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Year 2 Medicine > Upper Limb Nerve Injuries > Flashcards

Upper Limb Nerve Injuries Flashcards

1
Q

Approach to a Neurological problem (3)

A
  • Anatomically localise the lesion.
  • Consider the pathophysiology
  • Differential diagnosis
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2
Q

Approach to a Neurological problem

  • Anatomically localise the …
  • Consider the …
  • … diagnosis
A
  • Anatomically localise the lesion.
  • Consider the pathophysiology
  • Differential diagnosis
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3
Q

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
A
  • 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
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4
Q

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
A
  • 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
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5
Q

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.
A
  • 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.
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6
Q

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.
A
  • 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.
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7
Q

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.
A
  • 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.
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8
Q

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.
A
  • 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.
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9
Q

3 anatomical regions for localising the lesion:

A
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10
Q

Myotomes - Relationship between the spinal … & …

A

Myotomes - Relationship between the spinal nerve & muscle

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11
Q

Dermatomes - Relationship between the spinal … & …

A

Dermatomes - Relationship between the spinal nerve & skin

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12
Q

middle finger dermatome?

A

C7

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13
Q

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

A

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

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14
Q

Herpes Zoster- Which dermatomes ?

A
  • v1 branch
  • also T4/T5 region
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15
Q

Roots and myotomes

A
  • Each muscle has a root and nerve innervation
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16
Q

Roots and myotomes

A
  • Each muscle has a root and nerve innervation
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17
Q

Myotomes (simplified)

A
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18
Q

Shoulder abduction - what root and myotome?

A
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19
Q

Elbow flexion - what root and myotomes?

A
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20
Q

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

A
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21
Q

Finger extension and Finger flexion - what root and myotomes?

A
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22
Q

Finger abduction - what root and myotome?

A
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23
Q

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.
A
  • 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.
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24
Q

