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Limbs > Upper limb Nerve Injuries > Flashcards

Upper limb Nerve Injuries Flashcards

1
Q

Draw the brachial plexus.

A

Remember: proximal to distal on the posterior branch = upper subscapular, thoracodorsal, lower subscapular

Proximal to distal on the medial branch = medial pectoral, medial cutaneous nerve of the ARM, medial cutaneous nerve of the FOREARM

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2
Q

Name the supraclavicular branches of the brachial plexus and state which muscles they innervate.

A

Dorsal scapular nerve – rhomboids + levator scapulae (+C3-4)

Long-thoracic nerve - serratus anterior

Supraclavicular nerve – supraspinatus + infraspinatus

Subclavian nerve - subclavius

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3
Q

Name the infraclavicular branches of the brachial plexus and state the muscles that they innervate.

A

Lateral pectoral nerve – pectoralis major
Thoracodorsal nerve – latissimus dorsi
Upper subscapular nerve – subscapularis (and the lower subscapular nerve)
Lower subscapular nerve – teres major
Medial pectoral nerve – pectoralis minor and pectoralis major
Medial cutaneous nerve of the arm – sensory to medial part of the arm
Medial cutaneous nerve of the forearm – sensory to medial part of forearm

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4
Q

Name the terminal branches of the brachial plexus and state the muscles that they innervate.

A

Musculocutaneous – anterior compartment of arm
Axillary – deltoid + teres minor
Radial – posterior compartment of arm and forearm
Median – most anterior forearm muscles + thenar muscles + lumbricals 1+2
Ulnar – flexor carpi ulnaris + ulnar half of flexor digitorum profundus + all intrinsic hand muscles (except those innervated by the median)

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5
Q

The cords of the brachial plexus are named because of their position relative to what important structure?

A

Axillary artery

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6
Q 
Which spinal nerves make up each of the following nerves:
Dorsal scapular 
Long Thoracic 
Suprascapular 
Subclavian 
Lateral Pectoral 
Medial Pectoral 
Upper Subscapular 
Lower Subscapular 
Lower Subscapular 
Axillary 
Musculocutaneous 
Radial 
Median 
Ulnar
A 
Dorsal Scapular- C5
Long Thoracic- C567 
Suprascapular - C56 (+C4) 
Subclavian - C56 (+C4) 
Lateral Pectoral- C5,6,7 
Medial Pectoral- C8T1 
Upper Subscapular- C5,6 
Lower Subscapular- C5,6, C6,7,8 
Axillary- C5,6 
Musculocutaneous- C5,6,7 
Radial- C5,6,7,8,T1 
Median- C6,7,8,T1 
Ulnar- C8,T1
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7
Q

Which two muscles, which start outside the hand, does the ulnar nerve innervate?

A

Flexor carpi ulnaris (FCU)

Ulnar half of flexor digitorum profundus (FDP)

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8
Q

Which nerves supply the shoulder girdle muscles?

A

C3-C7

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9
Q

Which nerves supply the shoulder muscles and elbow joint flexors?

A

C5+C6

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10
Q

Which nerves supply the elbow extensors?

A

C7+C8

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11
Q

Which nerves are responsible for coarse wrist and hand movements?

A

C6-C8

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12
Q

Which nerves supply small muscles of the hand (fine movements)?

A

C8+T1

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13
Q

Why is the dermatome pattern different to the cutaneous nerve pattern?

A

A dermatome is the area of skin innervated by a single spinal nerve
A cutaneous nerve pattern is the area of skin innervated by a peripheral nerve
As the peripheral nerves contain various spinal nerve root fibres, the cutaneous nerve pattern is very patchy compared to the dermatome pattern.

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14
Q

What is the benefit of having a brachial plexus instead of having spinal nerves directly innervating the upper limb muscles?

A

If a muscle group is innervated by one nerve root, damage to that nerve root will cause total loss of function of the muscle. If it is innervated by more than one nerve root then there may still be some function.

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15
Q

What does the axillary nerve supply and what branch of the axillary nerve is responsible for sensory innervation of the skin of the regimental badge area?

A

Deltoid + teres minor

Superior lateral cutaneous branch

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16
Q

How is the axillary nerve commonly damaged?

A

Shoulder dislocation

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17
Q

What are the consequences of axillary nerve damage?

A

Loss of function of deltoid

Anaesthesia or parasthesia of the regimental badge area

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18
Q

How can you check to see whether the axillary nerve has been damaged in a shoulder dislocation?

A

Check for anaesthesia or parasthesia in the regimental badge area

19
Q

Describe the passage of the radial nerve through the arm.

A

Exits the axilla posterior to the axillary artery
Passes posterior to the humerus in the radial groove, with the deep brachial artery between the medial and lateral heads of triceps
Perforates the lateral intermuscular septum
Enters the cubital fossa
Divides into superficial radial nerve (sensory) and posterior interosseous nerve (motor)

20
Q

How is the radial nerve commonly damaged?

A

Fractures of the humerus – because the radial nerve is closely associated with the humerus in the radial groove

21
Q

What are the consequences of radial nerve damage?

A

Wrist drop

Anaesthesia of the dorsal palm (on the thumb side)
Wasting of posterior compartment muscles of arm and forearm

22
Q

What is the most important outcome in radial nerve injury and how does it happen?

