upper limb nerve lesions

8/2/2019 Upper Limb Nerve Lesions

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UPPER LIMB NERVE LESIONS

Radial nerve

AETIOLOGYHigh lesion (radial n)

fracture of humerus fracture or dislocation of shoulder axillary compression

back of chair (Saturday night palsy) crutch

prolonged tourniquet pressureLow lesion (posterior interosseous n)

fracture or dislocation at elbow local wound operation on proximal radius

CLINICAL FEATURES

High lesion

inability to extend arm (triceps) uncommon lesion usually distal to level of triceps innervation

wrist drop (ECRL, ECRB) inability to extend MCP jts of fingers (EDC) inability to extend thumb (EPL, EPB) sensory defect in anatomical snuffbox

Low lesion

as above but triceps OK radial deviation with wrist extension (ECU, ECRB, with

ECRL intact)

no sensory deficitEARLY TREATMENT

open injury explore

closed injury lively splint and ROM EMG at 3 weeks explore at 4-5 months if no recovery

TENDON TRANSFERS

High radial nerve palsyRequirements


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wrist extension finger (MCP jt) extension thumb extension and abduction ignore sensory lossAvailable muscles all extrinsics innervated by median and ulnar nerves (many)Transfers

basis is use of PT for wrist flexion classic Jones transfer uses FCU to restore finger extension

removes it as ulnar stabiliser may lead to radial deviation esp. if posterior interosseous palsy, as ECRL functioning

also uses FCR for thumb extension thus removes both wrist flexors

alternative is Starr transfer FCR for wrist extension PL for thumb extension preferred by Green

another option is Boyes transfer FDS III to EDC and IV to EPL through interosseous membrane useful when PL absent

Jones transfer PT to ECRL and ECRB FCU to EDC III-V FCR to EIP, EDC II, EPL (+/- EPB, APL) problem is that both wrist flexors are transferredFCR (Starr) transfer

PT to ECRB FCR to EDC PL to rerouted EPLTechnique of Starr transferPT transfer

origin of PT elevated with strip of periosteum PT freed proximally passed around radial border of forearm in subcutaneous

tunnel to dorsal surface

intertwined into ECRB tendonFCR transfer

FCR tendon transected near insertion passed around radial border of forearm in subcutaneous

tunnel to dorsal surface


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EDC tendons divided and transposed superficially toextensor retinaculum

EDC tendons anastomosed end-to-end with FCRPL transfer

PL tendon transected near insertion EPL tendon indentified and divided at musculotendinous

junction

rerouted out of Listers canal toward volar aspect acrossanatomical snuffbox

makes EPL abductor and extensor PL and EPL anastomosed if PL absent, EPL joined with EDC to FCR transfer

Posterior interosseous nerve palsy

Requirements as for radial nerve except wrist extension not requiredTransfers

as for radial nerve except PT transfer not requiredAssociation with fracture of humerus

options are early exploration exploration at 6-8 weeks late exploration

initial stages of recovery may take 4-5 months before function in BR or ECR detected

best option is to wait 4-5 months and then explore if noreturn of function (Green)

exceptions are open fractures failure of closed treatment to maintain satisfactory

alignment

associated vascular injuries loss of function after manipulation of fracture

Ulnar nerve

AETIOLOGY

High lesion (at or above elbow)

usually at elbow elbow fracture or dislocation compression at elbow

esp. anaesthetised or bedridden patients

entrapment in cubital tunnel


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esp. with valgus elbowLow lesion (below elbow)

usually at wrist laceration at wrist entrapment in ulnar tunnel (Guyons canal)

esp. in cyclists penetrating forearm wound

CLINICAL FEATURES

High lesion

as for low lesion but less clawing (ulnar 1/2 of FDP paralysed) weak wrist flexion

Low lesion claw hand deformity

hyperextension of MCP jts and flexion of IP jts of ring andlittle fingers

weakness of lumbricals with loss of MCP flexion and IPextension

unopposed MCP extension by extensors and IP flexion byflexors

less marked in high lesion because ulnar FDP paralysed

(paradoxical ulnar claw) weak finger abduction weak finger adduction

positive paper grip test weak thumb adduction

positive Froments sign (IP flexion) hypothenar and interosseous wasting numbness of ulnar 1 1/2 fingers numbness of ulnar dorsum of hand

if lesion proximal to dorsal branchEARLY TREATMENT

open injury explore and repair anterior transposition provides 5 cm length

closed injury knuckle duster splint and ROM EMG at 3 weeks explore a 6 weeks

entrapment


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observe for 3 months decompress if fails to settle

