Upper limb

Long Thoracic Nerve Injury Caused by:

o Stab woundo Lymph node removal during mastectomy

Paralysis of Serratus Anterior Muscle impaired ABDUCTION of the arm past the horizontal position

Arm cannot be pushed with To test serratus anterior clinically pt faces wall and pushes with both arms Medial border and Inferior angle of the scapula will become prominent

“Winging of the Scapula”

Axillary Nerve Injury Caused by:

o Fracture of surgical neck of the Humeruso Anterior dislocation of the shoulder

Paralysis of Deltoid Muscle impaired ABDUCTION of the arm to the horizontal position

Paralysis of Teres Minor lateral rotation of the arm is weakened Sensory loss occurs on the lateral side of the arm “sargent’s patch” To test deltoid muscle clinically – patients arm is abducted to the horizontal

and then patient is asked to hold that position against a downward pull

Radial Nerve Injury Caused by:

o Midshaft fracture of the Humeruso Badly fitted crutcho Falling asleep with the arm draped over a chair

Paralysis of Muscles in Extensor compartment in Forearm loss of extension of the wrist and digits and supination

Forearm extension is preserved because innervation of the triceps is largely intact lateral rotation of the arm is weakened

Sensory loss o Posterior Armo Posterior Forearmo Lateral aspect of the dorsum of the hand

Clinically: Hand will be flexed at the wrist and lie flaccid – Wrist Drop

Medial Nerve Injury at the Elbow Caused by:

o Supracondylar fracture of the humerus Paralysis of Muscles in Flexor compartment in the Arm

o Wrist flexion is weakened (Hand deviates to ulnar side on flexion)o Loss of flexion at the DIP and PIP joints in the index and middle

fingerso Loss of Supination

Paralysis of Lumbricals 1 and 2 Loss of MCP joint flexion in the index and middle fingers

Paralysis of Abductor Policis Brevis, Opponens Pollicis, Flexor Pollicis Brevis so that thumb abduction, opposition and flexion is lost

Sensory loss o Palmar and Dorsal aspects of the index, middle and half of the ring

fingerso Palmar aspects of the thumb

Clinically: o Thenar flattening (Ape Hand)o When patient is asked to make a fist – the index and middle fingers

tend to remain straight while the ring and little finger flex (Benediction Hand)

Test median nerve (motor) integrity – patient maintains an O with thumb and index finger while physician tries to pass probe through them (tests function of OPPONENS POLLICIS muscle)

Medial Nerve Injury at the Wrist Caused by:

o Wrist slashing (suicide attempt)o Carpal tunnel syndrome

No paralysis of flexor compartment muscles of the arm Paralysis of Lumbricals 1 and 2 Weakened MCP joint flexion in the index

and middle fingers Paralysis of Abductor Policis Brevis, Opponens Pollicis, Flexor Pollicis Brevis so

that thumb abduction and opposition is lost Thumb Flexion remains because flexor pollicis longus muscle is spared Sensory loss

o Palmar and Dorsal aspects of the index, middle and half of the ring fingers

o Palmar aspects of the thumb Clinically:

o Thenar flattening (Ape Hand) Test median nerve (motor) integrity – Tinels (tapping on flexor reticulum)

and Phalens (inverse hindu sign) (Carpal Tunnel Syndrome)

Ulnar Nerve Injury at the Elbow or Axilla

Caused by: o Medial epicondye fracture of the humerus

Paralysis of flexor carpi ulnaris o Hand will deviate to the radial side on flexion

Paralysis of medial part of flexor digitorum profundus Loss of DIP joint flexion in ring and little fingers

Paralysis of Lumbricals 3 and 4o Loss of MCP joint flexion in the ring and little fingero Loss of PIP and DIP joint extension in the ring and little fingers

Paralysis of Palmar and Dorsal Interosseus o Loss of finger abduction and adductiono Loss of MCP joint flexion in the fingerso Loss of PIP and DIP joint extension in the fingers

Paralysis of adductor pollicis muscle – loss of thumb adduction Paralysis of Abductor digiti minimi, flexor digiti minimi and Opponens digiti

minimi – little finger movements are lost Sensory loss

o Palmar and dorsal aspects of half of the ring finger and the little finger Clinically:

o Mild “Claw Hand” Test Ulnar nerve (motor) integrity – patient holds piece of paper between the

middle finger and ring finger and doc tries to remove it (tests function of interosseus muscles)

Ulnar Nerve Injury at the Wrist Caused by:

o Wrist slashing (suicide attempt) No Paralysis of flexor carpi ulnaris muscle No Paralysis of medial part of flexor digitorum profundus muscle Paralysis of Lumbricals 3 and 4

o Loss of MCP joint flexion in the ring and little fingero Loss of PIP and DIP joint extension in the ring and little fingers

Paralysis of Palmar and Dorsal Interosseus o Loss of finger abduction and adductiono Loss of MCP joint flexion in the fingerso Loss of PIP and DIP joint extension in the fingers

Paralysis of adductor pollicis muscle – loss of thumb adduction Paralysis of Abductor digiti minimi, flexor digiti minimi and Opponens digiti

minimi – little finger movements are lost Sensory loss

o Palmar and dorsal aspects of half of the ring finger and the little finger Clinically:

o SEVERE “Claw Hand”o Unopposed action of flexor digitorum profundum

Erb Duchenne or Upper Trunk Injury (C5 and C6 ventral primary rami) Violent stretch between head and shoulder (adduction traction of the arm

with hyperextension of the neck) This damages

o Musculocutaneous Nerve (Biceps brachii brachialis muscle)o Suprascapular Nerve (Infraspinatus muscle)o Axillary Nerve (Teres Minor Muscle)o Phrenic Nerve (Diaphragm)

Clinical Signso Arm is pronated and medially rotated (waiter’s tip)o Weakened Biceps brachii muscle (supinator of muscle) so pronator

muscles dompinateo Weakened Supraspinatus muscle (lateral rotator of the arm) means

that media rotators will dominateo Involvement of C5 component of Phrenic nerve – ipsilateral paralysis

of the diaphragmo

Klumpke or Lower Trunk Injury (C8 and T1 ventral primary rami) Sudden pull upward of the arm (abduction injury) This damages

o Median Nerve (muscles of the arm and forearm)o Ulnar Nerve (muscles of the arm and forearm)o Sympathetics of the T1 Spinal nerve

Clinical Signso Loss of Wrist functiono Horner’s syndrome

Myosis – pupil constriction due to paralyzed dilator pupillae muscle

Anhydrosis (hemianhydrosis ipsilateral) Ptosis – drooping of eyelid as a result of superior tarsal muscle

paralysis