Peripheral Nerves

The A to Z of

Dr A. L. Neill
BSc MSc MBBS PhD FACBS medicalamanda@gmail.com

Send your expressions of interest and pre-orders to: medicalamanda@gmail.com Anatomy update or aspenpharmacare supportive site for feedback and suggestions and other supportive material: http://www.aspenpharma.com.au/atlas/student.htm

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The A to Z of the Brain (Coming next!) The A to Z of Surface Anatomy The A to Z of Hair, Nails & Skin The A to Z of the Heart & Circulation The A to Z of the GIT The A to Z of the Organs The A to Z of Histology & Histopathology The A to Z of Emergency Medicine The A to Z of Anatomical Exercising The A to Z of Imaging & Radiology The A to Z of the Special Senses

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The A to Zs... Soon to be released!

The A to Z of Peripheral Nerves

Introduction

Acknowledgement

Thank you ASPENpharmacare Australia: Mr Greg Lan CEO, and all those who helped in the contribution of this edition and in the feedback of the other books in this series. Special thanks to Ante Mihaljevic of TM grapic design, who has assisted greatly with this new edition.

Dedication

To the fates, may they forgive me.

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Other A to Zs

The A to Z of Anatomical, Medical and Histological terms The A to Z of Bones, Joints and Ligaments and the BACK The A to Z of the Head and Neck The A to Z of Skeletal Muscles

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This book is particularly useful for those working in rehabilitation medicine, neurology ergonomics, trauma and accident victims. It use extends to those assessing and treating nerve damage from whatever causes, where a good understanding of both the nerve root and the peripheral nerve damage and the resulting loss of function and/or sensory deficit is essential. The alphabetical listing of each nerve with its muscle and sensory functions as well as the signs and causes of loss of the nerve facilitates quick summary and knowledge retrieval.

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The A to Z of Skeletal Muscles was the first of the A to Zs - a series of medical pocket reference books listing structures alphabetically so the book is its own index. They have proved to be invaluable tools for the medical practitioner and student alike, and I received some very helpful feedback and requests for more in the series. The size, binding, practicality of knowledge retrieval as well as the colours have all had very positive feedback and so have been maintained. This book, and ties in with the other publications and each are extensively cross referenced. In particular, although a complete volume, this book ties in with the soon to be released the A to Z of the Brain, which will incorporate the Brain, Cranial Nerves, Neural pathways and Spinal Cord.

The A to Z of Peripheral Nerves

How to use this book

PNs may be known by several names and these, as far as possible, have been cross-referenced so that the nerve may be found with minimal knowledge of its spinal roots or regional origin. It is hoped that this will prove a valuable resource for those examining individual nerves and multiple nerve lesions as in the study of ANATOMY and its many uses. As with all the A to Zs any suggestions on format or inclusions will be gratefully received. Thank you

Amanda Neill

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BSc MSc MBBS PhD FACBS

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The beginning of the book demonstrates the main micro-anatomical (histological) components of the nervous system alphabetically in the same format. Components of the basic spinal nerve (SN) structure are outlined and summarized. The Spinal Roots, Rami, and other components including, where applicable the nerve plexi (NP) are all listed for each nerve, along with lesions of loss or damage and the commonest event or trauma causing damage to the nerve described, generally on the opposite page of each diagram as well as listing of the key/legend to that diagram.

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This book is an alphabetical listing of all the peripheral nerves (PN). It excludes the cranial nerves (CN) and the autonomic nervous system (ANS). It contains diagrams of their pathways sensory and motor supply and can be cross-referenced with the A to Z of Skeletal Muscles, the A to Z of Bones, Joints and Ligaments and the A to Z of the Head and Neck as it lists all muscular and articular branches. It will be cross referenced with the A to Z of the Brain and the A to Z of Topographical/Surface Anatomy (the cutaneous branches) and the A to Z of Radiology and Imaging (boney components involved).

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Table of contents
Introduction Acknowledgement Dedication How to use this book Table of contents Abbreviations Common Terms used in Neurology The Nervous System - and its components Nerve cells - and their components Structure and Substructure of Skeletal Muscle Neuromuscular junctions = Motor end plate Neuromuscular spindle = muscle stretch receptor Neurotendinous spindle = tendinous stretch receptor The Spinal Nerves Nerve trunk and Peripheral Nerves Guide to Anatomical Planes and Relations Anatomical Movements Neurological examination Peripheral nerve examination Examination of other sensory deficits Examination of Reflexes Key to Muscles and their SN roots Map of Sensory innervation The Peripheral Nerves – index and regional key Root of the Neck The Brachial plexus - overview The Cervical plexus - overview The Peripheral Nerves 1 1 1 2 3 4 6 11 13 15 17 19 19 21 25 27 29 31 35 47 49 51 53 59 63 65 69 73

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Abbreviations

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A A adj. aka alt. AM ANS ant art AS

= actions /movements of a joint = anterior = adjective = also known as = alternative = arachnoid mater = autonomic nervous system = anterior = articulation (joint w/o the additional support structures) = Alternative Spelling, generally referring to the diff. b/n British & American spelling BBB = blood brain barrier bc = because BP = brachial plexus BS =blood supply b/n = between C = cervical / carpal c.f. = compared to CN = cranial nerve CNS = central nervous system Co = coccygeal CoP = coccygeal plexus collat. = collateral CP = cervical plexus Cr = cranial CSF = Cerebrospinal fluid CT = connective tissue DH = dorsal horn (of the spinal cord) dist. =distal DM =dura mater e.g. = example EC = extracellular (outside the cell) ext. = extensor (as in muscle to extend across a joint) fl. = flexor (as in muscle to flex across a joint) Gk. = Greek GM = grey matter IC = intracellular / intercostal IC = intercarpal IMC = intermetacarpal jt(s) = joints = articulations L = lateral
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L LL Lt. lig M MC med MN nMN N NS NT NTr P P PaNS pl. PM PN post. proc. prox. R RC S sing. Sc SC SN SP SyNS T TP UL V VB VC VH WM w/n w/o &

= left / lumbar = lower limb = Latin = ligament = mater = metacarpal = medial =myelinated nerve = non-myelinated nerve = nerve = nervous system/nerve supply = nervous tissue = nerve tract / trunk = plexus = posterior = parasympathetic nervous system = plural = pia mater = peripheral nerve = posterior = process = proximal = Right = radiocarpal = sacral = singular = spinal canal = spinal cord = spinal nerve = spinous process = sympathetic nervous system = thoracic = transverse process = upper limb, arm = vertebra = vertebral body = vertebral column = ventral horn (of the spinal cord) = white matter =within = without = and

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Common terms in Neurology
Action potential Aetiology Afferent Anasthesia Ansa Ante Aperture Articulation Association fibres Astrocytes Axial Axon Axon collaterals Basilar Basiocranium Bipolar Blood brain barrier Canal

Carotid Cavity bones

Caput Cephalic Cerebrospinal fluid

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Commissural fibres Commisure Condyle Cranial Nerve (CN) Cranium

Chiasma Cochlea

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relating to the base or bottom of structures bones of the base of the skull neurons with 1 dendrite + 1 axon (see unipolar, multipolar) = BBB the barrier protecting the brain from certain substances found in the BS

tunnel / extended foramen as in the carotid canal, at the base of the skull adj canular (canicular - small canal) to put to sleep; compression of the common or internal carotid artery causes coma. This refers to bony points related to the carotid vessels an open area or sinus w/in a bone or formed by two or more (adj. cavernous), may be used interchangeably with fossa. Cavity tends to be more enclosed fossa a shallower bowl like space (Orbital fossa-Orbital cavity). relating to the skull pertaining to the head = CSF fluid - fluid surrounding the brain and SC formed by the ependymal cells from filtered blood. It is part of the BBB, and contains sugar, urea and protein - approx 125mls and flows around the brain and SC at any time. (Gk = X) used for the crossing of the Optic fibres a snail hence snail-like shape relating to the Organ of Corti in the middle ear (adj. cochlear) those N fibres crossing the Median plane (e.g. anterior commisure) a decussation or crossing of large groups of fibres a rounded enlargement or process possessing an articulating surface. N coming directly from the brain not the SC the cranium of the skull comprises all of the bones of the skull except for the mandible., adj. cranial pertianing to the skull cranial nerves comnig out from the skul directly from the brain as opposed to the SC for spinal nerves. 6

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the generation of a N impulse through stimulation and depolarizing of the N cell membrane the cause of ...the study of causes of illnesses of deficits incoming - as with sensory fibres see Sensory loss of sensation a loop like structure before , in front - anterior = ventral as in anterior horn = ventral horn an opening or space between bones or within a bone. joint, which is a point of contact b/n 2 opposing bones / relating to a joint. - hence articular branches of a nerve supply the joint described. those N fibres (artic- = arthro-) which connect cortical areas of the brain ipsilaterally (as opposed to commissural fibres) hold neurons together, and repair their membranes (see Glia) refers to the head & trunk (vertebrae, ribs & sternum) of the body. N process carrying material away from the cell body to the target organ, each neuron has only one axon branches of the axon

The A to Z of Peripheral Nerves Crest Cutus Decussation Dendrite dendro Depolarization Dermatome Dislocation Dermatome Distal Dorsal Efferent Endocranium Endoneurium Epineurium Prominent sharp thin ridge of bone formed by the attachment of muscles particularly powerful ones eg Temporalis/Sagittal crest skin - hence cutaneous branches refer to the nerves supplying the skin and adnexae a crossing of nerve fibres inside the CNS nerve process bringing communication to the cell body (from = tree, bc of the tree-like shape of the dendrites). the loss of the potential across the cell membrane of a N due to stimulation and formation of a N impulse (see repolarization) the cutaneous innervation of a SN a displacement of any part particularly of bone = luxation /partial dislocation = subluxation the cutaneous distribution of the Spinal nerve root further away from the axial skeleton (opposite of Proximal) to the back from dorsum -back (= posterior, as in dorsal horn = posterior horn)

Ependymal cells

Extradural space Fascicle Foramen Fornix Fracture Funiculus Ganglion

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collection of N cell bodies outside the SC (also isolated islands of N cells w/n in the white matter of the brain) (from ganglia = swelling) Glia / Glial cells associated supporting cells of the NS connective tissue and immune functions, types: astrocytes, oligodendrocytes, ependymal cells and microglia Grey Matter (AS Gray) N tissue in the brain and SC which contains mainly N cells, dendrites unmyleinated axons and glial cells (opposite to White matter which contains mainly myelinated axons) Groove long pit or furrow Gyrus a circle, hence a coil of brain cortex. projection of grey matter in the SC (anterior and posterior horns are for motor and sensory Ns respectively) - also called dorsal and ventral horns respectively © A. L. Neill

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outgoing as in Motor nerves - see Motor refers to the interior of the “braincase” adj. endocranial divided into the 3 major fossae anterior (for the Frontal lobes) middle (containing Temporal lobes) and posterior (for the containment of the Cerebellum). innermost of the CT coverings of a PN fibre (see neurium, perineurium and epineurium) outermost of the CT coverings of a PN fibre (see neurium, perineurium and endoeurium) line the ventricles and the central canal of the SC (see Glia) form the CSF space external to the Dura mater but w/n the skull or boney canal of the SC

bundle, as in bundle of fibres in each PN there are a number of fascicles of nerve fibres a natural hole in a bone usually for the transmission of blood vessels and/or nerves.(pl. foramina). an arch = #, broken bone cord-like structure (generally on the surface of the brain)

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The A to Z of Peripheral Nerves Impulse Inter Interneurons Intra Introitus Lacerum Lacrimal Lambda Lamina Leminiscus Lesion Linea Locus Lumbar Magnum Medulla Meninges a depolarization of the N membrane resulting in the promulgation of a signal along the N process. between act between motor and sensory neurons in a reflex - transferring the signal from the sensory to the motor w/o higher imput within an orifice or point of entry to a cavity or space. something lacerated, mangled or torn eg foramen lacerum small sharp hole at the base of the skull often ripping tissue in trauma. related to tears and tear drops. (noun lacrima) from the Greek letter a capital ‘L’ and written as an inverted V.(adj. lambdoid) and used to name the point of connection between the 3 skull bones Occipital and Temporals. a plate as in the lamina of the vertebra a plate of bone connecting the vertical and transverse spines (pl. laminae) ribbonlike, flat band of N fibres (e.g. medial leminiscus) deficit or injury - lack of function arising from this pathology a line as in the Nuchal lines of the Occitipum a place (c.f. location, locate, dislocate). pertaining to the back particularly the lower back as in lumbago pain of the lower back.

