The Upper Limb Innervation

Overview Upper Arm Flexors: Musculocutaneous nerve Extensors: Radial nerve Forearm Flexor compartment: o Median nerve AIN (anterior interosseous nerve) o Ulnar nerve for one and half muscles Flexor carpi ulnaris Ulnar half of flexor digitorum profundus Extensor Compartment: o Radial nerve or its motor branch PIN (posterior interosseous nerve) Hand Intrinsic muscles: o Ulnar nerve supplies all except LOAF (Median Nerve) LOAF= Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis. (OAF= Thenar muscles) Musculocutaneous Nerve: Branch of lateral cord (C5,6,7) Motor - flexors of arm o Coracobrachialis, Biceps, Brachialis Sensory - Cutaneous to forearm o Skin from elbow to wrist by an anterior and posterior branch along radial border of forearm Course o Emerge at lateral border of biceps tendon, o Pierces the deep fascia at elbow flexure crease o Becomes lateral cutaneous nerve of the forearm Injury o Rarely injured o Test for flexion of elbow by biceps biceps must be palpated o Beware of brachioradialis (radial nerve) simulating the flexion action Axillary Nerve Posterior cord (C5,6) Motor o Posterior branch supplies teres minor, and winds around the posterior border of deltoid, supplying a small part of the muscle o Anterior branch lies on the posterior surface of the humerus and supplies deltoid Sensory o Upper lateral cutaneous nerve of the arm supplies skin over lower deltoid o (some small twigs from anterior branch supply skin over centre of muscle) o the shoulder joint and skin over the joint Passes backwards in axilla, lying above the posterior circumflex humeral vessels and in contact with the humeral neck just below capsule of the shoulder joint (which it supplies) Injury o Damaged in: 5% of dislocations of shoulder, # of prox humerus or misplaced injections of deltoid. o Deltoid becomes paralysed and may lose sensation in egg shaped area over the outer side of upper arm below acromion o TEST: abduction of shoulder (deltoid) and sensation

Median Nerve Arm/Forearm Formed by joining of lateral root of lateral cord plus medial root of medial cord (C5,6,7,8,T1) No muscular branches in arm. Twig to elbow and sympathetic to brachial artery Motor o Forearm most of the flexor muscles o Pronator teres, Palmaris longus, Flexor carpi radialis, Flexor digitorum superficialis o AND gives off Anterior interosseous nerve AIN descends on IO membrane to wrist and supplies deep flexor compartment: radial half of FDP, Flexor pollicis longus, Pronator quadratus Sensory o to interosseous membrane, periosteum of radius/ulna, wrist of intercarpal joints o Palmar cutaneous branch: pierce deep fascia just prox to flexor retinaculum supplying thumb on palmar side Course o leave axilla and slope in front of brachial artery beneath fascia of the arm o At elbow lies medial to the artery beneath bicipital aponeurosis o Descends between the two heads of pronator teres and beneath fibrous arch of FDS o Adherent to the deep surface of the muscle, it emerged on the radial side lying between FCR and PL before passing through the CARPAL TUNNEL into the hand o Median Nerve Wrist/Hand Median nerve divides in carpal tunnel and enters hand as the lateral and medial branch Supplies 3 thenar muscles and 2 lumbricals of the hand Nails on dorsum + flexor surface of the thumb, IF, MF and RF plus corresponding are of palm Lateral branch: o muscular recurrent branch [curves around distal border of flexor retinaculum] supplies the 3 thenar muscles (OP, APB, FPB). st o three palmar digital branches (two for thumb and one for index, this last one also supplying the 1 lumbrical) Medial branch: nd rd nd o 2 palmar digital nerves for adjacent 2 and 3 cleft, + 2ndlumbrical (from 2 cleft branch) o 5 palmar digital cutaneous branches supply nail beds + flexor surface of radial 3 and digits Carpal Tunnel Transverse carpal ligament (flexor retinaculum) is a heavy band of fibres which runs between hamate & pisiform medially to scaphoid and trapezium laterally, and forms fibrous sheath which contains carpal tunnel within fibroosseous tunnel; Posteriorly, it is