PERIPHERAL NERVE

INJURY
ANATOMY, ASSESSMENT, AND CLINICAL FEATURES

Karolle Alyssa M. Feliciano, PTRP

STRUCTURE OF THE BRACHIAL PLEXUS
STRUCTURE OF THE BRACHIAL PLEXUS
 NERVES OF THE BRACHIAL PLEXUS:
BRANCHES FROM THE NERVE ROOTS
1. DORSAL SCAPULAR NERVE C5
2. LONG THORACIC NERVE (OF BELL) C5/C6/C7
3. FIRST INTERCOSTAL NERVE T1
DORSAL SCAPULAR NERVE C5

MOTOR SUPPLY: levator
scapulae (elevates
scapula), rhomboid
major and rhomboid
minor (stabilize, retract and
medially rotate scapula)
LONG THORACIC NERVE (OF BELL) C5/C6/C7

MOTOR SUPPLY: 
serratus
anterior (protracts and
stabilizes scapula)
FIRST INTERCOSTAL NERVE T1

• SENSORY SUPPLY: narrow strip of skin

over first intercostal space
• MOTOR SUPPLY: first intercostal
muscles (elevate and depress ribcage during
inspiration and expiration)
 NERVES OF THE BRACHIAL PLEXUS:
BRANCHES FROM THE TRUNKS
1. SUPRASCAPULAR NERVE C5/C6
2. NERVE TO SUBCLAVIUS C6
SUPRASCAPULAR NERVE C5/C6

• MOTOR SUPPLY:
supraspinatus (stabilizes and
abducts shoulder)
and infraspinatus (stabilizes
and externally rotates shoulder)
NERVE TO SUBCLAVIUS C6

• MOTOR SUPPLY:
subclavius (depresses clavicle and
elevates first rib)
 NERVES OF THE BRACHIAL PLEXUS:
BRANCHES FROM THE CORDS
1. LATERAL PECTORAL NERVE C5/C6/C7
2. UPPER SUBSCAPULAR NERVE C5/C6
3. LOWER SUBSCAPULAR NERVE C5/C6
4. THORACODORSAL NERVE C6/C7/C8
5. MEDIAL CUTANEOUS NERVE OF FOREARM C8
6. MEDIAL CUTANEOUS NERVE OF FOREARM C8
LATERAL PECTORAL NERVE C5/C6/C7

• MOTOR SUPPLY: upper clavicular part

of pectoralis major (flexes, adducts and
internally rotates shoulder)
UPPER SUBSCAPULAR NERVE C5/C6

• MOTOR SUPPLY:
subscapularis (stabilises and
internally rotates shoulder)
LOWER SUBSCAPULAR NERVE C5/C6

• MOTOR SUPPLY:
subscapularis (stabilises and internally
rotates shoulder) and teres major (adducts
and internally rotates shoulder, protracts
and depresses scapula)
THORACODORSAL NERVE C6/C7/C8

• MOTOR SUPPLY: latissimus dorsi (extends, adducts

and internally rotates shoulder, externally rotates trunk)
Latissimus dorsi
MEDIAL PECTORAL NERVE C8/T1

• SENSORY SUPPLY: none to skin, may

have a role in sensation of chest wall pain
following breast surgery
• MOTOR SUPPLY: pectoralis
minor (stabilizes scapula, raises ribs during
inspiration) and lower sternocostal part
of pectoralis major (extends, adducts and
internally rotates shoulder)
MEDIAL CUTANEOUS NERVE OF ARM T1

• SENSORY SUPPLY: skin of lower

third of medial arm
• MOTOR SUPPLY: none
MEDIAL CUTANEOUS NERVE OF
FOREARM C8
• SENSORY SUPPLY: skin over biceps
muscle, antecubital fossa and medial
forearm
• MOTOR SUPPLY: none
 NERVES OF THE BRACHIAL PLEXUS:
THE TERMINAL BRANCHES
1. MUSCULOCUTANEOUS NERVE C5/C6/C7
2. AXILLARY NERVE C5/C6
3. RADIAL NERVE C5/C6/C7/C8/T1
4. MEDIAN NERVE
5. ULNAR NERVE C8 T1
MUSCULOCUTANEOUS NERVE C5/C6/C7
 CLINICAL FEATURES OF
MUSCULOCUTANEOUS NERVE PALSY
• SENSORY LOSS
• numbness over lateral forearm
• MOTOR DEFICIT
• paralysis of anterior compartment of arm – very weak elbow flexion and
weak forearm supination
• absent biceps reflex
• DEFORMITY
• wasting of anterior compartment of arm
• elbow usually held in extension with forearm pronated
AXILLARY NERVE C5/C6