Microglia Mixed N

Motor / motor N Multipolar Myelin

Myotome

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large pl magna middle coverings of the brain and SC made up of 3 layers - Dura (hard) mater on the outer to protect the NT; Arachnoid (spidery) mater in the middle to support the BS and Pia (soft) mater, the inner coating to coat the NT and act as a barrier to foreign substances. CSF flows b/n the inner 2 coverings. phagocytic cells of the NS (see Glia) a nerve containing both sensory and motor components most peripheral Ns are mixed causes muscle contraction. these Ns are efferent or moving away from the SC referring to a neuron which has many dendrites + 1 axon (see unipolar, bipolar) the phospholipids produced by Schwann cells to insulate the axons of PNs and allow impulses to travel for longer and faster to the target organ the muscular innervation of a SN N cell (neuron) capable of transmitting or firing off a signal caused by ion transfer - excitable cell N process - generally Axon carrying the impulse to the skeletal muscle site general term meaning either the neuron(s), process(es) or part of a bundle of neurons, either cranial, spinal or peripheral layers of Schwan cell membranes coating axon processes general term for the CT covering of a PN fibre (see endoneurium, perineurium and epineurium) refers only to the braincase of the skull. Nerve cell 8

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The A to Z of Peripheral Nerves Neurotransmitter Nucha Occiput Oligodendrocytes Pars Pathway Perineum Perineurium Peripheral N (PN) Peroneal Plexus Polarization Posterior Process substances in vacuoles at the foot of the nerve process which are released to induce a nerve impulses or in response to a nerve impulse. The nape or back of the neck adj.- nuchal.

The prominent convexity of the back of the head Occipitum = Occipital bone adj. occipital. in the CNS only, become Schwann cells in the PNS and SC, act as a barrier and insulator of axons and neurons.

Projection fibres Propioception Proximal Pure N Ramus Reflex

Refractory period Repolarization impulse Resting potential

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A part of. General term indicating a path of defined N fibres. body cavity inferior to the the pelvis adj perineal -pertaining to the perineum. middle of the 3 CT coverings of a PN fibre (see neurium, perineurium and epineurium) coming from the SC, - often the combination of 1 or moreSNs or part thereof and not the brain directly (cranial N) see Spinal N pertaining to the lower leg - particularly the Fibula. knot - a knot or web of nerves. pl plexi - from tangle or network as in brachial plexus or tangle of nerves involved in the innervation of the arm. the maintenance of an unequal charge across the membrane of the N, allowing the cell to be stimulated - all excitable cells have a polarized membrane. behind, at the back often used interchangebly with dorsal. A general term describing any marked projection or prominence as in the mandibular process, in neurology the nerve process either Dendrite or Axon depending upon the direction of the NI. axons which connect the Cerebral cortex with the Brainstem or SC sense of position of the body particularly the limbs or digits in space. closer to the axial skeleton (opposite of distal) a N which is either only sensory or motor not both (as in mixed N)

branch pl. Rami/branches - 2 main branches Ventral supplying all structures in front of the SC and Dorsal supplying al structures behind the SC - the Rami are mixed N referring to the Reflex arc of sensory impulse - going to the SC and causing a motor or efferent response w/o imput from the brain or other higher centres. time b/n depolarization and repolarization, where the N cannot be restimulated in part to stop the impulse from traveling in both directions. restoration of the resting potential after transmission of a N (see depolarization, polarization). the charge difference across the cell membrane of the N created by ionic imbalance. Elevated bony growth often roughened. the segment(s) of origin of the PN from the SN. N roots are pure either motor or sensory and made up of several rootlets arising directly from the dorsal or ventral horns of grey matter in the SC.

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The A to Z of Peripheral Nerves Sagittal Sensory Schwann cells Spinal Cord (SC) Spinal Nerve (SN) Spine Splanchocranium Stimulation Subdural space Subluxation Sulcus Sulcus Sural Suture an arrow, the sagittal suture is notched posteriorly, making it look like an arrow by the lambdoid sutures; the anatomical plane from anterior to posterior pertaining to input - which goes to the SC and then to the brain &/or reflex cells supplying phospholipid coat - insulation to the axons to preserve the N impulse in the PNS - role of the oligodendrocytes in the CNS. Extension of the brain protected by the VC, PN come from here N coming directly from the SC not the brain a thorn adj. - spinous descriptive of a sharp, slender process/protrusion. the splanchocranium refers to the facial bones of the skull. events which lead to the formation of a N impulse. space beneath the Dura mater external to the Arachmoid mater partial dislocation, particularly in the VC, term used to explain any mechanical impediment to nerve function. long wide groove often due to a BV indentation –space b/n the gyri of the grey matter in the brain long wide groove often due to a BV indentation. pertaining to the lower leg. The saw-like edge of a cranial bone that serves as joint between bones of the skull. the gap at the joining of N and nerve process, N and N, process to process or N and muscle for transmission or inhibition of an impulse via neurotransmitters - presynaptic before the synapse (where the neurotransmitter is released) / post synaptic after the synapse (where the neurotransmitter is received).

Synapse

Telodendria Temporal Thorax Tract Trunk

Ventral White matter

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axon terminal branches refers to time and the fact that grey hair (marking the passage of time) often appears first at the site of the temporal bone. relating to the chest area adj thoracic. vertical columns of axons, generally myelinated in the SC &/or brain when SNs join together as large combined large Ns to supply specific anatomical regions (e.g. BP) but again must re-organize to become PNs to the front, used interchangeably with anterior, relating to the chest N tissue which consists mainly of myelinated axons (see Grey matter)

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The Nervous system

In the PNS the Ns form 2 separate divisions the voluntary and the autonomic (ANS). The ANS is made up of the Sympathetic exiting from the thoracic region and Parasympathetic Ns, depending upon the region of the SC, and these nerves may travel with the PNs.

PROTECTIVE COVERINGS BRAIN

CENTRAL NERVOUS SYSTEM = CNS

BONEY = SKULL CONNECTIVE TISSUE = MENINGES

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SPINAL CORD = SC

BONEY = VC

CONNECTIVE TISSUE = MENINGES

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PERIPHERAL NERVOUS SYSTEM = PNS ANS CRANIAL NERVES (1-12) SPINAL NERVES = SNs

The nervous system is made up of: the CNS = Brain + SC, the PNS = Ns exiting from the CNS - CRANIAL directly from the brain (12 PAIRS) and from the SC (31 PAIRS), the protective coverings of the tissue are made up of - connective tissue the MENINGES of which there are 3 layers, the outer or DURA MATER and the inner often fused 2 layers THE ARACHNOID & PIA MATERS for the diffusions of CSF and blood around the Brain and SC, and boney coverings, the Skull around the brain and the vertebral column (VC) around the SC.

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The Nerve Cells

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nucleus and nucleolus dendrites neurilemma - protective myelin sheath from Schwann cells axon terminal branches / telodendria nodes of Ranvier axon and base of axon - axon hillock N cell body plasma with neurofibrils, Nissl bodies, mitochondria, Golgi & ribosomes presynaptic membrane synaptic vesicles neurotransmitter synaptic cleft postsynaptic membrane on dendrite or N cell body myofibril of skeletal muscle sarcolemma - cell membrane of the skeletal muscle cell sarcoplasm - plasma of the skeletal muscle cell subneural clefts mitochondria muscle end plate

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The basic functioning cell of the NS is the NEURON(E) = NERVE CELL. Most are multipolar meaning that they have multiple dendritic (2) processes, which feed impulses into the nerve cell body (7). All neurons only have one axon (6), taking an impulse away from the cell body. They may be insulated on their axons so that the nerve impulse can travel faster and longer by a myelin sheath (3) a white phospholipid material, produced by the Schwann cell - a connective tissue cell which supports the N and protects it from outside influences. The impulse terminates on to the target organ - generally skeletal muscle in the PNS via a neuromuscular junction located in the muscle-end-plate (18), or on another N via a synapse.

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A band - myosin to myosin filaments H band – myosin only segments minimum in contraction I band - actin only segment maximum in relaxation Z line - line of attachment of the actin filaments

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muscle eg. Biceps epimysium surrounding a whole muscle perimysium surrounding a muscle fascicle endomysium surrounding each muscle fibre muscle fibre nucleus (note the muscle cell is multinucleated) sarcolemma around each myofibril myofibril sarcomere basic contractile unit of the muscle myosin filament actin filament

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Structure and Substructure of Skeletal muscles

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Neuromuscular Junction –
Nerve end attaching to Skeletal muscle
1 axon - sheathed 2 mylein sheath – multiple lipid layers 3 Schwann cell 4 axonlemma – axon membrane 5 pre-synaptic vesicles 6 axon – unsheathed / naked 7 presynaptic membrane 8 junctional folds (in sarcolemma) 9 synaptic cleft (~20nm) 10 mitochondria 11 sarcolemma 12 myofilaments in muscle fibre

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longitudinal

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Neuro-Muscular Spindle –

Neuro-Tendinous Spindle –
feedback loop to tendon

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1 capsule of spindle 2 myelinated motor fibres 3 myelinated sensory fibres 4 unmyelinated motor fibres 5 annualospiral fibre endings 6 bag of nuclei in intrafusal muscle 7 motor end plates 8 muscle fibres i = intrafusal e = extrafusal 9 skeletal muscle nuclei 10 tendon fibres i = intrafusal e = extrafusal 11 naked axons 12 nuclei in tendon

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feedback loop to stop overextension in Skeletal muscle

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The Spinal nerves (SN) = NERVES which come from the spine cord (SC)
There are 31 pairs of Spinal nerves that branch off the SC. Cervical Thoracic Lumbar Sacral Coccygeal 1 2 3 4 5 6 7 8 9 10 11 12 13 8 (Nerve - C2 exits b/n vertebrae C1 & C2 and - nerve C8 b/n vertebrae C7 &T1) 12 (Nerve T4 exits b/n vertebrae T4 & T5) 5 (Nerve L3 exits b/n vertebrae L3 & L4) 5 1

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cervical enlargement of SC Cervical plexus (CP) Brachial plexus (BP) containing : Auxillary, Radial, Musculocutaneous, Median, and Ulnar Ns Intercostal Ns - thoracic Ns Lumbar enlargement of the SC Cauda equina Lumbar plexus (LP) Sacral plexus (SP) Cervical Ns C1-8 Thoracic Ns T1-12 Lumbar Ns L1-5 Sacral Ns S1-5 Coccygeal Ns C1

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The A to Z of Peripheral Nerves Each SN has a dorsal (pure sensory) and ventral (pure motor) root coming from the SC. The dorsal roots convey messages to the SC via the dorsal root ganglion and ventral roots take impulses away from the SC to the target organ, w/o synapse. After leaving the SC the “pure” nerves JOIN together to form a PERIPHERAL NERVE (generally a mixed nerve), which then re-splits to form VENTRAL and DORSAL RAMI (branches).

The roots of the PNs are named from exit points of each SN which joins together to make up the PN. These Ns interact with the ANS, via peripheral ganglion.

The basic structure of all SN is similar and they are classified as cervical, thoracic, lumbar, sacral and coccygeal depending upon from which region of the SC they exit. Reflex arcs only involve the loop of sensory imput from the dorsal root to the outflow of the ventral roots, bypassing the higher centres, so may remain intact with complete severance of the SC or brain damage. Diagrams represent the SC in the VC to show proportion and surrounding structures, as well as regions within the SC; a typical SN of the thoracic region with its segmental branches; and a general SN arrangement and pathways, including convergence with visceral afferents and efferents. The effects of this are seen in the sites of referred pain (p57). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 white matter sympathetic afferent and efferent communicating rami sympathetic ganglion vertebral body of the VC PN mixed N ventral root - pure motor dorsal root - pure sensory SC - meningeal coverings continue from the brain Nerve cell bodies / Grey matter posterior root ganglion - on the dorsal root SN which branches to form ventral and dorsal branches white matter - lateral column anterior horn of Grey matter in SC white matter - anterior column anterior median fissure central canal lateral horn - of grey matter white matter posterior column ventral ramus transverse process reflex arc mediastinal structures and BVs dorsal ramus cutaneous branches lateral cutaneous branch of the PN with their anterior and posterior terminal branches to supply skin in the region muscular branches to supply the regional muscle anterior cutaneous branch to supply skin in medial area viscera or organs and BS cutaneous afferent meet with visceral afferent travelling together as in referred pain sites.

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Nerve trunk and Peripheral Nerves

Cross section Longitudinal section

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1 epineurium - surrounding the trunk or large PN 2 perineurium - surrounding the PN and individual fascicles 3 endoneurium covering each process/in the fascicle 4 connective tissue 5 BVs 6 PN 7 feeding BV 8 extrinsic BV 9 oblique perforating BV 10 feeding BV

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A N trunk consists of several PNs travelling together and forming a Nerve structure which forms and reforms as a plexus eg the BP These Ns may be mixed containing sensory and motor Ns. They are surrounded by a protective CT covering, the epineurium, which carries the BVs and lymphatics. The perineurium surrounds individual PN fascicles and endoneurium surrounds the N processes. The vessels perforate the coverings to supply the N tissue and supporting tissues. Axons are further protected by Schwann cell insulating layers. Loose CT cushions and insulates the PNs w/in the trunk. As observed in referred pain patterns there may be overlap b/n PNs particularly in the same N tract.

