4 - 5 practicals mpt 2nd year pns
TRANSCRIPT
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Peripheral Nerve Injuries of the Upper
Limb
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Dermatomes of the Posterior Arm
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Dermatomes of the Anterior Arm
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Principles of Localization
Certain sites are prone to nerve
entrapments/injuries
Nerve opposing bone Ulnar nerve at the elbow
Closed spaces
Carpal tunnel Adjacent structures
Median nerve at the elbow, adjacent to
the brachial artery
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Principles of localization, cont
Order in which branches arise Movements at specific joints
Single nerve
Elbow extensionRadial
Multiple nerves
Elbow flexion
Musculocutaneous
Radial
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Case 1
A 38 yr woman was the restrained passenger in
a car struck head on
She braced her hands on the dashboardimmediately prior to impact
She suffered bilateral fractures of the humerus
at the spiral (radial) groove
She complains of diffuse aches in her arms and
neck and weakness in her arms
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Case 1, cont
FINDING MUSCLE ROOT PLEXUS P NWR DROP ECR, ECU C7, C8 POST C RADIAL
MT, LTFING DRP EDC,EI C7, C8 POST C RADIAL
MT, LT
ELB FLX BR C5,C6 POST C RADIAL
UT
SENS ---- C6 LAT C RADIAL
UT
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Triceps, long head
Triceps, lateral head Triceps, med hd
Brachioradialis
ECRL
ECRB SuperficialSupinator Radial sens
Ext Digit
Abd Pol Longus Post Interosseous
Ext Pol Longus
Ext Pol Br
Ext Indicies
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Sensory loss in a high radial nerve lesion
(Signficant variability b/w patients)
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Final Diagnosis
????????????
Bilateral radial nerve palsies at the spiral (radial)
groove related to fractures
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Case 2
A 25 year old man gets involved in a fist fight
and the police arrest him
When he is released on bail, he goes to see hisdoctor because he has numbness in the hand
On exam he had
a number of scratches and bruises on both
arms
normal strength
sensory loss on the dorsum of the hand
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Patients sensory loss
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Case 2, cont
FINDING ROOT PLEXUS PN
SENS LOSS < C6 < LAT CORD SUP
RADSENS
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Triceps, long head
Triceps, lateral head Triceps, med hd
Brachioradialis
ECRL
ECRB SuperficialSupinator Radial sens
Ext Digit
Abd Pol Longus Post Interosseous
Ext Pol Longus
Ext Pol Br
Ext Indicies
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Final Diagnosis
??????????????????
Superficial radial neuropathy secondary tohandcuffs
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Case 3
15 yo football player is hit be another player,
with the helmet striking him in the axilla
On getting up, he is aware of shoulderweakness and pain and is taken to the ER
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Case 3, cont
On exam he has:
Normal elbow flexion
Normal elbow extension
Normal shoulder adduction
Ability to initiate shoulder abduction, but he
cannot raise his arm more than 15 degrees Mild weakness of external (lateral) rotation
of the arm
A patch of sensory loss over his upper arm
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Case 3, sensory loss
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Case 3, cont
FINDING MUSCLE ROOT PLEXUS PN
Abd>15 Deltoid C5,6 Post C Axillary
UT
Ext Rot T. Minor C5,6 Post C Axillary
Infrasp C5,6 UT Suprascap
Sens -------
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C5
C6
C7
C8
T1
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Case 3, cont
If its at the posterior cord
Radial innervated muscles should beaffected
But elbow extension is spared
If its at the upper trunk Musculocutaneous innervated muscles
should be affected
But elbow flexion is spared
Pattern of sensory loss
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Case 3, Final diagnosis
????????
Axillary Neuropathy in the Axilla
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Case 4
A 55 yo hospital worker comes to see you with
a 2 week history of pain in her neck, shoulder,
and upper arm Symptoms began when she tried to help
restrain a combative patient
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Case 4, cont
On exam she she:
Weakness of shoulder abduction
Weakness of elbow flexion
Mild weakness of pronation
Sensory loss in her lateral forearm and
thumb both posteriorly and anteriorly
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Case 4, cont
FINDING MUSCLE ROOT PLEXUS PN
ARM
ABD
DELTOID
Suprasp
C5,6 POST C UT AXIL
SUPRASC
ELB FLX BC BRACH
BR
C5,6 MED C, UT
POST C UT
MUSC
RAD
PRON
SENS
PT
------
C6,7
C6
LAT C
LAT C, UT
MED
MULT
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Case 4, Final Diagnosis
????????
C6 Radiculopathy secondary to a
herniated disc
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Case 5
40 yo woman comes to see you because she has
noticed weakness and numbness in her right
hand This started 2 months ago and is slowly
worsening
She is otherwise healthy, and rides her bike at
lease 40 miles per week
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Case 5, cont
On exam she has:
Atrophy of the interosseous muscles of the
right hand Mild weakness of abducting and adducting
the fingers
Normal thumb abduction, opposition and
extension
Normal wrist flexion, abduction and
adduction
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Case 5, sensory loss
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CASE 5, cont
FINDING MUSCLE ROOT PLEXUS PN
FING AD PALM
INT
C8T1 MED C, LT ULNAR
FING
ABD
DORSAL
INT
C8T1 MED C, LT ULNAR
Sens loss ----
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Case 5, cont
If its the lower trunk, C8/T1, or medial cord
other muscles affected should include:
APB and Opponens pollicus (median) EPL and EPB (radial)
Can it be localized further to a specificsite of the ulnar nerve?
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Ulnar sensory loss in an ulnar lesion
proximal to the midforearm
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Ulnar nerve
Elbow
Flexor carpi ulnaris
Flex Dig Prof III/IV
Dorsal uln cut
Wrist
Adductor Pollicus Abductor
Flex Pollicus Br Opponens Digiti Minimi
Flexor
Dorsal/palmar
Interosseous
3rd/4th lumbricals
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Case 5, final diagnosis
?????????
Ulnar neuropathy at the wrist