Nerve injuries of

Upper limb
Erb’s palsy / erb Duchenne paralysis / Upper
brachial plexus injury
Site of injury : Area on the upper trunk which is the meeting point
of 6 nerves.

Etiology :
1) Blow or fall on the shoulder causing excessive displacement of
head to the opposite side and depression of shoulder to the same
side.
2) Difficult delivery of infant
Nerves injured Muscles paralysed Movements lost Effect
Suprascapular nerve Supraspinatus Initiator of abduction Shoulder adducted and
(C5, C6) Infraspinatus (supraspinatus) medially rotated by
Infraspinatus (lateral unopposed action of
rotation of shoulder pectoralis major)
joint)
Musculocutaneous Biceps brachii, Flexion of elbow joint Elbow extended and
nerve (C5, C6 and C7) coracobrachialis and (biceps brachii and forearm pronated
brachialis brachialis)
Supination of forearm
(biceps brachii)

Axillary nerve (C5, C6) Deltoid Abductor of shoulder Shoulder adducted

Teres minor joint (deltoid) And medially rotated
Lateral rotation of
shoulder joint (Teres
minor)

Nerve to subclavius Subclavius Clinically

(C5, C6) unrecognisable
Final condition of upper limb

Upper limb hangs limply by the side

Medially rotated
Elbow extended
Forearm pronated

Condition of upper limb has been

likened to porter or waiter hinting
for a tip – porter’s tip deformity
Klumpke’s paralysis
Lower lesion of brachial plexus involving tear of T1 nerve

Etiology : hyperabduction of arm as in a person falling from a

height trying to save himself by clutching at an object.

Nerves involved : T1 fibres running through median and ulnar

nerve

Muscles paralysed : all small muscles of hand.

Motor loss : Hyperextension of MCP joints and flexion of

interphalangeal joints of all fingers due to paralysis of lumbricals
and interossei – Clawed hand
MCP joints extended due to unopposed action of extensor
digitorum
Flexion of middle and terminal phalanges by unopposed action of
flexor digitorum superficialis and profundus.

Sensory loss along medial side of arm.

 Involvement of T1 also leads to Horner’s syndrome
Claw hand which is in interruption of sympathetic nerve supply
to the eye.
Characterised by
1) Miosis (constriction of pupil on affected side)
2) Anhydrosis (Absence of hemifacial sweating on
affected side)
3) Mild ptosis (drooping of eyelid)
4) Loss of ciliospinal reflex (Dilatation of ipsilateral
pupil in response to pain applied to the neck)
5) Enophthalmos (Sunken globe of eye)
Sites of injury of median nerve
1) Commonest – stab injury above the wrist
proximal to flexor retinaculum (nerve lies
between the tendon of flexor carpi
radialis and flexor digitorum superficialis).
2) Carpal tunnel – median nerve compressed
within the tunnel due
a) Swollen synovial sheaths of long flexor
tendons
b) Anterior dislocation of carpal bones –
commonest – lunate
3) Sometimes at the elbow in supracondylar
fracture of humerus.
MEDIAN NERVE DISTRIBUTION
 Median nerve injury at elbow due to supracondylar fracture of humerus
Sensory loss : Lateral half of palm of (palmar cutaneous branch of median nerve) and palmar aspect of lateral 3and a
half fingers extending to the dorsal surface of distal part of these fingers (palmar digital branches).
Motor loss
MUSCLES PARALYSED MOVEMENT LOST EFFECT
1) Pronator teres and quadratus Pronation of forearm Forearm supinated
2)Flexor carpi radialis Weak flexion of wrist with adduction
due to unopposed action of flexor
carpi ulnaris
3) Flexor digitorum superficialis and Flexion of interphalangeal joints of Index and middle fingers remain
lateral half of flexor digitorum index and middle finger. straight on trying to make a fist
profundus
4) Flexor pollicis longus flexion of terminal phalanx of thumb
5) Thenar muscles Flexion, abduction and opposition of Thumb laterally rotated and
thumb adducted
Weakness and wasting of thenar
eminence – flattened hand, APE like
APPearance
5) First and second lumbricals Weakness of flexion of MCP of index
and middle finger.
Median nerve injury above wrist proximal to flexor retinaculum
Sensory loss : Lateral half of palm of (palmar cutaneous branch of median nerve) and
palmar aspect of lateral 3and a half fingers extending to the dorsal surface of distal part of
these fingers (palmar digital branches of median nerve).
Motor loss
Muscles paralysed Movement lost Effect

Thenar muscles Flexion, abduction and Thumb laterally rotated and

opposition of thumb adducted. Loss of delicate
pincer like action of hand.
Weakness and wasting of
thenar eminence – flattened
hand, APE like appearance of
hand.

