Upper Limb Nerve Injuries

Question 1

Approach to a Neurological problem (3)

Answer 1

• Anatomically localise the lesion.
• Consider the pathophysiology
• Differential diagnosis

Question 2

Approach to a Neurological problem

• Anatomically localise the …
• Consider the …
• … diagnosis

Answer 2

• Anatomically localise the lesion.
• Consider the pathophysiology
• Differential diagnosis

Question 3

Upper Motor Neuron vs Lower Motor Neuron

• Lesion between nerve starting at … cortex and where it synapses at the … … cell = upper motor neuron
• Lower motor neuron = arises from the … … cell

Answer 3

• Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = upper motor neuron
• Lower motor neuron = arises from the anterior horn cell

Question 4

Upper Motor Neuron vs Lower Motor Neuron

• Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = … motor neuron
• … motor neuron = arises from the anterior horn cell

Answer 4

• Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = upper motor neuron
• Lower motor neuron = arises from the anterior horn cell

Question 5

UMN vs LMN in the upper limb

• UMN:
  
  • Held in flexed posture if chronic.
  • … tone
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • … reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • … tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • … reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Answer 5

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased tone
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • Flaccid tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Question 6

UMN vs LMN in the upper limb

• UMN:
  
  • Held in … posture if chronic.
  • Increased tone
  • … weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • … level
• LMN:
  
  • …/Fasciculations
  • Flaccid tone
  • Weakness in either a … distribution or a … nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Answer 6

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased tone
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • Flaccid tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Question 7

UMN vs LMN in the upper limb

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased tone
  • Pyramidal weakness (Flexor muscles … than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/…
  • Flaccid tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • … or peripheral nerve distribution of sensory loss.

Answer 7

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased tone
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • Flaccid tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Question 8

UMN vs LMN in the upper limb

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased …
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • Flaccid …
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Answer 8

• UMN:
  
  • Held in flexed posture if chronic.
  • Increased tone
  • Pyramidal weakness (Flexor muscles stronger than extensors)
  • Brisk reflexes.
  • Sensory level
• LMN:
  
  • Wasting/Fasciculations
  • Flaccid tone
  • Weakness in either a myotomal distribution or a peripheral nerve distribution
  • Reduced reflexes.
  • Dermatomal or peripheral nerve distribution of sensory loss.

Question 9

3 anatomical regions for localising the lesion:

Answer 9

Question 10

Myotomes - Relationship between the spinal … & …

Answer 10

Myotomes - Relationship between the spinal nerve & muscle

Question 11

Dermatomes - Relationship between the spinal … & …

Answer 11

Dermatomes - Relationship between the spinal nerve & skin

Question 12

middle finger dermatome?

Answer 12

C7

Question 13

A dermatome is an area of the skin supplied by nerve fibres originating from a single … … …

Answer 13

A dermatome is an area of the skin supplied by nerve fibres originating from a single dorsal nerve root.

Question 14

Herpes Zoster- Which dermatomes ?

Answer 14

• v1 branch
• also T4/T5 region

Question 15

Roots and myotomes

Answer 15

• Each muscle has a root and nerve innervation

Question 16

Roots and myotomes

Answer 16

• Each muscle has a root and nerve innervation

Question 17

Myotomes (simplified)

Answer 17

Question 18

Shoulder abduction - what root and myotome?

Answer 18

Question 19

Elbow flexion - what root and myotomes?

Answer 19

Question 20

Elbow extension, wrist extension, wrist flexion - what root and myotomes?

Answer 20

Question 21

Finger extension and Finger flexion - what root and myotomes?

Answer 21

Question 22

Finger abduction - what root and myotome?

Answer 22

Question 23

Reflexes - Upper Limb

• … reflex – C5 reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C6 reflex conveyed through the radial nerve.
• … jerk – C7 reflex conveyed through the radial nerve.
• Finger jerk – C8 reflex conveyed through the median and ulnar nerve.

Answer 23

• Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C6 reflex conveyed through the radial nerve.
• Triceps jerk – C7 reflex conveyed through the radial nerve.
• Finger jerk – C8 reflex conveyed through the median and ulnar nerve.

Question 24

Reflexes - Upper Limb

• Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
• … jerk – C6 reflex conveyed through the radial nerve.
• Triceps jerk – C7 reflex conveyed through the radial nerve.
• … jerk – C8 reflex conveyed through the median and ulnar nerve.

