnar nerve _____ the thumb in the plane of \_\_\_\_\_
adducts; the palm
74
Median nerve ______ the thumb. Also it abducts the thumb\_\_\_\_\_\_ to the plane of the thumb (not shown)
opposes; perpendicular
75
n**Lumbosacral plexus formed by nerve roots arising from the lumbosacral enlargement at \_\_\_\_\_**
**L1 – S4**
76
Rami → Dorsal Ramus → \_\_\_, _(nerve roots),_ \_\_\_\_→ Erector Spinae
**T1-12, L1-5, S1-3**
77
erector spinae develop from the _____ rami of **T1-12, L1-5, S1-3**
dorsal
78
the Lumbar plexus develops from ____ ramii of \_\_\_\_
anterior
L1-L4
79
\_\_\_\_\_plexus dev from ant ramii of L1-L4
Lumbar
80
\_\_\_\_\_ dev from ant ramii of S1-S4
Sacral plexus
81
Sacral plexus dev from ___ ramii of \_\_\_\_
anterior; S1-S4
82
Where is the iliohypogastric nerve? what does it supply and what does it do?
**supplies sensation** to skin over the lateral glute + hypogastric regions
**motor** to the internal oblique mm + transverse abdominal mm
83
The Lumbar Plexus gives rise to which nerves?
(Hint: FLOG)
* Obturator nerve (L2-4)
* Femoral nerve (L2-4)
* branches off femoral → Saphenous nerve
* Lateral (ant) femoral cutaneous n. (L2-3)
* Genitofemoral nerve (L1-2)
84
Obturator nerve
Has what nerve roots? Comes from which division of the lumbar plexus
anterior division
L2-L4
85
Femoral Nerve
Has what nerve roots? Comes from which division of the lumbar plexus
posterior dvision
L2-L4
86
Saphenous nerve
branches off what nerve, and comes from which division of the sacral plexus
femoral nerve
posterior division
87
Lateral (ant) femoral cutaneous n.
Has what nerve roots?
(L2-L3)
88
Genitofemoral nerve
L1-2
89
the Sacral Plexus gives off which nerves? (6)
* sciatic n
* common fibular nerve
* tibial n.
* Superior Gluteal nerve
* Inferior Gluteal nerve
* Posterior femoral cutaneous nerve
* Pudendal nerve, S2-4
90
The sciatic nerve gives off two branches. name them
**tibial nerve** (L4-S2) → Snyder (L4-S3)
**common fibular nerve** (L2-S1)
91
tibial nerve is part of which plexus?
what are its nerve roots? and which division?
what nerve does it give rise to?
Anterior Division
L4-S2 (TKJ) ; L4-S3 (Snyder)
gives rise to Sural Nerve
92
the common fibular nerve is a part of which plexus?
It has what n. roots and comes from which division?
(aka. peroneal n)
Sacral Plexus
Posterior Division
L4-S1
93
FLOG is the acronym for which plexus?
Lumbar
94
What nerves belong to the sacral plexus?
(HINT: SIPP-S(TC))
Superior gluteal nerve
Inferior gluteal nerve
Posterior femoral cutaneous nerve
pudendal nerve
\_\_\_\_
Sciatic nerve
tibial
common fibular nerve
95
**Superior Gluteal nerve**
which plexus? which division? which nerve roots?
sacral
**Posterior Division, L4-S1**
96
**inferior gluteal nerve**
which plexus? which division? which nerve roots?
sacral
## Footnote
**posterior, L5-S2**
97
Posterior femoral cutaneous nerve
which nerve roots?
S1-S3
98
Pudendal nerve
which nerve roots?
S2-S4
99
100
Important nerves in the leg are:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
obturator n
sciatic n
femoral n
tibial n
superificial fibular n
deep fibular nerve
101
What are the major motor functions of the tibial nerve?
foot plantar flexion, INV, toe flexion
102
Region of sensory loss that would occur with a tibial (posterior) neuropathy = \_\_\_\_
bottom of the foot
103
which areas would have loss of sensation with a superficial fibular nerve neuropathy
Loss of sensation over the lateral compartment of the lower leg + the dorsal aspect of the foot (except btwn great toe and middle toe)
superficial fibular nerve supplies the **fibularis longus** and the **fibularis brevis**. These muscles form the **lateral** compartment of the lower leg.