bordered by carpal bones, and transports median nerve & finger flexor tendons from forearm to hand; Superficial Anatomy o Palmaris longus passes in front of flexor retinaculum to become continuous with the palmar fascia o Palmar cutaneous branch of median nerve, which innervates skin over base of thenar eminence, arises short distance prox to flexor retinaculum, o Palmar cutaneous nerve of ulnar nerve course superficial to carpal ligament & is not involved in CTS; o Distal volar flexion crease crosses proximal end of scaphoid and pisiform & marks proximal edge of TCL; Contents of Tunnel: o median nerve & finger flexor tendons (FDS, FDP , & FPL); o motor branch of median nerve in hand arises under or just distal to flexor retinaculum, & winds around distal border of retinaculum to reach hypothenar muscles and the lateral 2 lumbricals [numerous variations in the branching have been described] o sensory branches innervate lateral three and 1/2 digits & palm of the hand; Injury to Median Nerve Low lesions Most commonly injured at wrist o cuts or compression in the carpal tunnel Eventually wasting of thenar eminence Theoretically sensory loss over radial 3 digits BUT only autonomous area of median nerve supply are over pulp pads of index and middle fingers (test IF) Test: abduction of thumb (AbPB) High lesions Wasting of front of forearm: paralysis of long flexors (except FCU and of FDP) and pronators Hand of benediction. When attempting to make a fist. Hand in pointing finger position of the index often with all other fingers flexed (+/-middle finger) o N.B. although FDP of MF is supposed to be supplied by Med N. its close connection to ulnar nerve can supply MF (FDP) thus allowing MF flexion Test: Flexor pollicis longus and finger flexors by pinching together the pads of thumb and index finger

Ulnar Nerve Direct continuation with the medial cord (C8, T1) In 95% of cases it also picks up C7 fibres in the axilla from the lateral cord Innervates some flexor muscles of the ulna side of forearm and skin of ulna one and a digits. Chiefly nerve for most of the intrinsic muscles of the hand (i.e. muscles fine finger movements) Several twigs on the elbow joint bind the nerve close against the lower end of the humerus Course Runs down behind brachial artery. inclines back and pierces medial intermuscular septum Descends along triceps on shaft of humerus between medial epicondyle and the olecranon Passes between the two heads of FCU and enters the flexor compartment of the forearm Crossing the sublime tubercle it descends on FDP under FCU (and is joined by ulnar artery) The two emerge from beneath the tendon of FCU just above the wrist and cross the flexor retinaculum alongside the pisiform bone On the retinaculum the nerve divides into its terminal superficial and deep branche Motor - Forearm Flexor carpi ulnaris (FCU) (C7), ulnar (usually) of FDP (C8,T1) Motor Wrist/Hand Deep branch (C8,T1): o passes deeply between and supplies: Abductor Digiti minimi. Flexor Digiti Minimi, Opponens Digiti Minimi o Crossing the palm in the concavity of the deep palmar arch it supplies: 2 ulnar lumbricals, all interossei, adductor pollicis. Sensory - Wrist Superficial branch (C8) o run distally beneath palmaris brevis (which it supplies) and is distributed to ulnar 1 and digits (INCLUDING nail beds) by 2 digital branches: o One supplies ulnar side LF ND th o 2 supplies the 4 cleft and bifurcates to supply the adjacent sides of RF and LF Palmar cutaneous branch (C8) o pierces skin above flexor retinaculum to supply skin over hypothenar muscles Dorsal cutaneous branch (C8) o winds around lower end of the ulna deep to the tendon of FCU, crosses triquetral bone and is distributed to the dorsal and palmar skin of 1 and fingers (LF, RF).. Supply falls just short of the nail beds o (N.B. not uncommonly it supplies 2 and not 1 and digits) Injury To Ulnar Nerve Most commonly injured below the elbow or at the wrist o Classical sign of a low lesion: claw hand =hyperextension of MCP joints of RF and LF Flexion of IPJs because the interossei and lumbricals are paralysed SO o cannot flex