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Guide to Anatomical Planes and Relations
This is the anatomical position.
A = Anterior Aspect from the front Posterior Aspect from the back used interchangeably with ventral and dorsal respectively B= Lateral Aspect from either side C = Transverse / Horizontal plane D= Midsagittal plane = Median plane; trunk moving away from this plane = lateral flexion or lateral movement moving into this plane medial movement; limbs moving away from this direction = abduction; limbs moving closer to this plane = adduction E = Coronal plane F = Median

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Anatomical Movements

Hip flexion

Hip extension

Hip abduction

Hip lateral and medial rotation

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Hip adduction Knee extension

Hip circumduction

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Foot dorsiflexion

Foot inversion

Foot normal position

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Fingers adduction

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Foot plantar flexion Fingers flexion Hand deviation radial/laterally ulna/medially Thumb opposition

Foot eversion

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Neurological examination General Considerations
When examining the neurological patient - look for: ASYMMETRY muscle wasting, hypertrophy, fasciculation DEFORMITY limbs held in a strained position / uneven posture TONE CHANGES IN THE LIMBS hyer-reflexia / spasticity / resistance to passive movement hypo- tonia / flaccidity

hyper-reflexive limbs will react to any sudden passive movement lifting the thigh suddenly will cause the leg to extend spontaneously dorsiflexing the ankle will cause jerky resistance - CLONUS

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Check for Brain or upper motor neurone problems before examining the PNs
TEST FOR PYRAMIDAL WEAKNESS damage to the motor cortex in the brain or the descending tracts

when the patient closes their eyes they cannot maintain the position of the outstretched arm - it will - ABDUCT, PRONATE & DROP (DOWN, OUT AND ROUND ABOUT !!)

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TEST FOR CEREBELLAR WEAKNESS (also as in DRUNK !!) incoordination - ATAXIA
patient demonstrates dysmetria (intention tremor) and dysdiadochokinesia (inability to repeat simple movements rapidly) as in: finger nose touching rapid supination and pronation in the upper limb

or tapping feet on the floor / running the heel of one leg down the shin to the big toe of the other patients cannot stand still without help even with their eyes open (if

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TEST FOR UPPER MOTOR NEURONE DISEASE BABINSKY reflex stroke the sole of the foot normal - foot will flex abnormal - foot will extend, knee will flex and leg will lift

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Peripheral nerve examination

RADIAL NERVE

TRICEPS (C6-8) cannot extend arm against resistance

EXTENSOR DIGITORUM (C7-8) fingers cannot extend against resistance (also POSTERIOR INTEROSSEUS NERVE)

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EXTENSOR POLLICUS LONGUS AND BREVIS (C7-8) thumb cannot extend against resistance (also POSTERIOR INTEROSSEUS NERVE)

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BRACHIORADIALIS (C5-6) from mid position - arm cannot flex against resistance

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MEDIAN & ULNAR NERVES

FLEXOR DIDGITORUM PROFUNDUS (C7-8) fingers cannot resist extension when flexed (both Ns)

OPPONENS POLLICIS (C8-T1) thumb cannot touch hypothenar eminence - cannot oppose (Median N)

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FIRST DORSAL INTEROSSEUS + ABDUCTOR DIGITI MINIMI (C8-T1) fingers cannot abduct against resistance (ulnar N)

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LONG THORACIC NERVE

SERRATUS ANTERIOR (C5-7) scapula wings when patient pushes arms into their body

AXILLARY NERVE

DELTOID (C5-6) arm cannot abduct against resistance >15 degrees

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MUSCULOCUTANEOUS NERVE
BICEPS (C5-6) arm cannot flex against resistance

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INFERIOR GLUTEAL NERVE

GLUTEUS MAXIMUS (L5, S1-2) (supine) cannot extend hip - ie keep foot on table against resistance

SUPERIOR GLUTEAL NERVE

GLUTEUS MEDIUS, MINIMUS, TENSOR FACSIA LATA (L4-5) (supine) cannot abduct hip against resistance

OBTURATOR NERVE

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ADDUCTORS (L2-4) (supine) cannot adduct hip against resistance (keep legs closed)

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SCIATIC NERVE

HAMSTRINGS (L5, S1-2) knee cannot flex against resistance

FEMORAL NERVE

ILIOPSOAS (L1-3) cannot flex hip against resistance

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UADRICEPS (L2-4) knee cannot extend against resistance

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DEEP & SUPERFICIAL PERONEAL + TIBIAL NERVES
TIBIALIS ANTERIOR (L4-5) foot cannot dorsiflex against resistance (cannot walk on high heels) (Deep Peroneal)

GASTROCNEMIUS, SOLEUS (S1-2) foot cannot plantar flex against resistance (cannot walk on toes) (Tibial)

EXTENSOR HALLICIS LONGUS EXTENSOR HALLICIS BREVIS (L5-S1) toes cannot dorsiflex against resistance (Deep Peroneal)

TIBIALIS POSTERIOR (L4-5) foot cannot invert against resistance (Tibial)

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PERONEUS LONGUS PERONEUS BREVIS (L5-S1) foot cannot evert against resistance (supf Peroneal)

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EXAMINATION of other sensory deficits

move the joints of the fingers or toes up and down closing the patients eyes VIBRATION determination of deficit by lack of perception of vibration tuning fork vibrated over the joints of the fingers and toes

SENSORY INATTENTION determination of deficit by lack of detection of 2 pinpricks at once in different regions or on different limbs Pathology - these test are primarily used to detect peripheral neuropathy ± demyelinating diseases. If the pattern of deficit is distal with improvement on proximal movement ie as the examiner moves closer to body core it is most likely the former.

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An erratic pattern of deficit is more, likely to be a demyelinating disease.

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2 POINT DISCIMINATION determination of deficit by lack of detection of 2 pinpricks at once over increasing distances (normal - detection at 5mm)

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POSITION SENSE determination of deficit by lack of detection of change of position

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EXAMINATION OF REFLEXES

may be enhanced by asking the patient to clench their teeth.

MUSCULOCUTANEOUS NERVE

BICEPS JERK - (C5,6) strike Biceps tendon - positive Biceps contraction

RADIAL NERVE

SCIATIC NERVE

KNEE JERK - (L2,3,4) / QUADRICEPS strike Patella with flexed relaxed leg - positive knee flexion ANKLE JERK - (S1,2) TIBIALIS ANTERIOR externally rotate leg - dorsiflex foot strike Archilles tendon - positive plantar flexion of the foot.

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other reflexes ABDOMINAL REFLEXES - stroking of the abdomen on the supine patient towards the umbilicus causes a contraction of the abdominal muscles - often absent particularly in obesity, pregnancy, post surgery and with age. CREMASTERIC REFLEX - stroke the inner thigh - positive testicular elevation.
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SUPINATOR JERK (C6,7) strike lower end of radis - positive Elbow and finger flexion TRICEPS JERK (C7,8) strike above the Olecranon - positive Elbow extension HOFFMAN REFLEX -determination of general hyper-reflexia flick thumb on the terminal phalanx while extended - positive thumb flexion

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This is to determine if the neural pathway at the spinal level is intact even with higher level loss as in Upper motor neurone loss, brain damage or spinal transection, or if there is progressive loss at a spinal level without detection of higher level loss, as in peripheral neuropathy ± deymeliniating diseases .

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Key to Muscles and their SN root supply (ventral branch) - from cephalic to caudal

Muscles of the Axis of the body 1 2 3 4 Longus Capitus Longus Colli Infrahyoid muscles Diaphragm

Muscles of the Girdles of the Muscles of the Limbs UL & LL body (Pectoral and Pelvic) 5 6 7 8 9 10 11 12 13 14 15 Sternocleidomastoid Trapezius Levator Scapulae Rhomboids Pectoral muscles Subscapularis Serratus muscles (Ant = a /Post = b) Deltoid Teres muscles Latissimus Dorsi Supra & Infraspinatus muscles 16 17 18 19 20 21 22 23 24 25 26 27 28

46 Sphincters of the pelvis 35 Psoas muscles (urtherae & ani) 36 Pelvic and Gluteal 47 Muscles of the ant. muscles perineum 37 Obturator muscles 48 Levator ani & Ischiococcygeus

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29 Intercostal muscles, Subcostales, Levator Costales 30 Tranversus Thoracis 31 Oblique muscles 32 Rectus Abdominus 33 Transversus Abdominus 34 Quadratus Lumborum

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Coracobrachialis Biceps brachii Brachioradialis Supinator Triceps Ext Carpi Ulnaris Pronator muscles Flexor Carpi Radialis Ext Digitorum Flexor Digitorum Flexor Carpi Ulnaris Interossei & Lumbricals Short muscles of the thumb & little finger 38 Sartorius 39 Gracilis & the Adductors 40 Hamstrings (Semimembranous Semitendinous & Biceps femoris) + Quadriceps 41 Pectineus 42 Peroneal muscles 43 Ant. muscles of the leg 44 Post. muscles of the leg 45 Muscles of the foot

please note variations in the supply occur due to individual anomalies of N pathways and origins

The A to Z of Peripheral Nerves C1 1 ±2 3 ±5 C2 1 2 3 5 6 C3 1 2 ±3 4 5 6 7 8 9 C4 2 C5 C6 C7 C8

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37 38 39 40 41 ±42 ±43

35 36 37 38 39 40

35 36 37 40

42 43 S4

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S2 36 37

S3 ±36

42 43 45 S5

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4 5 ±6 7 8 9 10 11a 12 13

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MAP OF SENSORY INNERVATION -

ANTERIOR

DERMATOMES (SEGMENTAL) - cutaneous distribution of the N roots

Quick Guide for dermatome level T5 = NIPPLE T10 = Umbilicus T12 = Inguinal Ligament PERIPHERAL NERVES

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Greater Auricular N Supraclavicular Ns + Anterior cutaneous N of the neck Intercostal Ns anterior + lateral branches Axillary N Medial cutaneous N of the arm + forearm (brachial + antebrachial) 6 Inferior lateral cutaneous branches of the Radial N 7 Musculocutaneous N 8 Median N 9 Ulnar N 10 Iliohypogastric + Genitofemoral N 11 Ilioinguinal + Genitofemoral N 12 Lateral Femoral cutaneous N 13 Obturator N 14 Femoral N (ant. cut. branch) 15 Saphenous branch of Femoral N 16 Superficial Peroneal N 17 Deep Peroneal N 18 Tibial N 19 Greater Occipital N 20 Cutaneous branches of the Dorsal rami 21 Trigeminal N / ganglion 21i Ophthalmic N 21ii Maxillary N 21iii Mandibular N

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determination of deficit by paraesthesia or anaesthesia corresponding to N root or PN cutaneous distribution

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V1 V2 V3 C2 C3 C4 T2 T3 T4 T5 T6 T7 C5 T2 T1 C6 L1 S3 C 6 C C 8 7 L2 L3 L4 L5

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MAP OF SENSORY INNERVATION -

POSTERIOR

DERMATOMES (SEGMENTAL - cutaneous distribution of the N roots)

PERIPHERAL NERVES

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1 Greater Auricular N 2 Supraclavicular Ns + Anterior cutaneous N of the neck 3 Intercostal Ns anterior + lateral branches 4 Axillary N 5 Medial Cutaneous N of the arm +forearm (brachial + antebrachial) 6 Inferior lateral cutaneous branches of the Radial N 7 Musculocutaneous N 8 Median N 9 Ulnar N 10 Iliohypogastric + Genitofemoral N 11 Ilioinguinal + Genitofemoral N 12 Lateral Femoral cutaneous N 13 Obturator N 14 Femoral N (ant. cut. branch) 15 Saphenous branch of Femoral N 16 Superficial Peroneal N 17 Deep Peroneal N 18 Tibial N 19 Greater Occipital N 20 Cutaneous branches of the Dorsal rami

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determination of deficit by paraesthesia or anaesthesia corresponding to N root or PN cutaneous distribution

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C4 C5

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MAP OF SENSORY INNERVATION
mapping of the viscera -organs with sensory innervation, basis of referred pain sites.

REFERRED PAIN

Visceral afferents converge on the same neurones in the posterior horn. Patient perceives pain in the cutaneous distribution (see p16 for Nerve pathways).

