Upper Limb Nerve Injuries Flashcards
1
Q
Approach to a Neurological problem (3)
A
- Anatomically localise the lesion.
- Consider the pathophysiology
- Differential diagnosis
2
Q
Approach to a Neurological problem
- Anatomically localise the …
- Consider the …
- … diagnosis
A
- Anatomically localise the lesion.
- Consider the pathophysiology
- Differential diagnosis
3
Q
Upper Motor Neuron vs Lower Motor Neuron
- Lesion between nerve starting at … cortex and where it synapses at the … … cell = upper motor neuron
- Lower motor neuron = arises from the … … cell
A
- Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = upper motor neuron
- Lower motor neuron = arises from the anterior horn cell
4
Q
Upper Motor Neuron vs Lower Motor Neuron
- Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = … motor neuron
- … motor neuron = arises from the anterior horn cell
A
- Lesion between nerve starting at motor cortex and where it synapses at the anterior horn cell = upper motor neuron
- Lower motor neuron = arises from the anterior horn cell
5
Q
UMN vs LMN in the upper limb
- UMN:
- Held in flexed posture if chronic.
- … tone
- Pyramidal weakness (Flexor muscles stronger than extensors)
- … reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- … tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- … reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
A
- UMN:
- Held in flexed posture if chronic.
- Increased tone
- Pyramidal weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- Flaccid tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
6
Q
UMN vs LMN in the upper limb
- UMN:
- Held in … posture if chronic.
- Increased tone
- … weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- … level
- LMN:
- …/Fasciculations
- Flaccid tone
- Weakness in either a … distribution or a … nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
A
- UMN:
- Held in flexed posture if chronic.
- Increased tone
- Pyramidal weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- Flaccid tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
7
Q
UMN vs LMN in the upper limb
- UMN:
- Held in flexed posture if chronic.
- Increased tone
- Pyramidal weakness (Flexor muscles … than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/…
- Flaccid tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- … or peripheral nerve distribution of sensory loss.
A
- UMN:
- Held in flexed posture if chronic.
- Increased tone
- Pyramidal weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- Flaccid tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
8
Q
UMN vs LMN in the upper limb
- UMN:
- Held in flexed posture if chronic.
- Increased …
- Pyramidal weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- Flaccid …
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
A
- UMN:
- Held in flexed posture if chronic.
- Increased tone
- Pyramidal weakness (Flexor muscles stronger than extensors)
- Brisk reflexes.
- Sensory level
- LMN:
- Wasting/Fasciculations
- Flaccid tone
- Weakness in either a myotomal distribution or a peripheral nerve distribution
- Reduced reflexes.
- Dermatomal or peripheral nerve distribution of sensory loss.
9
Q
3 anatomical regions for localising the lesion:
A
10
Q
Myotomes - Relationship between the spinal … & …
A
Myotomes - Relationship between the spinal nerve & muscle
11
Q
Dermatomes - Relationship between the spinal … & …
A
Dermatomes - Relationship between the spinal nerve & skin
12
Q
middle finger dermatome?
A
C7
13
Q
A dermatome is an area of the skin supplied by nerve fibres originating from a single … … …
A
A dermatome is an area of the skin supplied by nerve fibres originating from a single dorsal nerve root.
14
Q
Herpes Zoster- Which dermatomes ?
A
- v1 branch
- also T4/T5 region
15
Q
Roots and myotomes
A
- Each muscle has a root and nerve innervation
16
Q
Roots and myotomes
A
- Each muscle has a root and nerve innervation
17
Q
Myotomes (simplified)
A
18
Q
Shoulder abduction - what root and myotome?
A
19
Q
Elbow flexion - what root and myotomes?
A
20
Q
Elbow extension, wrist extension, wrist flexion - what root and myotomes?
A
21
Q
Finger extension and Finger flexion - what root and myotomes?
A
22
Q
Finger abduction - what root and myotome?
