Peripheral Nerves Of The

Upper Limb
Dr. Garima Gupta (P.T)
Lecturer SCMAT Kanpur
Topics
 Introduction
 Brachial plexus
 Anatomy
 Branches
 Lesions
 Individual study of upper limb nerves
 Long thoracic nerve
 Dorsal scapular nerve
 Suprascapular nerve
 Median and lateral pectoral nerves
 Musculocutaneous nerve
 Median nerve
 Ulnar nerve
 Radial nerve
 Cutaneous nerves of the upper limb
 Summary
 References

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 Introduction

 The bundle of nerve fibers found in peripheral nervous

system is called peripheral nerves.
 Peripheral nerves include those that supplies the skin,
muscles, joints and limbs and that those supply visceral
structures e.g.: heart, lung stomach etc.
 The peripheral nerves comprises of 12 pairs of cranial
and 31 pair of spinal nerves. The anterior primary rami of
all spinal nerves join together and/or branch to form
network of nerves known as plexus.
 The branches arising from plexus are also termed as
peripheral nerves.
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The Brachial Plexus

 It’s a large network of nerve fibers (plexus).

 Extending from spine(C5-T1), through the neck, the
axilla and into the arm.
 These nerves provide movement and feeling to the arm
and hand.
 Through these nerves brain sends electrical signal to the
individual muscles of arm and hand.

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Anatomy
 Plexus consist of Roots
Trunks
Divisions
Cords

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  Roots: Constituted by anterior primary rami of spinal
nerves C5, 6, 7, 8 and T1.
 Prefixed Plexus
 Postfixed Plexus
 Trunks: These roots merges to form 3 trunks
Upper C5-C6
Middle C7
Lower C8-T1

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 Divisions: Each trunk splits to form an anterior and
posterior division.
 Cords: Posterior cord by 3 posterior divisions of the
trunks.
Lateral cord by anterior division of upper and middle
trunks.
Medial cord by anterior division of lower trunk.

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Branches of the plexus for the upper limb

Branches of the roots

 Long thoracic nerve.(serratus ant.)(C5,6,7)
 Dorsal scapular nerve.(rhomboids)(C5)
Branches of the trunks
 No branches from middle and lower trunks.
 Suprascapular nerve. (supraspinatus and infraspinatus
muscle)(C5,6).
 Nerve to subclavius.(C5,6)

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Branches of the cords

 Branches of the lateral cord

1. Lateral pectoral (C5,6,7)

2. Musculocutaneous (C5,6,7)
3. Lateral root of median (C5,6,7)

 Branches of medial cord

1. Medial pectoral (C8,T1)

2. Medial cutaneous nerve of arm (C8,T1)
3. Medial cutaneous nerve of forearm (C8,T1)
4. Ulnar (C7,8,T1)
5. Medial root of median. (C8,T1)

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 Branches of posterior cord

1. Upper subscapular (upper part of subscapularis) (C5,6)

2. Thoracodorasl (latissismus dorsi)(C6,7,8)
3. Lower subscapularis (lower part of subscapularis+ teres major)
(C5,6)
4. Axillary (deltoid+ teres minor)(C5,6)
5. Radial (triceps+ anconeus+ extensor muscles of forearm)

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Brachial Plexus Injury

 Uncommon

 Serious effects

 Usually closed

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 Tassin – Gilbert classification :

1. C 5/6 = full recovery in 90%

2. C 5/6 + partial C 7 = full recovery in 50 – 75%
3. C 5/6/7 + partial C 8/ T 1 = full recovery in 33%
4. C 5/6/7/8 + T 1 = no chance of full recovery.

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Upper root lesion of brachial plexus

 Rusksack palsy

 Erb’s palsy.

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Lesion Motor deficits Sensory deficits Nerves

Loss of abduction, Posterior and Axillary,

flexion and rotation lateral aspect of Suprascapular,
at shoulder ; Weak arm - axillary n Upper and
shoulder extension - Lower
deltoid, rotator cuff subscapular
Erb’s Very weak elbow Radial side of Musculocutane
Palsy flexion and Forearm- ous ; Radial N.
supination of musculocutaneous brs. to
(C5,6) radioulnar joint - n. Thumb and 1st supinator &
biceps brachii & finger - superficial brachioradialis
br. of radial; digital muscles
brachialis
brs. - Median n.