Common sites of convergance and Pain referral
Nerve root 1 T1-3 2 T2-3 3 T7-8 4 T10-11 5 T10-L1 6 T11-12 7 T11-L1 8 S2-4

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Referred site Heart Ascending aorta Gall Bladder + Pancreas Testis / Ovary Kidney + Ureter Appendix Colon Prostate / Vagina + Cervix

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C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9

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T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

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Key
part of the Dorsal rami part of the Cervical Plexus part of Thoracic ventral rami part of the Brachial Plexus part of the Lumbar Plexus part of Sacral Plexus
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The Peripheral Nerves
Accesory Obturator nerve Accessory Phrenic nerve see also Phrenic nerve Anococcygeal nerves (see Dorsal rami sacral and coccygeal region) Ansa Cervicalis (= Ansa Hypoglossi, loop of the Hypoglossal N, nerve loop of the neck) Anterior Cutaneous nerve of the neck (= transverse cutaneous nerve of the neck) Anterior Tibial nerve (see Deep Peroneal nerve) Axillary nerve Common Peroneal nerve (= Fibular nerve) (see Posterior Interosseous nerve) Clunial nerves (see Femoral nerve) Cubital nerve (see Ulnar nerve) Deep Peroneal nerve (= Anterior Tibial nerve) Dorsal rami of the Spinal nerves - overview Dorsal nerve of the penis (see Pudendal nerve) Dorsal rami - Cervical region see also Greater occipital and Suboccipital nerves Dorsal rami - Lumbar region Dorsal rami - Thoracic region Dorsal rami - Sacral (and Coccygeal) region Dorsal Scapular nerve (see also Nerves to Levator Scapulae) Femoral nerve Fibular nerve (see Common Peroneal nerve) First Dorsal ramus (see Suboccipital nerve) First Thoracic IC nerve (= one of the intercostobrachial nerves) Genitofemoral nerve Greater Auricular nerve Greater Occipital nerve (Second dorsal ramus) Iliohypogastric nerve Ilioinguinal nerve Inferior Gluteal nerve Inferior Rectal nerve Intercostobrachial nerve (= Lateral cutaneous branch of second thoracic IC nerve) see also Second Thoracic Intercostal nerve Intercostobrachial nerves (see First thoracic IC nerve & Second thoracic intercostobrachial nerve) Intercostal nerves - lower Intercostal nerves - upper Labial nerve (see Pudendal nerve) Lateral cutaneous femoral nerve Lateral pectoral nerve Lateral plantar nerve Lesser occipital nerve (= small occipital nerve) Levator scapulae nerve (= nerve to Levator scapulae see also Dorsal scapular nerve) Long thoracic Nerve Longus capitus nerve (= nerve to Longus capitus) Longus colli nerve (= nerve to Longus colli) Lower cervical dorsal rami (see Dorsal rami cervical region) Lower subscapular nerve (see also Upper subscapular nerve) Lumbar Plexus - summary Lumbar Plexus - overview of the branches Medial cutaneous nerve of the arm (Medial brachial cutaneous nerve)

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The A to Z of Peripheral Nerves Medial cutaneous Nerve of the forearm (= Medial antebracheal cutaneous nerve) Medial pectoral nerve Medial calcaneal cutaneous nerve (see Tibial nerve) Medial sural cutaneous nerve (see Tibial nerve) Medial plantar nerve Median nerve Median nerve -palmar digital branches Middle Subscapular nerve (see Thoracodorsal nerve) Musculocutaneous nerve (see also Radial nerve) Obturator nerve (see also Accessory Obturator) Obturator internus nerve (= nerve to Obturator internus) Perforating cutaneous nerve Perineal nerve (see Pudendal nerve) Phrenic nerve (see also Accessory phrenic nerve) Piriformis nerve (= nerve to Piriformis) Posterior femoral cutaneous nerve Posterior Interosseous nerve (= Deep radial nerve) (see also Radial Nerve) Pudendal nerve Quaratus femoris nerve (=nerve to Quadratus femoris) Radial nerve (see also Musculocutaneous nerve) Radial nerve - terminal branches Rectus capitus anterior nerve (= nerve to Rectus captious anterior) Rectus capitus lateralis nerve (= nerve to Rectus capitus Lateralis) Sacral nerves - muscular Sacral plexus - overview Saphenous nerve (see Femoral Nerve) Scaleni and Longus colli nerve (=nerve to Scaleni and Longus colli) Scalenus medius nerve (=nerve to Scalenus medius) Sciatic nerve Scrotal nerve (see Pudendal nerve) Second Thoracic Intercostal nerve (= one of the intercostobrachial nerves) Spinal Nerves - cervical lumbar sacral & coccygeal thoracic Sternocleidomastoid nerve (=nerve to Sternocleidomastoid) Subclavius nerve (= nerve to Subclavius) Subcostal nerve (= Twelfth thoracic nerve) Suboccipital nerve (= First Dorsal ramus) Superficial peroneal nerve Superior gluteal nerve Supraclavicular nerve Suprascapular nerve Sural nerve (see Sciatic nerve) Third dorsal ramus Thoracic nerves - summary Thoracodorsal nerve (= Middle Subscapular nerve) Tibial nerve Trapezius nerve (= nerve to Trapezius) Twelfth thoracic nerve (see Subcostal nerve) Ulnar nerve Ulnar nerve - Deep terminal branch Upper subscapular nerve (see also Lower subscapular nerve)

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Root of the Neck
Anterior 1 vertebral artery (L) 2 TP of CI (Atlas) (L) 3 superior cervical ganglion (L) 4 Levator Scapulae 5 Scalenus Medius 6 phrenic N (N roots C3,4,5) 7 Scalenus Anterior 8 upper trunk of the BP (L) 10 inferior cervical ganglion (L) 11 Thoracic duct 12 subclavian vessels (L) 13 Sternothyroid (L) 14 Trachea

9 thyrocervical trunk and deep cervical branch

15 hyoid muscles (R) = Sterno- hyoid thyroid

R 17 CN X = Vagus N
18 Omohyoid

16 common carotid artery

19 BP = brachial plexus

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20 Oesophagus

21 TP of C6 (anterior tubercle) 22 middle cervical ganglion (R) 23 sympathetic trunk

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Branches above the clavicle 1 Nerves to Scalani & Longus colli 2 branch to the Phrenic N 3 Dorsal scapular N 4 Long thoracic N

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It is divided into ROOTS 5 C5-T1 (all the resulting SNs come from these roots) TRUNKS 3 the 4 major Ns emerging from the neck above the CLAVICLE UPPER, MIDDLE & LOWER DIVISIONS 6 the ANTERIOR & POSTERIOR branches of each TRUNK CORDS 3 described for their relation around the AXILLARY artery LATERAL, POSTERIOR & MEDIAL

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Divisions

Trunks

Cords

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Brachial Plexus and the Branches of these cords the PNs below the Clavicle-infraclavicular branches
LATERAL cord branches 1 Lateral pectoral N 2 Musculocutaneous N 3 Lateral root to the Median N Lesions Erb Duchenne paralysis loss of shoulder abduction, external rotation + weak elbow flexion and supination. MEDIAL cord branches 4 Medial Pectoral N 5 Medial Cutaneous N of the`arm 6 Medial Cutaneous N of the forearm 7 Medial root to the Median N 8 Ulnar N Lesions Klumpke’s paralysis: paralysis of the wrist and finger flexors ± Horner’s syndrome because of sympathetic outflow effects = eye constriction and pupil contraction loss of sweating on the face and neck. POSTERIOR cord branches 9 Upper Subscapular N 10 Thoracodorsal N 11 Lower Subscapular N 12 Axillary N 13 Radial N Lesions (Saturday night Palsy- crutches pushing into the Post. cord and causing damage) wrist drop due to damage to the Radial nerve. Erb Duchenne paralysis loss of shoulder abduction, external rotation + weak elbow flexion and supination. 14 Subclavian artery 15 Axillary artery

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It is divided into SUPERFICAL & DEEP BRANCHES

SUPERFICAL branches Ascending and descending superficial branches 1 Lesser Occipital N 2 Greater auricular N 3 Anterior Cutaneous N of the Neck 4 Supraclavicular N Lesions mainly loss of innervation of the front & side of the neck

DEEP branches - LATERAL 10 Sternocleidomastoid N 11 Trapezius N 12 Levator Scapulae N 13 Scalenus N Lesions mainly loss of lateral flexion and rotation of the neck other Nerves in this region include 14 Hypoglossal N (CNXII) 15 branch to the Vagus N (CNX) 16 Tranverse Cutaneous N to the Neck 17 branch to the Phrenic N 18 Lesser Occipital N 19 C1 ventral ramus 20 Accessory (CNXI)

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DEEP branches - MEDIAL 5 Rectus Capitus Lateralis N 6 Rectus Capitus Anterior N 7 Longus Capitus N 8 Longus Colli N 9 Ansa Cervicalis Lesions mainly loss of flexion and extension of the neck

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A Accessory Obturator nerve

L3-4 motor to Pectineus to Abductor Longus Articular Branches NONE Cutaneous branches NONE LESIONS weakens the hip associated lesions/losses iatrogenic - cut in pelvic surgery causes associated with ovarian cancer / cancerous groin nodes 1 2 3 4 to Pectineus to Adductor longus sympathetic chain 12th rib

Spinal Roots Nerve type Muscular branches

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LP (emerges from the anteromedial border of Psoas major present in 30% of patients)

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A Accessory Phrenic Nerve

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to diaphragm - sternal branches to diaphragm (lateral branches) to diaphragm (posterior branches to the crura surrounding the oesophagus) 4 1st rib 5 costal cartilages 6 12th rib 7 central tendon with aorta and IVC passing through 8 Clavicle 9 Scapula 10 oesophagus

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C3, C4, C5 mixed = motor + sensory to the diaphragm including the crura (1-3) Articular Branches NONE Sensory branches supplies branches to the pleura over the diaphragm and the diaphragm, including the central tendon for proprioception LESIONS minimal loss of function with an intact Phrenic N typical aetiologies damage to neck-Hyoid and thyroid muscles and Clavicle associated lesions/losses associated with deep neck injuries

Spinal Roots Nerve type Muscular branches

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CP (deep branches) see also Phrenic Nerve present in 30% from Ansa cervicalis from Nerve to Subclavius

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superior spinal root inferior spinal root N to Sternothyroid N to Sternohyoid N to Omohyoid superior belly N to Geniohyoid N to Omohyoid inferior belly N to N to Thyrohyoid Mandible tongue Hyoid bone Clavicle

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Spinal Roots + Cranial Ns CNXII (Hypoglossal) C1, C2, C3 Nerve Type mixed = motor + sensory Muscular branches branches to the Hyoid and Thyroid muscles Articular Branches NONE Cutaneous branches NONE LESIONS loss/weakness of infrahyoid muscles and depression of the Hyoid bone and Thyroid cartilages hence speech and/or swallowing difficulties typical aetiologies congenital malformation (at C2 bony points) deep wounds / trauma, #s, dislocations iatrogenic surgical injuries associated lesions/losses part of a C2 root radiculopathy severe trauma to the neck as in strangulation / hanging

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A Anterior (Transverse) Cutaneous Nerves of the Neck
CP (superficial branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches C2, C3 sensory NONE NONE skin over the anterior and lateral neck to the Manubrium ascending (1) & descending (2) branches loss of sensation/parasthesia on the area described

LESIONS

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A Axillary Nerve
BP (Infraclavicular branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches C5, C6 mixed = motor + sensory to Teres Minor & Deltoid (1-2) to the Glenohumeral joint (3) to the skin over the Deltoid and Triceps (also from the Suprascapular nerve) LESIONS weak external rotation of the Humerus weak abduction of the Humerus parasthesia over the Shoulder and back of the Arm typical aetiologies inferior dislocation of the shoulder associated lesions/losses sports injuries 1 2 3 4 5 6 7 N to Teres Minor N to Deltoid N to Genohumeral joint Axillary artery Scapula Clavicle 2nd rib

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Common Peroneal Nerve
SP (dorsal division) L4, L5, S1, S2 sensory deep peroneal (anterior tibial) superficial tibial (musculocutaneous) Muscular branches NONE Articular Branches 3 to the knee (3,4,5,) Cutaneous branches branches to the proximal leg an lateral foot LESIONS pain in leg and on the lateral side of the foot typical aetiologies common with injuries with crossed legs impact in car accidents associated lesions/losses sciatic N damage also commonly involves this nerve sacral / plexus injuries also commonly -trauma to leg, particularly if crossed or kneeling at the time of trauma. 1 2 3 4 5 6 7 8 9 deep peroneal N (anterior tibial N) superficial peroneal N superior lateral genicular N (travels with artery) lateral genicular N (travels with artery) anterior tibial recurrent N (travels with artery) lateral sural N (lateral cutaneous N of the calf) popliteal artery cruciate ligaments menisci Spinal Roots Nerve type MAJOR BRANCHES

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Deep Peroneal Nerve

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typical aetiologies

syndrome associated lesions/losses lower leg and foot injuries 1 2 3 4 5 6 7 8 9 10 11 Superficial peroneal N Lateral terminal branch Medial terminal branch N to Tibialis anterior N to Extensor hallicus longus N to Extensor Digitorum longus N to Peroneus tertius 1st interosseous muscle Extensor digitorum brevis Extensor hallicus brevis 2nd dorsal interosseous muscle

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L4, L5, S1, S2 mixed = motor +sensory Superficial peroneal Lateral terminal branch (S1,2) Medial terminal branch (S1,2) to the dorsum of the foot and toes to the ankle, medial of the foot and medial 3 toes branches to the 2 medial toes hallcus and the 2nd toe partial foot drop - weak dorsiflexion spared if superficial peroneal nerve intact common ankle sprains, dislocations and injuries particularly from hyperplantarflexion, entrapment may occur under the extensor retinaculum -anterior tarsal tunnel

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SP (dorsal division via the Sciatic nerve)

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Dorsal Rami of the Spinal nerves summary