A
23
Q
Reflexes - Upper Limb
- … reflex – C5 reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C6 reflex conveyed through the radial nerve.
- … jerk – C7 reflex conveyed through the radial nerve.
- Finger jerk – C8 reflex conveyed through the median and ulnar nerve.
A
- Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C6 reflex conveyed through the radial nerve.
- Triceps jerk – C7 reflex conveyed through the radial nerve.
- Finger jerk – C8 reflex conveyed through the median and ulnar nerve.
24
Q
Reflexes - Upper Limb
- Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
- … jerk – C6 reflex conveyed through the radial nerve.
- Triceps jerk – C7 reflex conveyed through the radial nerve.
- … jerk – C8 reflex conveyed through the median and ulnar nerve.
A
- Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C6 reflex conveyed through the radial nerve.
- Triceps jerk – C7 reflex conveyed through the radial nerve.
- Finger jerk – C8 reflex conveyed through the median and ulnar nerve.
25
Q
Reflexes - Upper Limb
- Biceps reflex – C… reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C… reflex conveyed through the radial nerve.
- Triceps jerk – C… reflex conveyed through the radial nerve.
- Finger jerk – C… reflex conveyed through the median and ulnar nerve.
A
- Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C6 reflex conveyed through the radial nerve.
- Triceps jerk – C7 reflex conveyed through the radial nerve.
- Finger jerk – C8 reflex conveyed through the median and ulnar nerve.
26
Q
Reflexes - Upper Limb
- Biceps reflex – C5 reflex conveyed through the … nerve.
- Supinator jerk – C6 reflex conveyed through the … nerve.
- Triceps jerk – C7 reflex conveyed through the … nerve.
- Finger jerk – C8 reflex conveyed through the … and … nerve.
A
- Biceps reflex – C5 reflex conveyed through the musculocutaneous nerve.
- Supinator jerk – C6 reflex conveyed through the radial nerve.
- Triceps jerk – C7 reflex conveyed through the radial nerve.
- Finger jerk – C8 reflex conveyed through the median and ulnar nerve.
27
Q
reflexes is depressed in … motor neuron lesion
A
reflexes is depressed in lower motor neuron lesion
28
Q
Nerve root …
A
29
Q
What is shown here?
A
nerve root impingement
30
Q
Nerve root impingement
- Causes – pain – radiates/ aggravated by … movement
- … loss
- weakness
- … loss
- Flexibility of cervical spine protects it from fractures or dislocation-
- but may get injury to neural structures – hyper flexion/extension
A
- Causes – pain – radiates/ aggravated by neck movement
- sensory loss
- weakness
- reflex loss
- Flexibility of cervical spine protects it from fractures or dislocation-
- but may get injury to neural structures – hyper flexion/extension
31
Q
Nerve root impingement
- Causes – pain – radiates/ aggravated by … movement
- … loss
- weakness
- … loss
- Flexibility of cervical spine protects it from fractures or … - but may get injury to neural structures – … flexion/extension
A
- Causes – pain – radiates/ aggravated by neck movement
- sensory loss
- weakness
- reflex loss
- Flexibility of cervical spine protects it from fractures or dislocation-
- but may get injury to neural structures – hyper flexion/extension
32
Q
MRI C-spine
- What is going on where red circle is?
