Kaan Yücel M.D., Ph.D . 7.February.2013 Thursday

1. Kaan Yücel M.D., Ph.D. 7.February.2013 Thursday

2. Dermatomes & Cutaneous Nerves of the Upper Limb DermatomesforC3-6 lateral margin of the upper limb Dermatomefor C7 on the middle finger DermatomesforC8, T1, T2 medial margin of the limb

3. Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb Biceps brachii tendon reflex C5 and 6 flexion of the elbow joint by tapping the biceps tendon

4. Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb Triceps tendon reflex C6, 7, and 8 extension of the elbow joint by tapping the triceps tendon

5. Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb Brachioradialis tendon reflex C5, 6, and 7 supination of the radioulnar joints by tapping the insertion of the brachioradialis tendon

6. Brachial Plexus Injuries Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy) C5 and C6 roots Lower Lesions of the Brachial Plexus (Klumpke Palsy) C8 and T1 roots

7. Upper Lesions of the Brachial Plexus • (Erb-Duchenne Palsy) • excessive displacement of the head to the opposite side • depression of the shoulder on the same side • in infants during a difficult delivery • in adults after a blow to or fall on the shoulder

8. Upper Lesions of the Brachial Plexus • (Erb-Duchenne Palsy) • C5 and C6 roots • suprascapular nerve • the nerve to the subclavius • musculocutaneousnerve • axillary nerve • supraspinatus abductor of the shoulder • infraspinatuslateral rotator of the shoulder • subclaviusdepresses the clavicle • biceps brachiisupinator of the forearm, flexor of the elbow, weak flexor of the shoulder • greater part of the brachialis flexor of the elbow • coracobrachialisflexor of the shoulder • deltoid abductor of the shoulder • teresminor lateral rotator of the shoulder

9. Upper Lesions of the Brachial Plexus (Erb-Duchenne Palsy) Waiter’s tip position Upperlimbhangingbytheside Mediallyrotated Forearmpronated + loss of sensation down the lateral side of the arm

10. Lower Lesions of the Brachial Plexus (Klumpke Palsy) usually traction injuries person falling from a height grasping smthg to break a fall baby's upper limb pulled excessively during delivery ulnar and median nerves C8 and T1 roots

11. Lower Lesions of the Brachial Plexus (Klumpke Palsy) ulnar and median nerves all the small muscles of the hand Claw(ed) hand hyperextension of metacarpophalangeal joints flexion of the interphalangeal joints

12. Lower Lesions of the Brachial Plexus (Klumpke Palsy) C8 and T1 roots loss of sensation along the medial side of the arm 8th cervicalnervedamaged + medial side of the forearm, hand, and medial two fingers Foerster (1933)

13. Long Thoracic Nerve Injuries serratus anterior C5, C6, C7 blows to or pressure on the posterior triangle of the neck during the surgical procedure of radical mastectomy • Difficulty in raising the arm above the head • Inferiorborder of scapula not closelyappliedtothechestwall • Protrudeposteriorly • Wingedscapula

14. Axillary Nerve Injuries posterior cord of the brachial plexus (C5 and 6) pressure of a badly adjusted crutch pressing upward into the armpit shoulderdislocationsQuadrangularspace fracttures of thesurgicalneck of humerus deltoid and teres minor Loss of skin sensation overthelowerhalf of deltoidregion (lateralpart of thearm) Upperlateralcutaneousnerve of thearm Impairedabduction of theshoulder (theotherone: Supraspinatusonly) Shoulderweakness Difficulty lifting thearmabovethehead

15. Axillary Nerve Injuries posterior cord of the brachial plexus (C5 and 6) I.M. injections Operations around the shoulder runs transversely under cover of the deltoid at the level of the surgical neck of the humerus

16. Radial Nerve Injuries commonly damaged in the axilla & in the spiral (radial) groove

17. Radial Nerve Injuries @ Axilla pressure of the upper end of a badly fitting crutch drunk falling asleep with one arm over the back of a fractures and dislocations of the proximal end of the humerus Motor Triceps, anconeus, and long extensors of the wrist No extension of theelbowjoint, wristjoint, andthefingers Wristdrop(flexion of thewrist) Supinationgoodbrachioradialis, supinatordown, but bicepsbrachii

18. Radial Nerve Injuries @ Axilla Sensory A small loss of skin sensation down the posterior surface of the lower part of the arm down a narrow strip on the back of the forearm A variable area of sensory loss on the lateral part of the dorsum of the hand on the dorsal surface of the roots of the lateral 3 ½ fingers Trophic Changes Slight

19. Radial Nerve Injuries @ Spiral Groove of Humerus At the time of fracture of the shaft of the humerus Followingtheformation of the callus Pressure of the back of the arm on the edge of the operating table Prolonged application of a tourniquet to the arm in a person with a slender triceps temporary radial palsy