COURSE
• it passes beneath the shoulder
joint through the quadrangular space with
the posterior circumflex humeral artery
• it then wraps around the surgical neck of
the humerus
 AXILLARY NERVE C5/C6

SENSORY SUPPLY
• the “sergeant’s patch” of skin over the lower
part of deltoid muscle
MOTOR SUPPLY
• shoulder muscles
• deltoid – abducts, flexes and extends
shoulder
• teres minor – externally rotates shoulder,
forms part of rotator cuff which stabilises
shoulder joint
 CLINICAL FEATURES OF AXILLARY NERVE
PALSY

• SENSORY LOSS • DEFORMITY

• numbness over “sergeant’s patch”
• MOTOR DEFICIT
• paralysis of deltoid – very
weak shoulder abduction from 15-90°;
weak shoulder flexion and extension
• paralysis of teres minor –
weak shoulder external rotation
• wasting of deltoid muscle, making
the bones of the shoulder joint very
prominent and obvious
• shoulder may appear adducted and
internally rotated
RADIAL NERVE C5/C6/C7/C8/T1

COURSE
• it passes behind the axillary artery and through the triangular
interval to enter the posterior compartment of the arm
• it then winds around the spiral groove of the humerus with
the profunda brachii artery, between the heads of triceps muscle
• it enters the antecubital fossa in front of the lateral epicondyle of the
humerus, between the brachialis and brachioradialis muscles
• it then branches in the proximal forearm into two terminal branches:
• superficial branch (mainly sensory) – descends under brachioradialis muscle to
end in the dorsum of the hand
• deep branch (mainly motor) – pierces supinator muscle and descends along
the posterior interosseous membrane with the posterior interosseous artery
 RADIAL NERVE C5/C6/C7/C8/T1

SENSORY SUPPLY
• 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)
 
 AREAS OF COMPRESSION:

RADIAL NEUROPATHY AT THE SPIRAL GROOVE

Causes
• Fracture – humerus
• External compression, injections
• Prolonged sleep or unconsciousness
• honeymooner’s paralysis
• Saturday night palsy
 AREAS OF COMPRESSION:

POSTERIOR INTEROSSEOUS
NEUROPATHY
• entrapment at the arcade of Frohse
• elbow fractures, laceration, or compression
from soft tissue masses
• Weak finger extensors and ECU
• No sensory deficits
MEDIAN NERVE C5/C6/C7/C8/T1
COURSE
• the median nerve runs down the arm with the brachial artery: it
initially lies lateral to the artery, then crosses over to lie medial to it about
halfway down the arm
• passes through the medial part of the antecubital fossa between the two
heads of pronator teres muscle
• travels through  anterior forearm bet the flexor digitorum superficialis and
flexor digitorum profundus muscles and gives three main branches:
• anterior interosseous nerve – descends along anterior interosseous
membrane with anterior interosseous artery
• deep branch – enters hand through the carpal tunnel beneath flexor
retinaculum of wrist, between flexor carpi radialis and flexor digitorum
superficialis tendons
• superficial/palmar cutaneous branch – arises just before the wrist and pierces
the palmar carpal ligament to enter the palm over the top of the carpal tunnel –
this nerve is therefore not affected by carpal tunnel syndrome
MEDIAN NERVE C5/C6/C7/C8/T1

SENSORY SUPPLY
• the median nerve does not supply any sensory
innervation to the axilla or upper arm
• 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)
MEDIAN NERVE C5/C6/C7/C8/T1
MOTOR SUPPLY
• the median nerve does not supply any motor innervation to
the axilla or upper arm
• 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
MEDIAN NERVE C5/C6/C7/C8/T1

intrinsic muscles of hand – LOAF musclesn

• Lumbricals 1 and 2ger
• opponens pollicis – opposes thumb
• abductor pollicis brevis – abducts thumb
• flexor pollicis brevis – flexes thumb at MCPJ
 AREAS OF COMPRESSION:

ANTERIOR INTEROSSEOUS SYNDROME

• Compression at the fibrous arch formed by
the FDS and pronator teres
• Repetitive forearm flexion and pronation
• Fracture – elbow and forearm
 AREAS OF COMPRESSION:

PRONATOR SYNDROME
Compression
• Between the two heads of the pronator teres
• Fascial band from the FDS
• Biceps aponeurosis
 AREAS OF COMPRESSION:

CARPAL TUNNEL SYNDROME

Compression
• Within the carpal canal, 1-2cm beyond the distal wrist crease
Risk Factors
• Female > male
• Dominant hand
• Repetitive hand movement
• Medical conditions
 ULNAR NERVE C8/T1
COURSE
• the ulnar nerve runs down the arm on the medial
side of the brachial artery
• it passes behind the medial epicondyle of the
humerus and enters the forearm between the two
heads of flexor carpi ulnaris
• it travels through the anterior compartment of
the forearm beneath flexor carpi ulnaris with
the ulnar artery
• it then enters the palm of the
hand through Guyon’s canal
ULNAR NERVE C8/T1
SENSORY SUPPLY
• the ulnar nerve does not supply any sensory
innervation to the axilla or upper arm
• skin over hypothenar eminence
• medial ⅓ palm of hand
• palmar aspect of lateral 1½ fingers
• medial ⅓ dorsum of hand
• dorsal aspect of medial 1½ fingers (little
finger and half of ring finger)
 ULNAR NERVE C8/T1
MOTOR SUPPLY
• two muscles of anterior compartment of forearm
• flexor carpi ulnaris – flexes and adducts wrist
• medial two parts of flexor digitorum profundus – flex ring and little fingers at DIPJs
• 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
• NB// adductor pollicis is not part of the thenar eminence and actually lies deep beneath it as a separate structure
 ULNAR NERVE C8/T1
• 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
 AREAS OF COMPRESSION

• CUBITAL TUNNEL SYNDROME:

Entrapment: cubital tunnel, which is formed by the ulnar groove between the medial
epicondyle of the humerus and the olecranon.
Causes: ganglion formation, arthritis, old fracture of the lateral humeral epicondyle,
dislocation of the ulnar nerve when the elbow is flexed.
 AREAS OF COMPRESSION

• CUBITAL TUNNEL SYNDROME:

• Sensory involve- ment is localized over the ulnar aspect of the hand on both the
palmar and dorsal aspects.
• The motor weakness in the forearm by the flexor carpi ulnaris and in the hand by
the adductor pollicis, and the flexor digitorum profundus, lumbricales, and
interosseus muscles (fourth and fifth digits).
• Result in a radial deviation on wrist flexion and a mild clawing of the fourth and
fifth fingers. flexor carpi ulnaris syndrome
 AREAS OF COMPRESSION
DEFORMITY
wasting of hypothenar eminence and intrinsic muscles of hand
• “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.
 AREAS OF COMPRESSION

• FLEXOR CARPI ULNARIS SYNDROME

• Ulnar Nerve is trapped as it passes under the arcuate ligament between the two
heads of FCU muscle.
• Clinical manifestation is same with Cubital tunnel syndrome
 AREAS OF COMPRESSION

ULNAR TUNNEL SYNDROME

Compression: Ulnar Tunnel (formed by Pisohamateligament)
Symptoms:
Pain at the palmar aspect of ulnar side of the hand and fourth and fifth digit.
MOTOR DEFICIT
Atrophy of hypothenar and interosseus muscles(esp the 1st dorsal interosseous)
POINTS TO REMEMBER:
 Thousands of candles can be lighted from a single
candle, and the life of the candle will not be shortened.
Happiness never decreases by being shared.

THANK YOU!
Thousands of candles can be
lighted from a single candle, and
the life of the candle will not be
shortened. Happiness never
decreases by being shared.

Thank You!