A
T2 sequence - CSF is white around spinal cord, slightly disrupted at C6 - disc is pressing on spinal cord (Disc prolapse - may get lower motor neurone signs at the level it’s pressing the root - but if also spinal cord, upper motor neurone signs below that = myelopathy (cervico myeloradiculopathy)
33
Q
Types of nerve (plexus) injury:
- Avulsion: … of the nerves from its … at the spinal cord. – Require surgical repair
- Rupture: … of the nerves but not from its … to the spinal cord – Require surgical repair
- Neuroma: … or … of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
- Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre
A
- Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
- Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
- Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
- Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
- Worst prognosis are the ones requiring surgery
34
Q
Types of nerve (plexus) injury:
- …: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
- …: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
- Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or … – Require surgical repair
- Neurapraxia: … remain intact, but … damage cause an interruption of the … down the nerve fibre
A
- Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
- Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
- Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
- Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
- Worst prognosis are the ones requiring surgery
35
Q
Types of nerve (plexus) injury:
- …: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
- …: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
- …: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
- …: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre
A
- Avulsion: Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
- Rupture: Tearing of the nerves but not from its attachment to the spinal cord – Require surgical repair
- Neuroma: tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
-
Neurapraxia: Axons remain intact, but myelin damage cause an interruption of the impulse down the nerve fibre – Good prognosis.
- Worst prognosis are the ones requiring surgery
36
Q
- Which of the following injuries will have a worse prognosis ?
- (Avulsion / rupture, neuroma, neurapraxia)
A
avulsion is worst, avulsion, rupture, neuroma require surgery whereas neurapraxia has a good prognosis
37
Q
What this showing? (… arm as a result of … root …)
A
What this showing? (flail arm as a result of cervical root avulsion) - motor cycle injury
(C5-T1 lesions causing flail arm, Left shoulder subluxation, Atrophy of the left deltoid, supraspinatous and infraspinatous)
38
Q
Brachial plexus injury:
- …
- Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
- …
- Lung cancer: Pancoasts tumour
- Radiotherapy
- …
- Brachial neuritis
- …
- Thoracic outlet syndrome
A
-
Trauma
- Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
-
Cancer
- Lung cancer: Pancoasts tumour
- Radiotherapy
-
Inflammatory
- Brachial neuritis
-
Structural
- Thoracic outlet syndrome
39
Q
Brachial plexus injury:
- Trauma
- Erb-… type paralysis: Avulsion of C5,C6 roots.
- … paralysis: Avulsion of C8, T1 roots.
- Cancer
- Lung cancer: … tumour
- Radiotherapy
- Inflammatory
- Brachial …
- Structural
- Thoracic outlet syndrome
A
- Trauma
- Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
- Cancer
- Lung cancer: Pancoasts tumour
- Radiotherapy
- Inflammatory
- Brachial neuritis
- Structural
- Thoracic outlet syndrome
40
Q
Brachial plexus injury:
- Trauma
- …-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C…, T… roots.
- Cancer
- … cancer: Pancoasts tumour
- Radiotherapy
- Inflammatory
- … neuritis
- Structural
- … outlet syndrome
A
- Trauma
- Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
- Cancer
- Lung cancer: Pancoasts tumour
- Radiotherapy
- Inflammatory
- Brachial neuritis
- Structural
- Thoracic outlet syndrome
41
Q
Brachial plexus injury:
- Trauma
- Erb-Duchenne type paralysis: Avulsion of C…,C… roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
- Cancer
- Lung cancer: Pancoasts tumour
- …therapy
- Inflammatory
- Brachial …
- Structural
- Thoracic … syndrome
A
- Trauma
- Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
- Klumpke paralysis: Avulsion of C8, T1 roots.
