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Peripheral Nerve of
    Upper Limb
           By : Hermizan Halihanafiah
Brachial Plexus
 Networking of spinal nerves, formed by ventral
 (anterior rami) of cervical spinal nerves C5-C8 and
 thoracic spinal nerves T1.
 Brachial plexus is responsible for cutaneous (sensory)
 and muscular (motor) innervation of the entire upper
 limb.
Brachial Plexus
    5 main nerves arise from brachial plexus:
2.   Axillary nerve
3.   Musculocutaneous nerve
4.   Radial nerve
5.   Median nerve
6.   Ulnar nerve
Brachial Plexus
Dermatomes
 Area of the skin that supplied by
  single spinal nerve.
 the area of the skin that provides
  sensory input to the dorsal roots of a
  pair of spinal nerves
 There are 8 cervical, 12 thoracic, 5
  lumbar and 5 sacral spinal nerves that
  relays cutaneous sensation (pain,
  thermal, itch, touch etc) from
  particular region of the body to the
  brain
 Dermatomes are useful in neurology
  for finding the site of damage to the
  spine
Dermatomes / myotomes
Head Dermatomes
 Trigeminal nerve
  (most of the
  anterolateral skin of
  the face)
 Cervical plexus (skin
  of the neck and pinna)
 Cervical spinal nerve –
  posterior root (skin
  posterior of the scalp
  and neck)
Axillary Nerve
 From root C5-C6
 Arise from posterior cord of brachial plexus at the
 level of axilla.
Peripheral Nerves of Upper Limb
Branches of Axillary Nerves
 Lies posterior to the axillary artery and anterior to the
  subscapularis muscles.
 Then axillary nerves will divide into anterior branch
  (upper branch) and posterior branch (lower branch).
 Anterior branch innervate anterior border of deltoid
  muscles (anterior and lateral fiber)
 Posterior border supply teres minor and posterior part
  of the deltoid (posterior fiber). Then it will branch of to
  formed superior lateral cutaneous nerve of arm
  (superior lateral brachial cutaneous).
Innervations of Axillary Nerve

 Muscular innervations
 - anterior branch – anterior and lateral fiber of deltoid
  muscles
 - posterior branch – teres minor and posterior fiber of
  deltoid

 Cutaneous innervation
- superior lateral brachial cutaneous nerve
 - carry information from the shoulder joint
 - skin covering inferior region of deltoid muscles.
Cont..
 Frequently injured due to
  shoulder dislocation because
  of the close to the proximity
  of this joint
 Paralysis of the deltoid and
  teres minor results
 Inability to abduct the arm
  beyond that possible by the
  action of the supraspinatus.
Peripheral Nerves of Upper Limb
Peripheral Nerves of Upper Limb
Musculocutaneous Nerve

 Arise from lateral cord of
  brachial plexus
 Opposite to the lower border
  of pectoralis minor
 Arise from root C5, C6 and
  C7.
Musculocutaneous Nerve

 Penetrate coracobrachialis and
  pass obliquely between biceps
  brachii and the brachialis to the
  lateral side of the arm.
 Then continue in the forearm as
  the lateral antebrachial
  cutaneous nerve.
Innervation of
       Musculocutaneous Nerve
 Muscular innervation
   Supply coracobrachialis, biceps brachii and brachialis

 Cutaneous innervation.
   Lateral antebrachial cutaneous nerve divide into
    anterior and posterior branch.
   Anterior branch – skin of anterolateral surface of
    forearm as far as ball of the thumb
   Posterior branch – skin of posterolateral surface of
    forearm.
Radial Nerve
 Arise from posterior cord
  of brachial plexus
 Arise from root C5, C6,
  C7, C8 & T1.
Radial Nerve
 It goes descending obliquely through the arm, first in
 the posterior compartment of the arm, and later in
 the anterior compartment of the arm, and continues
 in the posterior compartment of the forearm.
 The radial nerve enter the arm behind the axillary
 artery and then travel posteriorly on the medial side
 of the arm.
Radial Nerve
 Then radial nerve will innervate triceps brachii.

