PLEXOPATHY AND MONONEUROPATHY

• Course of Median nerve in arm. What are the clinical features and
treatment of Carpal tunnel syndrome?
MEDIAN NERVE

• Main nerve of the front of forearm.

• Controls the coarse movement of the
hand as it supplies most of the
muscles of the forearm – called
Laborer's nerve.
• Root value – C5 – T1.
• Arises both from the Medial and
Lateral cord of Brachial plexus.
• Descends in front of the arm in
relation to the Brachial artery.
• Gives the branch to Pronator teres
just above the elbow.
COURSE OF MEDIAN NERVE IN FOREARM

• Enters the forearm between two

heads of Pronator teres.
• Runs deep to Flexor digitorum
superficialis lying on the Flexor
digitorum profundus.
• 5 cm above the flexor retinaculum it
becomes superficial.
• Enters the wrist by passing through
the carpal tunnel.
• In the hand it supplies the Thenar
group of muscle and 1st / 2nd
Lumbricals.
C/F OF MEDIAN NERVE INJURY

INJURY ABOVE ELBOW

• E.g. Supracondylar fracture
• PARALYSED – Flexor pollicis longus and
Lateral part of Flexor Digitorum
profundus – unable to flex terminal
phalanx of thumb and index finger –
POINTING INDEX.
• PARALYSED Pronator teres – arm
attains supine position.
• PARALYSED Flexor Carpi Radialis –
Adducted hand with weak flexion.
• Paralysis of Thenar muscle – Ape
thumb deformity.
• Sensory loss in lateral 3 and half digit
• Vasomotor and tropic changes of skin.
CARPAL TUNNEL SYNDROME

• MC type of entrapment neuropathy.

• Median nerve entrapment in the
Carpal tunnel of wrist below the flexor
retinaculum.
• Age - 25 – 70 years more in females.
• CAUSE – Rheumatoid arthritis.
Acromegaly
Hypothyroidism
Pregnancy
CLINICAL FEATURES

• Intermittent attack of pain and

paresthesia along the distribution of
Median nerve in the hand.
• More at night.
• Relieved by hanging the hand.
• Paralysis of Thenar muscle – APE
THUMB deformity.
• Loss of opposition of thumb.
• Paralysis of 1st and 2nd Lumbricals –
lagging of index and middle finger
( partly) while attempting to fist the
hand.
• Loss of sensation over the lateral 3
and a half of digit and hand including
the nail bed.
• Vasomotor and tropic changes – dry
and scaly skin with cracked nails.
• PHALENS TEST – acute flexion of wrist
joint causes pain proximally in the
forearm.
• Book holding test / Froment’s test –
unable to hold book in between
thumb and index finger – weakness of
long flexors.
• Formation of Brachial plexus and its clinical importance.
BRACHIAL PLEXUS

• Location – in the posterior triangle of

neck between the Scalenus anterior
and Medius muscle.
• FORMATION – by ventral roots of C5 –
T1.
• If there is contribution from C4 it is
called prefixed.
• While if there is contribution from T2
it is called postfixed.
• Important branches from the ROOT –
• Nerve to Serratus anterior ( Long
thoracic nerve of Bell )
• Nerve to the Rhomboids.
• C5 C6 joins to form the upper trunk
• C7 continues as middle trunk
• C8 T1 joins to form lower trunk
• Each trunk divides into ventral and
dorsal division
• Ventral (anterior) division of upper
and middle trunk forms the LATERAL
CORD
• Ventral (anterior) division of lower
trunk forms the MEDIAL CORD
• Dorsal (posterior) division of upper,
middle and the lower trunk forms the
POSTERIOR CORD
LATERAL CORD

BRANCHES ( C5 C6 C7 )
• Lateral pectoral nerve – Pectoralis
Major and Minor
• Musculocutaneous nerve – supplies
the muscles in front of the arm –
Biceps
Brachialis
Brachioradialis
• Lateral root of Median nerve –
supplies the muscles of the front of
the Forearm and Thenar muscles.
MEDIAL CORD
BRANCHES ( C8 T1 )
• Medial pectoral nerve – Pectoralis
Major and minor.
• Medial root of Median nerve –
forearm and hand.
• Ulnar nerve – supplies 15 small
intrinsic muscles of the hand and
medial half of muscles of forearm.
• Medial cutaneous nerve of arm and
forearm – cutaneous supply on the
medial side.
POSTERIOR CORD
BRANCHES ( C5 – T1 )
• Nerve to Latissimus Dorsi
• Axillary nerve – supplies the Deltoid
and Teres major.
• Radial nerve – supplies mainly the
extensor group at the back of arm
(Triceps) and Forearm.
• Upper and lower Subscapular nerve.
ERB DUCHENNE PALSY