104
Motor function of the superficial fibular nerve = \_\_\_\_
**foot eversion**
superficial fibular nerve supplies the **fibularis longus** and the **fibularis brevis**. These muscles form the **lateral** compartment of the lower leg.
105
Motor function of the deep fibular nerve = \_\_\_\_
**dorsi flexion; great toe extension**
deep fib nerve inn.s the anterior compartment of the leg.
106
neuropathy of deep fibular nerve would result in = \_\_\_\_
loss of sensation in the toe space between the great toe and the 2nd toe
107
108
**_Upper Extremity nerve injuries_**
**Erb-Duchenne Palsy** is an injury to which plexus? which trunk?
what happens?
what pose might patient display?
brachial plexus; **upper trunk** injury
Loss of C5-6 muscles → Deltoid, biceps, infraspinatus, wrist extensors
**dead giveaway presentation = “Bellman’s” or “Waiter’s Tip” pose**
**(wrist flexion, sh IR, sh add)**
109
**_Upper Extremity nerve injuries_**
how might Erb's Palsy happen?
what is the prognosis?
Common with traction between neck and shoulder
* Difficult delivery
* Motorcycle accidents
Prognosis = depends on severity (think a few months ago)
110
**_Upper Extremity nerve injuries_**
this patient displays _____ which is an injury to \_\_\_\_\_?
upper trunk of brachial plexus
**adduction, IR, elbow extension, wrist flexion**
Weak deltoid – **adduction**
Weak biceps – **extended elbow**
Weak infraspinatous – **internally rotated**
Weak wrist extensors – **wrist flexed**
111
**_Upper Extremity nerve injuries_**
this patient displays Erb's Palsy, which means they likely have weakness in which muscles?
Weak deltoid → causes the adduction
Weak biceps -→ causes extended elbow
Weak infraspinatous → causes IR
Weak wrist extensors → causes wrist flexion
112
**_Upper Extremity nerve injuries_**
this patient displays Erb's Palsy,
a weak \_\_\_\_mm. results in the adducted arm
deltoid
113
**_Upper Extremity nerve injuries_**
this patient displays Erb's Palsy,
a weak \_\_\_\_mm. results in the extended elbow
bicep
114
**_Upper Extremity nerve injuries_**
this patient displays Erb's Palsy,
a weak \_\_\_\_mm. results in the IR
infraspinatus
115
**_Upper Extremity nerve injuries_**
this patient displays Erb's Palsy,
weak \_\_\_\_mm. results in the wrist flexion
wrist flexors
116
**_Upper Extremity nerve injuries_**
A Brachial Plexus **_Lower_** Trunk Injury results in a loss of ____ muscles
C8-T1
* Hand and finger extension weakness
* Atrophy of hypothenar muscles
* Sensory loss ulnar aspect of hand/forearm
117
**_Upper Extremity nerve injuries_**
loss of C8-T1 muscles are _______ plexus injuries that result in
* _____ weakness
* Atrophy of _____ muscles
* Sensory loss on \_\_\_\_\_\_
Lower brachial plexus
* Hand and finger extension
* hypothenar
* ulnar aspect of hand/forearm
118
**_Upper Extremity nerve injuries_**
## Footnote
Patient comes to you and complains of hand and finger extension weakness, atrophy of hypothenar muscles, and sensory loss in the ulnar aspect of their hand/forearm.
MOI= Stretch injury; caused by **upward traction movement.**
What type of injury is this?
Lower brachial plexus injury
C8-T1 are affected
119
**_Upper Extremity nerve injuries_**
TOS is what type of injury?
what happens in TOS?
lower brachial plexus injury
in TOS
* the lower brachial plexus is compressed as it passes between the clavicle and the 1st rib
* UE flexion and external rotation increases the compression → symptoms worsen
* Decreased brachial arterial pulses (Roos test)
120
**_Upper Extremity nerve injuries_**
TOS is a _____ plexus injury,
* \_\_\_\_\_\_brachial plexus is compressed as it passes between the ____ and the \_\_\_\_\_\_.
