7/24/2020 Nerve Supply to the Upper Limb

Nerve Supply to the Upper Limb

geekymedics.com/nerve-supply-to-the-upper-limb/

Laura Jayne Watson November 13, 2015

Introduction
The nerve supply to the upper limb is an absolutely essential topic for you to nail during
revision for your exams, as it is a relatively complex topic which will inevitably crop up in
anatomy questions, clinical case scenarios and OSCEs. It is also very relevant
once you start your clinical practice as a doctor.
This article will focus on the five terminal nerve branches of the brachial plexus
which supply the upper limb. These are the musculocutaneous nerve, the axillary
nerve, the radial nerve, the median nerve and the ulnar nerve. I have covered their
anatomy and function, as well as the clinical features you would expect to find with a
nerve injury. I have also, of course, provided a handy summary table at the end!

Structure of the Brachial Plexus

The nerve supply to the upper limb is almost entirely supplied by the brachial plexus; a
complex intercommunicating network of nerves formed in the neck by spinal
nerve roots C5, C6, C7, C8 and T1. I have covered the brachial plexus itself in more
detail in a separate article here.

The diagram below summarises the structure and branches of the brachial
plexus in all its demoralising glory. You can click to make it bigger!

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You can see that the three cords branch to form the five terminal nerve branches
which supply the upper limb:

the lateral cord gives the musculocutaneous nerve and the lateral root of
the median nerve
the posterior cord gives the axillary nerve and the radial nerve
the medial cord gives the medial root of the median nerve and the ulnar
nerve

The origins of these five nerves are distributed around the third part of the axillary
artery. The musculocutaneous, median and ulnar nerves lie anteriorly and form
a characteristic “M” shape around the axillary artery, which is a really easy landmark
to find on a prosection. When given a diagram or prosection of the brachial plexus to label
in exams, the way to stay calm and approach it like a boss is to find the “M” shape!

Musculocutaneous Nerve (C5/C6/C7)

ORIGIN
lateral cord of brachial plexus
formed from anterior divisions of superior and middle trunks

COURSE
it leaves the axilla by piercing coracobrachialis muscle
it then passes down the arm beneath biceps muscle
it ends as the lateral cutaneous nerve of forearm

SENSORY SUPPLY

skin of lateral forearm

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MOTOR SUPPLY
anterior compartment of arm (BBC)
biceps – flexes elbow, supinates forearm
brachialis – flexes elbow
coracobrachialis – flexes and adducts the arm at the glenohumeral joint

COMMON INJURIES
musculocutaneous nerve injuries are rare, as the nerve is protected beneath the
bulk of the biceps muscle
it may be damaged by stab wounds to the upper arm

CLINICAL FEATURES OF MUSCULOCUTANEOUS NERVE PALSY

SENSORY LOSS
numbness over lateral forearm
MOTOR DEFICIT
paralysis of anterior compartment of arm – very weak elbow flexion
and weak forearm supination
absent biceps reflex
DEFORMITY
wasting of anterior compartment of arm
elbow usually held in extension with forearm pronated

Axillary Nerve (C5/C6)

ORIGIN

posterior cord of brachial plexus

formed from posterior division of upper trunk

COURSE
it passes beneath the shoulder joint through the quadrangular space with
the posterior circumflex humeral artery
it then wraps around the surgical neck of the humerus

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SENSORY SUPPLY
the “sergeant’s patch” of skin over the lower part of deltoid muscle

MOTOR SUPPLY
shoulder muscles
deltoid – abducts, flexes and extends shoulder
teres minor – externally rotates shoulder, forms part of rotator cuff which
stabilises shoulder joint

COMMON INJURIES

fracture of surgical neck of humerus

stab wounds to posterior shoulder
anterior shoulder dislocation
pressure of crutches on armpits (“crutch palsy”)

CLINICAL FEATURES OF AXILLARY NERVE PALSY

SENSORY LOSS
numbness over “sergeant’s patch”
MOTOR DEFICIT
paralysis of deltoid – very weak shoulder abduction from 15-90°; weak
shoulder flexion and extension
paralysis of teres minor – weak shoulder external rotation
DEFORMITY
wasting of deltoid muscle, making the bones of the shoulder joint very
prominent and obvious
shoulder may appear adducted and internally rotated

Radial Nerve (C5/C6/C7/C8/T1)