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 Lesion Motor deficits Sensory Nerves
deficits
Susceptible to Suprascapular,
Erb’s palsy shoulder dislocation Upper and
- loss of rotator cuff Lower
muscles subscapular

“Waiters Tip"
position

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Lesion Motor deficits Sensory deficits Nerves

Loss of opposition Ulnar side of Thenar branch of

of thumb -Thenar forearm , hand Median nerve
muscles & & ulnar 1 1/2 &
digits - ulnar and
Klumke’s medial
Palsy
Loss of adduction of Ulnar nerve
(C8, T1 )
thumb - Adductor
pollices

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Lesion Motor deficits Sensory Nerves
deficits
Loss of following Deep branch of
finger movements: Ulnar & Median
abduction and
adduction of MCP
Klumpke’s joints; flexion at MCP
Palsy & extension of IP
(C8, T1 ) joints. Lumbricals &
interossei
Very weak flexion of Ulnar and
PIP& DIP joints FDS Median
and FDP

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Long thoracic nerve (Nerve of Bell)

 C 5-C7
 1st the nerve lies behind the brachial plexus, and the after
perforating scalenus muscle it reaches the upper most division
of the serratus anterior muscle.
 It then descend and gives off fine branches to the each division
of the serratus muscle.
 Serratus muscle fixes the medial edge of scapula to the chest.

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Clinical picture

1. Its paralysis causes – the

scapula to lift up medially
from the chest.
2. Winged scapula.

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Nerve Innervation Winging Position of abduction
scapula

Long Serr. Ant Medial Closer to Decrease

thoracic midline winging

Spinal Trapezius Lateral Away from Increase

accessory midline winging

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 Dorsal scapular nerve (nerve to rhomboids)

 C5
 Innervates- levator scapulae
and rhomboids.

Clinical picture

1. Mild malposition of scapula is

visible.
2. Scapula slightly externally
rotated and inferior angle is
slightly protruded.

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Suprascapular nerve

 C5-6
 Innervates supraspinous,
infraspinous and ligaments
and parts of the capsule of the
shoulder joint.

Clinical picture

1. Atrophy
2. Weakness of arm evelation(1st
15 degrees).
3. Tricks movements
4. Weakness of external rotation
of shd.
5. Pt will not be able to scratch
themselves behind the head.

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Median and Lateral pectoral nerves

 Purely motor.
 C5-T1
 Leave the plexus anteriorly and crosses subclavian artery
and vein, pass under the clavicle and reach the anterior
wall of axilla.
 Innervates the pectoral muscles.

Clinical picture

1. Weakness of adduction of the arm.

2. Atrophy of the muscles.
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Musculocutaneous nerve

 Mixed nerve.
 Main nerve of the front of the arm.
 It leaves the axilla, and enters the front of the arm by
piercing the coracobrachialis.
 In the arm it runs downwards and laterally b/w biceps
and brachialis to reach the lateral side of the tendon of
biceps.
 It ends by piercing the deep fascia 2 cm above the bend
of forearm.
 Continues below the elbow as the lateral cutaneous
nerve of the forearm.
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Clinical picture

1. Weakness of all 3 muscles.

2. Sensory deficits are less than expected bz it
anastomoses with superficial branch of radial nerve.

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Median (labourer’s) nerve

 Front of the forearm

 Enters the forearm by
passing b/w the 2 heads of
pronator teres.
 Along with the ulnar artery it
runs deep to FDS and above
to FDP.
 5 cm above the wrist it
becomes superficial and lies
b/w the tendon of FCR and
FDS.
 Enters the palm by passing
deep to flexor retinaculum.

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 Branches in the forearm
1. All superficial flexors of the
forearm, except the FCU.
2. Anterior interosseus branch is
given off in the upper part of the
forearm. It supplies the FPL and
lateral half of the FDP and pronator
quadratus.
3. Palmar cutaneous branches
supplies the skin over thenar
eminence and the central part of
the palm.
4. Articular brs are given to elbow jt
and to the proximal radioulnar jt.

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 Immediately below the retinaculum it divides into medial and
lateral divisions.

 In the carpal tunnel it lies in front of the ulnar bursa enclosing

the flexor tendons.

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 Lateral division gives off muscular branches to the thenar
muscles and 3 digital branches for the lateral 1 ½ digits
including thumb.

 Out of 3 digital branches 2 supplies the thumb and 1 the lateral

side of the index finger and also supplies 1st lumbricals.

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 Medial division divides into 2 digital branches for 2nd and 3rd
interdigital clefts supplying index, middle and ring fingers and
also 2nd lumbricals.

 In the hand median nerve supplies 4 ½ muscles namely

abductor pollicis brevis, superficial head of FPB, opponence
pollicis and 1st and 2nd lumbricals.

 Palmar skin over the middle and distal phalanges of the lateral
3 ½ digits.

