PERIPHERAL NERVE INJURY IN UPPER LIMB

ERB'S PALSY:
Injury to the upper trunk originating from C5 and C6 nerve roots or
injury to the C5 and C6 nerve root causes Erb- Duchenne palsy.
Causes
• Indirect injury
• Vacuum delivery
• Pressure on the supraclavicular area
• During anesthesia
• Injection of foreign vaccines and serum.
Signs and Symptoms
Sensory
There is loss of sensation in the area of deltoid insertion and lateral
aspect of the forearm and hand.
Motor
The muscle that will be totally paralyzed are :

 deltoid,
 biceps,
 brachia,
 brachialis,
 brachioradialis,
 supraspinatus,
 infraspinatus,
 teres minor,
 rhomboids and
 supinator.

The muscles that will not be totally paralyzed but will be just weak
are :
  triceps,
 latissimus dorsi,
 serratus anterior,
 pectoralis major and
 extensor carpi radialis.

Reflexes
Biceps and brachioradialis jerks are affected.
Deformity
The patient will exhibit a deformity which is usually called as
policeman’s tip or waiter’s tip.

This deformity consists of :

 Extension,
 adduction,
 internal rotation at the shoulder,
 extension at the elbow,
 pronation and flexion at the wrist and fingers.

Functional Disability
All the activities of daily living which involves flexion movement
at the shoulder and the elbow will be lost.

Thus the patient will have difficulty in eating, combing, washing,

dressing, reaching out and other similar activities.
Treatment
The treatment comprises of:
• Interrupted Galvanic stimulation to maintain the muscles
property.
• Passive movement and stretching to prevent any joint contracture
or deformity.
• Care of edema is very necessary as the hand is always in
dependent position with respect to the gravity hence more chances
of developing edema.
• Massage may be given to maintain the circulation and prevent
any trophic changes.
• Splint that is given is aimed at maintaining the shoulder in the
functional position. Two splints commonly used are aeroplane
splint and cheese splint. Both the splints prevents contracture of
adductors and internal rotators. These splints also prevents any
chances of shoulder dislocation.

It should be noted that the prognosis of Erb’s palsy is much better

than the Klumpke’s palsy as the distal that need to be covered by
the axon to reach the end organ is very short.
• Strengtheing exercises once recovery starts.

KLUMPKE’S PALSY:

Any lesion to the lower trunk of brachial plexus or to C8, T1 roots

of the spinal cord.
Causes
• Breech delivery
• Traction and fall in the abducted arm
• Operation in the axilla
• Tumor in the apical lobe of the lung
• Enlarged cervical rib.

Signs and Symptoms

Sensory
There will be loss of sensation :

 over the medial aspect of the arm,

 forearm,
 hand and
 hypothenar eminence.

Motor
There will be paralysis of all the intrinsics of the hand along with
wrist and finger flexors.
Deformity
The patient will have claw hand deformity.
Functional Disability
As the patient will lack intrinsic plus grip( MCP flexion with PIP and DIP
extension.) or lubrical grip, the patient’s power grip is very inefficient.
The skin will become very dry, scaly and the nails will become
brittle.

Treatment
• Stimulation
• Passive movements
• Massage
• Splintage: Knuckle bender splint is given for the hand.
• Strengthening exercises once the nerve gets innervated.

RADIAL NERVE INJURY (Fig. 6.4)

Causes
Axilla
• Crutch palsy
• Deep penetrating injury in the axilla
• Diphtheria involving the radial nerve in the axilla
• Lead poisoning which generally causes bilateral involvement of
the radial nerve
• Saturday night palsy.

Upper Arm
• Tourniquet’s palsy involving all three nerves
• Fracture shaft humerus Injection palsy
• Gun shot or glass cut injury
• Supracondylar palsy
• Radial nerve can be compressed under the fibrous arch formed
by the triceps muscle just 2 cm below the deltoid insertion. The
nerve gets compressed due to vigorous contraction of the triceps
muscles.