the MCP joints OR Extend the interphalangeal joints Claw is produced by unopposed action of the extensors and of FDP Ulnar paradox Injury at the elbow or above gives straighter fingers because the ulnar half of FDP is now out of action and cannot flex the DIPJs of RF/LF Wasting of interossei eventually becomes obvious on dorsum of hand guttering between metacarpals. Sensation: variable sensory loss on ulnar side of hand on LF and RF (often less than might be expected) Test: Low Lesion st as representative of small muscles of hand, test Abduction of the Index finger by 1 dorsal interosseous o The first dorsal interosseous can be tested by abducting the index finger against resistance; the muscle can be seen and palpated between the first two metacarpals. o The adducting capacity of the palmar interossei can he tested by trying to hold a piece of card between the adjacent extended fingers while an attempt is made to pull the card away. This test carried out between the index and middle fingers provides a reliable assessment of ulnar nerve integrity Test: High lesion: test the action of the ulnar half of FDP in flexing the DIPJ of the little finger

Radial Nerve From posterior cord (C5, 6, 7, 8, T1) Nerve of the extensor compartment of arm and forearm, supplies skin over them and on the dorsum of the hand + anatomical snuff box Branches tend to arise high above their destination Course - Arm Direct continuation of posterior cord Pass beyond the post wall of axilla and enter the triangular space below teres major Spirals across medial head of triceps to lie in lower part of radial groove on bare bone, deep to lateral head of triceps Pierces lateral intermuscular septum and can be rolled on the humerus (1/3 way down from deltoid tuberosity to lateral epicondyle) In flexor compartment lower arm held away from bare bone by brachioradialis and it descends in the intermuscular slit between brachialis and brachiolradialis Course - Forearm After giving off POSTERIOR INTEROSSEOUS NERVE (PIN) the remnant (which is purely cutaneous) retains the name of radial nerve- runs down flexor compartment of forearm, into anatomical snuff box with EPL to back of hand Here it divides into 2 or 3 to supply the skin of the radial three and digits (falling short of the nail beds) and the corresponding area of the dorsum of hand N.B. these nerves and the dorsal branch of the ulnar nerve commonly share the supply of 2 : 2 rather than the 3 : 1 usually quoted Sensory Posterior cutaneous nerve of the arm (C5) o extensor surface of arm down to elbow Lower lateral cutaneous nerve (C5)o lateral surface of arm down to elbow o in common with this arises the Posterior cutaneous nerve of forearm (C6,7) o supply a strip of skin over the extensor surface of the forearm down to wrist Motor Arm supplies Long, Lateral and Medial heads of Triceps Brachioradialis, extensor carpi radialis longus Motor - Forearm Posterior interosseous nerve (C5,6,7,8) o supplies extensor carpi radialis brevis ECRB and supinator on cubital fossa, o then spirals down around the upper end of radius between the two layers of supinator to the extensor compartment of the forearm o Motor supply (extensor compartment): Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Three thumb muscles (Abductor pollicis longus/ extensor pollicis brevis/ extensor pollicis longus) Extensor indicis o Sensory: interosseous membrane, periosteum of radius and ulna, wrist and carpal joints on extensor surface. Injury To Radial nerve Most commonly injured high up by humeral shaft fractures CAN GET Transient paralsysis: improper crutch fitting/ Saturday night palsy o characteristic lesion is wrist drop with the inability to extend wrist and MCPJs N.B. the IPJs can still be straightened by the action of the interossei and lumbricals) ST Sensory loss is minimal and usually confined to a coin-shaped area overlying the 1 dorsal interossei (due to overlap Med/ Ulnar N.) Test: High: Test extension of the elbow by triceps (remembering that the branches to triceps arise before the nerve reaches the humerus) Low: (i.e. PIN) Wrist extension