A

Loss of the power grip
To accommodate for extension, the flexors of the fingers are slightly longer than they need to be.
So extension of the wrist allows shortening of the flexors to maximise their efficiency and allow the power grip
With radial nerve palsy, you can’t extend the wrist anymore so you can’t perform the power grip

23
Q

Describe the passage of the musculocutaneous nerve down the arm.

A

Exits axilla by piercing coracobrachialis
Descends between biceps brachii and brachialis, supplying both
Continues as the lateral cutaneous nerve of the forearm

24
Q

When can the musculocutaneous nerve be damaged?

A

It isn’t often damaged by trauma because it is well protected by the anterior compartment muscles
It can be cut during surgery for breast cancer

25
Q

Describe the passage of the ulnar nerve down the arm.

A

Descends in the medial arm
Passes posterior to the medial epicondyle
Descends down the ulnar aspect of the forearm to the hand

26
Q

What are two common sites of damage of the ulnar nerve?

A

Injury to the medial epicondyle of the humerus

Injury to the wrist

27
Q

What situation commonly encountered by clinicians could cause injury at the wrist?

A

Self-harm and attempted suicide

28
Q

Which muscles do the ulnar nerve innervate?

A

Flexor carpi ulnaris (FCU)
Ulnar half of flexor digitorum profundus (FDP)
All the intrinsic hand muscles except LOAF (lumbricals 1+2, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis)

29
Q

Describe and explain the appearance of the hand in ulnar nerve injury.

A

Damage to the ulnar nerve causes loss of function of lumbricals 3+4
Lumbricals are responsible for flexion of the MCPs and extension of the IPJs
Loss of lumbrical function will cause flexion of the IPJs and extension of the MCPs
The hand has a half claw-like appearance (ring finger and little finger are flexed)

30
Q

What is the ulnar paradox? What causes it?

A

The claw is worse when the lesion is at the wrist than at the elbow
This is because the lesion at the elbow will mean that the ulnar nerve to both FDP (which causes flexion of the fingers) and the lumbricals (which cause extension of the fingers) will not be functioning meaning you get less flexion of the fingers
With a wrist lesion, the FDP is still functioning and able to cause flexion whereas the lumbricals are not functioning and can’t cause extension
So with wrist lesions you get an unopposed flexion of the fingers due to FDP, meaning that the flexion of the fingers is worse
‘the closer to the paw, the worse the claw’

31
Q

Describe the path of the median nerve down the arm.

A

The lateral and medial cords merge to form the median nerve, lateral to the axillary artery
It descends through the arm adjacent to the brachial artery with the nerve gradually crossing anterior to the artery to lie medial to the artery in the cubital fossa

32
Q

Which muscles do the median nerve supply?

A

All the anterior compartment of the forearm muscles except FCU and the ulnar half of FDP
Thenar muscles and lumbricals 1+2

33
Q

Describe the sensory innervation of the palmar surface of the hand.

A

Ulnar Nerve = little finger + ½ of ring finger
Median Nerve = ½ of ring finger + middle finger + index finger + ½ of thumb
Radial Nerve = small part of lateral side of thumb

34
Q

What branch comes off the ulnar nerve before it enters the carpal tunnel?

A

Palmar cutaneous branch

NOTE: this branches off the ulnar nerve before the carpal tunnel and so sensation to the thenar eminence is spared in carpal tunnel syndrome

35
Q

Describe the appearance of a hand in long-term carpal tunnel syndrome.

A

The thenar eminence will be wasted

There will be a small triangle of muscle that is still prominent – adductor pollicis (it is supplied by the ulnar nerve)

36
Q

What are the consequences of carpal tunnel syndrome?

A

Loss of fine movement in the lateral digits (thumb, index finger and middle finger)

Pain and Parathesia in areas provided by median nerve

37
Q

What are the consequences of injury to the long-thoracic nerve?

A

Winging of the scapula

This is due to loss of function of serratus anterior

38
Q

What is Erb-Duchenne Palsy and what can it be caused by?

A

Damage to the upper roots (C5, C6)

It can be caused by over-abduction of the neck (e.g. when falling on your neck or delivering a baby)

39
Q

Describe the appearance of a patient with Erb-Duchenne Palsy.

A

They arm is pronated and internally rotated at the shoulder

Their wrist is flexed – ‘waiter’s tip’

40
Q

Why is the arm pronated in Erb-Duchenne Palsy?

A

C5 and C6 are part of the musculocutaneous nerve, which innervates biceps brachii
The lack of biceps supination causes the forearm to pronate
NOTE: many muscles are affected – shoulder and anterior arm

41
Q

What is the name given to lower nerve root injury and what is it caused by?

A

Klumpke’s Palsy

It can be caused by over-abduction of the arm due to gripping overhead to break a fall

42
Q

Which nerves are usually affected in lower nerve root injury?

A

T1 (and sometimes C8)

43
Q

Which muscles does T1 innervate?

A

T1 mainly supplies the small muscles of the hand via the median and ulnar nerves so there is a loss of activity in many of the hand muscles

44
Q

What are the consequences of Klumpke’s Palsy?

A

The whole hand is clawed
This is due to loss of activity of the lumbricals – you get reduced extension of the IPJs and reduced flexion of the MCP joints

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