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cervical dorsal rami first dorsal ramus = Subocciptial nerve second dorsal ramus = Greater Occipital nerve third dorsal ramus lower cervical dorsal rami upper thoracic dorsal rami lower thoracic dorsal rami lumbar dorsal rami sacral dorsal rami coccygeal dorsal rami

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Dorsal Rami - Cervical

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Medial branches send branches to … 1 Semispinalis capitus 2 Semispinalis Cervicus 3 Multifidus 4 Interspinalis

Lateral branches send branches to … 5 Iliocostalis cervicus 6 Longissimus capitus 7 Longissimus cervicus
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C1-8 cervical dorsal rami mixed = motor + sensory each dorsal ramus has at least Medial and Lateral branches Muscular branches Lateral - to the lateral neck muscles Medial - to posterior medial neck muscles some overlap and dual innervation Articular Branches Lateral - NONE Medial - cervical zygapophysial joints Cutaneous branches Lateral - NONE Medial - to the dorsum neck - over Trapezius LESIONS generally little parasthesia because of multiple innervation in this region and synergistic muscle actions prevent muscle weakness from being shown but intrinsic muscles of the neck are vulnerable if there is a lesion in these nerves and may present as subluxations typical aetiologies whiplash injuries to the neck in car accidents / sudden jolts to the upper shoulders /lower neck and scapula region / sports tackles associated lesions/ neck pain / torsion and reduced neck losses movement may present weeks to months after trauma

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Dorsal Rami - Lumbar

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Articular Branches Cutaneous branches LESIONS

typical aetiologies

associated lesions/ losses

Medial branches send branches to … 1 Multifidus

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Lateral branches send branches to … 2 Sacropinalis 3 Longissimus thoracis 4 Iliocostalis lumborum

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L1-5 lumbar dorsal rami mixed = motor + sensory each dorsal ramus has at least Medial and Lateral branches Lateral - to the lateral deep lumbar back muscles Medial - to posterior medial deep lumbar back muscles some overlap and dual innervation Lateral - NONE Medial - lumbar zygapophysial joints Lateral - supply gluteal skin and region of greater trochanter Medial - NONE generally little parasthesia because of multiple innervation in this region and synergistic muscle actions prevent muscle weakness from being shown sports tackles and jolts to the spine / often in car accidents lower spinal trauma and degenration may present weeks to months after trauma/disease

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Dorsal Rami - Sacral (& Coccygeal) (Anococcygeal Nerves)

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Medial branches send branches to … 1 Multifidus

Lateral branches send branches to … 2 skin 3 Gluteus maximus

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S1-5 (Co1) sacral dorsal rami mixed = motor + sensory each dorsal ramus has at least Medial and Lateral branches Muscular branches Lateral - NONE Medial - to Multifidus Articular Branches Lateral - sacroliliac joint Medial - NONE Cutaneous branches Lateral - medial buttock region and skin over coccyx Medial - NONE LESIONS parasthesia in this region damage typical aetiologies to the lower back and coccyx / sports injuries, particlarly falling associated lesions/losses sitting on the floor after a chair is pulled away

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Dorsal Rami - Thoracic
Spinal Roots T1-12 thoracic dorsal rami Nerve type mixed = motor + sensory MAJOR BRANCHES each dorsal ramus has at least Medial and Lateral branches Muscular branches Lateral - to the lateral deep thoracic muscles Medial - to posterior medial deep thoracic back muscles some overlap and dual innervation Articular Branches Lateral - NONE Medial - thoracic zygapophysial joints Cutaneous branches Lateral - supply skin lateral to costal angles, iliac crest and buttocks Medial - to the mid-back as far as the mid scapula line LESIONS generally little parasthesia because of multiple innervation in this region and synergistic muscle actions prevent muscle weakness from being shown but intrinsic muscles of the thoracic spine are vulnerable if there is a lesion in these nerves and may present as subluxations typical aetiologies sports tackles and jolts to the spine / often in car accidents associated lesions/ rib trauma and spinal vertebral collapse as losses in osteoporosis and leukaemic deposits in the veterbral bodies - may present weeks to months after trauma/disease Medial branches send branches to … 1 Semispinalis thoracis 2 Multifidus 3 Longissimus thoracis 4 Spinalis thoracis

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Lateral branches send branches to … 5 Iliocostalis cervicus 6 Longissimus thoracis (cut to show deeper structures) 7 Levator costrum breves 8 Levator costrum breves + longus
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Dorsal Scapular Nerve
Spinal Roots Nerve type Muscular branches

BP see also Levator Scapulae nerve (CP) ±C3, ±C4, C5 motor to Levator Scapulae (1), Rhomboids Major and Minor (1-2) Articular Branches NONE Cutaneous branches NONE LESIONS ± Rhomboids and Levator Scapulae weakened - paralyzed resulting in winged scapula typical aetiologies neck and BP injuries associated lesions/losses unable to fully assess injuries to BP with injury to this N

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Femoral nerve
LP (emerges from the lateral border of Psoas major) Spinal Roots L2, L3, L4 (same as Obturator N) Nerve type mixed = motor + sensory MAJOR BRANCHES ANTERIOR division, POSTERIOR division Muscular branches ABDOMINAL to Iliacus to Pectineus ANTERIOR to Sartorius POSTERIOR to Rectus Femoris to the Vasti muscles to Articular genus Articular Branches ABDOMINAL, ANTERIOR NONE POSTERIOR to the hip and knee Cutaneous branches ABDOMINAL NONE ANTERIOR anterior thigh, knee & leg POSTERIOR medial of the ankle & the foot LESIONS weak hip and knee flexion of the anterior only - weakens the hip, knee flexion and instability of the posterior only - weak knee flexion associated lesions/ iatrogenic - cut in pelvic surgery cut in losses causes varicose vein surgery & knee surgery (posterior-Saphenous N) trauma to the femoral triangle (abdominal) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 ANTERIOR division POSTERIOR division to Iliacus to Pectineus Intermediate Femoral Cutaneous Medial Femoral Cutaneous anterior branch Medial Femoral Cutaneous posterior branch to Rectus Femoris to Vastus lateralis to Vastus medialis to Vastus intermedius to Articular genus to the hip to the knee Saphenous nerve Infrapatellar branch adductor canal for deep BVs and Ns
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First Thoracic Intercostal Nerve
part of BP Spinal Roots Nerve type Muscular branches Articular Branches T1 mixed = motor + sensory to intercostal muscles (1-2) costovertebral joints and sternocostal joints Cutaneous branches to skin overlying the 1st IC space anteriorly and axilla (3-4) LESIONS radicular pain over 1st IC space typical aetiologies neck and BP injuries of the Median and Ulna nerves associated lesions/losses unable to fully assess injuries to BP with injury to this N - unless associated with other IC nerve injuries 1 2 3 4 5 N to internal intercostal N to external intercostal to skin overlying the 1st IC space anteriorly and Manubrium. to skin overlying the axilla branch to BP

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Genitofemoral nerve
LP (emerges from the anterolateral border of Psoas major) L1, L2 mixed = motor + sensory to Genital area (cremaster muscle in males) Articular Branches NONE Cutaneous branches to femoral triangle to genital area LESIONS loss of cremaster reflex / parasthesia over area described associated lesions/losses iatrogenic - cut in appendectomy causes 1 2 3 Genital branch Femoral branch Genital branch (cutaneous) Spinal Roots Nerve type Muscular branches

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Greater Auricular Nerve
CP (superficial branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches C2, C3 sensory NONE NONE skin over the Parotid Gland (1) skin over the mastoid process and the back of the ear (2) loss of sensation on the area described

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LESIONS

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Greater Occipital Nerve (second dorsal ramus)
C2 cervical dorsal ramus mixed = motor + sensory Medial and Lateral branches to the capitus muscles in the neck / head (3-6) Articular Branches to the atlanto-occipital and atlanto-axial joints Cutaneous branches to the dorsum neck and head to the level of the ear LESIONS parasthesia to the back of the head in occipital region typical aetiologies whiplash injuries to the neck in car accidents associated lesions/losses injury to sternocleidomastoid / occiptal nerves often overcompensate and cause muscle spasm and headaches (seen several weeks after the accident) 1 2 3 4 5 6 Medial branch Lateral branch to Obliquus capitus inferior to Semispinalis capitus Longissimus capitus to Splenius capitus

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Iliohypogastric nerve
LP (emerges from the lateral border of Psoas major) Spinal Roots Nerve type Muscular branches T12, L1 mixed = motor + sensory to Transversus Abdominus to Internal abdominal oblique

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Ilio-inguinal nerve
Spinal Roots Nerve type Muscular branches

LP (emerges from the lateral border of Psoas major) L1 mixed = motor + sensory to Transversus Abdominus to Internal abdominal oblique
(also see intercostals - lower T7-12, & iliohypogastric n)

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Articular Branches NONE Cutaneous branches to groin / scrotum / mons pubis / labia majora LESIONS weakening of abdominal wall associated lesions/ iatrogenic - cut in appendectomy, losses causes nephrectomies / pfannenstiels excision may develop in large pregnancies a direct inguinal or abdominal hernia referred pain from Ureter and renal pelvis to Transversus Abdominus to Internal abdominal oblique lateral cutaneous branch anterior cutaneous branch

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(also see intercostals - lower T7-12, and ilioinguinal n)

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Inferior Gluteal nerve
SP (dorsal division) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS L5, S1, S2 motor to GM (2) NONE NONE difficulty running jumping and climbing stairs, rising from a seated position, skating typical aetiologies commoner than superior gluteal N injuries, but rare to be injured alone associated lesions/losses pelvic and back injuries 1 2 Pyriformis to Gluteus Maximus

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Inferior Rectal nerve see also Pudenal nerve
S2, S3, S4 mixed = motor + sensory from the PUDENAL nerve Perineal Posterior scrotal or Labial nerves Dorsal nerve to the Penis (Clitoris) Muscular branches to the levator ani, external anal sphincter & coccygeas Articular Branches NONE Cutaneous branches skin between the anus and the coccyx and lining the anal canal below the circumanal line LESIONS sagging of the pelvic floor / compromised rectal and bladder control (particularly in the female) cystocoele or rectocoele / prolapse of uterus in older females typical aetiologies pressure on the sacrum associated lesions/losses uterine prolapse / obesity / large abdominal mass 1 2 3 4 5 6 7 Perineal branch Posterior scrotal / labial nerves Dorsal nerve to penis / clitoris to the external anal sphincter Perineal diapragm Urethra Levator ani Spinal Roots Nerve type MAJOR BRANCHES

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Intercostal Nerves - Lower

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Collateral branches to Subcostalis Lateral Cutaneous branch Anterior Cutaneous branch to Internal intercostals N to external intercostals and the muscle attachment to Intercostals intimi External Oblique Rectus Abdominus N to Serratus posterior inferior N to External Oblique Transversus Abdominus layers of the abdominal wall reflected - pieced and innervated by the lower intercostal nerves segmentally 13 transverse process of thoracic VB 14 dorsal ramus of thoracic N (supplies muscles, skin and joints of the VC and back)
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T7-11 thoracic ventral ramus mixed = motor + sensory to muscles of thorax and abdomen costovertebral joints and sternocostal joints (ac) Cutaneous branches supplies skin over the abdomen and latissimus dorsi and the costal surface of the diaphragm T10 supplies skin over the umbilicus LESIONS loss of sensation and movements of the rectus muscles with entrapment in the muscle of nerve and fat - abdominal muscles cannot move so contraction occurs unilaterally Clicking rib syndrome - subluxation of interchondral joints refers pain to the abdomen in areas described - “clicks” when moving thorax/abdomen in sitting up typical aetiologies osteoporosis / leukaemia thoracic vertebral fractures associated lesions/ peritonitis and other diseases of the losses viscera / trauma to the abdomen cause abdominal spasm and guarding

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Intercostal Nerves - Upper
T3-6 thoracic ventral ramus mixed = motor + sensory Collateral branches (cb) 1 Lateral Cutaneous branches (lc) 2 Anterior Cutaneous branches (ac) 3 Muscular branches to muscles of the chest and back (4-10) Articular Branches costovertebral joints and sternocostal joints (ac) Cutaneous branches supplies skin over the intercostal space anteriorly laterally and posteriorly (lc, ac) LESIONS loss of sensation in areas described needs 2 or more intercostals nerves involved to be detected because of innervation overlap T4 corresponds to the nipple line T5,T6 pain in the same area as heart mistaken for angina pectoris / oesophageal spasm typical aetiologies osteoporosis / leukaemia thoracic vertebral fractures associated lesions/ thoracic vertebral damage / from trauma losses or disease 1 2 Collateral branches Lateral Cutaneous branch with their anterior and posterior terminal branches 3 Anterior Cutaneous branch 4 to Internal intercostals 5 to External intercostals 6 to Intercostals intimi 7 to Subcostalis 8 to Tranverse thoracis 9 to Serratus posterior inferior 10 to External oblique

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Order NOW to complete

Origins, insertions, actions, blood supply and nerve supply listed for all muscles, separate listing of all major muscle groups; separate index of all muscles; regional index of the muscle along the side and cross referencing with common muscle names.