Answer 24

• Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C6 reflex conveyed through the radial nerve.
• Triceps jerk – C7 reflex conveyed through the radial nerve.
• Finger jerk – C8 reflex conveyed through the median and ulnar nerve.

Question 25

Reflexes - Upper Limb

• Biceps reflex – C… reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C… reflex conveyed through the radial nerve.
• Triceps jerk – C… reflex conveyed through the radial nerve.
• Finger jerk – C… reflex conveyed through the median and ulnar nerve.

Answer 25

• Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C6 reflex conveyed through the radial nerve.
• Triceps jerk – C7 reflex conveyed through the radial nerve.
• Finger jerk – C8 reflex conveyed through the median and ulnar nerve.

Question 26

Reflexes - Upper Limb

• Biceps reflex – C5 reflex conveyed through the … nerve.
• Supinator jerk – C6 reflex conveyed through the … nerve.
• Triceps jerk – C7 reflex conveyed through the … nerve.
• Finger jerk – C8 reflex conveyed through the … and … nerve.

Answer 26

• Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
• Supinator jerk – C6 reflex conveyed through the radial nerve.
• Triceps jerk – C7 reflex conveyed through the radial nerve.
• Finger jerk – C8 reflex conveyed through the median and ulnar nerve.

Question 27

reflexes is depressed in … motor neuron lesion

Answer 27

reflexes is depressed in lower motor neuron lesion

Question 28

Nerve root …

Answer 28

Question 29

What is shown here?

Answer 29

nerve root impingement

Question 30

Nerve root impingement

• Causes – pain – radiates/ aggravated by … movement
  
  • … loss
  • weakness
  • … loss
• Flexibility of cervical spine protects it from fractures or dislocation-
• but may get injury to neural structures – hyper flexion/extension

Answer 30

• Causes – pain – radiates/ aggravated by neck movement
  
  • sensory loss
  • weakness
  • reflex loss
• Flexibility of cervical spine protects it from fractures or dislocation-
• but may get injury to neural structures – hyper flexion/extension

Question 31

Nerve root impingement

• Causes – pain – radiates/ aggravated by … movement
  
  • … loss
  • weakness
  • … loss
• Flexibility of cervical spine protects it from fractures or … - but may get injury to neural structures – … flexion/extension

Answer 31

• Causes – pain – radiates/ aggravated by neck movement
  
  • sensory loss
  • weakness
  • reflex loss
• Flexibility of cervical spine protects it from fractures or dislocation-
• but may get injury to neural structures – hyper flexion/extension

Question 32

MRI C-spine

• What is going on where red circle is?

Answer 32

T2 sequence - CSF is white around spinal cord, slightly disrupted at C6 - disc is pressing on spinal cord (Disc prolapse - may get lower motor neurone signs at the level it’s pressing the root - but if also spinal cord, upper motor neurone signs below that = myelopathy (cervico myeloradiculopathy)

Question 33

Types of nerve (plexus) injury:

• Avulsion: … of the nerves from its … at the spinal cord. – Require surgical repair
• Rupture: … of the nerves but not from its … to the spinal cord – Require surgical repair
• Neuroma: … or … of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
• Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre

Answer 33

• Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
• Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
• Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
• Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
  
  • Worst prognosis are the ones requiring surgery

Question 34

Types of nerve (plexus) injury:

• …: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
• …: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
• Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or … – Require surgical repair
• Neurapraxia: … remain intact, but … damage cause an interruption of the … down the nerve fibre

Answer 34

• Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
• Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
• Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
• Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
  
  • Worst prognosis are the ones requiring surgery

Question 35

Types of nerve (plexus) injury:

• …: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
• …: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
• …: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
• …: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre

Answer 35

• Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
• Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
• Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
• Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
  
  • Worst prognosis are the ones requiring surgery

Question 36

• Which of the following injuries will have a worse prognosis ?
  