ORIGIN
posterior cord
formed from posterior divisions of all three trunks

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COURSE
it passes behind the axillary artery and through the triangular interval to
enter the posterior compartment of the arm
it then winds around the spiral groove of the humerus with the profunda
brachii artery, between the heads of triceps muscle
it enters the antecubital fossa in front of the lateral epicondyle of the
humerus, between the brachialis and brachioradialis muscles
it then branches in the proximal forearm into two terminal branches:
superficial branch (mainly sensory) – descends under brachioradialis
muscle to end in the dorsum of the hand
deep branch (mainly motor) – pierces supinator muscle and descends
along the posterior interosseous membrane with the posterior
interosseous artery

SENSORY SUPPLY
posterior arm and forearm
lateral ⅔ of dorsum of hand
proximal dorsal aspect of lateral 3½ fingers (thumb, index, middle and
half of ring finger)

MOTOR SUPPLY

posterior compartment of arm

triceps – extends and adducts shoulder, extends elbow
posterior compartment of forearm
brachioradialis – flexes elbow
anconeus – extends elbow, stabilises elbow joint
supinator – supinates forearm
extensor carpi radialis longus and brevis – extend and abduct wrist
extensor carpi ulnaris – extends and adducts wrist
extensor digitorum, extensor pollicis longus and brevis, extensor
indicis and extensor digiti minimi – extend thumb and fingers at MCPJs
and IPJs
abductor pollicis longus – abducts thumb

COMMON INJURIES
fractures of proximal humerus, shaft of humerus or radius

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stab wounds to antecubital fossa, forearm or wrist

this includes blood tests and venflons!
pressure of crutches on armpits (“crutch palsy“)
the patient falling asleep with arm hanging over the back of a chair,
classically whilst drunk (“Saturday night palsy“)
somebody else falling asleep with their head lying on the patient’s arm
(“honeymoon palsy“)
excessively tight plaster casts, wristbands or handcuffs
prolonged tourniquet use on upper arm, for example during orthopaedic or
plastics procedures

CLINICAL FEATURES OF RADIAL NERVE PALSY

SENSORY LOSS
numbness of skin over posterior arm, posterior forearm and radial
distribution of dorsum of hand

MOTOR DEFICIT
paralysis of posterior compartment of arm – weak elbow extension
paralysis of posterior compartment of forearm – weak wrist
extension, weak thumb extension and finger MCPJ extension
NB// finger IPJ extension is still possible due to intact nerve supply to the
lumbrical muscles of the hand
absent triceps and supinator reflexes

DEFORMITY
wasting of triceps and posterior compartment of forearm
“WRIST DROP” deformity at rest and on attempted wrist extension – the
patient cannot extend their wrist/fingers, resulting in unopposed
wrist flexion. In the classical description of a radial nerve injury, the
forearm is also pronated, the fingers are flexed and the thumb adducted.

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“Wrist drop” deformity due to radial nerve

palsy – the patient cannot extend their wrist
or fingers

Median Nerve (C5/C6/C7/C8/T1)

ORIGIN
lateral and medial cords of the brachial plexus
lateral root arises from anterior divisions of superior and middle trunks
medial root arises from anterior division of inferior trunk

COURSE
the median nerve runs down the arm with the brachial artery: it initially lies
lateral to the artery, then crosses over to lie medial to it about halfway down the
arm
it then passes through the medial part of the antecubital fossa between the two
heads of pronator teres muscle
it travels through the anterior forearm between the flexor digitorum superficialis
and flexor digitorum profundus muscles and gives three main branches:
anterior interosseous nerve – descends along the anterior
interosseous membrane with anterior interosseous artery
deep branch – enters hand through the carpal tunnel beneath the flexor
retinaculum of the wrist, between flexor carpi radialis and flexor digitorum
superficialis tendons
superficial/palmar cutaneous branch – arises just before the wrist and
pierces the palmar carpal ligament to enter the palm over the top of the
carpal tunnel – this nerve is therefore not affected by carpal tunnel
syndrome

SENSORY SUPPLY
the median nerve does not supply any sensory innervation to the axilla or upper arm

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skin over thenar eminence

lateral ⅔ palm of hand
palmar aspect of lateral 3½ fingers
dorsal fingertips of lateral 3½ fingers (thumb, index, middle and half of
ring finger)