At the Elbow
• Tennis elbow
• Inflammation of the common extensor tendon may heal by
fibrosis and compress the radial nerve
• Fracture of the upper end of radius and ulna
• Direct blow to the posterior interosseous nerve
• A fibrous arch covers the posterior interosseous nerve as its
passes through the supinator muscles and can gets compressed
during forceful contraction of the muscles.
• Two layers of supinator can also compress the nerve against the
aponeurosis of extensor carpi radialis brevis.
• Compression of the posterior interosseus nerve due to ganglia,
neoplasm, bursae, VIC and fibrosis after trauma.

Signs and Symptoms

Sensory
There will be loss of sensation over the following areas depending
upon the level of lesion.
• Posterior part of the upper arm
• Lower lateral part of the arm
• Posterior part of the forearm
• Posterior part of the hand and the fingers up to the nail beds.
The autonomous zone for the radial nerve is the first web space.
When the posterior interosseous nerve only is involved then the
patient will not have anesthesia of the autonomous zone as the
posterior interosseous nerve is a purely motor nerve.

Motor Loss
The following muscles will be involved depending upon the level
of lesion:

 Triceps,
 brachioradialis,
 extensor carpi radialis longus and brevis,
 extensor carpi ulnaris,
 extensor digitorum,
 extensor digiti minimi,
 supinator,
 anconeus,
 abductor pollicies longus,
 extensor pollicies longus and brevis,
 extensor indicis.

Not all the muscles will be involved in all the cases of radial
nerve palsy. It all depends upon the site of radial nerve injury.
Careful examination of muscle power hence becomes an important
tool to detect the level of the nerve injury.

Reflexes
The triceps and brachioradialis jerk will be depressed or absent
depending upon the level of lesion.
 Deformity

 Wrist drop in which the wrist is held in some 45 degree of

palmar flexion due to the overaction of the wrist flexors
unopposed by their antagonist which is the paralyzed wrist
extensors.
 The thumb is held in palmar abduction and slight flexion due
to the unopposed action of the short flexor and short abductor.
 The metacarpophalangeal joints are held in about 30 degree of
flexion due to the unopposed action of the lumbricals, as the
extensor digitorum is paralyzed.
 There is only slight flexion at the interphalangeal joints as the
interossei extend these joints and are unaffected, the slight
flexion in that due to the wrist and metacarpophalangeal joints
taking up a position of flexion which automatically results in
slight flexion at the proximal and distal interphalangeal joints.
 Attempts to perform pure ulnar deviation results in vigorous
flexion along with ulnar deviation as there is unopposed
action of the flexor carpi ulnaris which is not balanced by the
paralyzed extensor carpi ulnaris.

Functional disability:

The patient generally will have a poor grip due to lack of wrist
extensor as fixator and cannot put objects like glasses or cups flat on
the table.
Common Trick Movements
• As the wrist extensors are paralyzed the patient may attempts to
perform wrist extension by forcefully contraction and then
relaxation giving an impression of wrist extension.
This type of trick movement is Rebound phenomena.
• To bring about extension of the MCP joint, in absence of
paralyzed extensor digitorum, the dorsal interossei may bring
about finger extension but the fingers will have the tendency to go
into abduction as well.
• Extension of DIP of the thumb is done by rebound phenomena
where the flexor pollicies longus forcefully contract and relax
giving rise to false impression of extensor pollicies longus action.
• Extensor carpi radialis is the first muscles to recover in radial
nerve palsy so attempted dorsiflexion results in a radial deviation
because the extensor carpi ulnaris is still paralyzed and hence
cannot balance.

 The early sign of recovery of the extensor carpi ulnaris is

reduced tendency of the wrist to go into radial deviation.
• Extension of the DIP of the thumb is also possible due to
accessory insertion of abductor pollicies brevis hence every time
the patient does abduction which is perpendicular to the palm.
There will be extension of the DIP of the thumb.
• Due to paralysis of triceps the patient may use gravitational
force to bring about elbow extension.