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Clinical picture

 When lesion is at the level of elbow

1. Pronator teres syndrome

2. Paralysis of FPL, inability to flex terminal phalanx of the thumb.

3. Paralysis of pronators, forearm is kept in supinated position.

4. Loss of flexion of IP joints of index and middle fingers. (Middle

finger remain straight while making fist.) (Oath hand)

5. Ape thumb deformity (thenar muscles)

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 When lesion is at the level of wrist

1. Loss of opposition of the thumb.

2. Ape thumb. (Simian hand)
3. Paralysis of the 1st and 2nd lumbricals makes the index and middle fingers
lag behind in slowly making fist
4. Index finger remain extended while clasping both hands by interlocking
fingers and thumb. Due to paralysis of both long flexors of the index
finger. (Oschner’s pointing index test)
5. Positive “bottle sign”. (weakness of thumb abduction)
6. Anterior interosseous nerve lesion (purely motor branch of median nerve)
supplies FPL and FDP to index and middle finger as well as pronator
quadratous. lesion makes it impossible to form an even ring with those
fingers ”O”. Called as ok sign. weakness of pinch grasp. There is no
sensory loss present.

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 Sensory disturbance
 The median nerve is especially
rich in autonomic fibers.
therefore lesion of autonomic
fibers cause autonomic
disturbance like edematous
changes of hands , fingers,
hyperpathia, causalgia.

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Carpal tunnel syndrome

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 Martin- Gruber connection- multiple communicating branches
b/w median nerve (some times anterior interosseus nerve) arises
and join ulnar nerve. this motor fiber communication commonly
referred as martin gruber connection, estimated to be present in
17% of individuals.
 It presumably explains why isolated ulnar and median nerve lesions
can sometimes be unpredictable in terms of pattern of intrinsic
muscle paralysis.
 Riche- Cannieu connection- communication b/w cutaneous
branches of median and ulnar nerve.

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Ulnar (Musician’s) nerve

 At the elbow, the nerve lies

behind the medial
epicondyle of the humerus,
enters the forearm by
passing b/w the 2 heads of
FCU.
 In the forearm the nerve
runs b/w FDP and FDS.
 Enters the palm superficial
to the flexor retinaculum.
 At wrist ,the ulnar
neurovascular bundle lies
b/w FCU and FDS.

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Branches in the forearm

 Muscular, to FCU and medial half of the FDP.

 Cutaneous

 Palmar cutaneous branch = hypothenar eminence.

 Dorsal cutaneous branch = proximal parts of the ulnar 2 ½
fingers and the adjoining area of the dorsum of the hand.

 Articular, to elbow joint.

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In the hand
 In the hand, nerve enters the palm by passing superficial to
retinaculum .here it divides into its superficial and deep terminal
branches.

 Superficial terminal branch:

1. Muscular – palmaris brevis.

2. Cutaneous -2 palmar digital nerves supply the medial 1 ½ fingers.
medial branch supplies the medial side of the little finger.
lateral branch is the common palmar digital nerve. It
communicates with the median nerve.

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 Deep terminal branch

1. Muscular – 3 hypothenar muscles, medial two lumbricals and 8

interossei.it terminates by supplying adductor pollicis,1st palmar
interossei and the deep head of FPB.

2. Articular – wrist joint.

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Clinical picture

 Lesion at elbow level:

1. FCU and FDP (medial half) are paralyzed. Due to that

medial border border of he hand become flattened and
attempt to produce flexion results in abduction of the
hand.
2. Ulnar Claw hand.
3. Tardy ulnar palsy
4. Cubital tunnel syndrome
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 Lesion at the level of wrist

1. Ulnar tunnel palsy

2. Sensory loss of medial 1/3
of palm and medial 1/3 of
fingers.
3. Unable to spread out
fingers = paralysis of
dorsal interossei

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Radial nerve

 Largest branch of posterior cord of brachial plexus.

 C 5, 6, 7, 8, T 1.

 In the lower part of axilla it runs downwards .

 In the upper part of humerus it passes obliquely across the

back of the humerus 1st b/w the lateral and medial head of
triceps and then in the shallow groove (radial/ spiral groove).

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 At the lower end of the groove , 5cm below the deltoid
tuberosity , the nerve pierces the lateral inter muscular septum
and passes into the anterior compartment of the arm.

 In the cubital fossa the nerve run in a gap b/w brachialis

(medially) and brachioradialis and ECRL (laterally).

 At the level of lateral epicondyle it gives off the superficial

branch (sensory) and deep branch of radial nerve (posterior
interosseous) (motor), which leaves the fossa by piercing the
supinator muscle.