 Radial nerve then enter the radial groove.

 Radial nerve emerge from radial groove and enter the
  anterior compartment of the arm.
 It continue the journey between brachialis and
  brachioradialis.
 When the radial nerve reaches the distal part of the
  humerus, it passes anterior to the lateral epicondyle and
  continue to the forearm.
Radial Nerve
 In the forearm, it will branch of to superficial branch
  (mainly sensory) and deep branch (mainly motor).
 Cutaneous innervation is provided by nerve that arise
  from radial nerve.
    Posterior brachial cutaneous nerve

    Inferior lateral brachial cutaneous nerve

    Posterior antebrachial cutaneous nerve

    Superficial branch of radial nerve
Radial Nerve
 Posterior cutaneous nerve of arm (posterior brachial
  cutaneous) - provides sensory innervations for much of
  the skin on the back of the arm.
 Inferior lateral cutaneous nerve of arm (inferior lateral
  brachial cutaneous) - provides sensory and vasomotor
  innervation to the lower, lateral aspect of the arm.
 Posterior cutaneous nerve of forearm (posterior
  antebrachial cutaneous).-skin of the posterior of the
  forearm
 Superficial branch – back of the hand
Radial Nerve Dermatomes
Radial Nerve
 Motor innervations
 Triceps brachii, anconeus, brachioradialis, supinator
 and mostly posterior compartment extrinsic hand
 muscles.
Cont…
 The radial nerve is often injured in its course close to
  the humerus, either from fracture or pressure from
  direct blow to the humerus (incorrect use of a crutch)
 Triceps usually escapes because derivation of the
  nerve giving off high in arm, but total paralysis of the
  extensor of the wrist and digits leads to the dropped
  wrist deformities.
Wrist Dropped
Fracture of the humerus
Ulnar Nerve
 Arise from medial cord of
  brachial plexus
 Root C8 and T1 (mostly
  C7)
 Descend on the
  posteromedial of the
  humerus.
 Then it goes posterior to
  the medial epicondyle.
Ulnar Nerve
 Enter anterior compartment muscles of forearm and

 supplies flexor carpi ulnaris and medial half flexor
 digitorum profundus.

 Then ulna nerve enter palm of the hand and branch off

 to the superficial branch and deep branch.

