Upper Limb Clinical Cases Flashcards
Shoulder – adducted and internally rotated-Loss of – abduction
Supraspinatus-Suprascapular (C5,6)
-Deltoid-Axillary (C5,6)
Shoulder – adducted and internally rotated-Loss of – external rotation
Infraspinatus-Suprascapular (C5,6
Teres minor-Axillary (C5,6)
Elbow – extended Loss of – flexion
Anterior compartment of
arm-Musculocutaneous
(C5,6,7)
- Erb’s Palsy
-• Damage to Upper Brachial Plexus C5,C6(C7)
-Arm adducted and internally rotated,
forearm extended and pronated
- Erb’s Palsy-• Sensory loss
along lateral border of limb
(C5,6,+/
-7 dermatomes)
Erb’s Palsy- Clinically involved nerves are:
Suprascapular: inability to initiate abduction and loss of external rotation • Axillary: loss of abduction to 90 degrees and external rotation • Musculocutaneous: loss of forearm flexion and weakened forearm supination
lower brachial plexus injury-
Damage to lower parts of brachial plexus - C8 / T1 lower trunk or medial cord
-Klumpke’s (KlumpkeDejerine) Palsy
lower brachial plexus injury-Ulnar
FCU, med ½ FDP, most intrinsic muscles of hand, loss of sensation in medial hand
lower brachial plexus injury-Med cut N of arm
Loss of sensation along medial aspect of arm
lower brachial plexus injury-Med cut N of forearm
Loss of sensation along medial aspect of forearm
lower brachial plexus injury-Medial head of median
LLOAF muscles
Lower Brachial Plexus C8 / T1-Sensory loss
medial
border of hand and forearm
and arm (C8 and T1
dermatomes)
Midshaft of humerus fracture-• What nerve is most likely injured and
what motor and sensory deficits are most
likely present?
• Radial nerve in radial groove
Radial Nerve-Origin
From posterior cord
Radial Nerve-• Motor supply:
• Supplies extensors of the forearm, wrist and digits (via the radial n., deep radial n. and posterior interosseous n.)
Radial Nerve- Sensory supply:
• Arm – posterior and lower lateral
• Forearm – posterior
• Hand – dorsum of hand / lateral 2 ½ digits
(proximal part of these digits)
Radial Nerve Injury-Injury in Axilla -motor
Loss of ability to extend
the elbow joint.
• Wrist drop • Impaired grip strength
Radial Nerve Injury-Injury in Axilla-Sensory loss:
• Arm – posterior and lower lateral • Forearm – posterior • Hand – dorsum of hand - lateral 2 ½ digits (proximal part of these digits)
Radial Nerve Injury-Injury at the midshaft of the humerus-motor
-Retain ability to extend the
elbow joint
-Wrist drop • Impaired grip strength
Radial Nerve Injury-Injury at the midshaft of
the humerus-Sensory loss:
• Arm - variable • Forearm – posterior • Hand – dorsum of hand - lateral 2 ½ digits (proximal part of these digits)
Median Nerve-Origin:
lateral & medial cords
Median Nerve-• Course:
• Crosses anterior to elbow through cubital fossa
• Supplies all muscles in superficial and intermediate flexor
compartment of forearm except FCU
• Just distal to the elbow, gives off the anterior
interosseous
• Supplies the deep flexor compartment except ulnar
half of FDP
•Through carpal tunnel into the hand
Median Nerve-•motor innervation
- palmar digital branches - 2 lumbricals (1st and 2nd)
* recurrent branch - OAF muscles
Median Nerve-•sensory innervation
-•palmar digital branches
•palmar digital branches - lateral 3 ½ fingers
palmar side and their distal phalanx on the dorsal
side
Median Nerve-•sensory innervation
-•palmar cutaneous branch
•palmar cutaneous branch - mid-palm (comes off
median in forearm and does not pass through carpal
tunnel)
Median Nerve Injury-Injury at/or above elbow
Weakened wrist flexion
-Thenar wasting
-Ulnar deviation (FCU unopposed) • Loss of flexion of index and middle
fingers at DIP and PIP joints (FDP
and FDS)
• Loss of pronation • Loss of opposition of thumb • Loss of flexion of the thumb • Weakened abduction of thumb
Median Nerve Injury-Injury at/or above elbow-Sensory loss:
• Palmar aspects of thumb, index, middle,
and half of ring finger up to the DIP on
the dorsal aspect