20. Radial Nerve Injuries @ Spiral Groove of Humerus mostcommonly @ distalpart of thegroove Motor Inabilityto extend the wrist &fingers Wristdrop Sensory A variable small area of anesthesia dorsal surface of the hand dorsal surface of roots of lateral 3 ½ fingers Trophicchanges Very slight or absent

21. RadialTunnel potential space located anterior to the proximal radius posterior interosseus nerve passes starting from the level of the humeroradial joint extending past the proximal edge of the supinator The radial nerve bifurcates into deep and superficial branches anterior to the lateral epicondyle of the humerus, between the brachialis and the brachioradialis, in the lateral border of the cubital fossa. After passing through the two heads of the supinator muscle, the deep branch becomes the posterior interosseous nerve.

22. Radial tunnel syndrome DIAGNOSIS Radialnerve Lateralpart of theelbow, radialtunnelbelowthesupinator Tenderness and pain @ lateral side of the elbow ANATOMY

23. TennisElbow(Lateralepicondylitis) sudden and often repeated use of the forearm extensor muscles previously been much used extensor carpi radialisbrevis Tenderness and pain @ lateral side of the elbow Pain on wrist extension, pain when shaking hands, and frequently a weakened grip. In tennis elbow, the tenderness ismostly right where the tendon attaches to the lateral epicondyle of the elbow. Inradial tunnel syndrome, the place that ismost tender is about two inches furtherdown the arm, right over where theradial nerve goes into the supinatormuscle.

24. Deepbranch of theRadialNerveInjuries Motor nerve Extensormuscles @ posteriorcompartment of theforearm fractures of the proximal end of the radius dislocation of the radial head SupinatorIntact Extensor carpi radialislongus No wristdrop No sensoryloss

25. SuperficialRadialNerveInjuries a variable small area of anesthesia over the dorsum of the hand dorsal surface of the roots of the lateral 3 ½ fingers

26. Musculocutaneous Nerve Injuries Rarelyinjured (protectedposition) • Weakflexion @ shoulderjoint • Flexion of theforearm @ elbowbyremainder of brachialis + flexors of forearm • Weaksupinationsupinatorradialnerve • Sensory loss along the lateral side of the forearm • lateral cutaneous nerve of the forearm

27. Median Nerve Injuries occasionally in the elbow region supracondylar fractures of the humerus most commonly by stab wounds or broken glass just proximal to the flexor retinaculum

28. Injuries to the Median Nerve @ the Elbow Motor pronator & flexormuscles of forearm (EXCEPT?) thenarmuscles Forearm in supineposition- Weakwristflexion-accompaniedbyadduction No flexion @ interphalangealjoints of index & middlefingers Weakflexion @ metacarpophalangealjoints –interossei- Middle & index fingers remain straight (extended) FIST POPE’S BLESSING

29. Injuries to the Median Nerve @ the Elbow Motor No Flexion of the terminal phalanx of the thumb Thenareminenceflattened Thumblaterallyrotated & adducted APE HAND DEFORMITY

30. Injuries to the Median Nerve @ the Elbow Sensory Lost skin sensation @lateralhalforless of thepalm of thehand palmaraspect of lateral 3 ½ fingers distal part of dorsal surfaces of lateral 3 ½ fingers

31. Injuries to the Median Nerve @ the Elbow Vasomotorchanges Skin areaaffectedwarmer & drier Arteriolar dilatation and absence of sweating / loss of sympathetic control Trophicchanges Chroniccases dry and scaly skin nails crack easily atrophy of the pulp of the fingers

32. Injuries to the Median Nerve @ the Wrist Motor Thenarmuscles & firsttwolumbricals Thenareminenceflattened Thumblaterallyrotatedandadducted Ape-likehand No opposition of thethumb MAKE A FIST, SLOWLY Index & middlefingerslagbehindthe ring & littlefingers

33. Carpal Tunnel Syndrome MOST COMMON PERIPHERAL NERVE INJURY IN THE UPPER LIMB

34. Carpal Tunnel Syndrome Burning pain or “pins and needles” along the distribution of the median nerve tothelateral 3 ½ fingers Weakness of thenar muscles No paresthesiaoverthethenareminence palmar cutaneous branch of the median nerve

35. Ulnar Nerve Injuries most commonly injured @ @ elbow where it lies behind the medial epicondyleusuallyassociatedwithfracture @ wrist where it lies with the ulnar artery in front of the flexor retinaculum.

