The Extremities – Upper Limb

I. The Brachial plexus

A. Formation

1. Trunks
a. Superior – C5 and C6
b. Middle – C7
c. Inferior C8 and T1

2. Divisions
a. Anterior divisions – flexor components
b. Posterior divisions – extensor components

3. Cords

a. Posterior cord – all three posterior divisions

b. Lateral cord – anterior divisions of superior and middle trunks
c. Medial cord – anterior division of the inferior trunk

B. Branches

1. Supraclavicular

a. Roots
1. Dorsal scapular nerve (C5) – rhomboids and levator scapulae
2. Long thoracic nerve (C5,C6, C7 – serratus anterior

b. Superior trunk
1. Nerve to the subclavius (C5 and C6) – subclavius
2. Suprascapular (C5 and C6) – supraspinatous and infraspinatous

2. Infraclaclavicular

a. lateral cord
1. Lateral pectoral nerve – pectoralis major and minor (mostly major)
2. Musculocutaneous nerve – muscles of the anterior compartment of
the arm
3. Lateral root of median nerve

b. Medial cord
1. Medial pectoral nerve – pectoralis major and minor (mostly minor)
2. Medial brachial cutaneous nerve
3. Medial antebrachial cutaneous nerve

1
 4. Ulnar nerve
5. Medial root of the median nerve

c. Posterior Cord
1. Upper subscapular nerve – subscapularis
2. Thoracodorsal nerve – latissimus dorsi
3. Lower subscapular nerve – subscapularis and teres major
4. Axillary nerve – teres minor and deltoid
5. Radial nerve – great extensor nerve of the upper extremity
(NOTE: Also supplies brachioradialis and sends a branch to the
brachialis)

II. Brachial Plexus Injuries

A. Upper trunk lesions (Erb-Duchenne Palsy

1. Usually caused by excessive increase in the angle between the neck

and shoulder.
2. Results in tearing of the nerve roots C5 and C6
3. Examples:

a. Newborns during a difficult delivery

b. Adults following a severe blow or fall on the shoulder

4. Nerve lesions and muscle paralysis may involve the following:

a. Suprascapular nerve
Supraspinatous – (abductor of the shoulder)
Infraspinatous – (lateral rotator of the shoulder)
b. Nerve to the subclavius
Subclavius (depresses the clavicle)
c. Musculocutaneous nerve
Biceps brachii (supinator of the forearm, flexor of the elbow,
Weak flexor of shoulder)
Brachialis (chief flexor of the forearm)
Coracobrachialis (flexor of shoulder)
d. Axillary
Deltoid (abductor of shoulder)
Teres minor (lateral rotator of shoulder)

Result: Upper limb hangs limply by the side, medially rotated by the
unopposed action of the pectoralis major muscle. The forearm is pronated due to
loss of action of the biceps (supination of forearm) Loss of sensation along the
lateral side of the limb.. “Waiter’s Tip Position”

2
B. Lower lesions of the Brachial plexus (Klumke’s palsy C8 and T1).

1. Traction injuries caused by excessive abduction of the arm.

2. Examples:

Newborn – forceful pull of the upper limb during a difficult delivery

Child falling from a height (e.g. tree and clutching an object one
handed (e.g. tree branch) to stop a fall.

3. Results in tearing of the C8 and T1 roots of the plexus

4. Ulnar nerve most affected
5. Result: Hand has a clawed appearance caused by hyperextension of the
metacarpophalangeal joints and flexion of the interphalangeal joints. The
extensor digitorum is unopposed by the lumbricals and interossei and
extends the metacarpophalangeal joints. The flexor digitorum
superficialis and lateral portion of the flexor digitorum profundus are
unopposed by the lumbricals and interossei and flex the middle and
terminal phalanges respectively. Loss of sensation along the medial side
of the arm, medial side of the forearm, and medial side of the hand and
medial two digits.

C. Lesion of the long Thoracic Nerve (C5, C6, C7) (Paralysis of serratus
anterior)

1. May be injured by blows or pressure on the posterior triangle of the

neck, stab wounds, surgical procedures, or sports injuries.
2. Paralysis of the serratus anterior muscle.
3. The medial border of the scapula becomes prominent and protrudes
posteriorly when someone pushes against a fixed object (winging of
the scapula).
4. Since the scapula can no longer be fixed to the posterior chest wall, the
triceps brachii is seriously weakened.
5. Abduction of the arm is seriously impaired because of lack of upward
rotation of the scapula.