* ____ and ____ increases the compression → symptoms worsen
* Decreased ______ (Roos test)
Lower trunk brachial plexus
* the lower; clavicle; 1st rib
* UE flexion & ER
* brachial arterial pulses
121
**_Upper Extremity nerve injuries_**
**Pancoast's syndrome** = an apical lung tumor that extends into the lower brachial plexus. The _______ nerve is occasionally involved as it loops downward into the thorax, producing hoarseness
Lower trunk brachial plexus injury
Recurrent laryngeal
122
**_Upper Extremity nerve injuries_**
what might this represent?
pancoast's injury = an apical tumor that extends into the lower brachial plexus.
can affect the recurrent laryngeal nerve as it decends into the drunk, producing hoarseness
123
**_Upper Extremity nerve injuries_**
You suspect your patient has TOS, what special test might you perform to confirm/ deny your suspicions? and how would this test be performed?
Roo's Test
**Roos test =** pt flexes elbow to 90; shoulder abducted to 90 and repeatedly open close hand for 1-3 min and watch for reproduction of symptoms.
124
**_Upper Extremity nerve injuries_**
Axillary neuropathy = \_\_\_\_\_
it is caused by \_\_\_\_\_\_
is can also be mixed up with
Axillary neuropathy = Weakness and numbness in the (lateral) shoulder
* can be caused by: Dislocation/ fracture of the proximal humerus → can lead to can compression of the axillary nerve
* Differentiated from **C5 root pathology** via biceps strength + rotator cuff tear (make sure to test sensation at lateral shoulder)
125
**_Upper Extremity nerve injuries_**
Radial neuropathy = \_\_\_\_\_\_
* **Weakness** that occurs
* in **all extensors of the elbow**, **hand**, & **fingers**
* weakness in forearm supination
* Loss of triceps reflex → [**Hint \* practice deep tendon reflexes]**
* Sensory loss in a radial nerve distribution
* Wrist drop is often present
126
**_Upper Extremity nerve injuries_**
**Radial Neuropathy:** can we caused by \_\_\_\_\_
* **Sleeping with arm over park bench** → known as _“Saturday night palsy”_
* **Improper crutch use** → “crutch palsy”
* **Fracture of humerus damaging the nerve as it enters spiral groove**
127
**_Upper Extremity nerve injuries_**
A patient comes in and tell you he fell asleep on a park bench with his arms displayed like the picture. You perform some tests, and note that he displays weakness in all extensors of his elbow, hand, and fingers. Tricep reflex is 0/4. Sensory testing is 2/5 along the radial nerve distribution. He is right-handed, and displays a wrist drop on that hand. He mentions also having a hard time turning his key to the right, to get through his front door.
What do you suspect he has?
Saturday night palsy/ radial neuropathy
turning his key to the right → Forearm supination
128
**_Upper Extremity nerve injuries_**
In saturday night palsy, the brachioradialis mm, will test weak.
…
129
**_Upper Extremity nerve injuries_**
In saturday night palsy, paresthesia can occur over which portion of the hand?
dorsum of hand, thumb and index finger
130
**_Upper Extremity nerve injuries_**
Median neuropathy = \_\_\_\_\_
* **Weakness** of :
* wrist flexion and abduction
* opposition of the thumb
* flexion of the second and third digits
**Sensory loss i**n the median nerve distribution
131
**_Upper Extremity nerve injuries_**
this patient displays \_\_\_\_\_
radial neuropathy
loss of sensation on the dorsum of hand, thumb and index finger
132
**_Upper Extremity nerve injuries_**
Weakness of wrist flexion and abduction, opposition of the thumb, flexion of the second and third digits. As well as sensory loss in the median nerve distribution are the symptoms of \_\_\_\_\_\_\_
Median neuropathy
“honeymooner’s palsy”
133
**_Upper Extremity nerve injuries_**
name 3 ways median neuropathy might occur
Sleeping with lover’s head resting on the upper arm
Fractures of the humerus or distal radius
Entrapment can occur as the nerve passes through the pronator teres muscle
134
**_Upper Extremity nerve injuries_**
Fractures of the humerus or distal radius can result in \_\_\_\_\_
median neuropathy
135
**_Upper Extremity nerve injuries_**
…
136
**_Upper Extremity nerve injuries_**
Carpal tunnel syndrome is what type of neuropathy?