- Cancer
- Lung cancer: Pancoasts tumour
- Radiotherapy
- Inflammatory
- Brachial neuritis
- Structural
- Thoracic outlet syndrome
42
Q
4 categories of brachial plexus injury are…
A
43
Q
Erbs palsy
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric … … palsy. (… … palsy) - C5/C6 innervated muscles
- Superior trunk of brachial plexus (adults- blow to shoulder)
- Weak muscles include -
- Biceps (flexes the …)
- Brachioradialis (flexes the arm in semi-… position)
- Deltoid (abducts the arm)
- Supraspinatus (abducts the arm)
- Supinator (externally rotates the arm)
A
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
- Superior trunk of brachial plexus (adults- blow to shoulder)
- Weak muscles include -
- Biceps (flexes the arm)
- Brachioradialis (flexes the arm in semi-prone position)
- Deltoid (abducts the arm)
- Supraspinatus (abducts the arm)
- Supinator (externally rotates the arm)
44
Q
Erbs palsy
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C../C… innervated muscles
- … trunk of brachial plexus (adults- blow to …)
- Weak muscles include -
- Biceps (flexes the arm)
- Brachioradialis (flexes the arm in semi-prone position)
- Deltoid (abducts the arm)
- Supraspinatus (abducts the arm)
- Supinator (externally rotates the arm)
A
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
- Superior trunk of brachial plexus (adults- blow to shoulder)
- Weak muscles include -
- Biceps (flexes the arm)
- Brachioradialis (flexes the arm in semi-prone position)
- Deltoid (abducts the arm)
- Supraspinatus (abducts the arm)
- Supinator (externally rotates the arm)
45
Q
Erbs palsy
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
- Superior trunk of brachial plexus (adults- blow to shoulder)
- Weak muscles include -
- Biceps (flexes the arm)
- … (flexes the arm in semi-prone position)
- … (abducts the arm)
- … (abducts the arm)
- … (externally rotates the arm)
A
- Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth (upper plexus palsy) - C5/C6 innervated muscles
- Superior trunk of brachial plexus (adults- blow to shoulder)
- Weak muscles include -
- Biceps (flexes the arm)
- Brachioradialis (flexes the arm in semi-prone position)
- Deltoid (abducts the arm)
- Supraspinatus (abducts the arm)
- Supinator (externally rotates the arm)
48
Q
Klumpke’s Palsy
- … for an object when falling from a ….
- … trunk plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- Arm works but hand does not!
A
-
Clutching for an object when falling from a height.
- Inferior trunk plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- Arm works but hand does not!
49
Q
Klumpke’s Palsy
- Clutching for an object when … from a height.
- Inferior trunk plexus injury involving C…/T…
- Involves trunk that supplies median and ulnar nerves
- Unable to … wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a … hand
- Arm works but hand does not!
A
- Clutching for an object when falling from a height.
- Inferior trunk plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- Arm works but hand does not!
50
Q
Klumpke’s Palsy
- Clutching for an object when falling from a height.
- Inferior trunk plexus injury involving C8/T1
- Involves trunk that supplies … and … nerves
- Unable to flex wrist or fingers
- Weakness of all … muscles of the …
- … loss hand and inner border of …
- May lead to a claw hand
- Arm works but hand does not!
A
- Clutching for an object when falling from a height.
- Inferior trunk plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- Arm works but hand does not!
51
Q
Klumpke’s Palsy
- Clutching for an object when falling from a height.
- … … plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- … works but … does not!
A
- Clutching for an object when falling from a height.
- - Inferior trunk plexus injury involving C8/T1
- Involves trunk that supplies median and ulnar nerves
- Unable to flex wrist or fingers
- Weakness of all small muscles of the hand
- Sensory loss hand and inner border of forearm
- May lead to a claw hand
- Arm works but hand does not!
53
Q
What tumour is this?
A
Pancoast tumour (close to inferior brachial plexus - affect hand)
54
Q
Post … damage near region - damage caused to …. brachial plexus (arm doesnt work, hand does)
A
Post radiation damage near region - damage caused - weakness to upper brachial plexus (Arm doesnt work, hand does)
62
Q
Thoracic outlet syndrome:
- Variations in anatomy cause … sites:
- Between anterior and middle scalene muscles
- Beneath clavicle in the costoclarvicular space
- Beneath tendon of Pectorlis minor
- …: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
- …: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.
A
- Variations in anatomy cause compression sites:
- Between anterior and middle scalene muscles
- Beneath clavicle in the costoclarvicular space
- Beneath tendon of Pectorlis minor
- Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
- Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.
