Introduction

The nerve supply to the upper limb is almost entirely supplied by

the brachial plexus, a complex intercommunicating network of
nerves formed in the neck by spinal nerve roots C5, C6, C7, C8
and T1.

Musculocutaneous nerve (C5/C6/C7)

Origin

The lateral cord of brachial plexus, formed from anterior

divisions of superior and middle trunks.

Course

The musculocutaneous leaves the axilla by piercing

coracobrachialis muscle. It then passes down the arm beneath
biceps muscle and ends as the lateral cutaneous nerve of forearm.

Sensory supply
 It supplies skin of lateral forearm.

Motor supply

The musculocutaneous nerve innervates

the anterior compartment of arm (BBC):

 Biceps: flexes elbow, supinates forearm

 Brachialis: flexes elbow
 Coracobrachialis: flexes and adducts the arm at the
glenohumeral joint

Common injures

Musculocutaneous nerve injuries are rare, as the nerve is protected

beneath the bulk of the biceps muscle. It may be damaged by stab
wounds to the upper arm

Axillary nerve

Sensory supply

The axillary nerve supplies the “sergeant’s patch” of skin over the
lower part of deltoid muscle.

Motor supply
 The axillary nerve innervates the following shoulder muscles:

 Deltoid: abducts, flexes and extends shoulder

 Teres minor: externally rotates shoulder, forms part of
rotator cuff which stabilises shoulder joint

Common injuries

Common injuries affecting the axillary nerve include:

 Fracture of surgical neck of humerus

 Stab wounds to posterior shoulder
 Anterior shoulder dislocation
 Pressure of crutches on armpits (“crutch palsy”)

Clinical features: Axillary nerve palsy

 Sensory loss: numbness over “sergeant’s patch”

 Motor deficit: paralysis of deltoid leading to very weak
shoulder abduction from 15-90°; weak shoulder flexion and
 extension. Paralysis of teres minor leading to weak shoulder
external rotation.

 Deformity: wasting of deltoid muscle, making the bones of the

shoulder joint very prominent and obvious. The shoulder

may appear adducted and internally rotated.

Radial nerve (C5/C6/C7/C8/T1)

Sensory supply

The radial nerve is responsible for the sensory supply to:

 Posterior arm and forearm

 Lateral ⅔ of dorsum of hand
 Proximal dorsal aspect of lateral 3½ fingers (thumb, index,
middle and half of ring finger)

Motor supply

The radial nerve supplies the triceps in the posterior compartment

of the arm. The triceps extends and adducts shoulder and extends
elbow.

The radial nerve innervates the following muscles in the posterior

compartment of the forearm:
 Brachioradialis: flexes elbow
 Anconeus: extends elbow, stabilises elbow joint
 Supinator: supinates forearm
 Extensor carpi radialis longus and brevis: extend and abduct
wrist
 Extensor carpi ulnaris: extends and adducts wrist
 Extensor digitorum, extensor pollicis longus and brevis,
extensor indicis and extensor digiti minimi: extend thumb and
fingers at MCPJs and IPJs
 Abductor pollicis longus: abducts thumb

Common injuries

Common injuries affecting the radial nerve include:

 Fractures of proximal humerus, shaft of humerus or radius

 Stab wounds to antecubital fossa, forearm or wrist (this
includes blood tests and cannulation)
 Pressure of crutches on armpits (“crutch palsy”)
 The patient falling asleep with arm hanging over the back of
a chair, classically whilst drunk (“Saturday night palsy”)
 Somebody else falling asleep with their head lying on the
patient’s arm (“honeymoon palsy”)
 Excessively tight plaster casts, wristbands or handcuffs
 Prolonged tourniquet use on the arm arm, for example
during orthopaedic or plastics procedures

Clinical features: Radial nerve palsy

Clinical features of radial nerve palsy include:

 Sensory loss: numbness of skin over posterior arm, posterior
forearm and radial distribution of dorsum of hand
 Motor deficit:
 paralysis of posterior compartment of arm: weak elbow
extension
 paralysis of posterior compartment of forearm: weak
wrist extension, weak thumb extension and finger MCPJ
extension
 Finger IPJ extension is still possible due to intact nerve
supply to the lumbrical muscles of the hand
 Absent triceps and supinator reflexes
 Deformity: “Wrist drop” deformity at rest and on attempted
wrist extension (Figure 2). The patient cannot extend their
wrist/fingers, resulting in unopposed wrist flexion. In the classical
description of a radial nerve injury, the forearm is also pronated,
the fingers are flexed, and the thumb adducted. There may also
be wasting of triceps and posterior compartment of forearm.
 Figure 2. “Wrist drop”
deformity due to radial nerve palsy. The patient cannot extend
their wrist or fingers.

Median nerve (C5/C6/C7/C8/T1)

Sensory supply

The median nerve does not supply any sensory innervation to the
axilla or upper arm.

