9. Radial Nerve:
Course:
Axilla: long head of Triceps
Arm:
◦ As it enter:
Posterior cutaneous nerve of arm
Medial head of Triceps
◦ Radial groove: Lateral head of Triceps
◦ Anconeus muscle
◦ Cutaneous branch to arm and forearm
12. o Pierces lateral intermuscular septum from behind at
middle and lower 3rd of arm to come anteriorly at
distal 3rd
Elbow:
◦ Superficial branch - sensory
◦ Deep branch – motor
(Extensor carpi radialis bravis & supinator)
◦ Pierces supinator & reaches posterior compartment
of forearm : Extensor muscles of forearm & hand
16. Major motor branches:
Before radial groove: Long head and medial head of
triceps
After radial groove:
◦ Before crossing elbow:
Lateral head of triceps, Anconeus, brachioradialis, Extensor
carpi radialis longus
◦ After crossing elbow:
Before piercing supinator: Extensor carpi radialis brevis,
Supinator
After piercing supinator: Extensor muscles of forearm and
hands
17. S.N. Types of Radial Nerve
Palsy
Extension
Elbow Wrist Fingers
(MCP)
1 Very High
Injury around Axilla and above
the radial groove.
(eg. Crutch palsy)
Lost Lost
(Wrist
drop)
Lost
(Finger drop)
2 High
Injury in the radial groove, so
Triceps innervation is
preserved. (eg. Saturday Night
palsy, Holstein Lewis Palsy)
Preserved Lost
(Wrist
drop)
Lost
(Finger drop)
3 Low
Injury below the radial groove,
so the triceps and wrist
extensor innervation is
preserved. (PIN
Palsy)
Preserved Preserved Lost
(Finger drop)
20. Median Nerve
Course:
Arm: descends adjacent to the brachial artery
Forearm: enters between two heads of Pronator teres
◦ Proximal 3rd: passes deep to the origin of Flexor
digitorum superficialis
◦ Middle 3rd: descends between Flexor digitorum
superficialis and profundus
◦ Distal 3rd : 5 cm above the wrist becomes superficial
and lies between FDS and Flexor Carpi Radialis
Hand: enters palm by passing deep to flexor retinaculum
24. Major Motor branches:
Arm: nil
Forearm:
◦ Proximal 3rd: All Flexors except Flexor carpi ulnaris
& medial half of flexor digitorum profundus
◦ Distal 3rd: nil
Hand:
◦ Thenar muscles (Abductor pollicis brevis, Flexor
pollicis brevis & Opponens pollicis)
◦ First two lumbricals
25. S.N. Types Results
1 High palsy
(Injury
proximal to
the elbow)
• Paralysis of all flexors except FCU & medial half
of FDP
• Paralysis of thenar muscles, first two lumbricals
• Pointing Index deformity/ Oschner clasp test
• Ulnar deviation of wrist on palmer flexon
• Pen test +ve
• Inability to perform OK sign/ Kiloh Nevin sign
(FDP+FPL)
• Benediction test +ve (unable to flex index &
middle finger on lifting hand)
• Hitchhiker’s sign (Inability to flex thumb- Flexor
pollicis longus)
2 Low palsy
(Injury distal
to the elbow
esp. in distal
3rd of forearm)
• Paralysis of hand muscles (thenar and first two
lumbricals)
• Ape thumb deformity (Paralysed oppenens
pollicis & unopposed evtensor pollicis longus )
• Pen test +ve (Abductor pollicis brevis)
28. Ulnar Nerve
Course:
Arm: medial to axillary artery
Junction of middle & distal 3rd of arm: pierces medial
intermuscular septum and reach to posterior compartment
Elbow: superficially behind medial epicondyle
Forearm: enters between two head of Flexor carpi ulnaris
then runs medially and anterior to flexor digitorum profundus
Wrist: passes in front of flexor retinaculum just lateral to
pisiform bone and divides into superficial & deep branches at
palm
29.
30.
31.
32.
33.
34.