63
Q
Thoracic outlet syndrome:
- Variations in anatomy cause compression sites:
- Between anterior and middle … muscles
- Beneath … in the costoclarvicular space
- Beneath tendon of … minor
- Neurogenic: predominantly affects the median-innervated abductor pollicis … muscle (thenar wasting)
- Vascular: … rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.
A
- Variations in anatomy cause compression sites:
- Between anterior and middle scalene muscles
- Beneath clavicle in the costoclarvicular space
- Beneath tendon of Pectorlis minor
- Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
- Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.
64
Q
Thoracic outlet syndrome:
- Variations in anatomy cause compression sites:
- Between anterior and middle scalene muscles
- Beneath clavicle in the costoclarvicular space
- Beneath tendon of Pectorlis …
- Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (… wasting)
- Vascular: High rib causes area of stenosis with a poststenotic dilatation. … may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to … phenomenon.
A
- Variations in anatomy cause compression sites:
- Between anterior and middle scalene muscles
- Beneath clavicle in the costoclarvicular space
- Beneath tendon of Pectorlis minor
- Neurogenic: predominantly affects the median-innervated abductor pollicis brevis muscle (thenar wasting)
- Vascular: High rib causes area of stenosis with a poststenotic dilatation. Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to Raynaud’s phenomenon.
65
Q
Thoracic outlet syndrome:
- Neurogenic:
- Leads to …, …, weakness
- Not localised to specific nerve distribution
- Reproducibly aggravated by elevation or sustained use of arms or hands.
- Vascular
- Forearm … within minutes of use.
- Swelling and …
- Collateral venous patterning over the … shoulder, chest wall and neck.
- Rarely pain, pallor and coldness (arterial involvement).
- … BP on affected arm, diminished distal pulses.
A
- Neurogenic:
- Leads to Paresthesia, numbness, weakness
- Not localised to specific nerve distribution
- Reproducibly aggravated by elevation or sustained use of arms or hands.
- Vascular
- Forearm fatigue within minutes of use.
- Swelling and cyanosis
- Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
- Rarely pain, pallor and coldness (arterial involvement).
- Lower BP on affected arm, diminished distal pulses.
66
Q
Thoracic outlet syndrome:
- Neurogenic:
- Paresthesia, numbness, …
- Not … to specific nerve distribution
- Reproducibly … by elevation or sustained use of arms or hands.
- Vascular
- … fatigue within minutes of use.
- … and cynaosis
- Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
- Rarely …, pallor and coldness (arterial involvement).
- Lower BP on affected arm, diminished distal pulses.
A
- Neurogenic:
- Paresthesia, numbness, …
- Not localised to specific nerve distribution
- Reproducibly aggravated by elevation or sustained use of arms or hands.
- Vascular
- Forearm fatigue within minutes of use.
- Swelling and cynaosis
- Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
- Rarely pain, pallor and coldness (arterial involvement).
- Lower BP on affected arm, diminished distal pulses.
67
Q
Long Thoracic Nerve
- Long thoracic nerve may be injured by blows or pressure in the … triangle of the neck
- or during a radical mastectomy.
- Leading to ‘winged …’
A
- Long thoracic nerve may be injured by blows or pressure in the posterior triangle of the neck
- or during a radical mastectomy.
- Leading to ‘winged scapula’
68
Q
Long Thoracic Nerve
- Long thoracic nerve may be injured by blows or pressure in the … … of the neck
- or during a radical ….
- Leading to ‘… scapula’
A
- Long thoracic nerve may be injured by blows or pressure in the posterior triangle of the neck
- or during a radical mastectomy.
- Leading to ‘winged scapula’
69
Q
Long Thoracic Nerve
- Long thoracic nerve supplies the serratus anterior muscle.
- The serratus anterior muscle pulls the … border of the … to the … thoracic wall and stabilises it there
- Impairment of the long thoracic nerve leads to “…” of the scapula
A
- Long thoracic nerve supplies the serratus anterior muscle.
