Upper Extremity Flashcards
What does NAVEL stand for?
N.A.V.E.L.- nerve (most lateral), artery, vein, empty space, lymphatics (most medial)
What roots form the brachial plexus?
Formed by the union of C5 – T1 with some minor contributions by C4 and T2
Trunks divide into what division?
Trunks divide into Anterior and Posterior Divisions
Divisions combine to form Cords: What are they?
Divisions combine to form Cords: Lateral, Medial and Posterior
Cords give off what?
Cords give off Branches of nerve terminals
What are the three trunks?
Superior – C5 and C6
Middle = C7
Inferior = C8 and T1
What is the lateral cord?
Lateral – gives off a branch of the median nerve and ends as the musculocutaneous
What is the Medial cord?
Medial – gives off a branch of the median nerve and ends as the ulnar
What is the Posterior cord?
Posterior – gives off the axillary nerve and ends as the radial
Radial nerve is form from what roots?
The radial nerve forms from the upper and middle roots C5,6,7.
How does the radial nerve travel?
It travels posterior to the axillary artery around the humerus and then emerges laterally at the level of the lateral epicondyle at the elbow at this level it branches to supply skin in the posterior forearm and thumb.
Motor function of the radial nerve?
Motor function: extension of elbow, wrist hand and fingers.
Sensory function of the radial nerve?
Sensory: Skin over the posterior forearm most of the thumb, 2/3 of the 1st and second digits, most of the sensory innervation of the thumb.
Stimulation of the radial nerve causes what?
Stimulation of the radial nerve causes extension of the wrist.
The median nerve forms from what?
The median nerve forms from portions of all the roots.
How does the median nerve travel?
It travels medial to the axillary artery and continues down on the anterior surface of the elbow it continues and divides to supply the flexor muscles of the forearm and sensation to most of the palmar surface of the hand.
What is the sensory part of the median nerve?
Sensory it supplies the thumb, index, middle and half of the ring finger on the palmar side on the dorsum of the hand it supplies the distal 3rd of the thumb and index fingers.
Median nerve stimulation does what?
The median nerve when stimulated produces opposition of the thumb and little finger, pronation of the forearm and flexion of the wrist.
The ulnar nerve arises from what?
The ulnar nerve arises from the inferior roots, C8-T1.
How does the ulnar nerve travel?
It travels laterally to the axillary artery, posteriorly to the medial epicondyle at the elbow it travels down to the hand where it supplies the deep and superficial parts of the hand.
Sensory part of the ulnar nerve?
Sensory it supplies the ulnar side of the ring finger and both the palmar and dorsal sides
Stimulation of the ulnar nerve does what?
Stimulation of the ulnar nerve causes 5th digit flexion and opposition and ulnar wrist deviation.
The axillary nerve arises from what?
The axillary nerve arises from the superior roots C5 and C6.
It exits the brachial plexus at the level of the cords.
Stimulation of the axillary nerve?
Stimulation of the axillary nerve causes contraction of the deltoid it abducts the arm at the shoulder
Motor response to the axillary?
It supplies motor innervation to the deltoid muscle it also supplies sensory innervation to the same area both anteriorly and posteriorly.
The musculocutaneous nerve (MCN) arises from what roots?
The musculocutaneous nerve (MCN) arises from roots C5-6-7.
It leaves the plexus before the axilla.
Motor innervation for the musculocutaneous?
Motor innervation to biceps and coracobrachialis muscles.
Sensory for the musculocutaneous?
Sensory to lateral aspect of forearm.
Stimulation of the musculocutaneous?
Stimulation produces bicep contraction.
Musculocutaneous nerve is ?
Musculocutaneous nerve is derived from the lateral cord. This nerve innervates the muscles in the flexor compartment of the arm. Carries sensation from the lateral ( radial) side of the forearm
Ulnar nerve is ?
Ulnar nerve is derived from the medial cord. Motor innervation is mainly to intrinsic muscles of the hand. Sensory innervation is from the medial ( ulnar) 1 & 1/2 digits ( the 5th. and 1/2 of the 4th. digits).
Median nerve is ?
Median nerve is derived from both the lateral and medial cords. Motor innervation is to most of the flexors muscles in the forearm and intrinsic muscles of the thumb (thenar muscles). Sensory innervation is from the lateral ( radial) 3 & 1/2 digits ( the thumb and first 2 and 1/2 fingers).