  • (Avulsion / rupture, neuroma, neurapraxia)

Answer 36

avulsion is worst, avulsion, rupture, neuroma require surgery whereas neurapraxia has a good prognosis

Question 37

What this showing? (… arm as a result of … root …)

Answer 37

What this showing? (flail arm as a result of cervical root avulsion) - motor cycle injury

(C5-T1 lesions causing flail arm, Left shoulder subluxation, Atrophy of the left deltoid, supraspinatous and infraspinatous)

Question 38

Brachial plexus injury:

• …
  
  • Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• …
  
  • Lung cancer: Pancoasts tumour
  • Radiotherapy
• …
  
  • Brachial neuritis
• …
  
  • Thoracic outlet syndrome

Answer 38

• Trauma
  
  • Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: Pancoasts tumour
  • Radiotherapy
• Inflammatory
  
  • Brachial neuritis
• Structural
  
  • Thoracic outlet syndrome

Question 39

Brachial plexus injury:

• Trauma
  
  • Erb-… type paralysis: Avulsion of C5,C6 roots.
  • … paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: … tumour
  • Radiotherapy
• Inflammatory
  
  • Brachial …
• Structural
  
  • Thoracic outlet syndrome

Answer 39

• Trauma
  
  • Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: Pancoasts tumour
  • Radiotherapy
• Inflammatory
  
  • Brachial neuritis
• Structural
  
  • Thoracic outlet syndrome

Question 40

Brachial plexus injury:

• Trauma
  
  • …-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C…, T… roots.
• Cancer
  
  • … cancer: Pancoasts tumour
  • Radiotherapy
• Inflammatory
  
  • … neuritis
• Structural
  
  • … outlet syndrome

Answer 40

• Trauma
  
  • Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: Pancoasts tumour
  • Radiotherapy
• Inflammatory
  
  • Brachial neuritis
• Structural
  
  • Thoracic outlet syndrome

Question 41

Brachial plexus injury:

• Trauma
  
  • Erb-Duchenne type paralysis: Avulsion of C…,C… roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: Pancoasts tumour
  • …therapy
• Inflammatory
  
  • Brachial …
• Structural
  
  • Thoracic … syndrome

Answer 41

• Trauma
  
  • Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
  • Klumpke paralysis: Avulsion of C8, T1 roots.
• Cancer
  
  • Lung cancer: Pancoasts tumour
  • Radiotherapy
• Inflammatory
  
  • Brachial neuritis
• Structural
  
  • Thoracic outlet syndrome

Question 42

4 categories of brachial plexus injury are…

Answer 42

Question 43

Erbs palsy

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric … … palsy. (… … palsy) - C5/C6 innervated muscles
• Superior trunk of brachial plexus (adults- blow to shoulder)
• Weak muscles include -
  
  • Biceps (flexes the …)
  • Brachioradialis (flexes the arm in semi-… position)
  • Deltoid (abducts the arm)
  • Supraspinatus (abducts the arm)
  • Supinator (externally rotates the arm)

Answer 43

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
• Superior trunk of brachial plexus (adults- blow to shoulder)
• Weak muscles include -
  
  • Biceps (flexes the arm)
  • Brachioradialis (flexes the arm in semi-prone position)
  • Deltoid (abducts the arm)
  • Supraspinatus (abducts the arm)
  • Supinator (externally rotates the arm)

Question 44

Erbs palsy

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C../C… innervated muscles
• … trunk of brachial plexus (adults- blow to …)
• Weak muscles include -
  
  • Biceps (flexes the arm)
  • Brachioradialis (flexes the arm in semi-prone position)
  • Deltoid (abducts the arm)
  • Supraspinatus (abducts the arm)
  • Supinator (externally rotates the arm)

Answer 44

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
• Superior trunk of brachial plexus (adults- blow to shoulder)
• Weak muscles include -
  
  • Biceps (flexes the arm)
  • Brachioradialis (flexes the arm in semi-prone position)
  • Deltoid (abducts the arm)
  • Supraspinatus (abducts the arm)
  • Supinator (externally rotates the arm)

Question 45

Erbs palsy

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
• Superior trunk of brachial plexus (adults- blow to shoulder)
• Weak muscles include -
  
  • Biceps (flexes the arm)
  • … (flexes the arm in semi-prone position)
  • … (abducts the arm)
  • … (abducts the arm)
  • … (externally rotates the arm)

Answer 45

• Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
• Superior trunk of brachial plexus (adults- blow to shoulder)
• Weak muscles include -
  
  • Biceps (flexes the arm)
  • Brachioradialis (flexes the arm in semi-prone position)
  • Deltoid (abducts the arm)
  • Supraspinatus (abducts the arm)
  • Supinator (externally rotates the arm)

Question 46

In Upper brachial plexus lesion (e.g. erbs palsy), the … works but the … does not work

Answer 46

• Arm cannot be-
• Elevated
• Abducted
• External rotated
• Flexed at elbow
• But fingers unimpaired
• Hand works but arm does not!

