1. Upper Limb Injuries

3. Golden Rules of Motor Supply
The RADIAL nerve
Profunda brachii
Golden Rules of Motor Supply
Arm: Posterior compartment
Forearm: Posterior compartment
Hand: Nothing

4. The RADIAL nerve
All function lost
No elbow extension
Wristdrop
No digit extension
Sensory loss on dorsolateral forearm & hand
Injured:
“Saturday night palsy”
Falling asleep on a chair with limb over the back rest
Crutches

5. Damage in spiral groove
The RADIAL nerve
Damage in spiral groove
Elbow extension preserved but weaker
Wristdrop
No digit extension
Sensory loss on dorsolateral forearm & hand
Injured:
Fractured shaft of humerus
Why is some of the elbow extension preserved?

6. Damage at radial head/neck
The RADIAL nerve
Damage at radial head/neck
Elbow extension normal
Minimal wristdrop (ECR supplied earlier)
No sensory loss - motor nerve
Injured:
Fracture head of radius

7. The MEDIAN nerve
How would you get injured in these two places?
A) Cubital fossa puncture wound
B) Forearm prior to carpal tunnel (defence wound, suicide attempt)
Carpal tunnel (compression) A B

8. The MEDIAN nerve
Can’t make fist with digits 2&3 (hand of ‘benediction’)
Digits 2&3 = No active flexion of IP joints
Digits 4&5 = weaker flexion (lacking FDS but FDP = ulnar nerve)
No forearm pronation
Weak wrist flexion that deviates to adduction (FCU = ulnar nerve)
Thenar wasting & opposition not possible
Thumb laterally rotated & adducted
Lumbricals 1 & 2 paralysed = digits lag in fist making (4+5 go down first the others follow) A

9. The MEDIAN nerve
Thenar wasting & opposition not possible
Thumb laterally rotated & adducted
Lumbricals 1 & 2 paralysed = digits lag in fist making (4+5 go down first the others follow) B

10. The ULNAR nerve
How is this nerve injured here?
A) Medial epicondyle fracture
B) Wrist, superficial to retinaculum A B

11. Digits 4 & 5 = no flexion of distal IP joint of (Lack of FDP)
Wrist abducts on flexion (Lack of FCU)
No digit ab-or adduction (except thumb abduction)
Some clawing of digits 4 & 5 at rest (less than wrist level injury) (loss of lumbricals & interossei, & unopposed extensor action)
Lumbricals 1 & 2 OK = no clawing of digits 2 & 3
Thenar muscles OK
Loss of most intrinsic hand muscles….
Hypothenar & interosseous wasting
Clawing of digits 4 & 5 worse in low lesion as FDP remains innervated and exacerbates IP joint flexion
The ULNAR nerve A

12. The ULNAR nerve
Loss of most intrinsic hand muscles….
Hypothenar & interosseous wasting
Clawing of digits 4 & 5 worse in low lesion as FDP remains innervated and exacerbates IP joint flexion B

13. Radial nerve damage: Wrist Drop

14. Median Nerve Damage: Thenar eminance wasting

15. Median nerve damage (in the area of the cubital fossa): Hand of benidiction

16. Ulnar nerve damage: Ulnar claw

17. Upper trunk damage
Erb’s Palsy
How can this injury occur and which roots are effected?
C5 and C6
Which nerves are affected?
Suprascapula
Lateral Pectoral
Axillary
Musculocutaneous
Dorsal Scapula
What is the resulting appearance of a patient with Erb’s Palsy?
Loss of C5 & 6: Axillary, suprascapular, dorsal scapula, lateral
pectoral & musculocutaneous nerves
Medially rotated shoulder: Loss of supra- & infraspinatus & unopposed medial rotation action from sternal head of pec major
Limp & loss of shoulder contour: Loss of deltoid
Pronated forearm: Loss of biceps brachii
Partial wrist drop/flexion at rest: Loss of extensor carpi radialis
Anaesthesia: Over C5 & C6 dermatomes

18. Erb’s Palsy: Waiter’s tip appearance

19. Patient falls from a tree grabbing a branch on the way down injuring themselves.
Given the history just presented to you, what king of injury is it likely that the patient will have sustained to his arm/hand. What are other ways he may be able to cause the same injury?
Klumpke’s Palsy
Shoulder dystocia, Pancoast tumour.
What trunks of the brachial plexus have been injured (1 mark). What will be the result of this injury (2 marks)?
C8 & T1.
Clawing of digits 2-5.
Loss of ALL small muscles of the hand.