Axillary nerve is ?
Axillary nerve is derived from the posterior cord. Motor innervation is deltoid and teres minor muscles that act on the shoulder joint. Sensory innervation is from the skin just below the point of the shoulder.
Radial nerve is ?
Radial nerve is also derived from the posterior cord. Called “Great Extensor Nerve” because it innervates the extensor muscles of the elbow, wrist and fingers. Sensory innervation is from the skin on the dorsum of the hand on the radial side.
Stimulate the radial nerve does what?
Radial nerve
Extension at elbow
Supination of forearm
Extension of wrist and fingers
Stimulate the median nerve does what?
Median Nerve
Pronation of forearm
Flexion of wrist
Opposition of the middle, forefinger and thumb
Stimulate the Ulnar nerve does what?
Ulnar nerve
Flexion of wrist
Adduction of all fingers
Flexion and opposition of medial two fingers toward thumb
Stimulate the Musculocutaneous does what?
Musculocutaneous
Flexion at elbow
If you block the radial nerve, what happens?
Radial (C5-T1)-Drop Wrist - Extensor carpi radialis longus and brevis, Ext. carpi ulnaris. Difficult to make a fist Sensory Deficit-Posterior lateral and arm; dorsum of hand index to thumb
If you block the Median nerve, what happens?
Median (C 5 -T1) at Elbow. Pronation of radioulnar joints. “Ape Hand”- thumb hyper extended and adducted - thenar muscles. Weakened opposition of thumb - thenar muscles. Sensory Deficit-Radial portion of palm; palmar surface and tips of radial 31/2 digits
If you block the Ulnar nerve, what happens?
Ulnar (C 8, T1) “Clawing” of fingers 3 and 4- M.P. joints hyper extended; Thumb - abducted and extended - adductor pollices. Sensory Deficit- Ulnar and dorsal aspect of palm and of ulnar 1 1/2 digits
If you block the Axillary nerve, what happens?
Axillary (C 5,6 ) Difficult abducting arm to horizontal – Deltoid. Sensory deficit- Lateral side of arm below point of shoulder “ inability to abduct arm”
If you block the Musculocutaneous nerve, what happens?
Musculocutaneous C 5,6,(7)Very weak flexion of elbow joint- Biceps and Brachialis. Sensory deficit-Lateral Forearm “unmuscular”
Injuries Median ? Axillary ? Ulnar ? Radial ? Musculocutaneous ?
Injuries Median (Ape hand) Unopposed thumb Axillary (inability to abduct arm) Ulnar (claw hand) Radial (wrist drop) Musculocutaneous (unmuscular)
Push Pull Pinch Pinch
Push radial
pull musculocutaneous
pinch 5th ulnar
pinch index median
What is the Most proximal approach to the brachial plexus**??
Interscalene approach
Most suitable for procedures on the upper arm or shoulder, is which block?
Interscalene block
Less suitable for procedures on the hand b/c C8-T1 harder to block from this approach
What are the landmarks of the interscalene block?
- clavicle
- posterior border of the sternocleidomastoid muscle
- EJ
- Cricoid Cartilage
You get Horners Syndrome with what block?
Interscalene block
What is horners syndrome?
HORNERS : nasal congestion, PTOSIS, MIOSIS AND ANHIDROSIS**
What is the landmarks for the supraclavicular block?
Landmarks: clavicle, subclavian pulse
What are the landmarks for the infraclavicular block?
1 = coracoid process 2 = clavicle 3 = humerus 4 = scapula
Infraclavicular Approach to Brachial Plexus Block Complications are what?
Pneumothorax
Chylothorax (lymph?)
Hemothorax
Complication of Axillary Block?
Inadequate anesthesia of the musculocutaneous nerve*****
US landmark for the nerves of the axilla block
(Median most lateral to the artery)**
(Ulnar nerve is the behind the artery)**
(radial nerve is below the artery)**
Rule of twos for beir block?
Rule of Two***
Two Ivs
Two Tourniquets
Twenty Minutes Min (minimal time the tourniquet has to be up)
Two hours max (max time lidocaine will work)
Beir block dose?
Inject LA 40 to 50cc of .5% Lido for arm and 100cc of .25% Lido for leg*** (don’t do this with DM pts)