Question 47

• Arm cannot be-
• Elevated
• Abducted
• External rotated
• Flexed at elbow
• But fingers unimpaired
  
  • Hand works but arm does not!
    
    • What lesion is this?

Answer 47

Upper brachial plexus lesion

Question 48

Klumpke’s Palsy

• … for an object when falling from a ….
  
  • • … trunk plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• Arm works but hand does not!

Answer 48

• Clutching for an object when falling from a height.
  
  • • Inferior trunk plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• Arm works but hand does not!

Question 49

Klumpke’s Palsy

• Clutching for an object when … from a height.
  
  • • Inferior trunk plexus injury involving C…/T…
  • Involves trunk that supplies median and ulnar nerves
  • Unable to … wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a … hand
• Arm works but hand does not!

Answer 49

• Clutching for an object when falling from a height.
  
  • • Inferior trunk plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• Arm works but hand does not!

Question 50

Klumpke’s Palsy

• Clutching for an object when falling from a height.
  
  • • Inferior trunk plexus injury involving C8/T1
  • Involves trunk that supplies … and … nerves
  • Unable to flex wrist or fingers
  • Weakness of all … muscles of the …
  • … loss hand and inner border of …
  • May lead to a claw hand
• Arm works but hand does not!

Answer 50

• Clutching for an object when falling from a height.
  
  • • Inferior trunk plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• Arm works but hand does not!

Question 51

Klumpke’s Palsy

• Clutching for an object when falling from a height.
  
  • • … … plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• … works but … does not!

Answer 51

• Clutching for an object when falling from a height.
  
  • - Inferior trunk plexus injury involving C8/T1
  • Involves trunk that supplies median and ulnar nerves
  • Unable to flex wrist or fingers
  • Weakness of all small muscles of the hand
  • Sensory loss hand and inner border of forearm
  • May lead to a claw hand
• Arm works but hand does not!

Question 52

Erbs palsy vs klumpke’s palsy - what is affected in either?

Answer 52

• Erbs - Hand works but arm does not! (brachial upper plexus palsy - C5/C6)
• Klumpke’s - Arm works but hand does not! (Inferior trunk plexus injury involving C8/T1)

Question 53

What tumour is this?

Answer 53

Pancoast tumour (close to inferior brachial plexus - affect hand)

Question 54

Post … damage near region - damage caused to …. brachial plexus (arm doesnt work, hand does)

Answer 54

Post radiation damage near region - damage caused - weakness to upper brachial plexus (Arm doesnt work, hand does)

Question 55

Metastatic brachial plexopathy vs Radiation induced brachial plexopathy

• Pancoast tumour (lung) – infiltration of the … brachial plexus
  
  • … in shoulder girdle and inner arm.
  • Ipsilateral … syndrome
• vs
  
  • Mean … yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • Is pain a consistent feature?
  • Predilection for upper brachial plexus

Answer 55

• Pancoast tumour (lung) – infiltration of the lower brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • Pain is not a consistent feature
  • Predilection for upper brachial plexus

Question 56

Metastatic brachial plexopathy vs Radiation induced brachial plexopathy

• Pancoast tumour (lung) – infiltration of the … brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • … horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for …, lung cancer and lymphoma
  • Pain is … a consistent feature
  • Predilection for …. brachial plexus

Answer 56

• Pancoast tumour (lung) – infiltration of the lower brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • Pain is not a consistent feature
  • Predilection for upper brachial plexus

Question 57

Metastatic brachial plexopathy vs Radiation induced brachial plexopathy

• …. tumour (lung) – infiltration of the lower brachial plexus
  
  • … in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • … is not a consistent feature
  • Predilection for upper brachial plexus

Answer 57

• Pancoast tumour (lung) – infiltration of the lower brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • Pain is not a consistent feature
  • Predilection for upper brachial plexus