First and second lumbricals Weakened flexion of MCP

joints of index and middle
fingers.
Difficulty in making a fist as
index and middle fingers lag
behind.
Carpal tunnel syndrome
Compression of median nerve within carpal tunnel

Etiology :
a) Swollen synovial sheaths of long flexor tendons
a) Anterior dislocation of carpal bones – commonest – lunate

Motor loss
Muscles paralysed : Thenar muscles, first and second lumbricals
1) Weakness and wasting of thenar eminence – flattened hand
2) Thumb laterally rotated and adducted – APE like appearance of hand
3) Absence of pincer like action of hand due to loss of opposition of
thumb.
4) Index and middle fingers tend to lag behind while making a fist due
to paralysis of first and second lumbricals.

Sensory loss : paresthesia (burning pain or pins and needle

sensation) only over the lateral 3 and a half fingers.
No paresthesia over lateral half of palm as palmar cutaneous branch of
median nerve spared.

Treatment : Decompress the tunnel by making a longitudinal

incision over flexor retinaculum.
Cutaneous distribution of ulnar nerve
Common sites of ulnar nerve
injury
1) At the elbow due to fracture of
medial epicondyle
2) Cubital tunnel : Compression by
tendinous arch connecting the two
heads of Flexor carpi ulnaris.
3) At the wrist

Superficial in position while passing infront of

flexor retinaculum.
Guyons’ canal : pisiform and hook of hamate
connected by pisohamate ligament. Ulnar
nerve compressed by this ligament while
passing between pisiform and hook of hamate.
Ulnar nerve injury at elbow (behind medial
epicondyle and cubital tunnel syndrome)
Sensory loss : over anterior and posterior surface of
medial third of hand and medial one and a half
fingers.
 Motor paralysis
Muscles paralysed Action lost effect
1) Flexor carpi ulnaris Wrist flexion weak with abduction of
wrist due to unopposed action of
flexor carpi radialis.
2) Flexor dgitorum profundus Flexion of terminal phalanx of ring Terminal phalanx of ring and little
tendon (medial half) and little finger fingers not capable of marked
flexion.

3) Palmar and dorsal interossei Adduction and abduction of fingers. Not able to grip a piece of paper
placed between fingers.
4) Adductor pollicis Adduction of thumb Patient grips a paper between
thumb and index finger by flexing
the terminal phalanx of thumb –
froment’s sign
5) Third and fourth lumbricals and Flexion at MCP joints and extension Hyperextension of MCP joints and
interossei muscles at interphalangeal joints of ring and flexion of interphalangeal joints of
little fingers. ring and little fingers – Ulnar claw
hand involving only ring and little
fingers in long standing cases.
6) Hypothenar muscles Weakness and wasting of
Ulnar claw hand
Ulnar nerve injury at the wrist
and guyon’s canal
Sensory loss : ulnar nerve and its palmar
cutaneous branch injured but dorsal
cutaneous branch spared.
Loss of skin sensation only over anterior
surface of medial third of palm and medial
one and a half fingers including dorsal
surface of the distal part of the same
fingers.
Motor loss
Muscles paralysed Action lost effect
6) Hypothenar muscles Weakness and wasting of
hypothenar eminence.
3) Palmar and dorsal interossei Adduction and abduction of Not able to grip a piece of paper
fingers. placed between fingers.
4) Adductor pollicis Adduction of thumb Patient grips a paper between
thumb and index finger by flexing
the terminal phalanx of thumb –
froment’s sign
5) Third and fourth lumbricals and Flexion at MCP joints and Hyperextension of MCP joints and
interossei muscles extension at interphalangeal joints marked flexion of interphalangeal
of ring and little fingers. joints of ring and little fingers –
Ulnar claw hand involving only
ring and little fingers in long
standing cases