In the hand, the median nerve supplies:

 Skin over thenar eminence

 Lateral ⅔ palm of hand
 Palmar aspect of lateral 3½ fingers
 Dorsal fingertips of lateral 3½ fingers (thumb, index, middle
and half of ring finger)
 Motor supply

The median nerve does not supply any motor innervation to the
axilla or upper arm

The median nerve supplies all muscles of anterior compartment of

forearm except flexor carpi ulnaris and the medial two parts of
flexor digitorum profundus:

 Pronator teres and pronator quadratus: pronate forearm

 Flexor carpi radialis: flexes and abducts wrist
 Palmaris longus: flexes wrist and tenses palmar aponeurosis
 Flexor digitorum superficialis: flexes fingers at PIPJs
 Lateral two parts of flexor digitorum profundus: flex index
and middle fingers at DIPJs
 Flexor pollicis longus: flexes thumb at IPJ

The median nerve also supplies the intrinsic muscles of hand (LOAF
muscles):

 Lateral two lumbricals: flex MCPJs and extend IPJs of index

and middle finger
 Opponens pollicis: opposes thumb
 Abductor pollicis brevis: abducts thumb
 Flexor pollicis brevis: flexes thumb at MCPJ

Common injuries

Common injuries affecting the median nerve include:

 Supracondylar fractures of humerus

 Stab wounds to antecubital fossa, forearm of wrist (this
includes blood tests and cannulation!)
 Deep wrist lacerations inflicted during deliberate self-harm
 Compression by carpal tunnel syndrome

Clinical features: Median nerve palsy:

 Sensory loss: numbness of skin over thenar eminence and

median distribution of hand. However, in carpal tunnel syndrome,
sensation to the palm is usually preserved due to an intact
palmar cutaneous branch.
 Motor deficit:
 Paralysis of most of anterior compartment of forearm:
weak forearm pronation, wrist flexion and abduction, and weak
finger flexion with preservation of DIPJ flexion at ring and little
fingers.
 Paralysis of thenar eminence: weak pincer grip and
overall grip strength, weak thumb opposition.
 Deformity: “Hand of benediction” deformity on attempted
finger flexion, the patient cannot flex their index or middle
fingers, resulting in unopposed extension of those two fingers
(Figure 3). They cannot make a fist with all of their fingers.
Wasting of anterior compartment of forearm and thenar
eminence
 Figure 3.”Hand of
benediction” due to median nerve palsy – the patient cannot flex
their index or middle fingers

Ulnar nerve (C8/T1)

Sensory supply

The ulnar nerve does not supply any sensory innervation to the
axilla or upper arm.

In the hand, the ulnar nerve supplies:

 Skin over hypothenar eminence

 Medial ⅓ palm of hand
 Palmar aspect of the medial 1½ fingers
 Medial ⅓ dorsum of hand
 Dorsal aspect of medial 1½ fingers (little finger and half of
ring finger)

Motor supply

The ulnar nerve innervates two muscles in the anterior

compartment of the forearm:

 Flexor carpi ulnaris: flexes and adducts wrist

 Medial two parts of flexor digitorum profundus: flex ring and
little fingers at DIPJs

The ulnar nerve innervates most of the intrinsic muscles of the

hand (HILA muscles):

 Hypothenar eminence: opponens digiti minimi, flexor digiti

minimi brevis and abductor digiti minimi: oppose, flex and abduct
little finger
 Interossei: palmar interossei adduct, dorsal interossei abduct
 Medial two lumbricals: flex MCPJs and extend IPJs of ring
and little finger
 Adductor pollicis: adducts thumb. adductor pollicis is not part
of the thenar eminence and actually lies deep beneath it as a
separate structure.

In addition, the superficial branch of the ulnar nerve

innervates palmaris brevis.

Common injuries

Common injuries affecting the ulnar nerve include:

 Supracondylar fractures of humerus
 Fractures or soft tissue injuries to medial epicondyle of
humerus
 Stab wounds to forearm or wrist (this include blood tests and
cannulation!)
 Compression either at the cubital tunnel in the elbow or at
Guyon’s canal in the wrist

Clinical features of ulnar nerve palsy include:

 Sensory loss: numbness over hypothenar eminence and ulnar

distribution of hand
 Motor deficit:
 Paralysis of flexor carpi ulnaris: weak wrist flexion and
adduction
 Paralysis of medial two parts of flexor digitorum
profundus: weak flexion of ring and little finger DIPJs
 Paralysis of most of the intrinsic muscles of the
hand: weak MCPJ flexion and IPJ extension of ring and little
fingers, loss of finger abduction and adduction, loss of opposition
of little finger
 Deformity: “Claw hand” deformity at rest and on attempted
finger extension: the patient cannot extend the IPJs of their ring
or little fingers, resulting in fixed flexion of the IPJs and
hyperextension of the MCPJs of these two fingers (Figure 4).

The clawed appearance is most pronounced when the nerve

is injured at the wrist, for example by compression in Guyon’s canal,
as the function of flexor digitorum profundus will be preserved. A
claw hand affecting all four fingers is much less common and is
usually due to a lesion of the lower part of brachial plexus, such as
Klumpke’s palsy. wasting of hypothenar eminence and intrinsic
muscles of hand