Question 58

Metastatic brachial plexopathy vs Radiation induced brachial plexopathy

• Pancoast tumour (lung) – infiltration of the lower brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean … yrs post radiation
  • Associated with treatment for breast, … cancer and lymphoma
  • Pain is not a consistent feature
  • Predilection for … … plexus

Answer 58

• Pancoast tumour (lung) – infiltration of the lower brachial plexus
  
  • Pain in shoulder girdle and inner arm.
  • Ipsilateral horners syndrome
• vs
  
  • Mean 6 yrs post radiation
  • Associated with treatment for breast, lung cancer and lymphoma
  • Pain is not a consistent feature
  • Predilection for upper brachial plexus

Question 59

Idiopathic brachial neuritis (Parsonage – Turner Syndrome)

• Aetiology not clear, …, post-…?
• Severe … over days; as … diminishes, it is followed by weakness and wasting (motor>sensory)
• Typically monophasic
• Rarely …lateral
• MRI shows thickening and enhancement.
• NCS/EMG is useful for prognostication.
• Treatment:
  
  • Analgesia, physiotherapy
  • Limited evidence for the use of steroids

Answer 59

• Aetiology not clear, infectious, post-infectious
• Severe pain over days; as pain diminishes, it is followed by weakness and wasting (motor>sensory)
• Typically monophasic
• Rarely bilateral
• MRI shows thickening and enhancement.
• NCS/EMG is useful for prognostication.
• Treatment:
  
  • Analgesia, physiotherapy
  • Limited evidence for the use of steroids

Question 60

Idiopathic brachial neuritis (Parsonage – Turner Syndrome)

• Aetiology not clear, infectious, post-infectious
• Severe pain over days; as pain diminishes, it is followed by weakness and wasting (motor>sensory)
• Typically …phasic
• Rarely bilateral
• MRI shows … and enhancement.
• NCS/EMG is useful for ….
• Treatment:
  
  • …, physiotherapy
  • Limited evidence for the use of steroids

Answer 60

• Aetiology not clear, infectious, post-infectious
• Severe pain over days; as pain diminishes, it is followed by weakness and wasting (motor>sensory)
• Typically monophasic
• Rarely bilateral
• MRI shows thickening and enhancement.
• NCS/EMG is useful for prognostication.
• Treatment:
  
  • Analgesia, physiotherapy
  • Limited evidence for the use of steroids

Question 61

Idiopathic brachial neuritis (Parsonage – Turner Syndrome)

• Aetiology not clear, infectious, post-infectious
• Severe pain over days; as pain diminishes, it is followed by … and … (motor>sensory)
• Typically monophasic
• Rarely bilateral
• MRI shows thickening and ….
• NCS/EMG is useful for prognostication.
• Treatment:
  
  • Analgesia, …
  • Limited evidence for the use of …

Answer 61

• Aetiology not clear, infectious, post-infectious
• Severe pain over days; as pain diminishes, it is followed by weakness and wasting (motor>sensory)
• Typically monophasic
• Rarely bilateral
• MRI shows thickening and enhancement.
• NCS/EMG is useful for prognostication.
• Treatment:
  
  • Analgesia, physiotherapy
  • Limited evidence for the use of steroids

Question 62

Thoracic outlet syndrome:

• Variations in anatomy cause … sites:
  
  • Between anterior and middle scalene muscles
  • Beneath clavicle in the costoclarvicular space
  • Beneath tendon of Pectorlis minor
• …: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
• …: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.

Answer 62

• Variations in anatomy cause compression sites:
  
  • Between anterior and middle scalene muscles
  • Beneath clavicle in the costoclarvicular space
  • Beneath tendon of Pectorlis minor
• Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
• Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.

Question 63

Thoracic outlet syndrome:

• Variations in anatomy cause compression sites:
  
  • Between anterior and middle … muscles
  • Beneath … in the costoclarvicular space
  • Beneath tendon of … minor
• Neurogenic: predominantly affects the median-innervated abductor pollicis … muscle (thenar wasting)
• Vascular: … rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.

Answer 63

• Variations in anatomy cause compression sites:
  
  • Between anterior and middle scalene muscles
  • Beneath clavicle in the costoclarvicular space
  • Beneath tendon of Pectorlis minor
• Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
• Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.