- The serratus anterior muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
- Impairment of the long thoracic nerve leads to “winging” of the scapula
70
Q
Long Thoracic Nerve
- Long thoracic nerve supplies the … … muscle.
- The … … muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
- Impairment of the long thoracic nerve leads to “winging” of the scapula
A
- Long thoracic nerve supplies the serratus anterior muscle.
- The serratus anterior muscle pulls the medial border of the scapula to the posterior thoracic wall and stabilises it there
- Impairment of the long thoracic nerve leads to “winging” of the scapula
71
Q
Impairment of the long thoracic nerve leads to “winging” of the …
A
Impairment of the long thoracic nerve leads to “winging” of the scapula
73
Q
Median Nerve innervated Hand Muscles
- L …
- O …
- A ….
- F …
A
- L ateral 2 lumbricals
- O pponens pollicis
- A bductor pollicis brevis
- F lexor pollicis brevis
74
Q
… wasting
A
- Thenar wasting
75
Q
Anatomy of the Carpal tunnel
A
76
Q
Carpal tunnel syndrome
- … N. Entrapment at Carpal Tunnel (also damaged in … fractures)
- Causes include:
- Diabetes
- Pregnancy
- …thyroidism
- Rheumatoid arthritis
- Repetitive strain
A
- Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
- Causes include:
- Diabetes
- Pregnancy
- Hypothyroidism
- Rheumatoid arthritis
- Repetitive strain
77
Q
Carpal tunnel syndrome
- Median N. Entrapment at Carpal Tunnel (also damaged in wrist …)
- Causes include:
- Diabetes
- …
- Hypothyroidism
- … arthritis
- Repetitive …
A
- Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
- Causes include:
- Diabetes
- Pregnancy
- Hypothyroidism
- Rheumatoid arthritis
- Repetitive strain
78
Q
What is Tinel’s sign?
A
Tinel’s test is used to test for compression neuropathy, commonly in diagnosing carpal tunnel syndrome.
79
Q
Carpal tunnel syndrome
- Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
- Causes include:
- Diabetes
- Pregnancy
- Hypothyroidism
- Rheumatoid arthritis
- Repetitive strain
A
- Median N. Entrapment at Carpal Tunnel (also damaged in wrist fractures)
- Causes include:
- Diabetes
- Pregnancy
- Hypothyroidism
- Rheumatoid arthritis
- Repetitive strain
80
Q
What is Phalen’s test?
A
- A positive Phalen maneuver is highly suggestive of carpal tunnel syndrome. The Phalen maneuver is performed by having the patient place the wrists in complete unforced flexion for at least 30 seconds If the median nerve is entrapped at the wrist, this maneuver reproduces the symptoms of carpal tunnel syndrome.
84
Q
Anterior interosseous nerve syndrome
- Pure … branch of the median nerve
- Weakness in flexors of ip joint of thumb (flexor … longus) & dip joints of index and middle fingers – (flexor … profundus) weakness of pronation
A
- Pure motor branch of the median nerve
- Weakness in flexors of ip joint of thumb (flexor policis longus) & dip joints of index and middle fingers – (flexor digitorum profundus) weakness of pronation
85
Q
What syndrome causes this?
A
86
Q
Sensory innervation of the median nerve in the forearm versus carpal tunnel
- lesion in … = affect palm and 3.5 finger
- lesion in … … = just affects finger tips
A
- lesion in forearm = affect palm and 3.5 finger
- lesion in carpal tunnel = just affects finger tips
87
Q
… palsy at elbow
A
Ulnar palsy at elbow
88
Q
… nerve palsy at wrist
A
Ulnar nerve palsy at wrist
89
Q
- ED: Extensor digitorum – … nerve
- L: Lumbricals – … nerve
- FDP: 3rd and 4th Flexor digitorum profundi – … nerve
- FDS: Flexor digitorum superficialis – … nerve
A
- ED: Extensor digitorum – radial nerve
- L: Lumbricals – ulnar nerve
- FDP: 3rd and 4th Flexor digitorum profundi – ulnar nerve
- FDS: Flexor digitorum superficialis – medial nerve
90
Q
Higher lesion in the upper limb:
- Paralysis of the ulnar half of the flexor … … (FDP), interossei and ….