MOTOR SUPPLY
the median nerve does not supply any motor innervation to the axilla or upper arm
all muscles of anterior compartment of forearm EXCEPT flexor carpi ulnaris
and the medial two parts of flexor digitorum profundus
pronator teres and pronator quadratus – pronate forearm
flexor carpi radialis – flexes and abducts wrist
palmaris longus – flexes wrist and tenses palmar aponeurosis
flexor digitorum superficialis – flexes fingers at PIPJs
lateral two parts of flexor digitorum profundus – flex index and
middle fingers at DIPJs
flexor pollicis longus – flexes thumb at IPJ
intrinsic muscles of hand – LOAF muscles
lateral two lumbricals – flex MCPJs and extend IPJs of index and middle
finger
opponens pollicis – opposes thumb
abductor pollicis brevis – abducts thumb
flexor pollicis brevis – flexes thumb at MCPJ

COMMON INJURIES
supracondylar fractures of humerus
stab wounds to antecubital fossa, forearm of wrist
this includes blood tests and venflons!
deep wrist lacerations inflicted during deliberate self harm
compression by carpal tunnel syndrome

CLINICAL FEATURES OF MEDIAN NERVE PALSY

SENSORY LOSS
numbness of skin over thenar eminence and median distribution of
hand
NB// in carpal tunnel syndrome, sensation to the palm is usually preserved
due to an intact palmar cutaneous branch

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MOTOR DEFICIT
paralysis of most of anterior compartment of forearm – weak forearm
pronation, wrist flexion and abduction, and weak finger flexion with
preservation of DIPJ flexion at ring and little fingers
paralysis of thenar eminence – weak pincer grip and overall grip
strength, weak thumb opposition

DEFORMITY
wasting of anterior compartment of forearm and thenar eminence
“HAND OF BENEDICTION” deformity on attempted finger flexion –
the patient cannot flex their index or middle fingers, resulting in
unopposed extension of those two fingers. They cannot make a fist with all
of their fingers.

“Hand of benediction” due to median

nerve palsy – the patient cannot flex their
index or middle fingers

Ulnar Nerve (C8/T1)

ORIGIN
medial cord of brachial plexus
formed from anterior division of inferior trunk

COURSE

the ulnar nerve runs down the arm on the medial side of the brachial artery
it passes behind the medial epicondyle of the humerus and enters the forearm
between the two heads of flexor carpi ulnaris

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it travels through the anterior compartment of the forearm beneath flexor

carpi ulnaris with the ulnar artery
it then enters the palm of the hand through Guyon’s canal

SENSORY SUPPLY

the ulnar nerve does not supply any sensory innervation to the axilla or upper arm
skin over hypothenar eminence
medial ⅓ palm of hand
palmar aspect of the medial 1½ fingers
medial ⅓ dorsum of hand
dorsal aspect of medial 1½ fingers (little finger and half of ring finger)

MOTOR SUPPLY
two muscles of anterior compartment of forearm
flexor carpi ulnaris – flexes and adducts wrist
medial two parts of flexor digitorum profundus – flex ring and
little fingers at DIPJs
most of the intrinsic muscles of the hand – HILA muscles
hypothenar eminence: opponens digiti minimi, flexor digiti minimi
brevis and abductor digiti minimi – oppose, flex and abduct little finger
interossei – palmar interossei adduct, dorsal interossei abduct
medial two lumbricals – flex MCPJs and extend IPJs of ring and
little finger
adductor pollicis – adducts thumb
NB// adductor pollicis is not part of the thenar eminence and actually lies
deep beneath it as a separate structure

COMMON INJURIES
supracondylar fractures of humerus
fractures or soft tissue injuries to medial epicondyle of humerus
stab wounds to forearm or wrist
this include blood tests and venflons!
compression either at the cubital tunnel in the elbow or at Guyon’s canal in
the wrist

CLINICAL FEATURES OF ULNAR NERVE PALSY

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SENSORY LOSS
numbness over hypothenar eminence and ulnar distribution of hand

MOTOR DEFICIT
paralysis of flexor carpi ulnaris – weak wrist flexion and adduction
paralysis of medial two parts of flexor digitorum profundus – weak
flexion of ring and little finger DIPJs
paralysis of most of the intrinsic muscles of the hand – weak MCPJ
flexion and IPJ extension of ring and little fingers, loss of finger
abduction and adduction, loss of opposition of little finger

DEFORMITY
wasting of hypothenar eminence and intrinsic muscles of hand
“CLAW HAND” deformity at rest and on attempted finger extension –
the patient cannot extend the IPJs of their ring or little fingers,
resulting in fixed flexion of the IPJs and hyperextension of the
MCPJs of these two fingers. The clawed appearance is most pronounced
when the nerve is injured at the wrist, for example by compression in
Guyon’s canal, as the function of flexor digitorum profundus will be preserved.
A claw hand affecting all four fingers is much less common and is usually due
to a lesion of the lower part of brachial plexus, such as Klumpke’s palsy.