What happens in carpal tunnel syndrome?
Median neuropathy
Carpel Tunnel Syndrome = and Entrapment syndrome
caused by compression of median nerve as it passes together with the tendons of the hand under the flexor retinaculum on the flexor surface of the wrist
137
**_Upper Extremity nerve injuries_**
Carpal tunnel syndrome affects the ____ nerve
the best muscle to test when suspecting carpal tunnel syndrome = \_\_\_\_. Although ____ and ____ can also be weak.
sensory loss will occur in which digits?
paresthesias radiating up arm can happen at what time of the day?
**_median_**
## Footnote
**abductor pollicis brevis = best muscle!**
**Thumb flexion & opposition** also weak
Sensory loss in first, second, and third digits
Night-time paresthesias radiating up arm
138
**_Upper Extremity nerve injuries_**
Your patient comes in and complains of numbness in their 1st, 2nd, and third digits. They display the hands of benediction. In their subjective, you clarify that this paresthesia worsens at night. Upon examination you find that the abductor pollicis brevis tests positive for weakness with a 2/5 MMT score. What do you suspect this injury is?
median nerve palsy
139
**_Upper Extremity nerve injuries_**
Nerve entrapment at the elbow in the cubital canal/tunnel (funny bone) results in
ulnar neuropathy
140
**_Upper Extremity nerve injuries_**
Ulnar neuropathy is caused by: \_\_\_\_\_
ulnar entrapment at the elbow in the cubital canal/tunnel (funny bone)
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**_Upper Extremity nerve injuries_**
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**_Upper Extremity nerve injuries_**
What is Tardy ulnar palsy?
Delayed result of a post-traumatic, degenerative, or congenital increased carrying angle of the elbow
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* Fractures of the medial epicondyle or Compression after resting the elbows on a hard table can cause \_\_\_\_\_\_
ulnar neuropathy
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Tardy ulnar palsy is the delayed result of a \_\_\_\_\_, \_\_\_\_\_, or congenital \_\_\_\_\_.
post-traumatic, degenerative, increased carrying angle of the elbow
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Your patient comes with complaints of weakness/ pain performing wrist flexion and adduction, finger ab/adduction and flexion of 4th and 5th digits. What do you suspect is going on?
patient displays ulnar claw
classic display of ulnar neuropathy
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your patient comes in and displays weakness in wrist flexion and abduction, weakness in finger abd/add, as well as flexion of the 4th and 5th digits. You also notice atrophy along the dark blue areas of the hands. What could be the patient's condition?
siminan hand
median and ulnar palsy/ neuropathy
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**_Lower Extremity nerve injuries_**
How might femoral neuropathy present?
Weakness of hip flexion and knee extension
Loss of patellar reflex
Sensory loss in anterior thigh
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**_Lower Extremity nerve injuries_**
Your patient presents with weakness of hip flexion and knee extension as well as loss of their patellar reflex. They also display sensory loss in anterior thigh. What might be the cause for this patient's condition?
femoral neuropathy
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**_Lower Extremity nerve injuries_**
Femoral neuropathy presents with
* Weakness of \_\_\_\_\_and \_\_\_\_\_\_
* Loss of \_\_\_\_\_\_
* Sensory loss in \_\_\_\_\_\_
hip flexion; knee extension
patellar reflex
anterior thigh
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**_Lower Extremity nerve injuries_**
what can cause femoral neuropathy?