• ERB’S POINT – meeting point of six

nerves in the upper trunk of brachial
plexus.
• Injury to this point of upper trunk
leads to Erb’s palsy.
• Nerve root paralyzed – mainly C5
partly C6.
• CAUSE – Birth injury
Fall on shoulder
 MUSCLE PARALYSED DISABILITY
• Deltoid • Loss of abduction and lateral rotation
• Biceps of arm
• Brachialis • Loss of flexion and supination of
forearm
• Brachioradialis
• Loss of Biceps and Supinator jerk
• PARTLY – Supraspinatus
• Sensation lost over a small area of
Infraspinatus Deltoid
Supinator
 DEFORMITY
• Arm hangs by the side of body
• Adducted and medially rotated.
• Forearm extended and pronated
• The deformity is known as Policeman
tip hand or Waiter tip hand deformity
• Course of Ulnar nerve. Clinical features of lesion at different levels
ULNAR NERVE

• Root value – C8 T1
• Arises from the medial cord
• Known as Musicians nerve as it
supplies small muscles of hand
responsible for fine movements.
• Palpable behind the medial
epicondyle of humerus.
 COURSE IN ARM
• Lies in the medial side of brachial
artery.
• Above the elbow it passes posteriorly
to lie behind the medial epicondyle of
humerus.
• At this point the nerve is palpable and
produces a tingling sensation when
pressed – hence the humerus is called
the ‘funny bone’
 COURSE IN THE FOREARM
• Lies behind the medial epicondyle of
humerus.
• Enters the forearm between two
heads of Flexor carpi ulnaris.
• Runs between the Flexor digitorum
profundus and superficialis.
• Enters the palm lying superficial to the
flexor retinaculum in the wrist.
• SUPPLY OF ULNAR NERVE
• Flexor carpi ulnaris
• Flexor digitorum profundus – medial
half
• Medial 1 and half of palm and dorsal 2
and half of hand.
 COURSE IN THE HAND
• In the hand it divides into superficial
branch and deep branch.
• Superficial branch – cutaneous –
supplies the medial 1½ of fingers.
• Deep branch – muscular –
All 3 hypothenar muscles.
Palmar interossei (Adductors)
Dorsal interossei (Abductors)
3rd and 4th Lumbricals (Flexor of
MCP joint)
INJURY OF ULNAR NERVE AT DIFFERENT LEVELS

• Commonly injured at the ELBOW EFFECTS / RESULTS

behind the medial epicondyle OR • Flattening of the medial border of
• Below the elbow between the two forearm.
heads of Flexor carpi ulnaris (Cubital • Weak flexion of wrist.
tunnel)
• Attempt of flexion of wrist produce
• MUSCLE PARALYSED abduction.
Flexor carpi ulnaris • Flexion of terminal phalanx of ring and
Medial half of Flexor digitorum little finger is lost.
Profundus (flexor of proximal and distal
interphalangeal joints)
Short muscles of the hand
INJURY IN THE WRIST - ULNAR CLAW HAND.

• ULNAR CLAW HAND – extension of the

Metacarpophalangeal joint and flexion of
the interphalangeal joint.
• ( Lumbricals are flexors of MCP joints / 3 rd
& 4th Lumbricals are supplied by Ulnar
nerve )
• Mostly in the ring and little finger.
• Flexor digitorum profundus is spared in
wrist lesion – marked flexion of the inter
phalangeal joint due to its action.
• . While lesion in the elbow paralyses the
FDP hence claw hand is less.
 SENSORY LOSS
• Loss over medial 1 ½ of palmar
surface of hand and finger.
• Loss over medial 2 ½ of the dorsum of
the hand and fingers.
RADIAL NERVE

Course in the ARM CLINICAL SIGNIFICANCE

• Root value – C5 – T1. • Very commonly damaged in the Radial
• Arises from the posterior cord. (Spiral) groove.
• Thickest branch of Brachial plexus. • Saturday night palsy – sleeping on arm
chair.
• In the arm mainly lies in the posterior
aspect in the Radial groove of • Crutch palsy.
Humerus between the two heads of • Fracture shaft of Humerus.
Triceps. • All leads to weakness and loss of
• Comes anteriorly in the lower part of power of extensors of wrist – WRIST
arm from the lateral side to lie DROP
between the Brachialis and
Brachioradialis.
 Course in the FOREARM
• Divides into superficial and deep
terminal branch in the antecubital
fossa.
• The superficial branch is cutaneous
supplying lateral half of the dorsum of
the hand.
• Deep branch supplies mainly the
extensors of the hand at the back of
forearm.
WRIST DROP

• Affects the Radial nerve in the Radial

(spiral) groove.
• CAUSE – fracture shaft humerus
Saturday night palsy
Crutch palsy.
• MUSCLE PARALYSED
Triceps (partly)
Brachioradialis
Extensor carpi radialis longus & brevis
Extensor digitorum
Extensor carpi Ulnaris
 CLINICAL EFFECTS
• Loss of Triceps jerk
• Flexed fingers
• Unable to extend the wrist and
fingers.
• Unable to grip an object tightly.
• Qs) Nerve injury in fracture humerus. Describe the clinical features
and management.
• Ans) Most common nerve injured in fracture (Shaft) humerus is Radial
nerve in the radial groove.
• Less commonly Axillary nerve in fracture neck of humerus and
Median nerve in supracondylar fracture.