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 Superficial branch:

 It runs downwards and in the distal 1/3 of the forearm it

crosses under the tendon of the brachioradialis muscle to go to
the extensor surface, where it branches out on the dorsal
surface of the wrist and the dorsum of the hand.
 It gives off 4 or 5 dorsal digital nerves, supplies thumb, index
finger and the medial half of the 3rd finger.
 An anastomosis connects it with the dorsal branch of the ulnar
nerve.

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  Deep branch: It emerges from the supinator on the back of the
forearm, lies b/w the superficial and deep muscles.

It supplies the extensor muscles of the forearm

Superficial muscles
 ECRB
 ED
 EDM
 ECU
Deep muscles
 Supinator
 AbPL
 EPB
 EPL
 EI
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Clinical picture

 At the level of axilla

 Crutch palsy: it also involves median, axillary, and

suprascapular nerve.

 In the arm

 Wrist drop+ Finger drop + Thumb drop

 Spiral groove: Saturday night palsy or honeymooner’s palsy.

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 At the elbow
 Radial tunnel syndrome: entrapment neuropathy.

 In the forearm
 Posterior interosseous nerve syndrome (Supinator syndrome). It’s a
pure motor syndrome. All the radial nerve innervated distal muscles
get involved. Pseudo claw hand deformity due to finger extensor
muscles weakness. Radial deviation and wrist extension is noted. Due
to ECU weakness.
 Superficial radial nerve neuropathy (Cheiralgia parathesia OR
wristwatch syndrome)

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Brachial Plexus Injuries

Nerve (Segment) Motor Deficit(s) Sensory

Deficits
Long Thoracic Winged Scapula- Serratus Anterior None
(C 5,6,7)
Suprascapular Hard to start shoulder abduction - None
(C 5,6 ) Supraspinatus
Axillary (C 5,6 ) Difficult abducting arm to Lateral side of arm
horizontal, below point of
Loss of shoulder roundness - shoulder
Deltoid
Musculocutaneous Very weak flexion of elbow joint- Lateral forearm
C 5,6,(7) Biceps & Brachialis
Weak supination of radioulnar joint
-Biceps
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Radial Drop Wrist – ECRL,ECRB,ECU Posterior lateral
(C 5 - T1) &arm; dorsum of
Difficulty making a fist - synergy between
hand
wrist extensors and finger flexors

Median Pronation of radioulnar joints- Pronator Radial portion of

( C 5 - T1) at teres & quadratus palm; palmar
Elbow surface & tips of
Weak wrist flexion -FCR
radial 31/2 digits
Weakened opposition of thumb - thenar

Ape Hand- thumb hyper extended and

adducted - thenar
Papal Hand Loss of flexion of I.P. joints of
thumb & fingers 1 & 2 -FPL; FDS,FDP

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Median (C 5 - T1) Weakened opposition of thumb - Palmar surface &
at Wrist Thenar muscles tips of radial 31/2
“Ape Hand”- thumb hyper extended digits
and adducted - Thenar muscles

Ulnar (C 8, T1) at “Clawing” of fingers 3 & 4 - MCP hyper Ulnar and dorsal
Elbow extended; PIP Flexed - Interossei & aspect of palm
Lumbricals and of ulnar 1 1/2
digits
Loss of abduction & adduction of M.P
joints of fingers –Interossei

Thumb - abducted and extended -AP

Loss of flexion of D.I.P. joints of

fingers 4 & 5 -FDP

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Ulnar (C 8, T1) “Clawing” of fingers 3 & 4- M.P. joints Ulnar and
at Wrist hyper extended; P.I.P. Flexed - Interossei dorsal aspect of
& Lumbricals palm and of
Loss of abduction & adduction of M.P ulnar 1 1/2
joints of fingers – Interossei digits

Thumb - abducted and extended -

adductor pollices

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Cutaneous nerves of the upper limb

 The skin of the upper limb is supplied by 15 sets of the

cutaneous nerves.

 Out of these only one set (supra clavicular) is derived from the
cervical plexus, and another nerve (intercostobrachial) is
derived from 2nd intercostal nerve.

 The remaining 13 sets are derived from the brachial plexus

through the musculocutaneous, median, ulnar, axillary, and
radial nerves.

 Some branches arises directly from the medial cord of the

plexus
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References
 Gray’s anatomy
 Human anatomy by B. D. Chaurasia
 Inderbir singh
 Peripheral nerve lesions by Mark Mumenthaler add Hans
Schliack
 Physical medicine and Rehablitation by Sara. J . Cuccrullo
 Oxford text book of orthopaedics and trauma Vol-3 by
Chisrtopher Bulstrode , Joseph Buckalter
 Text book of orthopaedics by Natarajan and Kotwal
 www.google.co.in

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Thank you