Ulnar paradox : Clawing of ring and little fingers become more prominent in distal lesions of ulnar nerve
Explanation : Sparing of medial half of Flexor digitorum profundus allow marked flexion of terminal phalanges of
ring and little fingers.
Extent of clawing of ring and little fingers helps in differentiating between proximal and distal lesions of ulnar
nerve.
Common sites of injury of
radial nerve
1) Axilla : Pressure of upper end of
crutch
Drunkard falling asleep with arm over
back of chair
Inferior dislocation of shoulder joint :
excessive stretching of radial nerve in
axilla

2) Spiral groove : Fracture of shaft of

humerus

3) Fracture of proximal end of radius or

dislocation of radial head or deep stab
injury of posterior forearm : affects
deep branch of radial nerve
Radial nerve distribution
Radial nerve injury in axilla

Sensory loss
Loss of skin sensation along
a) Posterior surface of skin of arm
b) Narrow strip of back of forearm
c) Lateral part of the dorsum of the hand and dorsal surface of
lateral three and a half fingers over the proximal phalanges
Muscles paralysed Muscle function Effects
1) Triceps and anconeus Extension of elbow Loss of elbow extension

2)Extensor carpi radialis longus and brevis, Extension of wrist

extensor carpi ulnaris Wrist drop
Unable to flex fingers strongly
for the purpose of gripping

3) Extensor digitorum, Extensor digiti Extension of MCP joints and Loss of extension of MCP
minimi interphalangeal joints of and interphalangeal joints
fingers of medial 4 fingers

4) Extensor pollicis brevis, extensor pollicis Extension of thumb and index Loss of extension of thumb
longus and extensor indices fingers and index finger

5) Brachioradialis and supinator Supination still occurs as

biceps is spared.
Wrist drop due to radial nerve palsy
Radial nerve injury in spiral groove

Occurs in distal part of spiral groove

beyond the origin of nerves to triceps and
anconeus and the cutaneous nerves.

Motor loss : Loss of extension of wrist and

fingers – wrist drop
Extension of elbow is spared.

Sensory loss : Lateral part of the dorsum

of the hand and dorsal surface of lateral
three and a half fingers over the proximal
phalanges
 Injury of deep branch of radial nerve or posterior
interosseus nerve
Inability to extend the thumb and MCP joints and interphalangeal joints of
other digits
Nerve supply to Extensor carpi radialis longus and supinator is spared.
As extensor carpi radialis longus is a powerful extensor of wrist joint, wrist
drop does not occur.
No sensory loss as this is a motor nerve.
Injury of axillary nerve
Etiology : 1) Pressure of upper end of crutch into
the armpit
2) Inferior dislocation of humeral head in shoulder
dislocations
3) Fracture of surgical neck of humerus

Muscles paralysed : Deltoid and teres minor

Motor paralysis : Weakness and wasting of deltoid

muscle – loss of rounded contour of shoulder –
greater trochanter can be easily palpated.
Abduction of shoulder joint is impaired as deltoid
and supraspinatus are prime movers.

Sensory loss : loss of skin sensation over the lower

half of deltoid due to involvement of upper lateral
cutaneous nerve of arm – regimental badge area of
loss of cutaneous sensation.
Injury to long thoracic
nerve /nerve of Bell
Etiology : during radical mastectomy

Muscle paralyzed: serrated anterior

Movements lost : Inability to rotate the

scapula during elevation of arm above right
angle.
Vertebral border and inferior angle of scapula
protrude backwards during pushing or
punching movements (winged scapula) due to
unopposed action of levator scapulae and
rhomboidus major and minor muscles.
Explain why : woman unable to comb her hair
after radical mastectomy
Name the nerve involved in the fracture of medial epicondyle of humerus. Describe the course and
distribution of the nerve beyond the elbow. Mention sensory and motor disabilities following the nerve
injury.[1+6+5] (2013)

A patient has reported with fracture of surgical neck of humerus :

(i) Which nerve is susceptible to injury?
(ii) What is the origin and distribution of the nerve?
(iii) Mention the effects of injury of the nerve.[2+5+5][2012 supple]

Short note on
Erbs palsy (2018 supple)
Claw hand (2019 supple)

Explain why
1. Injury to the radial nerve in the cubital fossa will not cause wrist drop. (2012)
2. Injury to the long thoracic nerve causes winging of the scapula. [2012
3. Injury to the long thoracic nerve causes winging of the scapula. [2012]
4. Fracture of shaft of humerus causes wrist drop. [2017]
5. Winging of scapula. [2015 supple][2016 supple][2018 supple]