Compression Syndromes

1. The brachial plexus is subject to compression in three general areas:

a. Between the scalene muscles (over the first thoracic rib, or by a

cervical rib or its fibrous vestige)
b. Behind a deformed clavicle
c. Deep to the coracoid process and pectoralis minor muscle

2. Arterial compression (subclavian or axillary artery) usually occurs

simultaneously in all three.

3
 3. The vein may also be compressed by the coracoid process or the clavicle
resulting in swelling and edema of the hand and arm.
4. Pain and paresthesia (tingling or numbness) will occur over the
distribution of affected nerves as well as muscle weakness and atrophy.
5. Most commonly, the T1 root is compressed (by a rib or increased tone of
scalene muscles resulting in Thoracic Outlet Syndrome.
6. Symptoms and signs are exaggerated by extension of the arm and retraction
of the shoulder.
7. Irritation of sympathetic fibers in the affected roots may result in
vasoconstriction, leading to painful ischemic changes in the hand
Reynaud’s Phenomena.

Tendinitis – Other

A. Lateral epicondylitis (tennis elbow) – Inflammation of the common extensor

tendon. Pain in lateral elbow region radiating down posterior forearm and
dorsum of hand.
B. “Anatomical Snuff Box” - Common site of fracture of scaphoid bone with
possible laceration of radial artery.

Dupuytren’s Contracture

Dupuytren’s contracture is a localized thickening and contracture of the palmar

aponeurosis. It commonly starts near the root of the ring finger and draws that
finger into the palm, flexing it at the metacarpophalangeal joint. Later, the
condition involves the little finger in the same manner. In long standing cases, the
pull on the fibrous flexor sheaths of these fingers results in flexion of the proximal
interphalangeal jopints. The distal interphalangeal joints are not involved. The
condition is frequently bilateral and common in men older than 50. The cause is
unknown, but evidence suggests a genetic predisposition. Treatment of the
contracture usually involves surgical excision of all fibrotic parts of the fascia to
free the fingers.

Nerve lesions of the upper limb

Axillary Nerve

1. Can be injured by pressure of badly adjusted crutch passing upward into armpit,
posterior displacement of humeral head into quadrangular space.
2. Paralysis of deltoid and teres minor, loss of sensation over lower half of deltoid

4
Radial Nerve

Injuries in the Axilla

1. May be caused by badly adjusted crutch, fractures and dislocations of the

proximal humerus, or by a drunkard falling asleep with one arm over the back of a
chair (“Saturday Night Palsy”).
2. Triceps, brachioradialis, supinator and all extensors paralyzed.
3. Inability to extend elbow joint or wrist joint.
4. Weak extension of the fingers is possible (lumbrical and interossei muscles are
unimpaired)
5. Α Wristdrop" or flexion of the wrist occurs because of unopposed action of wrist
flexors.
6. Supination is still performed well by the biceps brachii (strongest supinator).
7. Loss of some sensation down the posterior surface of the lower part of the arm
and down a narrow strip on the back of the forearm. Sensory loss on the lateral
part of the dorsum of the hand and dorsal surface of the roots of the lateral three
and one-half fingers.

Injuries in the Radial Groove

1. Fracture of the shaft of the humerus, pressure on back of arm

2. Extension of elbow unimpaired (damage occurs below level of triceps branches)
3. The patient is unable to extend the wrist and fingers and wristdrop occurs.
4. Loss of sensation on the dorsal surface of the lateral part of the hand and dorsal
roots of the lateral three and one-half fingers.

Median Nerve

Injuries at Elbow Region

1. May be injured as result of supracondylar fractures of the humerus.

2. Pronator muscles of forearm and long flexor muscles of the wrist and fingers with
the exception of the flexor carpi ulnaris and medial one-half of the flexor
digitorum profundus will be paralyzed.
3. Forearm is kept in the supine position. Wrist flexion is weak and is accompanied
by adduction.
4. No flexion is possible at the interphalangeal joints of the index and middle finger,
although weak flexion of the metacarpophalangeal joints of these fingers is
attempted by the interossei.
5. When the patient tries to make a fist, the index finger remains straight and the
middle finger bends slightly. The ring and little finger bend but are weakened by
the loss of the flexor digitorum superficialis (= Hand sign of Papal Benediction).
6. The muscles of the thenar eminence are paralyzed and wasted so that the
eminence is flattened. The thumb is adducted.
7. The hand looks flattened and “apelike”.