Question 64

Thoracic outlet syndrome:

• Variations in anatomy cause compression sites:
  
  • Between anterior and middle scalene muscles
  • Beneath clavicle in the costoclarvicular space
  • Beneath tendon of Pectorlis …
• Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (… wasting)
• Vascular: High rib causes area of stenosis with a poststenotic dilatation. … may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to … phenomenon.

Answer 64

• Variations in anatomy cause compression sites:
  
  • Between anterior and middle scalene muscles
  • Beneath clavicle in the costoclarvicular space
  • Beneath tendon of Pectorlis minor
• Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
• Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.

Question 65

Thoracic outlet syndrome:

• Neurogenic:
  
  • Leads to …, …, weakness
  • Not localised to specific nerve distribution
  • Reproducibly aggravated by elevation or sustained use of arms or hands.
• Vascular
  
  • Forearm … within minutes of use.
  • Swelling and …
  • Collateral venous patterning over the … shoulder, chest wall and neck.
  • Rarely pain, pallor and coldness (arterial involvement).
  • … BP on affected arm, diminished distal pulses.

Answer 65

• Neurogenic:
  
  • Leads to Paresthesia, numbness, weakness
  • Not localised to specific nerve distribution
  • Reproducibly aggravated by elevation or sustained use of arms or hands.
• Vascular
  
  • Forearm fatigue within minutes of use.
  • Swelling and cyanosis
  • Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
  • Rarely pain, pallor and coldness (arterial involvement).
  • Lower BP on affected arm, diminished distal pulses.

Question 66

Thoracic outlet syndrome:

• Neurogenic:
  
  • Paresthesia, numbness, …
  • Not … to specific nerve distribution
  • Reproducibly … by elevation or sustained use of arms or hands.
• Vascular
  
  • … fatigue within minutes of use.
  • … and cynaosis
  • Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
  • Rarely …, pallor and coldness (arterial involvement).
  • Lower BP on affected arm, diminished distal pulses.

Answer 66

• Neurogenic:
  
  • Paresthesia, numbness, …
  • Not localised to specific nerve distribution
  • Reproducibly aggravated by elevation or sustained use of arms or hands.
• Vascular
  
  • Forearm fatigue within minutes of use.
  • Swelling and cynaosis
  • Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
  • Rarely pain, pallor and coldness (arterial involvement).
  • Lower BP on affected arm, diminished distal pulses.

Question 67

Long Thoracic Nerve

• Long thoracic nerve may be injured by blows or pressure in the … triangle of the neck
  
  • or during a radical mastectomy.
• Leading to ‘winged …’

Answer 67

• Long thoracic nerve may be injured by blows or pressure in the posterior triangle of the neck
  
  • or during a radical mastectomy.
• Leading to ‘winged scapula’

Question 68

Long Thoracic Nerve

• Long thoracic nerve may be injured by blows or pressure in the … … of the neck
  
  • or during a radical ….
• Leading to ‘… scapula’

Answer 68

• Long thoracic nerve may be injured by blows or pressure in the posterior triangle of the neck
  
  • or during a radical mastectomy.
• Leading to ‘winged scapula’

Question 69

Long Thoracic Nerve

• Long thoracic nerve supplies the serratus anterior muscle.
• The serratus anterior muscle pulls the … border of the … to the … thoracic wall and stabilises it there
• Impairment of the long thoracic nerve leads to “…” of the scapula

Answer 69

• Long thoracic nerve supplies the serratus anterior muscle.
• The serratus anterior muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
• Impairment of the long thoracic nerve leads to “winging” of the scapula

Question 70

Long Thoracic Nerve

• Long thoracic nerve supplies the … … muscle.
• The … … muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
• Impairment of the long thoracic nerve leads to “winging” of the scapula

Answer 70

• Long thoracic nerve supplies the serratus anterior muscle.
• The serratus anterior muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
• Impairment of the long thoracic nerve leads to “winging” of the scapula

Question 71

Impairment of the long thoracic nerve leads to “winging” of the …

Answer 71

Impairment of the long thoracic nerve leads to “winging” of the scapula

Question 72

Median nerve

• 2 common sites of compression
  
  • … (Carpel tunnel syndrome)
  • …

Answer 72

• 2 common sites of compression
  
  • Wrist (Carpel tunnel syndrome)
  • Elbow

Question 73

Median Nerve innervated Hand Muscles

• L …
• O …
• A ….
• F …

Answer 73

• L ateral 2 lumbricals
• O pponens pollicis
• A bductor pollicis brevis
• F lexor pollicis brevis