Treatment
Conservative management:

 Homeostasis of the involved extremity must be established

before reconstruction.
 The patient must maintain a full range of passive motion in all
the joints of the hand and wrist.
  The therapist must prevent any contracture giving particular
attention to the thumb— index web.
 Individualized treatment may include a dynamic splint.
 The main aim behind giving splintage is to prevent wrist
flexion as well to give functional position of wrist extension so
that the patient can use his long flexors and intrinsic
effectively to perform various activities of daily living.
 Also the splint should be able to prevent adductor pollicies
and pronator contracture.
 The splints usually given is either static or dynamic splints.
 The static splints used are either cock up splint with a ventral
or dorsal support or a Robert Jones splints which keeps the
wrist and finger in extension.
 The dynamic splints used are either cockup splints with
extensor out triggers or cockup splint with reverse knuckle
bender.

Surgical treatment
The requirement for restoration of wrist and hand function are:
• Wrist extension
• Finger metacarpophalangeal extension
• Thumb extension
• Stability of the carpometacarpal joints of the thumb.

 Loss of forearm supination secondary to loss of supinator

muscle is inconsequential in the presence of a normal biceps
brachii.
 There is loss of gross grip strength related to radial palsy
because wrist extension is necessary to provide stability and to
allow full excursion of the digital flexors.
 Precision pinch is weak when the base of the thumb is
unstable due to paralyzed of the abductor pollicies longus.
Tendon transfer done is as follows

 Pronator Teres is transferred for restoration of extension of the

wrist thereby substituting for the loss of ECRL and ECRB.
 Thus after transfer the pronator teres will act as a wrist
extensor but will still perform pronator action.
 After the anastomosis the wrist should rest in 30 degree of
extension against gravity.
 If the tension becomes too much the functional wrist flexion
will become impossible.
 For gaining thumb stability it is desirable to repower the
abductor pollicies longus.
 Without this stability, strong pinch is impaired and incomplete
abduction of the first metacarpophalangeal joint will cause
some awkwardness during fine precision activity.
 The flexor carpi radialis tendon can be split and the radial half
of the tendon transferred to the abductor pollicies longus
tendon or the Palmaris longus tendon is transferred to the
extensor pollicies brevis tendon.

Elbow extension:

Trauma to the upper extremity in isolated radial palsy usually is

distal to the branches to the triceps muscle in the upper arm.
Posterior deltoid to triceps transfer is most preferable for elbow
extension activity which is such an important action for weight
bearing function of the upper limb.

Finger extension:
 Flexor carpi ulnaris to long finger extensor
transfer is the most preferable for restoring finger extension.

Robert Jones transfer is as under:

• Pronator Teres for ECRL and ECRB
• FCU for ED
• FCR for EPL/EPB/APL

 As following the transfer the wrist was rendered unstable as

no flexors were left on the flexors aspect.
 Therefore there was a modification known as Zachary’s
modification where FDS of the ring finger or Palmaris longus
was used for EPL/EPB/APL.
 Preoperatively the strength of the donor muscles should
always be strengthened to the maximum.
 Postoperative physiotherapy management: In operating room,
a double sugar tong splint is applied which immobilizes the
forearm in 30 degree of pronation, the wrist in 40-45 degree of
extension, the metacarpophalangeal joint in 0 degree of
extension and the thumbin maximum extension and
abduction.
 The first splint extends beyond the proximal interphalangeal
joints, which are volarly supported in 45 degree of flexion.
 This splint is removed in 48 hours and a long arm cast is
applied.
 The proximal interphalangeal joints are free but all other joints
are immobilized as noted above.
 After 5 weeks of surgery the patient is removed from rigid
immobilization and placed in a spring action cockup splint to
obtain independent action for wrist and finger extension.
 A planned exercise program will use synergistic movements.
  Following tendon transfer, after 3 weeks faradic reeducation is
started.
 In order to train the muscle for its new action one must resist
the original action of the muscle because in the initial stages
the transferred muscle will have the tendency to perform the
original action.
 In case of the transferred pronator teres, during the initial
stages of faradic reeducation, the forearm tends to go into
pronation which needs to inhibited.
 On inhibition the wrist will go into extension that has to be
encouraged.
 Once the muscle learn the new action it has to be strengthened
by various strengthening techniques and thereby it should be
used for various functions.