* Injury during pelvic surgery
* Compression by a retroperitoneal hematoma or a pelvic mass
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**_Lower Extremity nerve injuries_**
sciatic neuropathy can be caused by: \_\_\_\_
* Posterior hip dislocation
* Acetabular fracture
* Intramuscular injection placed too medially and inferiorly in the buttocks
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**_Lower Extremity nerve injuries_**
* Posterior hip dislocation, Acetabular fracture, and Intramuscular injection placed too medially and inferiorly in the buttocks can cause \_\_\_\_\_
sciatic neuropathy
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**_Lower Extremity nerve injuries_**
these signs and symptoms should lead you to suspect:\_\_\_\_\_
* Weakness in all foot/ankle muscles and knee flexion
* Loss of Achilles reflex
* Sensory loss in the foot and lateral leg below the knee
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**_Lower Extremity nerve injuries_**
**_Sciatic neuropathy presents with_** Weakness in ____ and \_\_\_\_\_, Loss of \_\_\_\_, and Sensory loss in the \_\_\_\_\_
all foot/ankle muscles; knee flexion
Achilles reflex
foot and lateral leg **below** the knee
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**_Lower Extremity nerve injuries_**
Your patient experiencing weakness in all foot/ankle muscles and displays weak knee flexion. While performing motor and sensory testing, you get a positive test for loss of the achilles reflex, sensation in the foot and lateral leg (below the knee) tests for 0/5. PMHx reveals acetabular fracture
sciatic neuropathy
* Weakness in all foot/ankle muscles and knee flexion
* Loss of Achilles reflex
* Sensory loss in the foot and lateral leg below the knee
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**_Lower Extremity nerve injuries_**
## Footnote
**Sciatica** is a vague term that **refers to all disorders causing painful paresthesias along the sciatic nerve distribution.**
It is caused by: \_\_\_\_\_\_
compression of the lumbosacral roots by disc material or osteophytes
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compression of the lumbosacral roots by disc material or osteophytes that causes paresthesia along the sciatic nerve distribution is a condition known as \_\_\_\_\_
Sciatica
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the following signs and symptoms are displayed in \_\_\_\_\_\_
* Plantar flexion severely compromised
* **Functionally**: cannot effectively stand on toes or curl toes.
* Sensation lost to a majority of the sole of the foot
**Tibial Nerve Injury**
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in tibial nerve injuries, ________ is severely compromised, and _____ is lost on majority of the sole of the foot. Functionally, the patient cannot effectively _____ on toes or curl toes.
plantar flexion
sensation
stand
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The following displays what type of injury?
* Plantar flexion severely compromised
* **Functionally**: cannot effectively stand on toes or curl toes.
* Sensation lost to a majority of the sole of the foot
Tibial Nerve Injury:
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What is anterior compartment syndrome?
Loss of motor activity due to compression of deep fibular/peroneal nerve
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Loss of dorsiflexion, eversion, and toe extension due to compression of deep fibular/peroneal nerve is known as \_\_\_\_\_\_
anterior compartment syndrome
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In \_\_\_\_\_\_\_\_
the patient will present with severe pain during ***passive*** plantar flexion, eversion, and flexion of the toes as well inability to dorsiflex, invert, and extend the toes.
along with progressive ischemic pain, pale foot, swelling in the leg, numbness/paresthesia
anterior compartment syndrome
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Sensory loss to 1st interdigital cleft occurs with
anterior compartment syndrome
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anterior compartment is an urgent condition that requires surgical intervention for tx. some presenting signs and symptoms that can be seen are: \_\_\_\_\_, \_\_\_\_\_, \_\_\_\_\_, and \_\_\_\_\_\_.
along with progressive ischemic pain
pale foot
swelling in the leg
numbness/paresthesia
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compression, laceration, and stretch of the \_\_\_\_\_\_nerve as it passes around the fibular head near the skin surface causes \_\_\_\_\_\_
common peroneal
Peroneal Nerve palsy
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* forced inversion
* tight stockings, casts, or ski boots
* Crossed legs
* Trauma (fibular head fracture)
can be causes for \_\_\_\_\_\_\_\_
Peroneal nerve palsy
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Peroneal nerve palsy is caused by: \_\_\_\_\_, \_\_\_\_\_, \_\_\_\_\_\_, \_\_\_\_\_
* forced inversion (stretching the common peroneal nerve)
* tight stockings, casts, or ski boots
* Crossed legs
* Trauma (fibular head fracture)
* lacerations
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A patient who had a fibular head fracture. During your subjective, the patient mentioned their cast gave them a lot of issues as it seemed to fit too tight. You perform a sensory assessment and notice impaired sensation over dorsolateral foot and shin (3/5). During your motor assessment you observe weak dorsiflexion and eversion. You also note a “foot drop” during your gait analysis. You suspect your patient has \_\_\_\_\_
Peroneal Nerve palsy
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patient presentation of \_\_\_\_\_
* “foot drop” with weak foot dorsiflexion and eversion
* Sensory loss over the dorsolateral foot and shin.
peroneal nerve palsy
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**Meralgia Paresthetica**
## Footnote
a condition characterized by tingling, numbness and burning pain (paresthesias + loss of sensation) in the outer part of the thigh.
caused by entrapment of the lateral cutaneous nerve as it passes under the inguinal ligament or fascia lata.