20. You are asked to perform a venepuncture on a patient for routine blood tests. Fresh and keen you take a “stab” at it.
Name two common places for venepuncture on the upper limb, the veins you will access here and the structures that are at risk of damage in these areas.
Which of these is the preferred site?
Anatomical snuff box – Cephalic Vein. Superficial branch of the radial nerve. Bicep Barachii Artery.
Cubital fossa – Median Cubital Vein, cephalic, basilic. Median Nerve. Radial Artery.
On this occasion you decide to go for the cubital fossa. All going well so far, you have cleaned the area, got gloves on, applied the tourniquet, approach the vein at the right angle… Unfortunately you miss the vein and damages the nerve in this area. Complete Severe!! What nerve is injured and what is the resulting motor and sensory loss?
Median Nerve Injury:
Cannot make fist with digits 2&3. (Hand of Benediction)
No active flexion of Interphalangeal joints of digits 2&3.
No forearm pronation
Weak wrist flexion deviates to the ulna. Ulnar deviation on wrist flexion.
Thenar wasting
Opposition not possible

21. You panic and don’t want to get in trouble and so blame this median nerve damage on something else.
How and where else can this nerve be damaged?
Supracondylar fracture
In the carpal tunnel:
Self defence wounds
Suicide attempt
Carpal tunnel compression
You are feeling brave and tell your consultant that your patient tried to attempt suicide and has been left with median nerve damage. Your consultant, Dr Doom, doesn’t quite believe you. He assess the patient and concludes that you are lying.
Aside from the fact that there are no signs of suicide attempts, how else can Dr Doom tell that the median nerve damage was not done at the carpal tunnel as explained?
The patient will be unable to make a fist: Hand of benediction, loss of FDS and FDP to digits 2&3.
Unable to pronate: Loss of pronator teres.
Ulnar deviation on wrist flexion: Loss of Flexor Carpi Radialis
Digits 4 & 5 have weaker flexion: Loss of FDS

22. Where will Dr Doom have tested for sensory innervation of this nerve?
Thenar Eminance
Where would he test for ulnar nerve damage?
Hypothenar Eminance
What is the difference between Ulnar Claw Hand and the Hand of Benediction?
Hand of benediction: You will only see this sign on active flexion of digits.
Ulnar claw hand is visible at rest/passive.

23. Meanwhile Anne is finally getting over her LTN injury, unfortunately she fell over due to being unstable because of her breast reduction and fractured her humerus.
What nerves are at risk of damage in a fracture of the humerus.
Axillary Nerve: Fracture of the surgical neck of the humerus
Radial Nerve: Mid-shaft fracture of the humerus, spiral groove.
Supracondylar Fracture: Median Nerve
Medial Epcondyle: Ulnar Nerve
Anne was unfortunate, she had a mid-shaft fracture of the humerus.
What travels in the spiral groove/radial sulcus (2 marks)?
Profunda brachii
Radial Nerve
Unfortunately she damaged the nerve running in the region. What will be the resulting clinical appearance?
Wrist Drop
Flexed arm
“Swan Like” apprearance
How and where can the radial nerve be injured?
Axilla: Shoulder dislocation, crutches, Saturday night palsy
Radial Sulcus: Midshaft fracture of the humerous
Head/Neck of radius: Fracture

24. What is the motor loss and weakness following this injury?
Elbow extension: Weak (Some of the triceps innervated proximal to injury)
Digit Extension: Absent (Complete loss of forearm extensors)
Sensory Loss: Dorsolateral forearm & hand
You try to console her, she is inconsolable. “How could this be worse?” she cries. “Well, I’m glad you asked, because if you damaged the redial nerve you would have the symptoms you have now plus…..”
Finish the sentence.
Complete function loss. On top of what she experienced she will also have No Elbow Extension
Anne is somewhat comforted by this. Great, it worked.
You are amazed at how much you remembered from Dr. T’s lectures goes on to describe what loss there would have been had she have damaged the radial nerve at the head/neck of the radius.
What would her signs/symptoms be?
Normal Elbow Extension
Minimal wrist drop: Extensor Carpi Radialis supplied earlier.
No sensory loss
Where will you test sensory innervation of the radial nerve in the arm?
First dorsal interosseos

25. A few weeks after her injury your patient Anne comes to you explaining she is having trouble gripping things.
Explain why Pamela has no power grip.
The wrist needs to be held in the neutral (anatomical) position by extensors in order to bring about a power grip. 
Lack of extensor action means wrist flexion occurs when FDP & FDS contract
This means that they are mechanically unable to flex the digits tightly. 
Furious she returns to you! What can you do to help her?
Splint the wrist into a neutral position, thus enabling a better use of the digits, especially for a power grip.