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All bones are separately listed, as well as an examination of all cavities, joints and anthropological markers. Radiology of the skull and its cavities are shown and explained from several aspects.

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All anatomical terms are listed along with a pronunciation guide and etymology (word origin), Tables of abbrev. medical prefixes, suffixes & word roots; degrees & professional associations are included, along with guides to basic anatomical principles.

All bones, their joints, movements, ligaments, relations, Blood and Nerve supply are listed. Each major joint is discussed in detail shown with and without their additional supportive structures.

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Contact Anatomy Update for further information and additional educational resources: GPO 637 Sydney 2001

The A to Z of Peripheral Nerves

your ‘A to Z’ set so far!

All peripheral nerves, their pathways, branches, alternative names and nerve root origins are listed, including functional deficits, likely aetiology of the trauma and examination techniques to illicit pathology deficits.

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As well as all the Bones Joints and ligaments of the body drawn individually - a separate section on postures, vertebral development and regional differences along with movements is included.

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All the bones and muscles of the Head & Neck region are described indiv. NS & BS listed + pathological lesions. radiological views and overviews of the region inc. lymphatic drainage arterial aas, cutan Ns and teeth

Mobile: 041001861 Fax: 612 93651000 medicalamanda@gmail.com

Brain

The A to Z of the

COMING SOON!

© A. L. Neill

The Brain, CNs, SC, & neural pathways are described, in colour coded sections and listed alphabetically as well as clinical examination of the CNs, neural damage assessment, the cerebral BS and is significance - cross ref. with all the other A to Zs.

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Lateral Cutaneous Femoral nerve
LP (emerges from the lateral border of Psoas major) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches L2-3 sensory NONE NONE supplies skin of thigh and gluteal region (1-2) LESIONS parasthesia to area described associated lesions/losses iatrogenic - cut in surgery causes

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Lateral Pectoral Nerve
BP (Infraclavicular branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS C5-7 (lateral cord - ant divisions) motor to muscles of the chest (1-2) to Glenohumeral joint NONE weakness in scapula, adduction and medical rotation of arm i.e. difficulty in reaching to touch opposite shoulder

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Lateral Plantar nerve
SP (ventral divisions) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS typical aetiologies trauma and associated losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 L4, L5, S1, S2, S3 mixed = motor + sensory

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superficial branch deep branch common plantar digital nerves proper plantar digital nerves to Quadratus Plantae to Abductor digiti minimi to Flexor digiti minimi brevis to 3rd plantar interosseous muscle to the 4th dorsal interosseous muscle Adductor hallicus (oblique head) Adductor hallicus (transverse head) 1st and 2nd plantar interossei 1st to 3rd lumbricals 1st to 3rd dorsal interossei

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Lesser Occipital Nerve (Small Occipital Nerve)
CP (superficial branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches C2, ±C3 sensory NONE NONE skin on the neck along the posterior border of Sternocleidomastoid to the Mastoid process, behind and around the Pinna of the ear loss of sensation on the area described

LESIONS

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Levator Scapulae (Nerve to) see also Dorsal Scapular nerve

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C3, C4 mixed = motor + sensory (proprioceptive) Muscular branches to Levator Scapulae Articular Branches NONE Cutaneous branches NONE LESIONS dropped shoulders, poor “shrugging”; winged* scapula(e) ; poor abduction of both ULs, particularly > 20º; unstable scapula - compromising the Deltoids, Rhomboids, Serratus and Spinati muscles - innervation is ispilateral hence unilateral injuries affect the same side typical aetiologies rare - direct injury in this area synergism with Trapezius limits functional loss associated lesions/ unable to fully assess injuries to losses brachial plexus with injury to this N

Spinal Roots Nerve type

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Long Thoracic Nerve
BP (supraclavicular branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS C5, C6, C7 motor to Serratus Anterior (2) NONE NONE “winged scapula” because of unopposed action of Levator Scapulae and Rhomboids cannot lift arm above the horizontal typical aetiologies heavy weights crushing the shoulder injuries to the posterior triangle* of the neck associated lesions/losses unable to fully assess injuries to the UL cannot assess shoulder function little UL abduction 1 2 3 Axillary artery Serratus Anterior Glenoid fossa

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Longus Capitus (Nerve to)
CP (deep branches) Spinal Roots Nerve Type Muscular branches Articular Branches Cutaneous branches LESIONS C1, C2, C3 motor to Longus Capitus NONE NONE loss/weakness of flexion of the neck loss/weakness/asymmetry of neck rotation typical aetiologies whiplash injuries from automobile or athletic injuries associated lesions/losses part of a C2 radiculopathy seen with loss of sensation on the neck

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CP (deep branches) BP (supraclavicular branches) Spinal Roots Nerve Type Muscular branches Articular Branches Cutaneous branches LESIONS

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C2-7, ± C8 motor to Longus Colli NONE NONE loss/weakness of flexion of the neck ipsilateral loss/weakness/asymmetry of neck rotation contralateral typical aetiologies whiplash injuries from automobile or athletic injuries associated lesions/losses part of a brachial plexus root injury associated with damage to Scalenus muscles and thoracic outlet syndrome

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Lower Subscapular Nerve

C5, C6, C7 motor to Subscapularis (inferior) (1) & to Teres major (2) Articular Branches NONE Cutaneous branches NONE LESIONS weak adduction & medial rotation of the Humerus typical aetiologies BP injuries associated lesions/losses BP injuries

Spinal Roots Nerve type Muscular branches

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Lumbar Plexus - overview of the Branches

all branches pierce Psoas major 1 2 3 4 5 6 7 8 9 10 11 12 13 14

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to Quadratus Lumborum Psoas minor Psoas major Iliohypogastric N Ilioinguinal N Lateral femoral cutaneous N Femoral N Genitofemoral N Obturator N Accessory Obturator N upper root of the Lumbosacral trunk inguinal ligament pubic symphysis anterior superior iliac spine

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T12, L1-4 motor to Quadratus Lumborum to Psoas minor (L1) to Psoas major (L1-3) Articular Branches NONE Cutaneous branches NONE LESIONS weakening of hip flexion (L2>L3) parasthesia over anterior thigh (L2>L1)

Spinal Roots Nerve type Muscular branches

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Lumbar Plexus summary
Spinal Roots Nerve type MAJOR BRANCHES T12, L1, L2, L3, L4 mixed = motor + sensory Muscular branches (1) Iliohypogastric N (2) Ilio-inguinal N (3) Genitofemoral N (4)

from the Ventral Divisions 5 6 Obturator N Accessory obturator N

from Dorsal Divisions

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Lateral femoral cutaneous N Femoral N Lumbosacral trunk to Sacral plexus

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LESIONS from specific Nerve roots L1 weakness in abdominal muscles / parasthesia over hip and groin L2 weak hip flexion / parasthesia to anterior thigh L3 weak leg adduction / reduced knee reflex / parasthesia to anterior thigh, knee, leg and foot commonest from disc L4/5 herniation, degeneration L4 weak leg adduction / foot drop (tibialis anterior) / parasthesia to leg and foot AETIOLOGY disc herniation, neurofibromas, meningiomas, other neoplasms and trauma

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Medial Cutaneous Nerve of the arm

Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS

C8, T1 (medial cord - ant divisions) mixed = motor + sensory NONE NONE skin on medial aspect of the arm and over the elbow (see also
intercostobrachial n + second intercostal n)

loss of sensation on the area described

aka Medial antebracheal cutaneous nerve BP (Infraclavicular branches)

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Medial Cutaneous Nerve of forearm

C8, T1 (medial cord - ant divisions) mixed = motor + sensory NONE NONE skin on medial aspect of the forearm loss of sensation on the area described

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aka Medial brachial cutaneous nerve BP (Infraclavicular branches)

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Medial Pectoral Nerve
BP (Infraclavicular branches) C6-8, T1 (medial and lateral cords ant division) Nerve type motor Muscular branches to anterior chest muscles (1-2) Articular Branches NONE Cutaneous branches NONE LESIONS weakness when touching opposite shoulder with arm Spinal Roots

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Medial Plantar nerve
SP (ventral divisions) L4, L5, S1, S2, S3 mixed = motor + sensory to the big toe Hallicus, and associated flexor foot muscles (4-6) Articular Branches to the ankle tarsus and metatarsus Cutaneous branches to the skin on the medial side of the sole of the foot and ball of the toes LESIONS Tarsal tunnel syndrome - “jogger’s foot” typical aetiologies damage to the tibial nerve in tarsal tunnel from external pressure from foot wear ± thickened retinaculum sensory loss at the heel indicates lesion above the ankle and tarsal tunnel associated lesions/ ankle dislocations and trauma losses Spinal Roots Nerve type Muscular branches

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hallucial medial digital N common plantar digital Ns proper plantar digital Ns Abductor Hallicus Flexor digitorum brevis Flexor hallicus brevis to 1st lumbrical

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Median Nerve
BP (Infraclavicular branches) C5-8 T1 (medial + lat cords - ant division) Nerve type mixed = motor + sensory NAMED BRANCHES Anterior interosseous (AI) (1) (terminal) Palmar digital (Pd) (2) Muscular branches to Pronator teres to Flexor carpi radialis to Palmaris Longus to Flexor digitorum superficialis to Flexor pollicus longus (Ai) to Pronator quadratus (Ai) to Flexor digitorum profundus (Ai) Articular Branches to the elbow joint to the radio-ulnar proximal to the interosseous membrane Cutaneous branches supplies the palmar skin on the lateral side LESIONS supinated forearm /weak pronation weak flexion of wrist and middle fingers radial deviation of wrist parasthesia on the lateral side of the hand typical aetiologies elbow / forearm injuries associated lesions/ UL injuries losses 1 2 3 4 5 6 7 8 9 Anterior interosseous N Palmar digital Ns Pronator teres Flexor carpi radialis Palmaris Longus Flexor digitorum superficialis Flexor pollicus longus Pronator quadratus Flexor digitorum profundus Spinal Roots

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Median Nerve -Palmar digital branches
BP (Infraclavicular branches) C5-8 T1 (medial + lat cords - ant division) Nerve type mixed = motor + sensory NAMED BRANCHES Lateral branch, Common palmar digital (terminal) branches, Proper palmar digital branches (ppd), Palmar cutaneous branch (pc) (1-4) Muscular branches to intrinsic hand muscles on the lateral side of the hand (5-9) Articular Branches to the finger and wrist joints Cutaneous branches supplies the skin on the sides and palm of resective digits (ppd) LESIONS supf wrist lacerations may result in parasthesia of the thumb and 1st 2 fingers carpal tunnel syndrome weak wrist and finger flexion Ape hand = cannot oppose the thumb cannot extend index and middle fingers deep lacerations of wrist combination of above typical aetiologies wrist lacerations / work or suicide parasuicide attempts carpal tunnel syndrome associated lesions/ wrist injuries sport injuries losses 1 2 3 4 5 6 7 8 9 10 Lateral branch Common palmar digital branches Proper palmar digital branches Palmar cutaneous branch to Abductor Pollicus brevis to Opponens Pollicus Flexor pollicus brevis to 2nd lumbrical to 1st lumbrical flexor retinaculum Spinal Roots

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Musculocutaneous Nerve
BP (Infraclavicular branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS C5-7 (lateral cord - ant divisions) mixed = motor + sensory flexors of the UL see also Radial N NONE lateral antebrachial cutaneous branch to skin on anterolateral surface of arm forearm from elbow to thumb loss of sensation on the area described inability to flex the elbow while supinated loss of biceps tendon reflex

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Obturator nerve
LP (emerges from the anteromedial border of Psoas major) Spinal Roots Nerve type Muscular branches L2-4 mixed = motor + sensory
ANTERIOR

to Adductor longus to Gracilis to Adductor Brevis to Pectineus (see also accessory obturator)
POSTERIOR

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to Adductor longus to Gracilis to Adductor Brevis to Pectineus to Obturator externus to Abductor magnus cutaneous branches hip joint (anterior) to the knee joint (posterior)

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to Obturator externus to Abductor magnus ±to Adductor brevis Articular Branches to the hip and knee joints Cutaneous branches to groin / medial thigh LESIONS inability to stabilze the hip / to cross legs associated lesions/ iatrogenic - cut in pelvic surgery losses causes associated with ovarian cancer / cancerous groin nodes referred pain from hip disease may present in this site (note femoral N is also from L2-4 use this in testing the lesion)

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Obturator Internus Nerve (= nerve to obturator internus)
L5, S1, S2 motor to Obturator internus (1) to Gemellus superior (2) Articular Branches NONE Cutaneous branches NONE LESIONS weak external rotation of the thigh typical aetiologies abdominal injuries - anything damaging L4/5 discs rare to see isolated associated lesions/ pelvic, back injuries degeneration losses Spinal Roots Nerve type Muscular branches

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SP (ventral division)