MEDIAN NERVE INJURY

Median nerve can be involved anywhere along the course:
Axilla
• Axillary aneurysm
• Traction injury
Arm
Penetrating injury
Elbow
• Penetrating injury
• Hansen’s disease
• Tourniquet’s palsy
• Golfer’s elbow
• Supracondylar fracture
Forearm
• Pronator teres syndrome; A fibrous band that travels between
the deep and superficial head of the pronator teres can compress
the median nerve due to over use or violent contraction of the
muscle.

• A fibrous arch which originates just proximal to the origin of the

flexor digitorum superficialis can compress the median nerve
causing selected paralysis of FDS and FDP.
• Volkmann’s ischemic contracture.

Wrist
• Glass cut injury can cause isolated involvement of the median
nerve or along with the ulnar nerve.
• Carpal tunnel syndrome.
  Anterior interosseous nerve can get involved due to fracture or
laceration of the forearm.
 It can be compressed by the flexor digitorum superficialis or
pronator teres.
 It can also be involved due to VIC or thrombosis of the ulnar
collateral vessels.

Signs and Symptoms

Sensory
There will be loss of sensation over the volar aspect of lateral 3½
fingers up to the distal phalanx on the dorsal side, skin overlying
the thenar eminence.

The autonomous zone for the median nerve is the pulp of the
thumb.
Motor:

The muscles supplied by the median nerve namely:

 the pronator teres,
 flexor carpi radialis,
 flexor digitorum superficialis,
 Palmaris longus,
 flexor digitorum profundus( the lateral half),
 pronatus quadratus,
 flexor pollicis longus,
 thenar muscles,
 the first and second lumbricals.

Deformity:

The deformity seen in median nerve palsy are as follows

depending upon the site and extent of lesion.
• The commonest deformity seen is ape hand or monkey hand
which occurs due to flattening of the thenar eminence, lack of
opposition of the thumb because of which the thumb is held
beside the index finger due to over action of the adductor pollicis
and extensor pollicis longus.
• Partial claw hand occurs due to paralysis of the first and
second lumbricals due to which there is unopposed action of the
extensor digitorum giving rise to hyperextension of the MCP
joint of the index and middle finger along with flexion of the IP
joint of these fingers.
With lesion at the wrist the IP flexion will increase due to
increased activity of flexor digitorum superficialis and profundus
as they will be spared.

• Pointing index finger:

When there is a higher lesion involving even the long flexors of
the hand, on asking to make a fist the index finger will point
forward. This happens because when the patient attempts to
make a fist, the profundus tendon of the ring finger will pull the
middle finger into partial flexion leaving the index finger in
extension and pointing forward.
• When patient with anterior interosseous nerve palsy is asked to
make a tip to tip pinch using the index and the thumb then due
to paralysis of the flexor digitorum profundus and flexor pollicis
longus the tip to tip pinch will show a tear drop appearance
instead of ‘O’.

Functional disability:
Most of the patient with median nerve palsy will be having
difficulty in holding both big and small object.
Their activity with the involved hand is generally clumpsy
because they cannot hold object confidentially in their hand nor
they can appreciate the sensation of the object unless and until
they see the object.

Trick movements:
Common trick movement which can be expected in patient’s
with median nerve injury are as follows:
• Due to paralysis of pronator teres the patient will try to pronate
with the help of brachioradialis along with internal rotation of
the arm.
• To perform radial deviation the patient substitutes with the
help of extensor carpi radialis and to perform wrist flexion, he
will use the flexor carpi ulnaris.
• In the absence of FPL, the patient may perform flexion of the
distal IP joint by rebound phenomena using a strong contraction
of the extensor pollicis longus and suddenly relaxing.
• To perform opposition action the patient uses abductor pollicis
longus and then let the thumb fall toward the palm due to the
force of gravity.
The first sign of recovery of median nerve following its lesion in
the wrist will be the ability of the thumb to rotate when the
thumb is supported in slight amount of palmar abduction and
flexion.
Treatment

Conservative physiotherapy management:

• Passive movement to the wrist and fingers to keep the parts
mobile
• Gentle stretching of the long flexors to prevent any form of
tightness
• IG stimulation to all the muscles supplied by the median nerve
• Care of the anaesthetic hand
• Splints: Opposition splints are given to maintain the thumb
in opposition and also to prevent contracture of the first web
space.
 The two types of splints which are commonly given are C-
bar and cockup splints.


