PERIPHERAL NERVE INJURIES

DEFINITION 4) KLUMPKE’S PALSY- excessive pulling or stretching during

- damaged to the nerves that connects to the brain & SC to vaginal birth
the rest of the body MOI: traction of lower trunk/root of brachial plexus (C8-
Types: T1 affected)
1) Traumatic (70%) - Claw Hand deformity 2° to intrinsic ms weakness
2) Non-traumatic (30%)- specific neuropathy
- Ex: Diabetic neuropathy- MC CN involved: 3,6 III. NEUROPATHIES of SH GIRDLE & UPPER ARM
MC PN involved: median nerve 1) LONG THORACIC N. INJURY- serratus ant
- Ex: CIDP, GBS, Toxic, Infectious (Hansen’s dse), CMTD Cause: Surgery (1st Rib resection, Axillary node resection,
Radical mastectomy*, Thoracotomy “FART”), Idiopathic,
CLASSIFICATION of NERVE INJURIES Traumatic, Acute brachial plexitis
SEDDON’S CLASSIFICATION S/Sx: Flex & Abd limited to 90°, Medial winging of
Neuropraxia Axonotmesis Neurotmesis scapula
- Intact axon - (+) Axon injury but - (+) Interruption of 2) SUPRASCAPULAR N. INJURY
- (+) Conduction surrounding axon Cause: Fx of scapula, Compression at Suprascapular
Block structures intact - (+) Conduction fail notch or Spinoglenoid notch
- N. compression - (+) Conduction fail - (+) Wallerian - Innervates supraspinatus & infraspinatus
- Good prognosis - (+) Wallerian degen. (Nerve S/Sx: AbER weakness, Tenderness over suprascapular
(Healing in 1-2mos degen. (N. crush) transection)
notch
in 3-4wks) - Good prognosis - Poor prognosis
3) AXILLARY N. INJURY- deltoid & teres minor
- Problem in myelin (Rate of regen: 1- even c surgery
sheath, (-) Atrophy 2mm/day) - (+) Aberrant Cause: Ant. Sh dislocation, Humeral neck fx
- Thick Myelinated - Myelinated motor recovery (incomp. S/Sx: AbER weakness, Sensory loss over deltoid area
motor n. & sensory n. recovery) 4) MUSCULOCUTANEOUS N. INJURY- biceps, brachialis,
coracobrachialis
SAUNDERLAND CLASSIFICATION Cause: Humeral shaft fx, Forceful elbow flex
I Conduction Block S/Sx: Elbow flex & sup weakness, Sensory loss over radial
II Axonal damage only aspect of FA
III Axon + Endoneurium 5) SPINAL ACCESSORY N. INJURY- SCM & trapz
IV Axon + Endoneurium + Perineurium Cause: Radical neck & Cervical lymph node dissection
V Axon + Endoneurium + Perineurium + Epineurium S/Sx: Lateral winging of scapula (Sliding door paralysis),
Depressed Sh, Sh shrug, flex, abd weakness
SPECIFIC LEVEL of ENTRAPMENT
I. ROOT LEVEL IV. IMPORTANT MONONEUROPATHIES
MOI: compression 1) MEDIAN NERVE
Cause: Herniated disc (MC), Fx, Spondylolisthesis, > Ligament of Struthers/Supracondylar synd
Spondylosis > Pronator Teres
Manifestation: Sharp shooting pain, Radiating pain > Lacertus Fibrosus/Bicipital Aponeurosis
II. TRUNK LEVEL > Sup & Deep heads of Pronator Teres
1) TOS- compression of neurovascular structures > AIN- FDP, FPL, PQ
- Lower trunk (C8-T1), Subclavian A. (BS to UE) > FCR & PDS
Sites: between 1st Rib & Clavicle (Costoclavicular synd) > Palmar Cutaneous branch- cutaneous sensation of
between Ant & Mid scalenes (Scalenus Anticus) thenar eminence
at the Pecs minor (Hyperabduction synd) > Carpal Tunnel Syndrome
S/Sx: Radiating pain, Paresthesia, Sharp bright lightning > OPB, APB, FPB, Lumbricals 1 & 2 (supplies 2nd-3rd digits)-
like pain cutaneous sensation of thumb, index, middle & lat. half
ST: Costoclavicular, Halstead, Adson, Roos, Allen, Wright of 4th finger
test “CHARAW” a) Carpal Tunnel Syndrome- MC peripheral neuropathy
2) PANCOAST TUMOR- compression of lower trunk of - MC site of median n. entrapment
brachial plexus 2° to Apical lung tumor (C8-T1 affected) Cause: Pregnancy, Repetitive trauma, Obesity, Lupus,
Manifestation: Horner’s synd, Radiating pain, Hypothyroidism, DM, RA, Assoc. c keyboarding or use
Paresthesia of vibratory tools
3) ERB DUCHENNE PALSY- excessive pulling or stretching S/Sx: Paresthesia/Tingling of thumb, index, middle &
during vaginal birth (Breech delivery) lat. half of 4th finger, Thenar weakness- atrophy
MOI: traction of upper trunk/root of brachial plexus (C5- (severe)= Ape/Simian hand, Aching pain in wrist & FA,
C6 affected) Nocturnal pain
- Waiter’s Tip deformity (weak ms: Sh abd & ER, Elbow Spared: Sensation in thenar eminence
flex, FA sup, Wrist ext) ST: Flick sign, Phalen’s test, Prayer sign