- The ring and little fingers are not flexed and there is no …
A
- Paralysis of the ulnar half of the flexor digitorum profundus (FDP), interossei and lumbricals. The ring and little fingers are not flexed and there is no claw.
91
Q
Lesion at the wrist:
- Flexion at the … (FDP is intact)
- Flexion at the … (interossei are paralysed)
- hyperextention at the … (lubricals are paralysed).
A
- Flexion at the DIP (FDP is intact)
- Flexion at the PIP (interossei are paralysed)
- hyperextention at the MCP (lubricals are paralysed).
92
Q
Sensory innervation of the ulnar nerve
- 1 = lesion where?
- 2 = lesion where?
- 3 = lesion where?
A
- 1) Lesion above dorsal cutaneous branch
- 2) Lesion below dorsal cutaneous branch
- 3) Lesion below palmar cutaneous branch
93
Q
Ulnar nerve
A
95
Q
Which hand has the ulnar n. palsy ? - what sign to work this out?
A
- Weakness of adductor pollicis leads to the Froment’s sign.
96
Q
Weakness of thumb adduction is due to a problem of the adductor pollicis muscle, which is mainly innervated by the … nerve. The typical sign of such an ulnar palsy is the …’s sign,
A
Weakness of thumb adduction is due to a problem of the adductor pollicis muscle, which is mainly innervated by the ulnar nerve. The typical sign of such an ulnar palsy is the Froment’s sign,
97
Q
Ulnar vs C8
- C8
- All finger extensors (… nerve)
- FDP of Index/middle (… nerve)
A
- C8
- All finger extensors (radial nerve)
- FDP of Index/middle (median nerve)
98
Q
‘Saturday night palsy’ – … nerve palsy
A
‘Saturday night palsy’ – Radial nerve palsy
99
Q
Radial nerve damage rarely causes extensive … loss
A
Radial nerve damage rarely causes extensive sensory loss
100
Q
… nerve damage rarely causes extensive sensory loss
A
Radial nerve damage rarely causes extensive sensory loss
101
Q
Radial nerve - extensive overlap with median/ulnar excepting … … box
A
Radial nerve - extensive overlap with median/ulnar excepting anatomical snuff box
102
Q
Nerve conduction studies
- Useful in determining the amplitude and … of a peripheral nerve
A
- Useful in determining the amplitude and velocity of a peripheral nerve
103
Q
Axonal vs demyelinating
- Axonal loss results in a decrease in …
- Demyelinating results in a decrease in …
A
- Axonal loss results in a decrease in amplitude
- Demyelinating results in a decrease in velocity
104
Q
Axonal vs demyelinating
- Axonal loss results in a … in amplitude
- Demyelinating results in a … in velocity
A
- Axonal loss results in a decrease in amplitude
- Demyelinating results in a decrease in velocity
105
Q
Neurogenic vs myogenic
- Needle EMG measures the electrical activity of the muscle during … contraction.
- The pattern of the electrical activity can help distinguish a lesion arising from the nerve (…) vs muscle (…)
A
- Needle EMG measures the electrical activity of the muscle during voluntary contraction.
- The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)
106
Q
Neurogenic vs myogenic
- Needle EMG measures the electrical activity of the muscle during voluntary contraction.
- The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)
A
- Needle EMG measures the electrical activity of the muscle during voluntary contraction.
- The pattern of the electrical activity can help distinguish a lesion arising from the nerve (neurogenic) vs muscle (myopathic)