 The C- bar can be made up of aluminium, orthoplast and
plaster of Paris.
 This is used to maintain the first web space and is held in
place with the help of 3 velcro straps one over the index
finger, one over the thumb and one at the deepest part of
the first web space.
 Cock up splint with an opposition out trigger is also used to
maintain the thumb in opposition.

Surgical management:
The basic requirement for hand function in median nerve injury
consist of the following component.
• Thumb abduction to perform opposition
• Flexion across the MCP joint of the thumb
• Flexion of the index and middle finger
• Sensation over the thenar eminence and pulp of the thumb.
In addition to the above even pronation of the forearm becomes
quite essential when there is a lesion higher up.
The preferable surgical procedure is a tendon transfer and the
commonest types of tendon transfer for median nerve injury is as
follows:
• Restoration of thumb opposition is done by transferring the
flexor digitorum superficialis of the ring finger which is detached
from its insertion wound around the flexor carpi ulnaris tendon
and inserted to the insertion of abductor pollicis brevis.
Following surgery, the thumb is immobilized in opposition
position for three weeks in POP after this an opposition splint
can be given for another 6 weeks during which physiotherapy
treatment involving reeducation of the transferred tendon is
done along the same line.
• Flexion of DIP of the thumb can be achieved by detaching
brachioradialis from its insertion and attaching it along with the
flexor pollicis longus. Extensor digiti minimi can also be used.
• Flexion of the index and middle finger can be achieved by
slitting the tendon of flexor digitorum profundus of the ring and
little finger and attaching them to the middle and index finger so
that the ulnar portion of the nerve can pull the fingers into
flexion.
• In very rare cases biceps tendon may be transferred to perform
pronation.
In all the above cases faradic reeducation may be started after 3
weeks.
Intermetacarpal blocks may also be given between the first and
second metacarpal to maintain the first web space permanently.

ULNAR NERVE INJURY

Causes
At the Cervical Spine
• Prolapse intervertebral disc
• Osteophyte due to cervical spondylosis
• Rheumatoid diseases of the cervical spine
At the Base of the Neck
• Cervical rib
• Thoracic outlet syndrome
• Scalenus anticus syndrome

At the Axilla
Crutch palsy.
Arm
• Tourniquet palsy
• Fracture of the supracondylar region of humerus
• Hansen’s disease.
Elbow
• Cubitus valgus causing Tardy ulnar nerve palsy:

 At the elbow the ulnar nerve passes through a tunnel the roof
of which is formed by a fibrous arch.
 This arch becomes tight during elbow flexion as the floor of
the capsule bulges out.
 In cubitus valgus the floor is already elevated which increases
the compression on the ulnar nerve.
 Initially this leads to only conduction block but later to
degeneration.
• Dislocation of the elbow.
 • Fracture of the medial epicondyle of the humerus.
• Hansen’s disease.

At the Forearm
• Volkmann’s ischemic contracture
• Tight plaster

At the Wrist
• Glass cut injury
• Compression of the ulnar nerve as it passes through the canal of
Guyon.

 The medial border of this canal is formed by the tendon

of flexor carpi ulnaris and pisiform bone.
 The floor of the canal is formed by the flexor retinaculum and
the roof is formed by the superficial part of the flexor retinaculum.
• Fracture of the carpus bone
• Tumors
• Osteoarthritis.
Signs and Symptoms
Sensory Loss
The patient will have loss of sensation on the skin overlying the
hypothenar eminence, the medial 1½ finger up to the nail beds.


Motor Loss
The muscles that will be affected are:

 flexor carpi ulnaris,

 medial half of the flexor digitorum profundus,
 the hypothenar muscles,
 medial two lumbricals,
 the adductor pollicis, and
 the interossei.

Deformity
The patient will exhibit classical claw hand deformity where there
is hyperextension of the MCP joint of the ring and little finger to
about 30 degrees, due to over action of the extensor digitorum and
extensor digiti minimi.

