2. DR TATHEER ZAHRA ASSISTANT PROFESSOR ANATOMY NERVES OF UPPER LIMB & THEIR LESIONS

3. NERVE SUPPLY OF UPPER LIMB MOTORSENSORYAUTONOMIC

5. DERMATOMES (FOERSTER, 1933) (GARRETT, 1948)

6. BRACHIAL PLEXUS

8. SURGICAL APPROACH

9. TYPES OF NERVE LESIONS COMPRESSIONSTRETCHSECTION

10. BRACHIAL PLEXOPATHY  Can refer to involvement of the entire plexus, or parts of the plexus –Trunk lesion –Cord lesion  Distribution of weakness and numbness depends upon the part of the plexus affected

11. PATTERN OF INJURY  Pattern of root contribution to the plexus: –Upper trunk lesion: Sensory loss in C5 & C6 –Middle trunk lesion: Sensory loss in C7 –Lower trunk lesion: Sensory loss in the combined C8 & T1 dermatomes

13. PRINCIPLES OF LOCALIZATION  Certain sites are prone to nerve entrapments/injuries –Nerve opposing bone ~ Ulnar nerve at the elbow –Closed spaces ~ Carpal tunnel –Adjacent structures ~ Median nerve at the elbow, adjacent to the brachial artery  Order in which branches arise  Movements at specific joints –Single nerve o Elbow extension ~ Radial –Multiple nerves o Elbow flexion ~ Musculocutaneous, Median

14.  A: VARIATIONS IN BRACHIAL PLEXUS:  Prefixed brachial plexus  Post fixed brachial plexus  B: BRACHIAL PLEXUS INJURIES:  Incomplete paralysis  Complete paralysis  Erb-Duchenne palsy  Backpacker’s palsy  Klumpke paralysis  C: BRACHIAL PLEXUS BLOCK:

15. ERB-DUCHENNE PALSY (WAITER’S TIP)

17. BACK PACKER’S PALSY

18. KLUMPKE PALSY

19. Affection of: 1- Most of the small muscles of the hand (T1) 2- Ulnar flexors of the flexor compartment of forearm are partially affected (C8) Complete claw hand

20. BRACHIAL PLEXUS BLOCK

21. INJURY TO NERVE ROOTS & BRANCHES

22. INJURY TO DORSAL SCAPULAR NERVE

23. LONG THORACIC NERVE INJURY

24. WINGING OF SCAPULA

25. INJURY TO CORDS & TERMINAL BRANCHES

26. THORACODORSAL NERVE INJURY

27. INJURY TO AXILLARY NERVE

28. Anterior Shoulder Dislocation Dislocated Head Normal Head

32. Combined Axillary and Long Thoracic Nerve Injuries Winging of the Scapula Waisting of shoulder

33. MUSCULOCUTANEOUS NERVE

35. RADIAL NERVE

37. RADIAL NERVE INJURY IN ARM

38. WRIST DROP

39. MEDIAN NERVE

40. Waisted Thenar Muscles

41. MEDIAN NERVE INJURY AT ELBOW (HAND OF BENEDICTION)

42. PRONATOR SYNDROME

43. MEDIAN NERVE INJURY A- Above Elbow: 1- Loss of pronation 2-Week flexion 3-Ulnar deviation 4-Inability to flex thumb 5-Inability to oppose fingers 6-Inability to flex middle digits 7-Inability to flex Index middle fingers -Sensory loss -Ape hand deformity B- Above Wrist: 1- No Loss of pronation 2- No Week flexion 3- No Ulnar deviation 4- No Inability to flex thumb 5- Inability to oppose fingers 6- No Inability to flex middle digits 7- No Inability to flex index and middle fingers -Sensory loss -Ape hand deformity Flexed little and ring Extended index and middle Adducted and extended thumb Flat thenar eminence

45. CARPAL TUNNEL SYNDROME

47. ULNAR NERVE

50. (CUBITAL TUNNEL SYNDROME)

51. ULNAR NERVE INJURY A - Above Elbow: 1- Week flexion 2- Loss of adduction 3- Inability to adduct thumb 4- Inability to put the hand in writing position - Sensory loss - Partial claw hand deformity B - Above Wrist: 1- No Week flexion 2- No Loss of adduction 3- Inability to adduct thumb 4- Inability to put the hand in writing position - Sensory loss to fingers only - Partial claw hand deformity is more prominent (Ulnar paradox)

52. ULNAR CANAL SYNDROME/ GUYON TUNNEL SYNDROME

53.  Symptoms  Tingling  Numbness  Pain on the outside or middle of the forearm; this sensation of discomfort may run all the way to the little finger.  Treatment  Anti-inflammatory medications  Wrist splints  Therapeutic exercises HANDLEBAR NEUROPATHY

55. AAn inability to oppose the thumb to the little finger can result from damage to the ________ nerve. a) Axillary b) Musculocutaneous c) Radial d) Ulnar e) Median

56. HHyperextension of the proximal phalanges of the little and ring fingers can result from damage to the ________ nerve. a) Ulnar b) Axillary c) Radial d) Median e) Musculocutaneous

57. WWrist drop can result from damage to the ________ nerve. a) Median b) Ulnar c) Radial d) Anterior interosseous e) Axillary

58. REFERENCES  Cinical Anatomy By Regions, By RICHARD S. SNELL, 8 th edition  Clinical Oriented Anatomy, By KEITH L. MOORE & ARTHUR F. DALLEY, 5 th edition  LAST’S Anatomy, By CHUMMY S SINNATAMBY, Churchill Livingstone, 11 th edition  GRAY’s Anatomy, 40 th edition