35. Major motor branches:
Arm: nil
Forearm:
◦ Proximal 3rd:
-Flexor carpi ulnaris
-Medial half of flexor digitorum profundus
◦ Distal 3rd : nil
Hand:
◦ Superficial branch: Hypothenar muscles
◦ Deep branch:
-Adductor pollicis
-All interossei &
-Medial two lumbricals
36. S.N. Types of Ulnar
Nerve Palsy
Result
1 High
(Injury proximal to elbow)
• Motor & sensory deficits in forearm
& hands
2 Low
(Injury
distal to
elbow )
Junction of
middle & lower
3rd of forearm
• FDP & FCU spared
• Motor & sensory lost in rest of hand
& fingers
Proximal to
Guyon’s canal
• FDP, FCU & dorsal sensation spared
Distal to
Guyon’s canal
• Spared: FDP, FCU,Hypothenar
muscles, Palmaris brevis, dorsal &
volar sensation
• Lost: Interossei & Lumbricals
(medial 2)
37. Examinations:
Flexor carpi ulnaris: on flexing wrist against
gravity hand deviates towards radial side
Abductor digiti minimi: abduct little finger
against resistance on flat table
Interossei: at MCP joints
◦ Palmer- ADduction (PAD)
◦ Dorsal- ABduction (DAB)
Egawa’s test: palm facing downward in flat table
move middle finger sideways
38. Card test: hold card between two extended fingers
tightly, power assessed
First dorsal interossei: Abduct index finger against
resistance
Lumbericals: flexon at MCP Joints
Adductor pollicis: firm grasp of book between
thumb and index finger with thumb fully extended
thumb
Book test/Froment’s sign: If ulnar nerve is injured,
flexor pollicis longus is used in place of adductor
pollicis with flexed PIP
39. Claw Hand (Main-en-Griffe):
Deformity with hyperextended MCPs and flexed IP joints
of fingers
◦ True claw hand (median & ulnar nerve) &
◦ Ulnar claw hahnd/ A claw like hand (ulnar nerve only)
Ulnar paradox:
◦ ‘higher the lesion in ulnar nerve; less is the deformity and vice-
versa’
◦ Cause: Injury at elbow – paralysis of medial half of FDP – less
obivious flexion of IP joints – atypical claw hand
◦ Usual: low lesion – unopposed action FDP over paralysed medial 2
lumbricals – claw hand
40.
41. Sensory
Examination:
Dorsal aspect: little and
ring finger except lateral
half of tip of ring finger
Ventral aspect: little
finger and medial half of
ring finger
Dorsal
view
43. Look:
Deformities
Skin and nail changes (sudomotor changes)
Muscle wasting (Hypothenar and thenar
muscles)
Patient picking up a small object
Feel:
Temperature
44. Tenderness - bimanual palpation of joints (MCP,
PIP, DIP, Carpometacarpal, Wrist, Elbow)
Anatomical snuffbox tenderness- scaphoid #
Thenar and hypothenar muscle bulk
Tinel’s test
45. Move:
A) Range of motion (ROM):
Elbow:
◦ Flexion:
Active : 145°
Passive : 160°
◦ Extension: bringing back to anatomical position from
flexion
Wrist: flexion & extension, adduction and abduction
MCP: flexion & extension, adduction and abduction
PIP, DIP: flexion & extension
46. B) Muscle power (MRC grading: 0-5) and
special tests for individual nerves
Measure:
Both limb simultaneously & compare for any asymmetry present
Landmark: Elbow joint (tip of olecranon)
◦ Above Elbow: Midpoint between the acromian tip & olecranon (esp in
children below 5 years = malnutrition)
◦ Below Elbow: Fixed distance below the olecranon (10cm)
47. Upper Limb Examination based
on myotomes and dermatomes
Motor Examination:
C 5 = shoulder abduction
C 6 = elbow flexion/ wrist extension
C 7 = elbow extension/ wrist flexion/ finger extension
C 8 = finger flexion
T 1= finger abduction
48. Sensory Examination Nerve
Roots
Reflexes
Site
Antecubital
fossa just
proximal to
elbow
Lateral side C 5 Biceps Jerk
Medial side T 1
dorsal surface
of proximal
phalanx of
Thumb C 6 Supinator Jerk
(Brachioradialis
reflex)
Middle finger C 7 Triceps Jerk
Little finger C 8
49. References:
Apley’s System of Orthopaedics and Fractures 9th
edition
Gray’s Anatomy for Students 3rd edition
McRae Clinical Orthopaedic Examination 5th edition
MBBS viva made easy by Prof Amit Joshi
Clinical Assessment and Examination in Orthopedics 2nd
edition
Anatomyzone youtube videos