The IP joint of these two fingers will be held in flexion, the proximal
IPjoint is held at about 25 degrees of flexion.

The distal IP joint may be flexed or extended depending upon the

site of injury to the ulnar nerve.
If the ulnar nerve is involved at the wrist there will be about 10 to
15 degrees of flexion at the distal IP joint due to over action of the
flexor digitorum profundus but if the lesion is at the elbow then
there will be paralysis of even the profundus causing reduced
flexion at the distal interphalangeal joint.

Ulnar paradox:

With lesion at the elbow there is reduced flexion at the distal IP

joint due to paralysis of flexor digitorum profundus.

With reinnervation the flexion at the DIP joint will increase giving
an appearance of increase deformity although this is a prognostic
sign.

Functional Disability

• The patient will lack intrinsic plus position or lumbrical grip

• Power grip is more affected due to lack of the elevation of the
hypothenar eminence, inability of the fingers to wrap around
the object and due to the lack of clamping action of the thumb.
• Pinch power reduces
• Spherical grip is lacking due to absence of lateralization of fingers
• Lateral pinch becomes inefficient due to paralyzed adductor
pollicis.

Trick Movements
• Due to paralysis of the lumbricals, extension of the IP joint will be
possible only when the MCP joint is supported in flexion.
Due to paralysis of dorsal interossei, the patient will try to abduct
the finger using extensor digitorum which also causes extension
of the fingers.
• Adduction of the finger can be brought about by direct
substitution using the long flexors of the hand.
• Ulnar deviation can be brought about by extensor carpi ulnaris.
• When the patient is asked to perform wrist flexion, the flexor
carpi radialis substitutes pulling the hand into radial deviation.
Hence the first sign of recovery after a ulnar nerve injury at the elbow
is reduced tendency to go into radial deviation.
• In place of adductor pollicis the patient will use flexor pollicis
longus this is called as Forment’s sign.
• Cocontraction of flexor pollicis longus and extensor pollicis
longus nullify their action at the DIP thereby pulling the thumb
into adduction.
• The first sign of recovery following ulnar nerve injury at the
wrist is increased abduction attitude of the little finger because
the abductor digiti minimi is the first muscle to recover.
Management
• IG stimulation
• Passive movement and stretching
• Care of anesthetic hand
• Splintage: The splint used should be able to keep the MCP joint in
flexion and to maintain the IPjoint in extension.

Hence a knuckle bender splint is used. This splint consists of a

volar support at the MCP joint and two dorsal supports on the
proximal phalanx and on the metacarpal bones .
Surgical management Tendon transfer surgery are the usual
surgical approach practiced in ulnar nerve injury.

The commonest tendon transfer done is Paul Brand’s transfer

where Extensor carpi radialis is detached from its insertion and
lengthened by a free tailed graft of plantaris muscle.

This is then slit into four, moved through the lumbrical canal and
got to the dorsal aspect where it is attached to the extensor
aponeurosis.
When there is severe clawing of the hand with wrist flexion,
Riordan’s technique is used where the flexor carpi radialis is
detached from its insertion, lengthened and then inserted in the
same way as Brand’s surgery.
When there is no habitual flexion of the wrist, Bunnell’s surgery
may be tried in which case the flexor digitorum of the ring finger is
slit into four tendon and then inserted in the same manner as the
Brand’s surgery.

Postoperative physiotherapy:
Following the transfer the fingers are immobilized in lumbrical grip
position by POP that is removed after 10 days. After ten days the
suture is removed and the plaster is reapplied for 3 more weeks. At
the end of 3 weeks the POP is removed
and a cylinder POP applied to all the fingers in an attempt to
maintain them in extended position. This is kept for another 10
days after which Faradic Re-education may be given to get active
lumbrical grip movement. If the patient is not able to achieve it
sometimes POP may be reapplied for another 2 to 3 weeks.
However,
if the clawing is no longer present and if the patient is able to
perform
the movement actively then strengthening exercises is started.
Initially gentle exercises like paper crumpling is given and
eventually
various power activities can be strengthened. Lastly, dexterity
functions can be trained by various pegbo and exercises.