36. Injuries to the Ulnar Nerve @ theElbow CUBITAL TUNNEL SYNDROME (2ND mostcommon) Motor Flexor carpi ulnaris& medial half of flexor digitorumprofundus ring & littlefingers No flexion of the terminal phalanges of the ring & littlefingers Flexion of wrist = abductionparalysis of flexorcarpiulnaris medial border of the front of the forearmflattned/wasted Allthesmallmuscles of thehandparalyzedEXCEPT ?

37. Injuries to the Ulnar Nerve @ theElbow Motor Extensordigitorum can abduct the fingers to a small extent when metacarpophalangeal joints are hyperextended Impossible toadductthethumbadductorpollicisparalyzed Froment’ssign Grip a piece of paperbetweenthethumbandindexfingers Froment sign: The patient is asked to hold the paper between the thumb and index finger. (A) With the intact ulnar nerve, the patient is able to make use of the adductor pollicis. ( B) When the ulnar nerve is deficient, the patient compensates for the denervated adductor by using the flexor pollicis longus (median nerve innervated).

38. Injuries to the Ulnar Nerve @the Elbow Motor 2 mediallumbricals & interosseiHyperextendedmetacarpophalangeal joints Flexedinterphalangeal joints fourth &fifth fingers “claw” deformity main en griffe

39. Injuries to the Ulnar Nerve @ theElbow Motor Flattening of hypothenareminence Loss of theconvexcurvetothemedialborder of thehand Hollowingbetweenmetacarpalbones @ dorsum of thehand wasting of dorsalinterossei

40. Injuries to the Ulnar Nerve @ theElbow Sensory Loss of skin sensation anterior & posterior surfaces of medial 1/3 of the hand medial 1 ½ fingers Vasomotor Changes warmer and drier skin area arteriolar dilatation and absence of sweating /loss of sympathetic control

41. Injuries to the Ulnar Nerve @ theWrist Motor Small handmusclesparalyzed, wasted – EXCEPT 3 thenar @ first 2 lumbricals Clawhand Moreobvious Flexordigitorumprofundusintact Markedflexion of the terminal phalanges Ulnarparadox Higherlesion Lessobviousclawdeformity Moreproximalinjury Lessclaw

42. ULNAR NERVE ENTRAPMENT SYNDROMES PROXIMAL/ @ ELBOW CUBITAL TUNNEL SYNDROME BETWEEN MEDIAL EPICONDYLE & FLEXOR CARPI ULNARIS DISTAL/ @ WRIST GUYON’S CANAL Roof: Palmarisbrevis, hamate,pisiformebones & FCU Q: Medialhalf of Flexordigitorumprofundusaffected in whichonemost?

43. Injuries to the Ulnar Nerve @ theWrist Sensory Main ulnarnerve Palmarcutaneousbranch Posteriorcutaneousbranch 6.25 cm,2 inchabovethepisiform bone palmar surface of the medial 1/3 hand medial 1 ½ fingers the dorsal aspects of the middle and distal phalanges ofthe same fingers

44. BrachialPlexusBlock • Injectionof an anestheticsolutionintoorimmediatelysurroundingtheaxillarysheathinterruptsconduction of impulses of peripheralnerves. • Thedistalpart of thesheath is closedwithfingerpressure, and a syringeneedle is insertedintotheproximalpart of thesheath. • Sensationblocked in alldeepstructures of theupperlimbandthe skin distaltothemiddle of thearm.

45. Brachialplexus can be anesthetizedusing a number of approaches: Interscaleneblock Supraclavicularblock Infraclavicularblock Axillaryblock

46. AxillaryBlock PROCEDURE • Palpateaxillaryarterywithintheaxillarysheathhighup in theaxilla • Abductthearmtoan anglegreaterthan90° • Compressthearterythere • Inserttheneedprox. tothepoint of compression • Disadvantage: Leaking of anestheticintomusculocutanouesnerve • Anatomyof complications • Vesselpuncture • Hematomaformation

47. Anastomosis around the shoulder 1st part of subclavian artery 3rd part of axillary artery Brachial artery

48. Quadrangular Space Syndrome compression of axillary nerve & posterior circumflex humeral artery downward displacement of humeral head in shoulder dislocations fractures of surgical neck of humerus Paralysis deltoid teres minor loss of skin sensation over lower half of the deltoid

49. Rotator Cuff Tendinitis Subscapularis Supra-infraspinatus Teres MINOR Lesions of the cuff common cause of pain in the shoulder region Subacromial bursitis Supraspinatus tendinitis Pericapsulitis spasm of pain in the middle range of abduction when the diseased area impinges on the acromion stabilizing the shoulder joint

50. Rupture of the Supraspinatus Tendon advanced cases of rotator cuff tendinitis necrotic supraspinatus tendon calcified or rupture Holdhumeralhead @ glenoid fossa at thebeginning of abduction No initation of abduction of thearm, unlesspassivelyassitedforthefirst 15°