“Claw hand” due to ulnar nerve palsy – the

patient cannot extend their ring or little
fingers

Real Anatomy: Prosected Specimens

Here is a really great little video from adivineanatomy on YouTube, which walks you
through the brachial plexus and the peripheral nerves of the upper limb on a prosection:

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Watch Video At: https://youtu.be/F2-9yeRE0wY

Real Anatomy: Surgery

This video on YouTube shows an ulnar nerve transposition procedure to treat
compression in the cubital tunnel at the elbow. You can see that the ulnar nerve is a
fairly sizeable structure in real life – you can roll it under your fingers at your medial
epicondyle quite easily if you are so inclined.

Watch Video At: https://youtu.be/pR3V9OHYtJs

Clinical Anatomy
If you require a refresher of how to perform a neurological examination of the
upper limb, here is our super awesome Geeky Medics OSCE guide

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Dermatomes and Myotomes

The sensory supply to the upper limb can be broken down into dermatomes (the area
supplied by each spinal nerve root) and peripheral nerve territories. The best way to
learn these, especially the complicated supply to the hand, is literally to draw it on
yourselves or on each other! The motor supply to the upper limb can also be broken down
into myotomes (the movements which test individual spinal nerve roots) as well as
peripheral nerve functions.

The table below summarises how to test the function of each spinal nerve.

PERIPHERAL NERVE INJURIES

Upper limb nerve injuries summary table

A thorough understanding of upper limb anatomy is absolutely essential if you want to

succeed in a neurological examination OSCE station. The nerve supply to the upper
limb is commonly damaged by fractures, penetrating trauma and
external compression. These unfortunate events generate lots of patients with
abnormal neurological examination findings who can be used in your exams!
Learning the patterns of different nerve injuries can, unfortunately, be both
complicated and tedious. I have, therefore, alongside their anatomical course and
functions, detailed the clinical features you would expect to see with injuries to each of
the nerves in the individual sections above. I have also created a separate little summary
table detailing the features of different nerve injuries below (you can click to enlarge
it). To make them easier to memorise I have broken them down into three
groups: sensory loss, motor deficits and deformity.

There are several different types and pathologies of nerve injuries:

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neurapraxia – the nerve is stretched and damaged but not torn

rupture – the nerve is torn at a point along its length
axonotmesis – the nerve fibre is partially severed: the axon and myelin
sheath are torn but the surrounding epineurium, perineurium and connective
tissues are preserved. Natural recovery is possible through axonal
regeneration, so these injuries can often be managed conservatively with
support and physiotherapy.
neurotmesis – the nerve fibre is completely severed. There is no prospect
of natural recovery, so this type of injury requires surgery to restore function.
avulsion – the nerve root is torn off the spinal cord at its origin. This can happen
in brachial plexus injuries but would not usually cause injury to individual upper
limb nerves.
post-traumatic neuroma – a growth of scar tissue at the site of a previous
nerve injury, which leads to compression

If you want to learn about brachial plexus injuries, these are covered in detail in a
separate anatomy article here.

Summary
The big summary table below sums up everything we’ve just covered in what I hope is a
concise and memorable fashion. Again, you can click to enlarge it and it should print out
nicely onto a sheet of A4 paper. I hope you found this guide useful – good luck and may
the forceps be with you!

References
International Standards for Classification of Spinal Cord Injury 2011 Revised
Edition, available from [LINK]
Netter FH; “Atlas of Human Anatomy, 5th Edition” – Elsevier Saunders 2010.
Sinnatamby CS; “Last’s Anatomy, 12th Edition” – Churchill Livingstone 2011

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Snell RS; “Clinical Anatomy by Regions, 9th Edition” – Lippincott Williams

and Wilkins 2011

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