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Perforating Cutaneous Nerve
SP (anterior division) S2, S3 sensory Superficial peroneal Lateral terminal branch (S1,2) Medial terminal branch (S1,2) Muscular branches NONE Articular Branches NONE Cutaneous branches branches to skin over Gluteus Maximus (1) LESIONS parasthesia over area described above typical aetiologies CP injuiries associated lesions/ losses Spinal Roots Nerve type MAJOR BRANCHES

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Phrenic Nerve
CP (deep branches) see also Accessory Phrenic Nerve Spinal Roots Nerve type Muscular branches Articular Branches Sensory branches C3, C4, C5* mixed = motor + sensory to the Diaphragm including the crura (1-3) NONE supplies branches to the pleura over the Diaphragm and the Diaphragm including the central tendon for proprioception (1-3) unilateral - paralysis of ½ the Diaphragm on the same side minimal loss of function bilateral - complete paralysis of the Diaphragm - severe dyspnea; coughing; sneezing; respiratory muscles, atrophy of the diaphragm damage to cervical spinal roots and/or cords trauma to the Chest iatrogenic surgical trauma in heart or chest surgery deep neck injuries, pneumothorax, cardiac arrest

LESIONS

typical aetiologies

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anterior / sternal branches of nerve anterolateral branches of nerve posterior branches of the nerve

*C34&5 keeps the diaphragm alive

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Piriformis Nerve = nerve to piriformis
SP (dorsal division) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS typical aetiologies associated lesions/ losses 1 2 3 S1, S2 motor to Piriformis NONE NONE weak external rotation of the thigh abdominal injuries - anything damaging L4/5 discs rare to see isolated pelvic, back injuries degeneration

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to Piriformis Sciatic N Greater Trochanter

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Posterior Femoral Cutaneous nerve
SP (dorsal + ventral divisions) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS typical aetiologies associated lesions/ losses 1 2 3 4 S1, S2 sensory NONE NONE Gluteal branches (cluneal) Perineal branches branches to the back of the thigh and leg parathesia over the area described prolonged bicycle riding pelvic and back injuries

Gluteal branches Perineal branches branches to the back of the thigh and leg gluteal line inferior border of Gluteus maximus

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Posterior Interosseous Nerve = Deep Radial nerve

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to Ext Carpi Radialis Brevis to Supinator to Ext Digitorum to Ext Digiti Minimi to Ext Carpi Ulnaris to Ext Pollicus longus to Ext Indicis to Abductor Pollicus Longus to Ext Pollicis brevis

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C5, C6, C7, C8, T1 motor to muscles on the back of the forearm (1-9) Articular Branches to the radioulnar joint to the interosseous membrane to the RC IC and IMC joints Cutaneous branches NONE LESIONS weak extension/flexion of the Elbow weak extension of the wrist “wrist drop” weak supination parasthesia on the back of the arm and forearm and lateral surface of the arm typical aetiologies BP injuries, broken arm, elbow injuries associated lesions/ UL injuries losses

Spinal Roots Nerve type Muscular branches

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Pudendal nerve
SP (anterior division directly from SP) S2, S3, S4* mixed = motor + sensory Inferior Rectal / Inferior Haemorrhoidal Perineal Posterior scrotal or Labial nerves Dorsal nerve to the Penis (Clitoris) Muscular branches to the levator ani, external anal sphincter & coccygeas, muscles of the anterior perineum Articular Branches to ligaments and joints of the pelvis pubic symphysis and ligaments Cutaneous branches skin between the anus and the coccyx and lining the anal canal below the circumanal line - all areas of the labia and scrotal areas / clitoris / penis including sensation of the urethra LESIONS sagging of the pelvic floor / compromised rectal and bladder control (particularly in the female) cystocoele or rectocoele / prolapse of uterus in older females / anesthesia of the scrotal and labial area and lower anal canal / impotence typical aetiologies pressure on the sacrum associated lesions/ uterine prolapse / obesity / large losses abdominal mass this nerve is often blocked during birth this paralyses & numbs the associated structures near the base of the vagina and rectal areas 1 Perineal branch 2 Posterior scrotal / labial nerves 3 Dorsal nerve to penis / clitoris 4 to the external anal sphincter and levator ani from perineal branch 5 superficial posterior scrotal/labial nerves 6 Deep posterior scrotal / labial nerves . 7 Transverse Perineal Superficialis 8 to Bulbospongiosus 9 to Ischiocavernosis 10 to Tranverse Perineal Profundus 11 to Sphincter Urethrae Spinal Roots Nerve type MAJOR BRANCHES

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*(S2, 3 & 4 keeps the penis from the floor)
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Quaratus Femoris Nerve = nerve to quadratus femoris
L4, L5, S1 motor to Quadratus Femoris (1) to Gemellus inferior (2) Articular Branches to the hip joint Cutaneous branches NONE LESIONS weak external rotation of the thigh typical aetiologies abdominal injuries - anything damaging L4/5 discs rare to see isolated associated lesions/ pelvic, back injuries degeneration losses Spinal Roots Nerve type Muscular branches

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Radial Nerve

Spinal Roots Nerve type NAMED BRANCHES terminal Muscular branches Articular Branches

C5, C6, C7, C8, T1 post cord mixed = motor + sensory Superficial Terminal (ST) Deep radial = Posterior interosseous nerve (PIN) to muscles on the back of the arm and forearm (3-9) see also Musculocutaneous nerve to the elbow joint carpo/metacarpo/and
phalangeal joints of thumb to middle finger (ST)

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Superficial terminal branch Posterior interosseous N = Deep Radial N Triceps long head Triceps medial head Triceps lateral head Anconeus Brachioradialis Extensor carpi radialis longus Brachialis Posterior Brachial cutaneous Inferior lateral brachial cutaneous branch Posterior antebrachial cutaneous branch
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Cutaneous branches supplies the skin on the back of the arm and the lateral part of the forearm and back of the wrist (1, 10-12) - and thumb to middle finger (ST) LESIONS weak extension/flexion of the Elbow weak extension of the wrist “wrist drop” weak supination parasthesia on the back of the arm and forearm and lateral surface of the arm and thumb and fingers typical aetiologies BP injuries, broken arm elbow injuries associated lesions/ UL injuries losses

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BP (Infraclavicular branches) see also Radial nerve Spinal Roots Nerve type Muscular branches
(all from posterior interosseous nerve- PIN)

C5, C6, C7, C8, T1 post cord mixed = motor + sensory 1-10 listed below

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to Extensor Carpi Radialis Brevis to Supinator to Extensor Digitorum to Extensor Digiti Minimi to Extensor Carpi Ulnaris to Extensor Pollicus Longus to Extensor Indicis to Abductor pollicus longus to Abductor Pollicus Brevis cutaneous branches

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to all the distal forearm, wrist and hand joints (PIN) to proximal and distal phalangeal jts. (ST) Cutaneous branches supplies the skin on the back of the (all from ST) arm and the lateral part of the forearm and back of the wrist and thumb to middle finger (10) LESIONS weak extension of the wrist “wrist drop” weak supination parasthesia on the back of the arm and forearm and lateral surface of the arm and thumb and first 2 fingers typical aetiologies injuries below the elbow associated lesions/ UL injuries losses

Articular Branches

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Rectus Capitus Anterior (Nerve to)
CP (deep branches) Spinal Roots Nerve Type Muscular branches Articular Branches Cutaneous branches LESIONS typical aetiologies ±C1, C2, C3 motor to Rectus Capitus Anterior (1) NONE NONE loss/weakness of flexion of the head at the atlanto-occipital jt part of a C2 radiculopathy whiplash injuries from automobile or athletic injuries

Rectus Capitus Lateralis (Nerve to)
CP (deep branches) Spinal Roots Nerve Type Muscular branches Articular Branches Cutaneous branches LESIONS

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±C1, C2, C3 motor to Rectus Capitus Lateralis (2) NONE NONE loss of lateral flexion of the head on the affected side (ipsilateral)

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Sacral Muscular nerves
SP (anterior division directly from SP) Spinal Roots Nerve type MAJOR BRANCHES Muscular branches Articular Branches Cutaneous branches LESIONS S4 motor Peroneal (then to the anal sphincter) to the levator ani and coccygeus NONE skin between the anus and the coccyx sagging of the pelvic floor / compromised rectal and bladder control (particularly in the female) cystocoele or rectocoele / prolapse of uterus in older females pressure on the Sacrum uterine prolapse / obesity / large abdominal mass

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Peroneal branch of S4 to Levator ani to Coccygeus to the external anal sphincter

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Sacral Plexus summary

MAJOR BRANCHES from the Ventral Divisions only 1 N to Quadratus femoris 2 N to Obturator Internis Perforating Cutaneous N Pudendal N Sacral muscular Ns MAJOR BRANCHES from Dorsal Divisions only 3 N to Piriformis 4 Superior gluteal N 5 Inferior gluteal N MAJOR BRANCHES from both Divisions 6 Posterior femoral cutaneous N 7 Sciatic N 8 Sciatic N - Tibial division 9 Common Peroneal N = Tibialis anterior N other Cutaneous branches 10 Sural N 11 Median Calcanean N 12 Medial plantar N 13 Lateral plantar N 14 Lateral Sural N 15 Medial branch of deep peroneal N 16 Superficial peroneal branches

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Lesions from specific Nerve roots L4 lumbosacral trunk - weak hip, leg adduction / weak knee extension / “foot drop” (tibialis anterior) / parasthesia to leg and foot L5 Trendelenburg’s sign / weak knee flexion / foot drop = weak dorsiflexion of foot / weak eversion of foot / weak toe extension / parasthesia of the foot dorsum and soul S1 weak hip extension / weak plantar flexion and toe fexion S2/S3 weak inversion of foot / weak flexion of toes / parasthesia of back of leg / loss of control of pelvic floor and anal sphincter 9pudendal nerve)
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L4, L5, S1, S2, S3 mixed = motor +sensory

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Scaleni and Longus Colli (Nerves to)

Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS

typical aetiologies associated lesions/ losses 1 2 3 4

to Scalaneus anterior to Scalenus Medius to Scalenus Posterior to Longus Colli

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* TOS = Turn to opposite side
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±C4, C5, C6, C7 C8 motor to the Scaleni muscles and Longus Colli NONE NONE ± TOS with resultant muscle spasm in injury innervation is ispilateral hence unilateral injuries affect the same side weakness of neck flexion and weak contralateral rotation of the neck (loss limited by synergism with Sternocleidomastoid) rare - direct injury in this area unable to fully assess injuries to BP with injury to this N

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BP (supraclavicular branches) see also Longus Colli nerve (CP) and Scalenus Medius nerve (CP)

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Scalenus Medius (Nerve to)

Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS

typical aetiologies associated lesions/ losses

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C3, C4, C5-C8 motor to Scalenus Medius NONE NONE ± TOS innervation is ispilateral hence unilateral injuries affect the same side (weak neck flexion and turning, function may be taken over by SCM. rare - direct injury in this area synergism with Trapezius and SCM limits functional loss unable to fully assess injuries to BP with injury to this N

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Sciatic nerve
LP SP (dorsal + ventral divisions) L4, L5, S1, S2, S3 mixed = motor + sensory hamstrings, all the muscles of the leg and foot and adductor magnus Articular Branches to the hip joint Cutaneous branches to the back and sides the thigh and all of the leg and foot LESIONS complete - paralysis of leg and foot with parasthesia in the leg and foot / weak hip adduction DD injuries of common peroneal only typical aetiologies car accidents, hip trauma, spinal injuries, L4/5 disc damage associated lesions/ pelvic and back injuries losses 1 2 3 4 5 6 7 Spinal Roots Nerve type Muscular branches

Tibial division through ventral root Fibular division through dorsal root (common peroneal) to Biceps femoris (short head) to biceps femoris (long head) to Semitendinous to Semimembranous to Adductor magnus

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Second Thoracic Intercostal Nerve
T2 thoracic ventral ramus mixed = motor + sensory Anterior Cutaneous branch (ac) (1) Lateral Cutaneous branch / intercostobrachial nerve (ic) (2) Muscular branches to the intercostal muscles (3,4,7) and accessory muscles of respiration Articular Branches costovertebral joints and sternocostal joints (ac) Cutaneous branches supplies skin over the 2nd intercostals space (ac) supplies skin to axilla floor /upper half of arm on medial and posterior side (ic) LESIONS loss of sensation in areas described - in particular underarm numbness typical aetiologies iatrogrenic - in breast cancer surgery associated lesions/ surgery in thoracic region as in losses mastectomies 1 2 3 4 5 6 7 Anterior Cutaneous branch Lateral Cutaneous branch / intercostobrachial nerve to Internal intercostal to External intercostal to Serratus posterior superior to Tranverse thoracis to intercostals intimi

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Spinal Roots Nerve type NAMED BRANCHES -terminal

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Spinal Nerves - Cervical

*note 8 cervical Ns and 7 cervical vertebrae C8 exits b/n C7 and T1 C2-7 b/n C1-C7.

