4 - 5 practicals mpt 2nd year pns

7/30/2019 4 - 5 Practicals Mpt 2nd Year Pns

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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


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


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

4 - 5 practicals mpt 2nd year pns

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