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.
A
  • 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.
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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.
* 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.
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.
* 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.
27
reflexes is depressed in ... motor neuron lesion
reflexes is depressed in **lower** motor neuron lesion
28
_Nerve root ..._
29
What is shown here?
nerve root impingement
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
* 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
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
* 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
32
_MRI C-spine_ * What is going on where red circle is?
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)
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
* 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
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
* **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
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
* **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
36
* Which of the following injuries will have a worse prognosis ? * (Avulsion / rupture, neuroma, neurapraxia)
avulsion is worst, avulsion, rupture, neuroma require surgery whereas neurapraxia has a good prognosis
37
What this showing? (... arm as a result of ... root ...)
**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)
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
* **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
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
* 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
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
* 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
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
* 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
42
4 categories of brachial plexus injury are...
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)
* 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)
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)
* 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)
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)
* 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)
46
In Upper brachial plexus lesion (e.g. erbs palsy), the ... works but the ... does not work
* Arm cannot be- * Elevated * Abducted * External rotated * Flexed at elbow * But fingers unimpaired * **Hand works but arm does not!**
47
* Arm cannot be- * Elevated * Abducted * External rotated * Flexed at elbow * But fingers unimpaired * Hand works but arm does not! * What lesion is this?
Upper brachial plexus lesion
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!
* **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!
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!
* 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!
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!
* 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!
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!
* 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!
52
Erbs palsy vs klumpke's palsy - what is affected in either?
* **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)**
53
What tumour is this?
Pancoast tumour (close to inferior brachial plexus - affect hand)
54
Post ... damage near region - damage caused to .... brachial plexus (arm doesnt work, hand does)
Post **radiation** damage near region - damage caused - weakness to **upper** brachial plexus (Arm doesnt work, hand does)
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
* 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
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
* 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
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
* **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
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
* 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
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
* 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
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
* 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
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_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 ...
* 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**
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_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.
* 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.
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_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.
* 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.
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.
* 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.
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_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.
* 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.
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_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.
* 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.
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_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 ...’
* 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**’
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_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’
* 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’
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_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
* 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
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_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
* 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
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Impairment of the long thoracic nerve leads to “winging” of the ...
Impairment of the long thoracic nerve leads to “winging” of the **scapula**
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_Median nerve_ * 2 common sites of compression * ... (Carpel tunnel syndrome) * ...
* 2 common sites of compression * **Wrist** (Carpel tunnel syndrome) * **Elbow**
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_Median Nerve innervated Hand Muscles_ * L ... * O ... * A .... * F ...
* L **ateral 2 lumbricals** * O **pponens pollicis** * A **bductor pollicis brevis** * F **lexor pollicis brevis**
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... wasting
* **Thenar** wasting
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_Anatomy of the Carpal tunnel_
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_Carpal tunnel syndrome_ * ... N. Entrapment at Carpal Tunnel (also damaged in ... fractures) * Causes include: * Diabetes * Pregnancy * ...thyroidism * Rheumatoid arthritis * Repetitive strain
* **Median** N. Entrapment at Carpal Tunnel (also damaged in **wrist** fractures) * Causes include: * Diabetes * Pregnancy * **Hypothyroidism** * Rheumatoid arthritis * Repetitive strain
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_Carpal tunnel syndrome_ * Median N. Entrapment at Carpal Tunnel (also damaged in wrist ...) * Causes include: * Diabetes * ... * Hypothyroidism * ... arthritis * Repetitive ...
* Median N. Entrapment at Carpal Tunnel (also damaged in wrist **fractures**) * Causes include: * Diabetes * **Pregnancy** * Hypothyroidism * **Rheumatoid** arthritis * Repetitive **strain**
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_What is Tinel's sign?_
Tinel's test is used to test for compression neuropathy, commonly in diagnosing carpal tunnel syndrome.
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_Carpal tunnel syndrome_ * Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures) * Causes include: * Diabetes * Pregnancy * Hypothyroidism * Rheumatoid arthritis * Repetitive strain
* Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures) * Causes include: * Diabetes * Pregnancy * Hypothyroidism * Rheumatoid arthritis * Repetitive strain
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What is Phalen's test?
* 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.
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Anterior interosseous nerve arises from ... nerve just above elbow
Anterior interosseous nerve arises from **median** nerve just above elbow
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_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
* 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
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_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
* 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
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_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
* 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
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What syndrome causes this?
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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
* lesion in **forearm** = affect palm and 3.5 finger * lesion in **carpal tunnel** = just affects finger tips
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... palsy at elbow
**Ulnar** palsy at elbow
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... nerve palsy at wrist
Ulnar nerve palsy at wrist
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* ED: Extensor digitorum – ... nerve * L: Lumbricals – ... nerve * FDP: 3rd and 4th Flexor digitorum profundi – ... nerve * FDS: Flexor digitorum superficialis – ... nerve
* ED: Extensor digitorum – **radial** nerve * L: Lumbricals – **ulnar** nerve * FDP: 3rd and 4th Flexor digitorum profundi – **ulnar** nerve * FDS: Flexor digitorum superficialis – **medial** nerve
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_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 ...
* 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**.
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_Lesion at the wrist:_ * Flexion at the ... (FDP is intact) * Flexion at the ... (interossei are paralysed) * hyperextention at the ... (lubricals are paralysed).
* Flexion at the **DIP** (FDP is intact) * Flexion at the **PIP** (interossei are paralysed) * hyperextention at the **MCP** (lubricals are paralysed).
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_Sensory innervation of the ulnar nerve_ * 1 = lesion where? * 2 = lesion where? * 3 = lesion where?
* **1) Lesion above dorsal cutaneous branch** * **2) Lesion below dorsal cutaneous branch** * **3) Lesion below palmar cutaneous branch**
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Ulnar nerve
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Ulnar nerve supplies ... pollicis brevis
Ulnar nerve supplies **adductor** pollicis brevis
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Which hand has the ulnar n. palsy ? - what sign to work this out?
* Weakness of adductor pollicis leads to the **Froment’s sign.**
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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,
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,
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_Ulnar vs C8_ * C8 * All finger extensors (... nerve) * FDP of Index/middle (... nerve)
* C8 * All finger extensors (**radial** nerve) * FDP of Index/middle (**median** nerve)
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_‘Saturday night palsy’ – ... nerve palsy_
_‘Saturday night palsy’ – **Radial** nerve palsy_
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Radial nerve damage rarely causes extensive ... loss
Radial nerve damage rarely causes extensive **sensory** loss
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... nerve damage rarely causes extensive sensory loss
**Radial** nerve damage rarely causes extensive sensory loss
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Radial nerve - extensive overlap with median/ulnar excepting ... ... box
Radial nerve - extensive overlap with median/ulnar excepting **anatomical snuff box**
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_Nerve conduction studies_ * Useful in determining the amplitude and ... of a peripheral nerve​
* Useful in determining the amplitude and **velocity** of a peripheral nerve
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_Axonal vs demyelinating_ * Axonal loss results in a decrease in ... * Demyelinating results in a decrease in ...
* Axonal loss results in a decrease in **amplitude** * Demyelinating results in a decrease in **velocity**
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_Axonal vs demyelinating_ * Axonal loss results in a ... in amplitude * Demyelinating results in a ... in velocity
* Axonal loss results in a **decrease** in amplitude * Demyelinating results in a **decrease** in velocity
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_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 (...)
* 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**)
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_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)
* 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)
107
Nerve conduction studies are useful in determining the ... and ... of a peripheral nerve
Nerve conduction studies are useful in determining the **amplitude** and **velocity** of a peripheral nerve

Year 2 Medicine (162 decks)

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