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dorsal rootlets = dorsal root dorsal ramus dorsal root ganglion ventral ramus grey rami communicans sympathetic chain imput from thoracic Ns vertebral artery white matter - myelinated axons grey matter - nerve cell bodies - unmyelinated nerve processes 10 dura mater 11 arachnoid mater 12 spinous process of the VB

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C1-C8* mixed = motor + sensory see sensory / motor map of the SNs VC damage accidents

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Spinal Nerves - Lumbar

note the SC finishes in the adult at L1/2, hence the SN may exit at a level lower than their Spinal roots the roots running down in the VC until their exit - L1 - arises at the level of T10, but exits b/n T12/L1 / L2-3 arise at T11 / L4-5 arise at T12 *SC terminates L1/2 in adults L3/4 in children.

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dorsal rootlets = dorsal root dorsal ramus dorsal root ganglion ventral ramus ventral root grey rami communicans sympathetic chain vertebral artery white matter - myelinated axons t grey matter - nerve cell bodies - unmyelinated nerve processes 10 dura mater 11 arachnoid mater 12 spinous process of the VB

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L1-L5* mixed = motor + sensory see sensory / motor map of the SNs VC damage accidents

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Spinal Nerves - Sacral and coccygeal

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dorsal rootlets = dorsal root dorsal ramus dorsal root ganglion ventral ramus grey rami communicans sympathetic chain vertebral artery white matter - myelinated axons t grey matter - nerve cell bodies - unmyelinated nerve processes dura mater arachnoid mater spinous process of the VB cauda equina sacrum with S1-5 N foraminae

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S1-Co1 mixed = motor + sensory see sensory / motor map of the SNs VC damage accidents

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Spinal Nerves - Thoracic

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*SNs T1-12 exit b/n VBs T1-L1

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dorsal rootlets = dorsal root dorsal ramus dorsal root ganglion ventral ramus ventral root grey and white rami communicans sympathetic chain vertebral artery white matter - myelinated axons t grey matter - nerve cell bodies - unmyelinated nerve processes dura mater arachnoid mater spinous process of the VB Aorta

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T1-T12* mixed = motor + sensory see sensory / motor map of the SNs VC damage accidents

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Sternocleidomastoid (Nerve to)
CP (deep branches) see also Trapezius (Nerve to) Spinal Roots + Cranial Ns Cranial XI (Accesssory) C1-C5 Nerve type mixed = motor + sensory Muscular branches to the Sternocleidomastoid (1) to Trapezius (2) Articular Branches NONE Cutaneous branches NONE LESIONS unilateral - cannot rotate head to the affected side, cannot shrug ipsilateral shoulder bilateral cannot rotate head or shrug shoulders, cannot lift chin - head drops forwards typical aetiologies intracranial damage to Accessory nerve as in stroke head trauma affecting jugular foramen associated lesions/ any injury to the jugular foramen losses may involve other cranial Ns particularly IX, X, and XII* *these syndromes include Vernet’s = lesions of IX-XI Villaret’s = lesions of IX-XII + VII Jackson’s = lesions of IX, XI & XII Schmidt’s = lesion in nucleus ambiguous (XI) affecting swallowing & phonation

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Discussed in gretaer detail in the A to Z of the brain

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Subclavius Nerve (Nerve to Subclavius)

Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS typical aetiologies associated lesions/losses

C5, C6 motor to Subclavius NONE NONE none unless the Accessory Phrenic nerve is injured diaphragm weakness broken clavicle (collar bone)

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see also Accessory nerve (CP) BP (supraclavicular branches)

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Subcostal Nerve
part of the LP (twelfth thoracic nerve) T12 (ventral ramus) mixed = motor + sensory Medial and Lateral branches to the muscles of the abdominal wall (1-6) Articular Branches to the 12th costovertebral joint (10) Cutaneous branches to the skin overlying pubis, greater trochanter and gluteal area (8-9) LESIONS weakness and bulging of the lower abdominal wall (Beever’s sign) typical aetiologies spinal injuries associated lesions/losses any injuries involving the SC and VC , iatrogenic laminectomy and other operations in this area. 1 2 3 4 5 6 7 8 9 10 to Quadratus lumborum to Transverse abdominus to Internal oblique to External oblique to Rectus Abdominus to Pyramidalis Inguinal ligament lateral Cutaneous N anterior Cutaneous N to costovertebral joint Spinal Roots Nerve type MAJOR BRANCHES Muscular branches

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Suboccipital Nerve (first dorsal ramus)
C1 cervical dorsal ramus mixed = motor + sensory Medial and Lateral branches to the capitus muscles in the head and neck Articular Branches to the craniovertebral joints Cutaneous branches to the dorsum neck and head crosses and supplies similar area to the lesser occipital nerve LESIONS parasthesia to the back of the head in occipital region typical aetiologies whiplash injuries to the neck in car accidents associated lesions/losses injury to sternocleidomastoid / occiptal nerves often overcompensate and cause muscle spasm and headaches (seen several weeks after the accident) 1 2 3 4 5 6 7 to Rectus Capitus posterior major to Rectus Capitus posterior minor to Obliquus Capitus superior to Obliquus Capitus inferior to Semispinalis Capitus Medial branch Lateral branch

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Superficial Peroneal nerve
LP/SP (dorsal division) L4, L5, S1, S2 mixed = motor + sensory medial (1) lateral (2) dorsal digital (3) Muscular branches to Peroneus longus (4) and brevis (5) Articular Branches NONE Cutaneous branches NONE LESIONS weak eversion of the foot / unopposed inversion of the foot parasthesia on the lateral side of the lower leg typical aetiologies abdominal injuries - anything damaging L4/5 discs iatrogenic pudendal block etc incorrect rare to see isolated associated lesions/losses pelvic and back injuries 1 2 3 4 5 medial lateral dorsal digital to Peroneus longus to Peroneus brevis Spinal Roots Nerve type Named branches

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Superior Gluteal nerve
SP (dorsal division) L4, L5, S1 motor superior and inferior branches to muscles in the buttock and the hip abductors (1-5) Articular Branches to the sacroiliac joint Cutaneous branches NONE LESIONS Trendelenburg’s sign = dropping of pelvis to opposite side when elevating leg /instability of core when walking etc. typical aetiologies abdominal injuries - anything damaging L4/5 discs iatrogenic pudendal block etc incorrect rare to see isolated associated lesions/losses pelvic and back injuries
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superior branch to gluteus medius superior branch to gluteus minimus inferior branch to gluteus medius inferior branch to gluteus minimus inferior branch to tensor fascia lata Sciatic nerve

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Supraclavicular Nerve
CP (superficial branches) Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS C3, C4 sensory NONE NONE skin above the clavicle anterior (1) lateral (2) and posterior (3) loss of sensation on the area described

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Suprascapular Nerve
BP (supraclavicular branches) C5, C6 motor ±sensory to the dorsal muscles around the Scapula (1, 2) Articular Branches to the shoulder joints (3, 4) Cutaneous branches to the skin over the Deltoid LESIONS weak abduction and lateral rotation of the Humerus atrophy of muscles around the Scapula typical aetiologies Injuries to the BP injuries to Clavicle associated lesions/losses BP injuries, neck injuries 1 2 3 4 5 6 7 to Supraspinatus to Infraspinatus to Glenohumeral joint to Acromioclavicular joint Clavicle Acromian spine of Scapula Spinal Roots Nerve type Muscular branches

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Third Dorsal ramus
C3 cervical dorsal ramus mixed = motor + sensory Medial and Lateral branches to the capitus muscles in the neck and head (3-5) Articular Branches to the atlanto-occipital and atlantoaxial joints (6) Cutaneous branches to the dorsum neck and head to the level of the ear LESIONS parasthesia to the back of the head in occipital region typical aetiologies whiplash injuries to the neck in car accidents associated lesions/losses injury to sternocleidomastoid / occiptal nerves often overcompensate and cause muscle spasm and headaches (seen several weeks after the accident) 1 2 3 4 5 Medial branch Lateral branch to Splenius capitus to Semispinalis capitus to Longissimus capitus

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Thoracic Nerves Summary
do not form plexi - remain segmental, ventral rami do not fuse and do not communicate form the intercostal Ns (IC Ns) T12 passing under the 12th rib = Subcostal N = Twelfth thoracic N

T6-12 = thoraco-abdominal Ns = lower thoracic IC Ns

T8-12 auxillary supply to the diaphragm dorsal rami supply the muscles and skin of the backsupply the intrinsic muscles of the back supply the intervertebral discs and vertebral joints 1 2 3 4 5 6 7 8 IC Ns to Rectus Abdominus abdominal wall muscles segmentally supplied by the IC Ns. inguinal ligament Pubic Symphysis ASIS = anterior superior iliac spine costal cartilages IC spaces IC muscles

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T1±T2 = intercostobrachial Ns (contribute to the BP) supply the muscles and skin of the abdomen and thorax

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Thoracodorsal Nerve = Middle Subscapular nerve
Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS C6, C7, C8 motor to Latissimus Dorsi NONE NONE weak adduction, extension and medial rotation of the Humerus typical aetiologies BP injuries, clavicular injuries associated lesions/losses BP injuries

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BP (Infraclavicular branches)

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Tibial nerve
SP (ventral divisions) from sciatic N L4, L5, S1, S2, S3 mixed = motor + sensory to the back of the leg and soul of the foot Articular Branches to the knee and ankle joints Cutaneous branches to the skin on the sole and medial heel LESIONS uncommon due to deep placement of the N cannot flex or abduct or adduct toes toes / cannot stand on tip toes / weak knee flexion / weak plantar flexion some parasthesia of the foot and toes typical aetiologies car accidents, leg - knee trauma, L4/5 disc damage associated lesions/ leg and knee injuries losses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Medial Sural Cutaneous nerve to Gastrocnemius (lateral head) to Gastrocnemius (medial head) to Plantaris to Soleus to Popliteus to Tibialis posterior to knee joint to tibiofibular joints Medial calcaneal cutaneous nerve Medial plantar nerve Lateral plantar nerve Sural nerve to flexor digitorum longus to flexor hallicus longus Spinal Roots Nerve type Muscular branches

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Trapezius (Nerve to)

*winged scapula definition = inability of the upper scapula to adhere to the posterior chest wall flails away from the body and destabilizes the scapula and its associated muscles

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Spinal Roots + Cranial Ns Cranial XI (Accesssory) C3, C4 Nerve type mixed = motor + sensory (proprioceptive) Muscular branches to Trapezius Articular Branches NONE Cutaneous branches NONE LESIONS unilateral - dropped ipsilateral shoulder ; winged* scapula bilateral - cannot properly move arms at all particularly not over 20º compromising the function of Deltoids, Rhomboids, Serratus and Spinati muscles typical aetiologies damage to Accessory nerve in the posterior triangle iatrogenic eg when sampling regional lymph nodes in biopsy associated lesions/losses unable to assess injuries to brachial plexus with injury to this N

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Ulnar Nerve
BP (Infraclavicular branches) C8, T1 (medial card - ant division) mixed = motor + sensory Dorsal (Do) (1) Superficial (ST) (2) Deep (De) (3) Muscular branches to Flexor Carpi Ulnaris (4) to Flexor Digitorum Profundus (5) to Palmaris Brevis (ST) to all the intrinsic hand muscles (De) Articular Branches to the elbow joint to the joints in the little and ring fingers (Do) to some of the wrist joints (De) Cutaneous branches supplies the palmar skin on the ulnar side and the little and ring fingers (ST) F LESIONS weak flexion and ulna deviation of the wrist “clawed hand” wasting of Palmaris brevis in the Hypothenar eminence (ST) parasthesia on the ulna side of the hand and fingers described above typical aetiologies BP injuries, broken arm elbow injuries associated lesions/ UL injuries losses 1 2 3 4 5 6 7 8 9 Dorsal branch (terminal) Superficial branch (terminal) Deep branch (terminal) to Flexor carpi ulnaris to Flexor digitorum profundus (medial half) Palmar cutaneous branch 1st dorsal digital branch 2nd dorsal digital branch 3rd dorsal digital branch Spinal Roots Nerve type NAMED BRANCHES (terminal)

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Ulnar Nerve Deep Terminal branch (De)
C8, T1 (medial card - ant division) mixed = motor + sensory to Abductor digiti minimi (1) to Flexor Digiti Minimi (2) to Opponens digiti minimi (3) to Dorsal interossei (4) to Palmar interossei (5) to 3rd and 4th Lumbricals (6) to Adductor Pollicus (7) Articular Branches to some of the wrist joints Cutaneous branches NONE LESIONS inability to spread fingers and extend little finger wasting and paralysis of the hypothenar muscles no thumb adduction typical aetiologies elbow injuries associated lesions/losses UL injuries Spinal Roots Nerve type Muscular branches

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Upper Subscapular Nerve

Spinal Roots Nerve type Muscular branches Articular Branches Cutaneous branches LESIONS

C5, C6, C7 motor to Subscapularis (superior) NONE NONE weak medial rotation of the Humerus typical aetiologies BP injuries associated lesions/losses BP injuries

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Dr. A. L. NEILL
BSc MSc MBBS PhD FACBS

medicalamanda@gmail.com www.amandasatoz.com 0410 018 681 fax: 61 2 9365 1000

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