5
8. Skin sensation is lost on the lateral half or less of the palm of the hand and the
palmar aspect of the lateral three and one-half fingers. Sensory loss also occurs
on the skin of the distal part of the dorsal surfaces of the lateral three and one-half
fingers.

Injuries at the Wrist (Most common site of injury)

1. Paralysis of the thenar muscles and first two lumbricals.

2. The thenar eminence is wasted and flattened.
3. The thumb is adducted.
4. Inability to oppose the thumb.
5. Paralysis of the first two lumbricals can be recognized clinically when the patient
is asked to make a fist and the index and middle fingers lag behind the ring and
little fingers.
6. Sensory losses are identical to those found in elbow lesions.

Carpal Tunnel Syndrome

1. Caused by compression of the median nerve within the carpal tunnel.

2. Syndrome consists of burning pain or "pins and needles" along the distribution of
the median nerve to the lateral three and one-half fingers and weakness of the
thenar muscles.
3. No sensory loss occurs over the thenar eminence because this area of skin is
supplied by the palmar cutaneous branch of the median nerve, which passes
superficially to the flexor retinaculum.

The Ulnar Nerve

Injuries at the Elbow

1. Common site of injury where it lies behind the medial epicondyle.

2. Paralysis of the flexor carpi ulnaris, medial one-half of the flexor digitorum
profundus, the small muscles of the hand except the thenar muscles and the first
two lumbrical muscles.
3. Flexion of the wrist joint results in abduction due to paralysis of the flexor carpi
ulnaris,
4. Flattening of the medial part of the forearm due to wasting of the flexor carpi
ulnaris and medial one-half of the flexor digitorum profundus.
5. The small muscles of the hand will be paralyzed except the muscles of the thenar
eminence and the first two lumbrical muscles. Therefore abduction and adduction
of the fingers is not possible and the patient cannot grip a piece of paper placed
between the fingers.
6. It is impossible to adduct the thumb because the adductor pollicus is paralyzed.
7. The metacarpophalangeal joints become hyperextended because of paralysis of
the lumbrical and interosseous muscles. Because the first and second lumbricals

6
 are not paralyzed (median nerve), hyperextension of the metacarpophalangeal
joints is most prominent in the fourth and fifth fingers.
8. The interphalangeal joints are flexed owing again to the paralysis of the lumbrical
and interosseous muscles. The flexion deformity at the fourth and fifth digits is
more pronounced because the first and second lumbrical muscles of the index and
middle fingers are not paralyzed.
9. The hand assumes a characteristic “claw” deformity.
10. Wasting of the muscles results in flattening of the hypothenar eminence.
11. Loss of skin sensation over the anterior and posterior surfaces of the medial third
of the hand and medial one and one-half fingers.

Injuries at the Wrist

1. The small muscles of the hand will be paralyzed and show wasting except for
the muscles of the thenar eminence and the first two lumbrical muscles.
2. The “clawhand” is much more obvious because the flexor digitorum
profundus is not paralyzed and marked flexion of the terminal phalanges
occurs.
3. Loss of sensation will occur over the anterior and posterior surfaces of the
medial one-third of the hand and the medial one and one-half fingers.

Joints of the Upper limb

A. Sternoclavicular joint – Costoclavicular ligament, principal support. Only

joint between upper limb and axial skeleton.

B. Acromioclavicular Joint

1. Coracoclavicular ligament principal support.

2. Dislocation – shoulder fall away from clavicle because of weight of upper
limb.

C. Shoulder Joint

1. Principal support is rotator cuff tendons

a. Supraspinatous – superior support

b. Infraspinatous and teres minor – posterior support
c. Subscapularis – anterior suport

2. Weakest inferiorly (no rotator cuff tendons)

3. Dislocations:

a. Anterior-inferior (common)

1. Sudden violence applied to the joint when it is fully abducted.

7
 2. The inferior (weak) part of the capsule tears and the humeral head
is displaced inferior to the glenoid cavity.
3. The strong flexors and adductors of the shoulder pull the humeral
head forward and upward into the subcoracoid position.

b. Posterior (rare)

1. Rare and caused by sudden violence to the front of the joint

capsule.
2. Results in subglenoid displacement of the humeral head into the
quadrangular space.
3. Could cause damage to the axillary nerve with paralysis of the
deltoid and teres minor muscles and loss of skin sensation over the
lower half of the deltoid.