 Deep branch innervate hypothenar muscles,

 intermediate hand muscles and thenar hand muscles
 (adductor pollicis, flexor pollicis brevis (rare))
Ulnar Nerve
 Superficial branches of Ulnar nerve will innervate
 palmaris brevis and skin anterior and posterior of the
 hand (medial aspect of the hand/ one an half digits)
Peripheral Nerves of Upper Limb
Peripheral Nerves of Upper Limb
Hand Dermatomes
Cont…
 Ulnar nerve may be damaged in the groove behind
    the medial epicondyle either by trauma or
    entrapment.
   Leads to partial or completely lost of muscular and
    sensory innervations.
   The results of the ulna nerve lesion leads to the
    typical ‘claw hand’ deformities.
   Due to lost of the power in the intrinsic hand muscles
    and unopposed actions of antagonistic muscles group.
   Wasting of hypothenar eminence.
   There are ‘guttering between metacarpals, inability to
    abduct the fingers or adduct the thumb.
Claw Hand Deformities
Median Nerve
 Arise from lateral root of lateral cord (C5,6,7) and
 medial root and medial cord (C8,T1) of brachial
 plexus.
 Passes down the midline of the arm in close
 association with the brachial artery.
 Passes in front of elbow joint (cubital fossa) then
 down to supply the muscles of the anterior of
 forearm.
 Then it continue into the hand through carpal tunnel
 At the cubital fossa the anterior interosseous nerve
  arises from the median nerve
 Descend through the forearm and end at the wrist by
  giving the articular branch to the radiocarpal and
  intercarpal joint.
 It supplies flexor pollicis longus, lateral half flexor
  digitorum profundus and pronator quadratus
Median Nerve
   Motor – all anterior (flexor) compartment of
    forearm (except flexor carpi ulnarisand ulnar
    half of the flexor digitorum profundus ),pronator
    teres & quadratus, intrinsic hand muscles
    (LOAF;1,2 lumbricals, OP, FPB, APB)
   Sensory – skin of the palmar aspect of the thumb
    and the lateral 2 ½ fingers and the distal ends of
    the same fingers and skin of distal phalanx on
    same finger
Median nerve
dermatomes
Cont…
 Median nerve can be injured by deep cut with
  resultant lost of flexion at all IP joint except the distal
  ones in the ring and little finger.
 MCP still can be flexed at this fingers ( lumbricals)
 In the hand thumb is extend and adducted, lost of
  ability to abduct and oppose.
 Compression at the carpal tunnel give rise the carpal
  tunnel syndrome (CTS)
Carpal Tunnel Syndrome
 Compression median
  nerve at the carpal tunnel
 Patient will experience
  numbness, tingling, or
  burning sensation at the
  thumb, index, middle and
  radial half of the ring
  finger.
 If untreated – weakness or
  atrophy of the thenar
  muscles.
Brachial Plexus Injury
 Obstetric brachial plexus palsy
 Injury to all or portion of a child brachial plexus
  occurring at that time of the delivery.
 Excessive lateral traction on the head so that the head
  is pulled away from the shoulder.
 Divide into :
 Erb’s Duchenne Palsy
 Klumpkee’s Palsy
Peripheral Nerves of Upper Limb
Erb’s Duchenne Palsy
 Involving upper roots (C5, C6 and C7)
 Affecting the musculature of the upper arm
 Shows the “waiter tips” posture of the paralyze limb.
 The arm lies medial rotation at the side of the chest
 The elbow is extended (paralyzed C5, C6)
 Forearm is pronated
 Wrist and digits are flexed
Erb’s Duchenne Palsy
               This posture occurs because
                  of paralysis and atrophy of:
                 Deltoid
                 Biceps brachii
                 Brachialis
                 brachioradialis
Klumpke’s Palsy
 Rare
 Involving lower root (C8 and T1)
 Affecting forearm and hand
 Characterize by paralysis and atrophy of the small hand muscles
  and flexor of the wrist.
 Claw hand
Peripheral Nerves of Upper Limb

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Peripheral Nerves of Upper Limb