**No motor involvement or reflex changes\***
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a condition characterized by paresthesias + loss of sensation such as tingling, numbness and burning pain in the outer part of the thigh is characteristic of _____ .
Meralgia Paresthetica
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Meralgia Paresthesia is caused by \_\_\_\_
some lifestyle factors that may contribute to meralgia paresthesia are \_\_\_\_
Entrapment of the Lateral cutaneous nerve as it passes under the inguinal ligament or fascia lata
obesity, pregnancy, weight loss, heavy equipment belts
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T/F
## Footnote
Unlike other neuropathies, there is no motor involvement or reflex changes in meralgia paresthesia
true!
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**Morton’s metatarsalgia**
_NOT MORTON"S NEUROMA_
Tight fitting shoes can compress the digital nerves, especially of the 3rd and 4th toes, producing patches of numbness and paresthesias
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Tight fitting shoes can compress the digital nerves, especially of the 3rd and 4th toes, producing patches of numbness and paresthesias is characteristic of
**Morton's** **metatarsalgia**
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**Morton's** **metatarsalgia =** patches of numbness and paresthesias at \_\_\_\_\_\_. Caused by \_\_\_\_\_that \_\_\_\_\_.
the 3rd and 4th toes
tight fitting shoes
can compress the digital nerves
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NCV = \_\_\_\_\_
Nerve conduction studies
Stimulating electrodes are placed on the skin overlying a nerve, and recording electrodes are placed over a muscle innervated by the nerve
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In NCV's, Stimulating electrodes are placed on \_\_\_\_\_\_\_, and recording electrodes are placed \_\_\_\_\_\_\_. –With stimulus, a _____ or \_\_\_\_\_\_can be recorded
the skin - _overlying a nerve_
over a muscle - _innervated by the nerve_
compound motor action potential (CMAP)
sensory nerve action potential (SNAP)
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**Know that if a nerve injury is suspected, an ____ is what we order for the patient**
NCV (nerve conduction study)
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**In NCV's, There are standard values for SNAP** (Absent to reduced sural amplitude) and **CMAP** (Compound Motor Action Potential) **latencies or conduction velocities for each major nerve when stimulated at various points along the nerve.**
* Can detect demyelination or axonal destruction
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EMG = electromyography,
When conducting an evaluation, an electrode is inserted \_\_\_\_\_. MUP's (\_\_\_\_\_) are recorded from the muscle cells
directly into the muscle
MUP’s = Motor unit action potentials
Recruitment pattern – synergy (UMN)
Fasciculations – (LMN)
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Sensory NCS (SNAP) Absent to reduced sural amplitude with borderline conduction velocities Motor NCS (CMAP) Normal to mildly prolonged distal latencies, reduced amplitudes, borderline conduction velocities
The summation of the sensory neuron APs of a peripheral nerve is termed the Sensory Nerve Action Potential (SNAP). In antidromic recording, the stimulus is delivered in the opposite of the physiologic direction (in sensory NCS, this is proximal to distal). Orthodromic recording measures AP propogation in the normal physiological direction and is distal to proximal for sensory NCS. The more common method of recording SNAPs is antidromic due to larger signal amplitudes and ease of recording[2](https://now.aapmr.org/nerve-conduction-velocities/)
The summation of the motor neuron APs, transmission through the neuromuscular junction and subsequent muscle fiber AP is termed the Compound Motor Action Potential (CMAP). The CMAP includes information about the number of afferent motor axons the nerve contains, the diameter and amount of myelin of those axons, the function of the neuromuscular junction (NMJ), and the number of excitable muscle fibers
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median neuropathies
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atrophy as a result of median neuropathy
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ulnar neuropathy