TENDON TRANSFERS

High ulnar nerve palsyRequirements

correct clawing index abduction thumb adduction DIP flexion of ring and little fingers ulnar wrist flexion (not important) sensation on ulnar border of handTransfersClaw fingers

Zancolli capsulodesis modified Bunnell FDS transferThumb adduction

ECRB (with free graft) between 2nd and 3rd metacarpals toinsertion of AP

Index abduction

EPB to tendon of 1st DIDIP flexion

tenodesis of middle FDP to ring and little FDPTechnique of capsulodesis transverse palmar incision each A1 pulley opened flexor tendons retracted volar plate incised beneath MC head two lateral incisions made volar capsule advanced proximally finger flexed to 20o volar plate sutured to new position mild flexion contracture of MCP jt createdTechnique of FDS transfer

use middle or ring finger midlateral incision along radial side of finger tendon sheath opened FDS tendon released transverse proximal incision at proximal palmar crease FDS tendon identified and withdrawn tendon split into 4 tails radial midlateral incision along radial side of other fingers


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extensor aponeurosis identified each tail of tendon passed

through lumbrical canal volar to deep transverse MC ligament over oblique fibres of extensor apparatus to dorsum of extensor apparatus

flex MCP jts 90o and PIP jts at neutral suture each tail to aponeurosis under some tension

Low ulnar nerve palsyRequirements

as above except do not need DIP flexion

Median nerve

AETIOLOGY

High lesion

elbow fracture or dislocation forearm fracture penetrating forearm wound

Low lesion

laceration at wrist fracture of distal radius carpal dislocation entrapment in carpal tunnel

CLINICAL FEATURES

High lesion

as for low lesion PLUS paralysis of

superficial finger flexors deep finger flexors to radial fingers long thumb flexor radial wrist flexor forearm pronators

results in Benedictine sign index finger straight ulnar fingers flexed middle finger flexed because middle FDP closely attached

to ring FDP

interosseous nerve palsy gives Benedictine sign paralysis of radial FDP and FPL


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weakness of pronation (quadratus) no thenar weakness no sensory loss

Low lesion

paralysis of AbPB wasting of thenar eminence numbness in radial 3 1/2 fingers and palm

EARLY TREATMENT

open explore and repair

closed reduce fracture or dislocation explore if fails to improve

TENDON TRANSFERS

High median nerve palsyRequirements

index and middle flexor power flexor power in thumb IP thumb opposition sensation thumb and radial indexTransfers

Extrinsic ECRL to FDP (index and middle) BR to FPLIntrinsic

opponensplasty many options best is transfer of EIPTechnique of opponensplasty

incision over index MCP j EIP divided with some extensor hood hood repaired second incision over dorsum of hand to free EIP from EDC incision over dorsoulnar wrist to displace tendon ulnarward tendon passed subcutaneously around ulnar aspect of wrist

to pisiform

then tunnelled across palm to thumb MCP jt tendon interweaved into AbPB tendon and into EPL tendon


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Other lesions

AXILLARY NERVE

Aetiology

dislocation of shoulder

proximal humeral fracture brachial plexus injury deltoid-splitting approach

Clinical features

weakness of shoulder abduction abduction still may be possible by supraspinatus

numbness in regimental patch areaTreatment

usually resolves following fracture or dislocation exploration if fails to recover within 3 months may require shoulder arthrodesis

LONG THORACIC NERVE

C5,6,7 runs down posterior axillary wall supplies serratus anterior

Aetiology

surgery shoulder or neck operations 1st rib resection mastectomy

carrying loads on shoulderClinical features

winging of scapulaTreatment

stabilisation of scapula by transferring pectoralis major orminor to lower part

SPINAL ACCESSORY NERVE

C3,4 supplies sternocleidomastoid then runs in posterior triangle of neck to supply trapezius

(upper half)

Aetiology

stab wounds to neck operations on posterior triangle

esp. lymph node biopsy


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traction injuriesClinical features

sagging of shoulder inability to shrug

Treatment if open, immediate exploration and repair if closed, wait 6 weeks for recovery if no recovery, explore to

confirm diagnosis repair by suture or grafting

SUPRASCAPULAR NERVE

C5,6 runs through suprascapular notch supplies supraspinatus and infraspinatus

Aetiology

fracture of scapula direct blow to superior border of scapula traction carrying heavy load

Clinical features

scapular pain weakness of external rotation of shoulder may be confused with rotator cuff disease

Treatment

usually resolves may respond to decompression by division of suprascapular

ligament

upper limb nerve lesions

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