Thenar wasting
Thenar eminence is flattened due to atrophy of thumb
OAF muscles
Median Nerve Injury-Injury at or above elbow
-BENEDICTION HAND
- when patient
attempts to make a fist
-attempts to make a fist
• The index and middle fingers stay
straight
-• The ring and little fingers flex
-Thumb remains in plane of palm
Median Nerve Injury-Injury at wrist
• Flexor muscles in forearm are NOT paralyzed so no benediction hand. • Wrist flexion, forearm pronation and long flexor of thumb all intact • LLOAF muscles of intrinsic hand are paralyzed: • Atrophy of thenar muscles: • Loss of opposition of thumb • Weakened abduction and flexion of thumb
Carpal Tunnel Syndrome
Entrapment syndrome causing increased
pressure in the carpal tunnel
• Compresses the median nerv
Carpal Tunnel Syndrome-Sensory deficits
Paresthesia in the median
nerve distribution in the hand (except central
palm which is supplied by the palmar cutaneous
branch), nocturnal pain common
Carpal Tunnel Syndrome-Motor deficits
Loss of function to muscles
supplied by median nerve in the hand
positive Tinel sign
n refers to distally radiating pain and/or paresthesia
elicited by percussing a superficial peripheral nerve
The Phalen maneuver
performed by apposing the wrists
in goo of flexion. Paresthesia in the hand within 60 seconds is
considered a positive test
Median Nerve Injury-Injury in proximal palm:
laceration to the base of the
thumb
• Recurrent branch • Motor only nerve • Flexor muscles in forearm are NOT paralyzed • OAF muscles of intrinsic hand are paralyzed • Atrophy of thenar muscles, loss of opposition, weakened flexion and abduction of thumb • No sensory loss
Fracture of the hook of the hamate-Which neurovascular structures are at most
risk?
Ulnar nerve, artery and vein
Ulnar Nerve-Motor innervation
Deep motor branch to all the muscles of the
hand except LLOAF
Ulnar Nerve-Sensory innervation
• Superficial cutaneous branch - sensory to the palmar medial 1 ½ digits • Dorsal cutaneous branch: sensory to the dorsal medial 2 ½ digits
Ulnar Nerve-Course
• At distal third of the forearm gives a
dorsal cutaneous branch
• Divides into superficial branch and deep
branch
Ulnar Nerve Injury-Injury at or above elbow
Paralysis of FCU; hand deviates radially • Paralysis of ulnar ½ FDP; lose flexion of ring & little fingers at DIP (FDS still intact for flexion at PIP)
Ulnar Nerve Injury-Injury at or above elbow-Sensory loss:
• Medial palmar 1 ½ & dorsal 2 ½
digits
Ulnar Nerve Injury
Paralysis of hypothenar muscles • Paralysis of 3rd and 4th lumbricals: decreased flexion of at MCP and decreased extension at IP joints of ring and little finger • Paralysis of all interosseous muscles – ’metacarpal guttering’ • Loss of adduction of thumb
Ulnar Nerve Injury-At Anterior Wrist
• No paralysis of FCU or ulnar ½ of FDP • Paralysis of hypothenar muscles • Paralysis of 3rd and 4th lumbricals: decreased flexion of at MCP and decreased extension at IP joints of ring and little finger • Paralysis of all interosseous muscles –’metacarpal guttering’ • Loss of adduction of thumb
Ulnar Nerve Injury-At Anterior Wrist-Sensory loss:
Palmar part of little & 1/2 of
ring fingers
Right Ulnar Nerve Damage-Froment’s Test
Patient can’t “hold on” to the paper with adductor muscle, but FPL and FPB are intact (median) which allows for “holding on” by FLEXING the interphalangeal joint of the thumb
Fracture of surgical neck of humerus-What neurovascular structures are
most likely damaged?
• Axillary nerve and posterior humeral
circumflex artery
Axillary Nerve- Origin:
• From posterior cord
Axillary Nerve-Motor supply:
• Supplies deltoid and teres minor
Axillary Nerve-Sensory supply:
Upper lateral part of arm
Axillary Nerve-Signs and symptoms of injury
- Decreased lateral rotation
- Decreased abduction
- Loss of sensation to the lateral shoulder
Humeral Fractures
- Surgical neck
- Mid-shaft
- Supracondylar fractures
- Medial epicondyle