4. Rotator Cuff Tendinitis – Inflammation of supraspinatous tendon and

subacromial bursitis from excessive abduction.
5. Rupture of Supraspinatous Tendon – Common in the elderly.

Extremities – Lower limb

I. Femoral Triangle

A. Borders:
1. Inguinal ligament
2. Sartorius
3. Adductor longus

B. Contents: (lateral to medial)

1. Femoral nerve
2. Femoral sheath
a. Femoral artery
b. Femoral vein
c. Femoral canal
3. Deep inguinal lymph nodes

C. Boundaries of the Femoral Ring (upper end of femoral canal)

6. Inguinal ligament
7. Pectineus muscle and fascia on superior pubic ramus
8. Lacunar ligament
9. Femoral vein

8
II Adductor Canal

A. Borders:
1. vastus medialis
2. Adductor longus and magnus
3. Sartorius

B. Contents:
1. Femoral vessels
2. Saphenous nerve
3. Nerve to the vastus medialis

Compartments

Anterior Compartment of the Thigh

Nerve Supply – Femoral Nerve

Actions – Flexion of thigh at the hip joint, Extension of the leg at the
Knee joint

Medial Compartment of the Thigh (Adductor compartment)

Nerve Supply – Obturator nerve

Group Action – Adduction of the thigh at the hip joint

Posterior Compartment of the Thigh (Hamstrings)

Nerve Supply – Tibial Division of the Sciatic Nerve

Group Action - Extension of the Thigh at the hip joint
Flexion of the Leg at the Knee joint

Posterior Compartment of the Leg

Nerve Supply – Tibial Division of the Sciatic Nerve

Group Action – Plantar Flexion of the Foot

Anterior Compartment of the Leg

Nerve Supply – Deep Fibular (Deep Peroneal) Nerve

Group Action – Dorsiflexion of the Foot

Lateral Compartment of the Leg

Nerve Supply – Superficial Fibular ( Superficial Peroneal) Nerve

Group Action – Eversion of the Foot

9
Trendelenburg Gait

Note: Gluteus medius and minimus are chief abductors of the thigh. Equally
important function is steadying the pelvis while walking (e.g. raise foot off ground,
contraction of gluteal muscles of the opposite side).

If the gluteus medius and gluteus minimus muscles of one side (e.g., the right)
are paralyzed, the person exhibits a very characteristic gait. When the lower limb on the
unaffected side (in this case left) enters its swing phase, its side of the pelvis (left side)
drops because the right gluteus medius and minimus muscles cannot hold the pelvis
level. Such a drop of the pelvis on the left side will ordinarily shift the entire trunk
toward the left with the result that the body’s center of gravity is no longer over the
supporting right foot. The person would tend to fall over to his or her left side. In order
to prevent a fall, the person will laterally flex the lumbar spine toward the right bringing
the center of gravity of the trunk over the right foot. This manner of walking, involving
drop of the pelvis on the good side and lateral flexion of the trunk toward the paralyzed
side is called = Trendelenburg gait.

Anterior Tibial Syndrome

A. Thick unyielding crural fascia covers anterior leg compartment muscles.

B. Swelling of unused muscles (Shin splints), painful.
C. Elevated pressure leads to ischemia, nerve degeneration, paralysis of muscles,
eventual muscular atrophy and degeneration (Anterior tibial syndrome).

Nerve Injuries in the Lower Limb

Femoral Nerve Injury

1. May be compressed by tumors within the abdominopelvic cavity, damaged by

fracture of the superior pubic ramus, dislocation of the hip, or penetrating wounds
in the thigh (stab or gunshot).
2. The quadriceps femoris muscle is paralyzed and the knee can not be extended
3. Skin sensation is lost over the anterior and medial sides of the thigh, over the
medial part of the lower leg, and along the medial border of the foot as far as the
ball of the big toe.