Question 74

… wasting

Answer 74

• Thenar wasting

Question 75

Anatomy of the Carpal tunnel

Answer 75

Question 76

Carpal tunnel syndrome

• … N. Entrapment at Carpal Tunnel (also damaged in … fractures)
• Causes include:
  
  • Diabetes
  • Pregnancy
  • …thyroidism
  • Rheumatoid arthritis
  • Repetitive strain

Answer 76

• Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
• Causes include:
  
  • Diabetes
  • Pregnancy
  • Hypothyroidism
  • Rheumatoid arthritis
  • Repetitive strain

Question 77

Carpal tunnel syndrome

• Median N. Entrapment at Carpal Tunnel (also damaged in wrist …)
• Causes include:
  
  • Diabetes
  • …
  • Hypothyroidism
  • … arthritis
  • Repetitive …

Answer 77

• Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
• Causes include:
  
  • Diabetes
  • Pregnancy
  • Hypothyroidism
  • Rheumatoid arthritis
  • Repetitive strain

Question 78

What is Tinel’s sign?

Answer 78

Tinel’s test is used to test for compression neuropathy, commonly in diagnosing carpal tunnel syndrome.

Question 79

Carpal tunnel syndrome

• Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
• Causes include:
  
  • Diabetes
  • Pregnancy
  • Hypothyroidism
  • Rheumatoid arthritis
  • Repetitive strain

Answer 79

• Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
• Causes include:
  
  • Diabetes
  • Pregnancy
  • Hypothyroidism
  • Rheumatoid arthritis
  • Repetitive strain

Question 80

What is Phalen’s test?

Answer 80

• A positive Phalen maneuver is highly suggestive of carpal tunnel syndrome. The Phalen maneuver is performed by having the patient place the wrists in complete unforced flexion for at least 30 seconds If the median nerve is entrapped at the wrist, this maneuver reproduces the symptoms of carpal tunnel syndrome.

Question 81

Anterior interosseous nerve arises from … nerve just above elbow

Answer 81

Anterior interosseous nerve arises from median nerve just above elbow

Question 82

Anterior interosseous nerve

• arises from median nerve just above elbow.
  
  • Prone to compression between 2 heads of … … muscle
  • Gripping tightly with forced …
  • Prolonged use of a screwdriver!
  • May also be damaged in careless blood taking

Answer 82

• arises from median nerve just above elbow.
  
  • Prone to compression between 2 heads of pronator teres muscle
  • Gripping tightly with forced pronation
  • Prolonged use of a screwdriver!
  • May also be damaged in careless blood taking

Question 83

Anterior interosseous nerve

• arises from median nerve just above …
  
  • Prone to compression between 2 heads of pronator teres muscle
  • Gripping tightly with forced …
  • Prolonged use of a …!
  • May also be damaged in careless … taking

Answer 83

• arises from median nerve just above elbow.
  
  • Prone to compression between 2 heads of pronator teres muscle
  • Gripping tightly with forced pronation
  • Prolonged use of a screwdriver!
  • May also be damaged in careless blood taking

Question 84

Anterior interosseous nerve syndrome

• Pure … branch of the median nerve
• Weakness in flexors of ip joint of thumb (flexor … longus) & dip joints of index and middle fingers – (flexor … profundus) weakness of pronation

Answer 84

• Pure motor branch of the median nerve
• Weakness in flexors of ip joint of thumb (flexor policis longus) & dip joints of index and middle fingers – (flexor digitorum profundus) weakness of pronation

Question 85

What syndrome causes this?

Answer 85

Question 86

Sensory innervation of the median nerve in the forearm versus carpal tunnel

• lesion in … = affect palm and 3.5 finger
• lesion in … … = just affects finger tips

Answer 86

• lesion in forearm = affect palm and 3.5 finger
• lesion in carpal tunnel = just affects finger tips

Question 87

… palsy at elbow

Answer 87

Ulnar palsy at elbow

Question 88

… nerve palsy at wrist

Answer 88

Ulnar nerve palsy at wrist

Question 89

• ED: Extensor digitorum – … nerve
• L: Lumbricals – … nerve
• FDP: 3rd and 4th Flexor digitorum profundi – … nerve
• FDS: Flexor digitorum superficialis – … nerve