  • 1. Peripheral Nerve of Upper Limb By : Hermizan Halihanafiah
  • 2. Brachial Plexus  Networking of spinal nerves, formed by ventral (anterior rami) of cervical spinal nerves C5-C8 and thoracic spinal nerves T1.  Brachial plexus is responsible for cutaneous (sensory) and muscular (motor) innervation of the entire upper limb.
  • 3. Brachial Plexus  5 main nerves arise from brachial plexus: 2. Axillary nerve 3. Musculocutaneous nerve 4. Radial nerve 5. Median nerve 6. Ulnar nerve
  • 5. Dermatomes  Area of the skin that supplied by single spinal nerve.  the area of the skin that provides sensory input to the dorsal roots of a pair of spinal nerves  There are 8 cervical, 12 thoracic, 5 lumbar and 5 sacral spinal nerves that relays cutaneous sensation (pain, thermal, itch, touch etc) from particular region of the body to the brain  Dermatomes are useful in neurology for finding the site of damage to the spine
  • 7. Head Dermatomes  Trigeminal nerve (most of the anterolateral skin of the face)  Cervical plexus (skin of the neck and pinna)  Cervical spinal nerve – posterior root (skin posterior of the scalp and neck)
  • 8. Axillary Nerve  From root C5-C6  Arise from posterior cord of brachial plexus at the level of axilla.
  • 10. Branches of Axillary Nerves  Lies posterior to the axillary artery and anterior to the subscapularis muscles.  Then axillary nerves will divide into anterior branch (upper branch) and posterior branch (lower branch).  Anterior branch innervate anterior border of deltoid muscles (anterior and lateral fiber)  Posterior border supply teres minor and posterior part of the deltoid (posterior fiber). Then it will branch of to formed superior lateral cutaneous nerve of arm (superior lateral brachial cutaneous).
  • 11. Innervations of Axillary Nerve  Muscular innervations - anterior branch – anterior and lateral fiber of deltoid muscles - posterior branch – teres minor and posterior fiber of deltoid  Cutaneous innervation - superior lateral brachial cutaneous nerve - carry information from the shoulder joint - skin covering inferior region of deltoid muscles.
  • 12. Cont..  Frequently injured due to shoulder dislocation because of the close to the proximity of this joint  Paralysis of the deltoid and teres minor results  Inability to abduct the arm beyond that possible by the action of the supraspinatus.
  • 15. Musculocutaneous Nerve  Arise from lateral cord of brachial plexus  Opposite to the lower border of pectoralis minor  Arise from root C5, C6 and C7.
  • 16. Musculocutaneous Nerve  Penetrate coracobrachialis and pass obliquely between biceps brachii and the brachialis to the lateral side of the arm.  Then continue in the forearm as the lateral antebrachial cutaneous nerve.
  • 17. Innervation of Musculocutaneous Nerve  Muscular innervation  Supply coracobrachialis, biceps brachii and brachialis  Cutaneous innervation.  Lateral antebrachial cutaneous nerve divide into anterior and posterior branch.  Anterior branch – skin of anterolateral surface of forearm as far as ball of the thumb  Posterior branch – skin of posterolateral surface of forearm.
  • 18. Radial Nerve  Arise from posterior cord of brachial plexus  Arise from root C5, C6, C7, C8 & T1.
  • 19. Radial Nerve  It goes descending obliquely through the arm, first in the posterior compartment of the arm, and later in the anterior compartment of the arm, and continues in the posterior compartment of the forearm.  The radial nerve enter the arm behind the axillary artery and then travel posteriorly on the medial side of the arm.
  • 20. Radial Nerve  Then radial nerve will innervate triceps brachii.  Radial nerve then enter the radial groove.  Radial nerve emerge from radial groove and enter the anterior compartment of the arm.  It continue the journey between brachialis and brachioradialis.  When the radial nerve reaches the distal part of the humerus, it passes anterior to the lateral epicondyle and continue to the forearm.
  • 21. Radial Nerve  In the forearm, it will branch of to superficial branch (mainly sensory) and deep branch (mainly motor).  Cutaneous innervation is provided by nerve that arise from radial nerve.  Posterior brachial cutaneous nerve  Inferior lateral brachial cutaneous nerve  Posterior antebrachial cutaneous nerve  Superficial branch of radial nerve
  • 22. Radial Nerve  Posterior cutaneous nerve of arm (posterior brachial cutaneous) - provides sensory innervations for much of the skin on the back of the arm.  Inferior lateral cutaneous nerve of arm (inferior lateral brachial cutaneous) - provides sensory and vasomotor innervation to the lower, lateral aspect of the arm.  Posterior cutaneous nerve of forearm (posterior antebrachial cutaneous).-skin of the posterior of the forearm  Superficial branch – back of the hand