26. Anne has just had a surgical resection of her axilla for removal of axillary lymph nodes. What is the axilla (1 mark) and what are its borders (4 marks)?
The axilla is a fat filled region superior to the armpit. Anterior: Pec Major, Anterior axillary fold Posterior: Subscapularis, Scapula, Posterior axillary fold: Lat Dorsi, Teres Major Medial: Lateral thoracic wall, serratus anterior Lateral: Intertubercular groove

27. What nerve is at risk of damage during this surgery (1 marks)
What nerve is at risk of damage during this surgery (1 marks)? How else may it get damaged (3 marks)?
The Long Thoracic Nerve (C5-7) Trauma Brachial plexus injury Root of neck injury (Posterior triangle)

28. What muscle is innervated by the long thoracic nerve (1 mark), what is its location (1 mark)? What is the function of this muscle?
The serratus anterior. Passes from ribs 1-8 in the mid axillary region, deep to the scapula to insert into its medial border. Prevents the medial scapula border from lifting away from the thorax (winging) when a posterior force applied to an outstretched upper limb.

29. Unfortunately Mr. Baig was not as careful as he should have been in surgery and has unfortunately injured Pamela’s LTN. What movements will Pamela find difficult?
Punching out Combing hair There may be some instabilty

30. How can you test the functioning of the LTN
How can you test the functioning of the LTN? If there is damage, what sign will be present?
Patient faces a wall, places palms of hands on the wall. Lock their arms in an extended position and then lean into the wall (almost like doing the first stage of press up into the wall). Serratus anterior contraction should prevent scapula winging WINGING OF THE SCAPULA

31. Vishal has been martial arts training recently and has just learnt how to use a samurai sword with deadly accuracy. He wants to test out his new skills so he cuts Charli’s Cranial Nerve XI on the left side. What is the name of this nerve (1 mark)? What does it innervate (2 marks)? State any abnormalities in Charli’s appearance. What will be the changes/abnormalities of function as a result of this horrific injury (4 marks)? Name of the nerve: Accessory nerve Innervates: Trapezius, Sternocliedomastoid Appearance: The shoulder on the affected side (left) would appear lower than the right (unaffected) due to the paralysis of trapezius. On the left side (affected side) he would not be able to: Shrug his shoulders There would be limited shoulder abduction (loss of pectoral girdle rotation) Pectoral gridle stabilisation and movement would be abnormal Ask the patient to turn their head to the right against resistance, there will be weakness in doing this

32. What will happen to him over time (2 marks)?
After several months there would be wasting of trapezius and loss of the curved contour of the lower lateral neck

33. Peter is so horny, but he is having trouble wanking
Peter is so horny, but he is having trouble wanking. He is suffering from carpal tunnel syndrome. Name the symptoms of carpal tunnel syndrome (2 marks) What might Spunk Master Pete find difficult (1 mark)? If this had been going on for some time, what sign may you be able to see?
Tingling in the lateral 3.5digits Nocturnal pain in lateral 3.5 digits Buttoning up his trousers after wanking. Note: Patients who have carpal tunnel syndrome report difficulty closing buttons on their clothes. Thenar wasting would be evident if carpal tunnel has been chronic

34. Which nerve is involved in Carpal Tunnel Syndrome (1 mark)
Which nerve is involved in Carpal Tunnel Syndrome (1 mark)? What else passes through the carpal tunnel (3 marks)?
Median Nerve 4 tendons of the Flexor Digitorum Profundus 4 tendons of the Flexor Digitorum Superficialis 1 tendon of the Flexor Pollicus Longus

35. Describe the anatomy of the carpal tunnel.
2cm distal to the most distal wrist crease Lateral and Medial walls formed by the U-shaped bones of the carpal tunnel. Roof: Flexor retinaculum Attaches to the hook of hamate and pisiform medially and tubercle of the tripezium and scaphoid laterally.

36. What causes carpal tunnel syndrome
What causes carpal tunnel syndrome? What conditions are associated with carpal tunnel syndrome?
Anything that occupies space in the carpal tunnel: Ganglion cyst, Giant cell tumour, Neuroma, Lipoma, Soft tissue thickening, fluid retention.. Hypothyroidism Pregnancy

37. What test might you perform to confirm the diagnosis of carpal tunnel (2 marks)?
Tinnels Phalen’s

38. Cubital Fossa
Superior: Inter-epicondyle line Medial: Pronator teres Lateral: Brachioradialis Roof: Fascia and bicipital aponeurosis Floor: Fascia of the bicipital aponeurosis (Fascia of the biceps)