b) AIN/Kiloh Nevin Syndrome- pure motor neuropathy
- involves entrapment of median n. at the FA
- Compression of median n. at fibrous arch formed by
the PT & FDS
Cause: Repetitive FA flex/pron, Elbow/FA fx, Assoc. c
brachial neuritis
S/Sx: Weak FDP, FPL, PQ, Aching pain in FA/elbow
ST: Pinch grip test= (-)ok sign, (+)pulp to pulp
c) Pronator Syndrome- entrapment of median n. in ff:
- between heads of PT head
- beneath the fascial band of FDS
- beneath the bicipital aponeurosis/lacertus fibrosis
Cause: Trauma from tight casting & overuse synd, IV
catheter, Repeated forceful ctxn of PT
S/Sx: Aching pain in volar aspect of FA, Flexor wrist &
thenar ms wasting, Clumsiness & loss of dexterity,
Hand numbness worsened by repeated FA pron
Spared: Pronator Teres
d) Entrapment of MN by Ligament of Struthers
S/Sx: All ms innervated by MN are affected, Sensory
loss/Paresthesia/Numbness along the sensory
distribution of MN
2) RADIAL NERVE
> Supplies Triceps, Anconeus, ECRL, Brachioradialis
> Sensory: Post. arm, Lateral Inf. arm & SBRN
> Superficial Branch- sensory after spiral groove; for
Dorsum of Hand
> Deep Branch/PIN- motor; Supplies ECRB, Supinator, ECU,
Ext. Digitorum, EDM, APL, EPB, EPL
a) Crutch Palsy- entrapment of RN at axillary region
Cause: Improper use of crutch
S/Sx: All ms innervated by RN are impaired, Sensory loss/
Numbness over post. arm, post. FA, dorsolateral hand &
dorsal aspect of digits (1-4), (+)wrist drop
b) Saturday Night/Honeymoon’s/Bride’s Groom/
Tourniquet palsy- entrapment of RN at spiral groove
Cause: External compression from tourniquet, Persistent
pressure from a sleeping partner’s hand over the Pt’s
outstretched hand, Occur when Pt’s hand is draped over
a period of time
S/Sx: Impairment of all ms innervated by RN, Sensory
loss/ Numbness over post. FA, dorsal hand & dorsal
aspect of digits 1-4, (+)wrist drop
c) PIN syndrome- entrapment of PIN at FA/elbow region
- Radial Tunnel/Supinator synd- compression of PIN at
Arcade of Frohse (MC site of entrapment in radial tunnel)
2° to Fx, tight cast, trauma
S/Sx: No sensory loss, Radial dev upon wrist ext, ECU &
Finger ext weakness
Motor spared: Triceps, Anconeus, ECRL, Brachioradialis
d) Cheiralga Paresthetica- aka Hand cuff/Wristwatch/Sup.
RN palsy- entrapment of Sup. RN at wrist
Cause: Tight bracelet, Tight wristwatch, Handcuff
neuropathy, Scaphoid Fx
S/Sx: Sensory loss/Numbness over dorsolateral hand &
dorsal aspect of digits 1-4
3) ULANR NERVE
> Superficial layer (sensory) & Deep layer (motor)
> Palmar Cutaneous (ventromedial hand) & Dorsal
Cutaneous (dorsomedial hand & post. aspect of little finger,
middle half of ring finger)
> Sup. Terminal branch- ant. aspect of little finger & medial
half of ring finger
> Supplies FCU, FDP (3rd-4th), Palmaris Brevis, Interossei,
Lumbricals (medial), FDM, ADM, OPM, Add. Pollicis, FPB
a) Ulnar Neuropathy at Elbow- entrapment of UN at ff:
- Ulnar groove (med. epicondyle + olecranon)
- Cubital tunnel (heads of FCU)- Cubital Tunnel synd
Cause: Repetitive elbow flex, Gripping, External pressure
to ulnar groove
S/Sx: Impairment of all ms innervated by UN, Sensory
loss/Numbness along UN sensory distribution
b) Ulnar Tunnel Syndrome- aka Guyons’s Canal synd/
Handlebar/Jackhammer palsy- entrapment of UN at
guyon’s or pisohamate canal
Cause: Wrist ganglion, RA, ↑p° to medial side of wrist
S/Sx: Weakness of Palmar Brevis & All ms innervated by
deep branch of UN, Sensory loss/Numbness over ant.
aspect of little finger & medial half of ring finger
4) LFCN INJURY/MERALGIA PARESTHETICA/BERNHARDT
ROTH SYNDROME- benign & self-limiting; Idiopathic
- Assoc. c pregnancy, diabetes & obesity
- Other sources of compression: wearing tight waistbands,
habitual leaning against table, heavy toolbelts
S/Sx: Pain/Numbness/Paresthesia over anterolateral
aspect of thigh
5) PERONEAL NERVE INJURY- sites of compression:
a) Fibular head- causes: cast, prolonged squatting, tight
stocking, fibular head fx*, crossing legs for long period of
time, improper bed pos’n
S/Sx: DF & Eve weakness, Foot slap during HS, Foot drop
(steppage gait), Sensory loss/Numbness over dorsum of
foot & ant. leg region
b) Extensor Retinaculum- Ant. Tarsal Tunnel syndrome-
entrapment of deep peroneal n. 2° to trauma
S/Sx: Weakness of EHB & EDB, Sensory loss/Numbness
over 1st dorsal web space
6) TIBIAL NERVE INJURY- sites of compression:
a) Popliteal Fossa- d/t Baker cyst, Too much seat depth
S/Sx: PF & Inv weakness, Loss of sensation/Numbness of
sole of foot & along sural distribution
b) Flexor Retinaculum- Tarsal Tunnel syndrome
Cause: Trauma, Ganglion cyst, Lipomas
S/Sx: Weakness of Intrinsic ms, Sensory loss/Numbness
in sole of foot
*Impingement of Medial Plantar Nerve- Jogger’s Foot-
commonly seen among runners c flat feet or pronated foot
S/Sx: Weakness of FHB, Abd Hallucis, FDB & 1st Lumbrical,
Sensory loss/Numbness in calcaneus
7) FEMORAL NERVE INJURY- entrapment of FN within
Retroperitoneal space in pelvis & under inguinal ligament
 Cause: Ant. hip d/L, Trauma, Retroperitoneal hematoma 2°
to anticoagulation, Lithotomy pos’n c extreme flex & ER
S/Sx: Knee ext weakness 2° to quads affectation (fwd trunk
leaning), ↓/Absent knee jerk, Groin pain, Sensory loss/
Numbness in anteromedial thigh & leg along saphenous
distribution

8) SCIATIC NERVE INJURY- Injection Palsy, Piriformis

syndrome, Fat wallet syndrome
Cause: Poorly placed injections, Femoral Fx, Post. Hip d/L,
THA injury, Space occupying lesion such as hematoma,
tumor & HO
S/Sx: All peroneal & tibial innervated ms are impaired, All
cutaneous sensation mediated by peroneal & tibial n. are
also impaired

9) OBTURATOR NERVE INJURY- aka Obstetric Palsy

Cause: Child birth
S/Sx: Weakness of hip add, Sensory loss/Numbness in
middle medial thigh