  • 24. Radial Nerve  Motor innervations  Triceps brachii, anconeus, brachioradialis, supinator and mostly posterior compartment extrinsic hand muscles.
  • 25. Cont…  The radial nerve is often injured in its course close to the humerus, either from fracture or pressure from direct blow to the humerus (incorrect use of a crutch)  Triceps usually escapes because derivation of the nerve giving off high in arm, but total paralysis of the extensor of the wrist and digits leads to the dropped wrist deformities.
  • 27. Fracture of the humerus
  • 28. Ulnar Nerve  Arise from medial cord of brachial plexus  Root C8 and T1 (mostly C7)  Descend on the posteromedial of the humerus.  Then it goes posterior to the medial epicondyle.
  • 29. Ulnar Nerve  Enter anterior compartment muscles of forearm and supplies flexor carpi ulnaris and medial half flexor digitorum profundus.  Then ulna nerve enter palm of the hand and branch off to the superficial branch and deep branch.  Deep branch innervate hypothenar muscles, intermediate hand muscles and thenar hand muscles (adductor pollicis, flexor pollicis brevis (rare))
  • 30. Ulnar Nerve  Superficial branches of Ulnar nerve will innervate palmaris brevis and skin anterior and posterior of the hand (medial aspect of the hand/ one an half digits)
  • 34. Cont…  Ulnar nerve may be damaged in the groove behind the medial epicondyle either by trauma or entrapment.  Leads to partial or completely lost of muscular and sensory innervations.  The results of the ulna nerve lesion leads to the typical ‘claw hand’ deformities.  Due to lost of the power in the intrinsic hand muscles and unopposed actions of antagonistic muscles group.  Wasting of hypothenar eminence.  There are ‘guttering between metacarpals, inability to abduct the fingers or adduct the thumb.
  • 36. Median Nerve  Arise from lateral root of lateral cord (C5,6,7) and medial root and medial cord (C8,T1) of brachial plexus.  Passes down the midline of the arm in close association with the brachial artery.  Passes in front of elbow joint (cubital fossa) then down to supply the muscles of the anterior of forearm.  Then it continue into the hand through carpal tunnel
  • 37.  At the cubital fossa the anterior interosseous nerve arises from the median nerve  Descend through the forearm and end at the wrist by giving the articular branch to the radiocarpal and intercarpal joint.  It supplies flexor pollicis longus, lateral half flexor digitorum profundus and pronator quadratus
  • 38. Median Nerve  Motor – all anterior (flexor) compartment of forearm (except flexor carpi ulnarisand ulnar half of the flexor digitorum profundus ),pronator teres & quadratus, intrinsic hand muscles (LOAF;1,2 lumbricals, OP, FPB, APB)  Sensory – skin of the palmar aspect of the thumb and the lateral 2 ½ fingers and the distal ends of the same fingers and skin of distal phalanx on same finger
  • 40. Cont…  Median nerve can be injured by deep cut with resultant lost of flexion at all IP joint except the distal ones in the ring and little finger.  MCP still can be flexed at this fingers ( lumbricals)  In the hand thumb is extend and adducted, lost of ability to abduct and oppose.  Compression at the carpal tunnel give rise the carpal tunnel syndrome (CTS)
  • 41. Carpal Tunnel Syndrome  Compression median nerve at the carpal tunnel  Patient will experience numbness, tingling, or burning sensation at the thumb, index, middle and radial half of the ring finger.  If untreated – weakness or atrophy of the thenar muscles.
  • 42. Brachial Plexus Injury  Obstetric brachial plexus palsy  Injury to all or portion of a child brachial plexus occurring at that time of the delivery.  Excessive lateral traction on the head so that the head is pulled away from the shoulder.  Divide into :  Erb’s Duchenne Palsy  Klumpkee’s Palsy
  • 44. Erb’s Duchenne Palsy  Involving upper roots (C5, C6 and C7)  Affecting the musculature of the upper arm  Shows the “waiter tips” posture of the paralyze limb.  The arm lies medial rotation at the side of the chest  The elbow is extended (paralyzed C5, C6)  Forearm is pronated  Wrist and digits are flexed
  • 45. Erb’s Duchenne Palsy  This posture occurs because of paralysis and atrophy of:  Deltoid  Biceps brachii  Brachialis  brachioradialis
  • 46. Klumpke’s Palsy  Rare  Involving lower root (C8 and T1)  Affecting forearm and hand  Characterize by paralysis and atrophy of the small hand muscles and flexor of the wrist.  Claw hand