Answer 89

• ED: Extensor digitorum – radial nerve
• L: Lumbricals – ulnar nerve
• FDP: 3rd and 4th Flexor digitorum profundi – ulnar nerve
• FDS: Flexor digitorum superficialis – medial nerve

Question 90

Higher lesion in the upper limb:

• Paralysis of the ulnar half of the flexor … … (FDP), interossei and ….
• The ring and little fingers are not flexed and there is no …

Answer 90

• Paralysis of the ulnar half of the flexor digitorum profundus (FDP), interossei and lumbricals. The ring and little fingers are not flexed and there is no claw.

Question 91

Lesion at the wrist:

• Flexion at the … (FDP is intact)
• Flexion at the … (interossei are paralysed)
• hyperextention at the … (lubricals are paralysed).

Answer 91

• Flexion at the DIP (FDP is intact)
• Flexion at the PIP (interossei are paralysed)
• hyperextention at the MCP (lubricals are paralysed).

Question 92

Sensory innervation of the ulnar nerve

• 1 = lesion where?
• 2 = lesion where?
• 3 = lesion where?

Answer 92

• 1) Lesion above dorsal cutaneous branch
• 2) Lesion below dorsal cutaneous branch
• 3) Lesion below palmar cutaneous branch

Question 93

Ulnar nerve

Answer 93

Question 94

Ulnar nerve supplies … pollicis brevis

Answer 94

Ulnar nerve supplies adductor pollicis brevis

Question 95

Which hand has the ulnar n. palsy ? - what sign to work this out?

Answer 95

• Weakness of adductor pollicis leads to the Froment’s sign.

Question 96

Weakness of thumb adduction is due to a problem of the adductor pollicis muscle, which is mainly innervated by the … nerve. The typical sign of such an ulnar palsy is the …’s sign,

Answer 96

Weakness of thumb adduction is due to a problem of the adductor pollicis muscle, which is mainly innervated by the ulnar nerve. The typical sign of such an ulnar palsy is the Froment’s sign,

Question 97

Ulnar vs C8

• C8
  
  • All finger extensors (… nerve)
  • FDP of Index/middle (… nerve)

Answer 97

• C8
  
  • All finger extensors (radial nerve)
  • FDP of Index/middle (median nerve)

Question 98

‘Saturday night palsy’ – … nerve palsy

Answer 98

‘Saturday night palsy’ – Radial nerve palsy

Question 99

Radial nerve damage rarely causes extensive … loss

Answer 99

Radial nerve damage rarely causes extensive sensory loss

Question 100

… nerve damage rarely causes extensive sensory loss

Answer 100

Radial nerve damage rarely causes extensive sensory loss

Question 101

Radial nerve - extensive overlap with median/ulnar excepting … … box

Answer 101

Radial nerve - extensive overlap with median/ulnar excepting anatomical snuff box

Question 102

Nerve conduction studies

• Useful in determining the amplitude and … of a peripheral nerve​

Answer 102

• Useful in determining the amplitude and velocity of a peripheral nerve

Question 103

Axonal vs demyelinating

• Axonal loss results in a decrease in …
• Demyelinating results in a decrease in …

Answer 103

• Axonal loss results in a decrease in amplitude
• Demyelinating results in a decrease in velocity

Question 104

Axonal vs demyelinating

• Axonal loss results in a … in amplitude
• Demyelinating results in a … in velocity

Answer 104

• Axonal loss results in a decrease in amplitude
• Demyelinating results in a decrease in velocity

Question 105

Neurogenic vs myogenic

• Needle EMG measures the electrical activity of the muscle during … contraction.
• The pattern of the electrical activity can help distinguish a lesion arising from the nerve (…) vs muscle (…)

Answer 105

• Needle EMG measures the electrical activity of the muscle during voluntary contraction.
• The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)

Question 106

Neurogenic vs myogenic

• Needle EMG measures the electrical activity of the muscle during voluntary contraction.
• The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)

Answer 106

• Needle EMG measures the electrical activity of the muscle during voluntary contraction.
• The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)

Question 107

Nerve conduction studies are useful in determining the … and … of a peripheral nerve

Answer 107

Nerve conduction studies are useful in determining the amplitude and velocity of a peripheral nerve