Sciatic Nerve Injury

1. Sometimes damaged by penetrating wounds, fractures of the pelvis, dislocations

of the hip joint.
2. Most frequently injured by badly placed intramuscular injections in the gluteal
region. To avoid this, injections should be made on the upper lateral quadrant of
the buttock.
3. In the majority of sciatic nerve lesions, the common fibular nerve is the most

10
 affected.
4. The hamstring muscles are paralyzed, but weak flexion of the knee is possible
because of the action of the sartorius (femoral nerve) and gracilus (obturator
nerve). All the muscles below the knee are paralyzed, the weight of the foot
causes it to assume a plantar flexed position (footdrop).
5. Sensation is lost below the knee except for a narrow area down the medial side of
the lower part of the leg and along the medial border of the foot as far as the ball of
the big toe, which is supplied by the saphenous branch of the femoral nerve.

Sciatica

Sciatica is pain in the lower back and hip region radiating down the back of the
thigh and leg. It may be caused by herniation of an intervertebral disc with pressure on
one or more roots of the lower lumbar or sacral spinal nerves or pressure on the sacral
plexus or sciatic nerve by an intrapelvic mass (e.g., tumor).

Common Fibular (Peroneal) Nerve Lesions

1. The common fibular nerve is the most frequently injured nerve of the lower limb.
2. Fractures of the fibular neck may damage the nerve directly or it may be
entrapped in the callus that forms during healing. Because of its superficial
course over the neck of the fibula it may be damaged in sports injuries.
3. The muscles of the anterior and lateral compartment of the leg are paralyzed
(dorsiflexors and everters).
4. Consequently, the opposing plantar flexors and inverters of the foot cause the foot
to be plantar flexed (footdrop) and inverted (Equinovarus).
5. Loss of sensation occurs down the anterior and lateral sides of the leg and dorsum
of the foot and toes, including the medial side of the big toe. The lateral border of
the foot and lateral side of the little toe are unaffected (sural branch of tibial
nerve). The medial border of the foot as far as the ball of the big toe is unaffected
(saphenous branch of femoral nerve).

Tibial Nerve Lesions

1. The hamstring muscles, all muscles of the back of the leg, and all muscles of the
sole of the foot are paralyzed.
2. Consequently, the opposing dorsiflexors and everters, dorsiflex and evert the foot
(Calcaneovalgus)
3. Sensation is lost on the sole of the foot

Obturator Nerve lesions

1. Occasionally injured in penetrating wounds, anterior dislocations of the hip joint,

or abdominal herniae through the obturator foramen.
2. Results in paralysis of the adductor muscles.
3. There is minimal sensory loss on the medial aspect of the thigh.

11
Joints of the Lower Limb

A. Hip Joint

1. Iliofemoral ligament – One of the strongest ligaments in the body.

2. Some freedom of movement sacrificed for stability (compare with
shoulder joint).
3. Congenital dislocation – Failure of complete development of the
Acetabulum (8 times as common in females)
4. Traumatic Dislocation (rare, motor vehicle accidents)

a. Seated position with joint flexed and adducted

b. Femoral head displaced posteriorly tearing this part of the
capsule and shattering the femoral head.
c. Sciatic nerve may be damaged.

B. Knee Joint

1. “Unhappy Triad of Knee Injuries”

a. Rupture of tibial collateral ligament

b. Tearing of the medial meniscus
c. Tearing of the anterior cruciate ligament

2. Examination of knee injuries;

a. Torn anterior cruciate ligament – Tibia can be pulled

excessively forward when the knee is flexed “Anterior Drawer
Sign”
b. Torn posterior cruciate ligament – Tibia can be pulled
excessively backward when the knee is flexed “Posterior
Drawer Sign”.

C. Ankle Joint

1. Damage usually results when foot is excessively inverted with the

ankle plantar flexed.
2. Usually results in tearing of the anterior talofibular ligament.

Maintenance of the Arches of the Foot (main Supports)

1. Plantar calcaneonavicular ligament (spring ligament) – Sustentaculum

tali to navicular bone.
2. Long plantar ligament – Calcaneus to cuboid
3. Short plantar ligament – Calcaneus to cuboid
4. Plantar aponeurosis

12